Speaking to an audience at Oxford University, Bishop Anthony Fisher of the Diocese of Parramatta, Australia declared, “The elderly are not a problem, a market, a budget: They are real individuals, our own people, our ancestors, in due course – ourselves.”
It seems amazing that these words need to be spoken aloud, but Bishop Fisher was responding to a disturbing push by the British National Health Service (NHS) to withhold medical care from the elderly as a cost-cutting measure.
Recently, the British media reported on the increasing use of the Liverpool Care Pathway (LCP) to deny even nutrition and hydration to the elderly who are hospitalized.
Archbishop Peter Smith of the Bishops’ Conference of England and Wales formally requested an investigation into this practice. In spite of growing public concern, a spokesman for the Department of Health responded to the Bishop’s request with, “We continue to fully support its proper use as a way of managing a patient’s care with dignity and respect in their last days.”
There are no plans by the National Health Service to assess the possibility of abuses or inappropriate applications of the Liverpool Care Pathway.
Perhaps more disturbing, the Daily Mail reports that the British National Health Service (NHS) has instructed all primary care physicians to submit a list of their patients whom they anticipate will die in the next twelve months. These patients will be flagged in the system to receive “end-of-life” care only.
The NHS hopes this targeted rationing of care will save more than £1 billion. However, none of these primary care physicians have a crystal ball. They cannot foresee the intricacies of any given patient’s health care needs a full year in advance.
Certainly it is desirable to discuss general principles of end of life care with patients in order to understand their desires and expectations. But decisions about the specific level of care each patient receives should be based on the patient’s or the patient’s surrogate’s assessment of the benefits and burdens of a particular treatment as determined at the time the care is needed.
There are too many variables to make definitive decisions twelve months in advance. There is also no avenue of appeal for patients who have been flagged by their primary care doctors for minimal care only.
These worrisome trends in Great Britain should serve as harbingers of things to come in the United States. The Affordable Care Act, commonly known as Obamacare, is positioned to pursue this same path of health care rationing.
There is a veritable alphabet soup of agencies and committees designed to minimize the health care given to select populations in America in order to cut health care costs. The Federal Council Coordinating Comparative Effectiveness Research (FCCCER) , Patient Centered Outcome Research Institute (PCORI) , and Accountalbe Care Organizations (ACO) are all established to save money by decreasing the care that is given.
The PCORI is currently funded at the level of $600,000 per year and tasked with finding ways to decrease health care spending. That means it has to find a minimum of $600,000 worth of savings every year just to justify its existence. What cannot be saved with increased efficiency must be made up with decreased care.
Accountable Care Organizations will dramatically change the doctor-patient relationship. These associations of doctors, hospitals, and ancillary health care services join forces to treat patients as cheaply as possible. They will receive a lump sum payment for each patient. They make money when they spend less than this amount on patient care and lose money when they spend more.
Each physician will be held accountable for the health care spending he generates. Therefore, instead of focusing squarely on the welfare of his patients, a physician’s primary responsibility will be holding the line on spending and maximizing the ACO profits. Failure to do so can result in sanctions and financial penalties.
Defenders of the Affordable Care Act point to a provision in section 3403 of the ACA that sets up the Independent Payment Advisory Board (IPAB). The law explicitly states the IPAB is prohibited from making “any recommendation to ration health care, raise revenues or Medicare beneficiary premiums … increase Medicare beneficiary cost-sharing (including deductibles, coinsurance and copayments), or otherwise restrict benefits or modify eligibility criteria.” This provision has no effect on the FCCCER, the PCORI, and ACO’s that are setting practice guidelines.
A closer look at those who guided the legislation may help us understand what little protection this provides. Dr. Ezekiel Emanuel, one of the chief Obama health care advisors and a primary architect of the Affordable Care Act has kept up a steady stream of articles in the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine (NEJM) trying to reassure physicians that the Affordable Care Act is going to be a boon to American health care.
Dr. Emanuel, however, is a champion of utilitarian ethical principles. He believes that patients can be judged according to their value to society and it is reasonable to allocate care accordingly. In one of his papers he argues that care can be rationed according to the investment society has made in a given patient. For example, he states a fifteen-year-old deserves more care than a three-year-old because society has invested more in the formation and education of the fifteen-year-old. From Dr. Emanuel’s perspective, prioritizing the efficiency of the entire health care system over the needs of individual patients is a desirable outcome of health care reform.
Much attention has rightly been focused on the power of the HHS to mandate that certain medical services, specifically contraception, sterilization, and abortifacients be covered by insurance. It is important to remember that the Affordable Care Act also gives the HHS the power to restrict services that are deemed excessive.
Nutrition and hydration may become a privilege of the young and healthy for the sake of efficiency. But the elderly and the disabled are not inconveniences to be marginalized and discarded. They are not cogs in some nebulous health care system. They are unique individuals; mothers, fathers, daughters, sons, brothers, and sisters. They each deserve to be regarded with full human dignity and their lives must be fully respected. Decisions about care must be tailored to the individual situations and should be made by the patient in consultation with his doctor at the bedside– not by bureaucrats in a remote office.
Regardless of this November’s election results, we all need to remain on high alert to make certain that the Affordable Care Act is not allowed to grow into what is already common in Europe, a means of getting rid of the least convenient members of society.