It was an extraordinary, unprecedented moment in American history: the president of the United States, on stage in Portsmouth, N.H., trying to assure people that the government does not intend to kill their grandmothers.
And not everyone was convinced.
Few issues in the debate over health care reform have gotten Americans, to use President Obama's turn of phrase, "all wee-weed up" as has the idea that reform means "death panels" will determine who is worthy of treatment — and therefore, continued life.
Nowhere in any section of any of the health care bills before Congress will one find the phrase "death panel." Nor is there any suggestion that a governmental panel will issue rulings on life or death for a given patient.
But one notion that is in the House bill — government-funded end-of-life counseling — combined with the thinking of prominent bioethicists that some lives have greater value than others led critics to conclude that some government-directed limits on care to the elderly or infirm are possible.
The death panel furor exploded into American consciousness in early August when former Republican vice presidential candidate Sarah Palin used the phrase in a posting on her Facebook page.
"The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care," Palin wrote on Aug. 7. "Such a system is downright evil."
Palin's comment brought her immediate criticism as supporters of health care reform branded her statement an outrageous lie. But while conservative critics of reform, such as the Wall Street Journal's editorial page and National Review, agreed that the idea of 'death panels' is "over the top" and "hysteria," they noted there are legitimate questions about elements of the bill and the ideas of its architects that lead down similar paths.
Section 1233 of H.R. 3200 — the main reform bill under consideration in the House of Representatives — says that Medicare will pay for "advance care planning consultations" between a physician and patient once every five years, or more frequently if the patient has a significant change in health, such as the diagnosis of a life-threatening illness, or admission to a nursing home.
The section says this consultation shall include discussion of such end-of-life concerns as: living wills, health care proxies, orders for life-sustaining care, hospice care, as well as state and national resources for guiding the patient through these decisions.
Medicare does not currently pay for such consultations.
Supporters say this section simply provides patients with the information they need to make informed choices at a difficult time in their own lives or the lives of loved ones. Nothing more.
Edwin Park, senior fellow with the liberal-leaning Center on Budget and Policy Priorities, argues that some conservative critics are taking inconsistent positions on issues like advance care planning simply for the sake of opposing the reform bill.
"Up to this point, everyone thought this is a good idea," Park said of end-of-life counseling. "The doctor-patient relationship is built on consent. That's a time when people might not be able to provide their consent."
But the critics — some of them no one's idea of a "right-wing nut job" — note that health care reform is all about saving money. Studies show that medical treatment in the final year of life consumes 27 percent of the Medicare budget and 10 percent to 12 percent of all health care spending — and along comes a doctor with suggestions about how you might consider checking out a little earlier.
Charles Lane, a member of the editorial board of the Washington Post, said as much in an Aug. 8 op-ed in that newspaper titled "Undue Influence."
"Section 1233, however, addresses compassionate goals in disconcerting proximity to fiscal ones," Lane wrote. "Supporters protest that they're just trying to facilitate choice — even if patients opt for expensive life-prolonging care. I think they protest too much: If it's all about obviating suffering, emotional or physical, what's it doing in a measure to 'bend the curve' on health-care costs?"
Tom Miller, resident fellow at the conservative-leaning American Enterprise Institute, says that the payments to doctors for having the discussion along with the mandates about what the conversation will include are a questionable combination.
"When you start putting it in a framework of 'here's what you're going to discuss and here's what we'll pay for,' it seems to imply a bias toward doing less and steering you toward an earlier exit," Miller said.
The notion that government bureaucrats want to pull the plug on Grandma so dominated the health care reform discussion that Sen. Charles Grassley, R-Iowa, said the end-of-life counseling provisions would be pulled from the Senate Finance Committee version of the bill.
The counseling, however, remains a part of H.R. 3200.
The other line of thinking that leads to "death panel" fears comes from the work of bioethicists — medical academics who ponder the deeper questions of health care: Suppose you have one kidney and two patients needing a transplant. How should medical professionals decide who gets the life-saving organ?
One of the nation's leading bioethicists is Dr. Ezekiel Emanuel, brother of White House Chief of Staff Rahm Emanuel. Dr. Emanuel is President Obama's special adviser on health care.
In defense of her "death panel" statement, Palin criticizes Dr. Emanuel's "Orwellian" theories on health care.
Palin writes: "Dr. Emanuel has written that some medical services should not be guaranteed to those 'who are irreversibly prevented from being or becoming participating citizens ... An obvious example is not guaranteeing health services to patients with dementia.'"
But a New York Times piece last week strongly defends Dr. Emanuel, noting that he has written more than a million words on health care, including pieces in opposition to euthanasia and doctor-assisted suicide.
Dr. Emanuel told the Times he was not advocating for denying medical care to the disabled, merely reporting a growing consensus among competing political philosophies about how a society should allocate health care services — a consensus he does not personally share.
"You can only call me someone who's interested in euthanizing patients and denying care to patients by willful distortion of my record," Dr. Emanuel told the Times.
But the very idea that there are "ivory tower" academics out there pondering who is worthy of care and who is not is worrying to some.
"As you empower more of these closeted bodies, without a transparent process to let other views in, there's a growing suspicion that there's a small group that knows what's best for you," said Miller of the American Enterprise Institute.
In the final analysis, "death panels" are nothing more than a bumper-sticker slogan critics have used to fire up their troops. But behind the overheated rhetoric, there are legitimate questions about end-of-life care that should be part of the debate on health care reform.
Perhaps the best advice to those worried about death panels comes in a piece in The Weekly Standard by conservative humorist P.J. O'Rourke. He writes:
"I myself could point out the absurdity of protestors' concerns about government euthanasia committees. Federal bureaucracy has never moved fast enough to get to the ill and elderly before natural causes do."
