I’m happy to plug more work for bioethicists, so there should certainly be one of those on board. Add a few specialized physicians–an oncologist and a geriatrician at least. Then a federal employee with access to a particular hospital or region’s medical budget. And then maybe a rotating slot for John Public similar to jury duty.

The decisions wouldn’t be between treating and killing, but between providing life-extending and life-comforting care. As you point out, these sorts of decisions are already made by insurance companies and by the cold forces of the market. The hope is that a democratically accountable panel of mixed experts and advocates would be more fair and more compassionate, even if they’d inevitably upset families when decisions didn’t align with their personal interests.

It may sound trite, but there is no easy answer here. Absolutist positions fail. We cannot just let people die when the cost of their treatment exceeds a preset limit, and we cannot spend all of our limit health care resources trying to keep people alive when they are in a terminal vegetative state.

We have to make subjective choices about when extreme measures are taken. Are we doing that now? Yes. Health insurance companies are doing it. And the market is doing it, in the sense that people with more money have more options.

I think that the thing about these methods that appeals to people is the fact that the decision is made by someone else, or by economic realities. I don’t pretend to have a better solution, but if you believe that these decisions should not be based on someone’s financial situation, then you probably won’t agree with the current system.

I agree with the principle of a duty to die, but I don’t think the family ethics can be extended to society without some public/private qualifications. It would be too much of a taxpayer burden for the government to extend every terminal patient’s life indefinitely, but as Ed suggests, there’s just something unAmerican about individual death by bureaucracy. So instead of “death panels,” how about “palliative care” panels?

A “coalition of stakeholders” (as the infamous bill puts it) could decide when a patient being treated for a terminal illness no longer warrants a hospital bed, and limit public support to the resources necessary for in-home palliative care. No artificial life-support technologies, just physical therapy and medicinal pot until they give up the ghost. Requiring that hopeless patients to be left to their family’s care outside of the hospital would cost less to the public, free up hospital staff, technology, and infrastructure, and indeed leave the dying patient in a much more loving, and far less clinical, environment from which to depart. If the family decides to use their own resources to artificial extend the individual’s life, the state could reasonably be required to provide whatever limited resources fall under the “palliative” criteria.

The basis of this public duty to provide palliative care would not rest on an individual’s rights, or the sanctity of an individual’s life, but rather on the claims that a loving family can make on the state as healthcare provider. Dr. Hardwig’s argument introduces the possibility of obligations generated by “connections,” and the possibility that “being with others” brings responsibilities not traceable to an ethics of the individual. To me, by opening the door to rights and claims made by families on their dying members, we also open the door to rights and claims made by families on their political communities. By taking the connected family as a moral unit, we can see how the state might be required to provide the family with palliative care for its elders and terminally ill, while limiting that requirement just outside the hospital’s automatic doors.

If I may attempt to unearth the intuition that makes “death panels” unAmerican, it may not be that the state should artificially extend every citizen’s life indefinitely. Rather, it may be that in the United States, the decision to end an innocent person’s life simply should not be made in public, by the public, or for the public good. It has to be a private decision, arrived at by the private family, in the privacy of the home. The American intuition seems psychologically programmed to avoid acting on the public good, but the good of the family seems to gain national priority with each election cycle. So while the state may not have the authority to decide when to pull the plug, it could still have the authority to limit what we as taxpayers are required to provide for families that wish to extend their terminal relations’ lives. Families that cannot afford life-extension, then, have a right to unlimited palliative care, but not the resources that can compensate for organ and brain failure available in a hospital setting.

As for terminally ill patients with no family or friends, assuming they have a home, they could be provided with whatever prescriptions or oxygen tanks would help make them more comfortable, and a weekly visit from a nurse or therapist would be a much more reasonable provision from the state, without putting the public in the awful position of “pulling the plug on grandma” (or, in this case, “crazy cat lady down the road”). True, there would still be the rare, tragic case of the poor old man with no one to turn to and no place to go other than Our Lady of Utility Maximization’s Community Healthcare Center. But then, the public interest in extending his life is quantitatively nil. If there are religious organizations who object to the state’s refusal to act on the sanctity of this old man’s life, let them establish private “never say never” clinics with funding from the likes of Bill Frist.

http://www.youtube.com/watch?v=FBYk4F164Hk

Ed: I don’t think that the argument works both ways. There seems to be something different between “a duty to benefit others” and “a duty not to be an unreasonable drain on others.”

If those aren’t equivalent then we might have the duty to die and not a duty to live. (Or the other way around.)

I’m not sure why you say “Similarly, I see nothing wrong with an individual deciding to continue living, even at expense to others.” Could you say more about that? Are there any limits on that statement?

I think most of us would reason that an a person’s life is her own and she can end it if she chooses. However, if people have a duty to die, because our life takes too much of a toll on others, then it stands to reason that people also have a duty to live, if their lives can offer much to others. This reasoning then removes an individuals right to end her own life.

Personally, I don’t like this implication and so I reject it. In the average case, I believe an individual should be able to decide the time of their own death. Similarly, I see nothing wrong with an individual deciding to continue living, even at expense to others. Indeed, we do it every day and we have no metric that proves our lives enrich the lives of others more than we deteriorate them.

My existence today has financial and emotional costs on people directly and indirectly connected to me. How much money do I have to make, or how many friends must I have before my life is deemed too worthy to be ended? How much should I cost my fellow citizens, or how many enemies must I have before my life is forfeit? I answer all of these last questions with one word: none.

How about government-mandated cryogenic freezing? Then they could unfreeze you when they had developed technology sophisticated enough to make you live forever. Teddy Kennedy 4Prez in 2016!!!

Seriously though, this reminds me of an episode of This American Life I heard on NPR a while back. They had an hour-long radio documentary about social workers in major metropolitan areas who have to deal with people who die alone in their homes with no family or friends. Apparently big cities, like LA and NYC, have special task forces, or just one lonely investigator, charged with going through a dead shut-in’s material belongings, looking for evidence of wills, funeral arrangements, and any other documents about their finances and possible long-lost relatives. If they don’t find any contact for the person, the belongings and any savings are either sold at a public auction or donated to charity, and the body of the deceased gets cremated.

The creepiest part was, once a year, the investigators will appoint a chaplain to have a funeral for the anonymous dead. They’ll be buried in a mass grave, just a little 3′x3′ cube, where all their ashes are mixed together and covered with a layer of dirt, marked by a little footstone that only says the year of the burial. The funerals are always open to the public, and they said that sometimes people will show up, just out of the blue. After the little secular ceremony, the grave is covered up and left, the latest installment in a long line of footstones year after year, stretching back for decades, or even centuries.

Cities are weird places, man.

http://www.thislife.org/Radio_Episode.aspx?episode=346