In advance of a Friday Institute of Medicine conference in Washington, DC involving policymakers in implementation of its September 2014 report that urged promotion of “advance care planning,” the Powell Center for Medical Ethics at the National Right to Life Committee is issuing a report entitled, “The Bias Against Life-Preserving Treatment in Advance Care Planning.”
Advance care planning refers to counseling potential patients on deciding when to accept or reject life-preserving medical treatment and advising on legal documents embodying that decision.
“Although the Institute of Medicine report gives lip service to what its subtitle calls ‘Honoring Individual Preferences,'” said Powell Center Director Burke Balch, “its pervasive focus is summed up by its statement, ‘Because most people who participate in effective advance care planning choose maximizing independence and quality of life over living longer, advance care planning can potentially save health care costs….’ The Institute’s emphasis on cost-slashing should intensify, rather than calm, the fear of older people and those with disabilities that the renewed push for government funding and promotion of advance care planning is less about discovering and applying their own wishes than about pushing them to accept premature deaths.”
The Powell Center document cites a 2013 Health Affairs article entitled “Decision Aids: When ‘Nudging’ Patients to Make A Particular Choice Is More Ethical Than Balanced, Nondirective Content,” which gave this advice on how to get people with prostate cancer to agree not to have costly surgery:
[I]f incontinence and impotence are presented as plainly stated–that is, with no detailed description of these risks– men with early-stage prostate cancer may be swayed toward the option of surgery. If instead those possible effects of surgery are presented vividly via personal stories, men may be swayed away from the surgery option.
The Powell Center report gives examples of advance care planning materials in widespread use that, it argues, violate the principle of informed consent by selectively presenting facts in a distorted and unbalanced manner to “nudge” unwary patients to reject cardio-pulmonary resuscitation (CPR), IV fluids, and medically assisted feeding. Other advance care planning materials, it charges, describe disabilities and illnesses in an inaccurately repugnant way so as to induce people to agree that a low “quality of life” is not worth living.
The Powell report notes that providers of advance care planning materials to health insurers frequently tout the money it saves them. For example, to implement an advance care planning program, Aetna hired the “Center to Advance Palliative Care,” which proudly reported that the result of its efforts was an average reduction of more than $12,000 annually in benefits for senior citizens covered by the insurance company.
Tax funding for Medicare advance care planning was a part of the original House bill for Obamacare that was dropped amidst controversy over critics’ charges that it was designed to save money by pushing senior citizens to agree to forego costly treatment. Recently, however, the Obama Administration has announced it will initiate notice and comment rule-making on an AMA proposal to revive such a measure.
The Powell Center report concludes, “Significant safeguards would need to be incorporated in any governmental program promoting . . . advance care planning in order for [it] to be truly protective of the values and intent of patients, and to ensure they are not pressured into rejecting treatment against their wishes…all in the name of cost-savings.”
The report is available here: www.nrlc.org/communications/advancecareplanningbias