Monday, November 23, 2009

Death Panel Plots and Mammogram Conspiracies

A number of friends are in despair over the possibility of rational political and public reflection about health policy.

I'm not.

Perhaps I'm a cockeyed optimist, but I see the summer's folly about death panels and the eruption about the Preventive Services Task Force recommendations as part of a societal learning process.

In the teaching I do about health care limits I often point out that limits are part of sharing finite resources within a population and that the way we learn about sharing as children teaches important political lessons.

Sharing toys doesn't come naturally. Parents (a) give cognitive messages ("it's fair that Johnny gets a turn with the toy") (b) provide emotional succor for the tantrums that follow, while (c) being firm about the need to share in order (d) not to raise selfish monsters. This process takes lots of time.

Some of the death panel madness was fomented by duplicitous politicians and talk radio hosts, just as we saw during the Bush years at the end of Terri Schiavo's life. But some people truly experienced the idea of end of life counselling as an assault on life and freedom by a death-dealing government. If 2 year olds could speak as adults I expect that they would respond to being asked to share their toys in similar fashion - "This toy means my whole life to me - you're killing me by asking me to share it - this idea of sharing is worse than a death panel!" We don't expect the child to learn all at once, and we can't expect the same from the body politic.

Unfortunately, the duplicitous politicians and audience-hungry talk show hosts are like bystanders who would rush up to the child having a tantrum to say - "you're right - it's outrageous that you've been asked to share your toy - your parent is a socialist!" This will make the learning harder and slower.

The mammogram furor is related, but different. The ever-changing recommendations are genuinely confusing, and people of intelligence and integrity can reasonably disagree. But seeing a government plot in the very idea of the new recommendations has to be understood in light of Kubler Ross's stages of grief theory. Recognizing that mammograms are not a magic bullet that can be counted on to ward off breast cancer confronts us with mortality. Denial of the epidemiological facts about the limitations of the test, combined with our suspicion that the government is a harsh parent insisting that we share all that is important to us with others, underlies some of the backlash we are seeing.

For those who understand the need for limits and for evidence-based health policy, what's needed is the patient persistence that good parents have in teaching us to share. This doesn't mean that fellow citizens who understand end of life counselling to mean death panels or see epidemiology as government conspiracy are childish. Surprising as it is to those of us who obsess about health policy and health system ethics, not everyone has been wonkishly immersed in these issues. Societal learning takes time.

The differential diagnosis between between an honorable person on a learning trajectory and a duplicitous politician can be difficult. But it's hard to believe that people as smart as Newt Gingrich and John Boehner really believe the death panel drivel they indulged in. I leave it to Rahm Emanuel to devise the best responses to duplicitous opportunism. But for all those who are open to learning, President Obama's ability to explain and inspire are what's needed. And as wise parents know, he'll have to do it again and again!

(For an excellent discussion of playground learning, see Steve Almond's op ed here. And for an important analysis of the death panel madness, see a discussion by Representative Earl Blumenauer here.)

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