The imagery was something out of science fiction, or perhaps a horror movie – Sarah Palin and her infant son standing in front of a hooded tribunal that was charged with the decisions of who should live and who should die.  We heard of Death Panels, and an icy shiver went down our national spine and the Republicans, who have always been home to inept novelists and song writers but the most proficient slogan writers, gained control of the House of Representatives.  

Typically, the mention of Death Panels stopped with the utterance of the words, with no discussion of what was actually involved.  In the context of the Affordable Healthcare Act the claim was pretty much a lie – there were no panels making life or deathj decisions, at least no panels empowered by the Act itself.  The Republicans were misrepresenting a program of end of life counseling, and even that was simply a provision for paying physicians to perform a valuable service that many were doing anyway without compensation.  Patients should be prepared for the consequences of terminal illness, which may include a Living Will and a Health Care Proxy.  These are simply advance notices of when the patient would prefer to be left in peace, and who should make treatment decisions if the patient is no longer able to communicate.  These are things that should be discussed in advance of need, but because many physicians are rushed, it doesn’t always get done.  The Affordable Healthcare Act simply made this consultation billable, in the hope that more MDs would find the time if they were being paid.  IOt was a good idea, actually a Republican idea, that was twisted beyond recognition.

Of course real Death Panels already existed, and do exist in both private and public health coverage, and they can be both good and bad.  The private insurance plans favored by Republicans already contain a lifetime cap on expenses, so that the decision ofho lives and who dies is determined by the size of the bill.  Your policy might set a maximum expense of a few hundred thousand dollars, and after the insurer has paid out that much, you’re on your own.  Public plans are often no better.  The states, faced with declining tax revenues, have made it harder to get Medicaid coverage, even though the people tossed off the Medicaid rolls can’[t afford private coverage.  In Arizona, the decision to discontinue coverage for some types of solid organ transplants has already caused preventable deaths.  Life and death decisions based solely on cumulative costs may fairly be questioned.  We ask questions about the value of human life, and resolve them at tragically low prices.  Since the decision is financial, and the insurer, whether a profit making company or a state is concerned solely with cost, they’re saying that the child of a hedge fund manager, who can write a check for any additional treatment, is more worthy than the child of a poet or a Social Worker.  Sarah Palin can stop worrying about standing in front of the panel now – her salary from Fox News should be enough to cover any expenses.

And yet, we do need Death Panels.  Medical costs are high, and while we enshrine decisions made by physicians, MDs often make bad or wasteful choices.  Clinical studies routinely contradict each other, and there have been instances of outright fraud.  It isn’t always obvious what the best treatment for a given condition is.  A few years ago there was a fraudulent claim that bone marrow transplants could cure some types of breast cancer.  When the insurers, who were right for once, refused to pay for the treatment, television news picked up the story, and the insurers, faced with the bad publicity, paid for wasteful treatment.

The answer is a series of completely objective reviews of the available information – Evidence Based Medicine.  Perform controlled studies, and provide treatment based on what has been shown to work and refuse to pay for what doesn’t.  If two treatment are equal, only pay for the less costly one.  Many hospitals and specialty associations already have treatment guidelines and protocols for various diseases in order to optimize the quality of care, and these protocols should be reviewed and the best ones adopted on a national level.  That would assure that every patient gets the best possible care at the best possible price.