Living Wills

In my latest column for The Week, I try to encourage a mature discussion of the real issues lurking beneath the mythical death panel. One of these is the issue of Medicare-funded end-of-life counseling. I’m in favor of it. Why? First, because I’m in favor of end-of-life counseling and living wills generally. I think it’s important to plan for death, and to make explicit to yourself and your loved ones what you do and do not want for yourself at the end of life while you’re still in shape to do that. Second, because it helps individuals who depend on Medicare to retain control over life and death decisions — that is, it helps keep government from taking control of these decisions. Because I expect that in the absence of something like a living will, the default is to consume more end-of-life care than the patient would choose in a context of reflection and adequate information, I expect that the net cost of Medicare-funded counseling sessions would be negative. Because the financial and professional motives of doctors push in the direction of keeping patients alive as long as possible, I don’t think there’s reason to worry that during counseling sessions doctors will try to talk patients into choosing to pull the plug early. Between an increase in patient control over life and death decisions and potential savings to taxpayers, I find it hard to see what the problem is.

That said, there are interesting objections to living wills, whether or not they involved a Medicare-funded counseling session. A Facebook commenter said this:

Living wills are a mistake. People tend to underestimate how they will adapt to lower quality of life due to age and illness, and how they will cling to each last sweet second of life.

He’s right that people tend underestimate the extent of adaptation to pain and reduced function. That’s the sort of thing a doctor might bring up in a counseling session. But it’s not clear how relevant it is. Living wills, as I understand them, primarily involve questions of what to do when a patient has lost consciousness, or is a state of heavily drugged consciousness, and is being kept alive by a respirator or other apparatus that is substituting for an organ that no longer functions. The big questions are about whether to withdraw active life-extending interventions or not, and under what conditions. If you’re functioning at a level sufficient to revise your living will, you can do that. It’s not like you’re locked into your first draft. And it’s not as if it is possible to set out in advance the conditions under which one would like to be legally euthanized. So I’m not sure I see the mistake.