Paul Greenberg

They were supposed to be gone. They were supposed never to have existed. Remember the foofaraw over the part of ObamaCare that was going to have Medicare finance, uh, consultations about end-of-life treatment? They soon were dubbed death panels. The name stuck, and every time advocates of the idea derided it -- untrue! fictional! absurd! wholly imaginary! -- they only gave it more currency.

Which term do you prefer, end-of-life counseling or death panels? It makes quite a difference when discussing the issue. Because when it comes to a political conflict, vocabulary remains the Little Round Top of every engagement, the strategic height that determines the outcome of the battle. And any mention of death tends to, well, kill off enthusiasm for a proposal. Whether we're talking death panels or the death tax. (Its advocates much prefer to speak of the estate tax even if it's the same thing.) Why be blunt? Especially if it's going to cost your side of the debate votes.

Awkward facts must be sidestepped, euphemisms invented. The way abortion has become Choice. Names count; what a proposal is called may determine whether it ever gets into law. And so the death panels/end-of-life consultations had to be dropped from the final version of ObamaCare, which goes by an official euphemism of its own: the Patient Protection and Affordable Care Act (PPACA) of 2009. And its Section 1233 raised concerns that the patient might be protected to death.

At the least the controversial section was sure to produce a whole new para-medical sub-specialty. For where there's a Medicare payment, payees are bound to spring up. (In economicspeak, this is called incentivizing.) What do you think the practitioners of this new art/science would be called? Nothing very precise, one can be sure. Preferably something long and latinate, a term that softens the hard edges of its meaning, something high-toned, even classical. How about thanatopsists?

You can almost see the new occupation being plugged into every top-flight medical center's table of organization. ("Thanatopsy? It's in Annex B on Level II. You'll have to take the elevator to the main floor, cross the parking lot, go through the underground garage, enter the red door and get off on Blue Level. It's simple. Just follow the signs. Be sure to bring your parking ticket, photographic ID, proof of insurance, medical records, list of pharmaceuticals, and....")

Thanatopsy. What better way for fledgling bioethicists to begin a long career of not calling things by their right names? Why alarm people by facing the facts of life, or rather death? Better to speak of end-of-life care or advance planning or, well, anything but death. Euphemism is the health of bioethics, which is never to be confused with ethics, or at least the kind explored by Aristotle or Bonhoeffer.

It's a strange thing: The very people so eager to plan for death never use the word. In any event, Section 1233 and its provision for periodic consultations about (insert appropriate euphemism here) never made it into law. Oh, death, where is thy sting, grave thy victory?

Answer: In a brand-new Medicare regulation in effect as of this brand-new year -- January 1, 2011 A.D. Issuing a regulation is always the fallback position for an administration that can't convince Congress to follow its lead. What an inconvenience it is to have to deal with popularly elected legislators anyway; they're so fickle, so sensitive, so slow to see reason ... and so accountable to the voters at the next election. Why not just work around them? Spare them the heat. We'd be doing them a favor, right?

And so it was done. Section 1233 now has been reborn as a Medicare regulation authorizing payment for "voluntary advance planning" to discuss, uh, end-of-life issues with patients and provide them with information about preparing an "advance directive" should they develop a life-threatening illness. Or well before.

With the disappearance of the old-time family doctor (and friend) in American medicine, the kind of physician who might be counted on to know a patient's condition, convictions, temperament and particular idiosyncrasies, we can now rely on experts to conduct these consultations. What a comfort. Kind of.

Don't get me wrong. There's no reason to doubt the president when he assures us in his ever-delicate way that there's nothing in his vast new health plan that "would pull the plug on grandma." These doctors, or some specially trained intern on their staff, would just ask the old lady a few questions periodically.

But as every polemicist knows, the way a question is asked can determine the answer. To quote one of those experts -- a thanatopsist? -- at the University of Michigan, someone with heart disease might be asked: "If you have another heart attack and your heart stops beating, would you want us to try to restart it?" Or someone with emphysema could be asked, "Do you want to go on a breathing machine for the rest of your life?" Or the cancer patient would be asked, "When the time comes, do you want us to use technology to try and delay your death?" As if anyone could know when the time will come, and how the patient will feel about it then. And please note the phraseology: It's not save your life, but delay your death. Never underestimate the power of negative thinking.

Life-and-death decisions that once could be safely left to the common-sense wisdom of the doctor most familiar with the patient now can be boiled down to a standard form--and a standard, billable procedure. Welcome to this Brave New World where any mention of death is banished. Just call it end-of-life. Euphemism is the first sign that you don't want to look too closely at what is being proposed.

Like a zombie who was supposed to have disappeared at the end of the first act of this drama, Section 1233 now has been revived. Even though it's taken on the form of a regulation instead of legislation. Thanks to the convenience of modern bureaucracy, all that messy business of congressional hearings and votes and open debate can be avoided just by issuing a new rule. But don't noise it about. Its modest backers have tried to keep its resuscitation as quiet as possible.

To quote an e-mail sent out by the Hon. Earl Blumenauer, a congressman from Oregon and an enthusiastic backer of this stealth regulation, the new rule represents a "quiet victory." Or as he told supporters: "While we are very happy with the result, we won't be shouting it from the rooftops. ... The longer this goes unnoticed, the better our chances of keeping it."

The surest sign of a suspect political project is that it has to be adopted as quietly as possible. In this case, quiet as death.

So those celebrating this latest advance in society's pervasive culture of death are advised to sip their champagne without making much ado about it. No sense in alarming the rubes, who tend to have this irrational attachment to life.


Paul Greenberg

Pulitzer Prize-winning Paul Greenberg, one of the most respected and honored commentators in America, is the editorial page editor of the Arkansas Democrat-Gazette.