Category Archives: death / end of life care and choices

The Myth of the Greedy Geezer

The following appeared today as an opinion piece on Al Jazeera English.

Old people are becoming everyone’s favourite scapegoat for America’s economic woes. Among the growing ranks of self-styled deficit hawks, Social Security and
Medicare are depicted as an intolerable burden to the nation’s already crippled
economy, which can only be saved through massive cuts to these so-called old-age entitlement programs. To advance this agenda, proponents of entitlement cuts have attacked not only the programs themselves, but the people who benefit from them – the selfish old folks like myself, who insist upon bankrupting the
country for the sake of their own costly health care and retirement income.

We in the over-65 set have become the present-day equivalent of Reagan’s notorious “welfare queens,” supposedly living high on the hog at the expense of the taxpayer. According to what I call the Myth of the Greedy Geezer, we lucky
oldsters spend our time lolling about in lush retirement villas, racing our golf
carts to under-priced early-bird dinner specials and toasting our good fortune
with cans of Ensure – all at the expense of struggling young people, who will
never enjoy such pleasures since the entitlement “Ponzi scheme” will collapse
long before they are old.

The fervour for entitlement-cutting remains strongest among conservatives, but these days, even President Obama is taking part, promoting the recommendations of his National Commission on Fiscal Responsibility and Reform, commonly known as the Deficit Commission (and to its opponents as the Cat food Commission, since that’s what old people will be eating when the Commission finishes its work).

The appointed chair of the Deficit Commission, Alan Simpson, is one of the primary promulgators of the Myth of the Greedy Geezer. A former Republican senator from Wyoming who is known for his colourful turns of phrase, Simpson insists that “This country is gonna go to the bow-wows unless we deal with entitlements, Social Security and Medicare.” The majority of the people opposed to such cuts, he claims, are “These old cats 70 and 80 years old who are not
affected in one whiff. People who live in gated communities and drive their
Lexus to the Perkins restaurant to get the AARP discount. This is madness.”…

Read the rest at Al Jazeera.

Soylent Greenbacks: David Brooks Wants Some People to Die for Debt Reduction

To help solve the debt crisis, the best thing I can do is die. Maybe not right now, but certainly before I put too much strain on the public purse—and since I’m 74, that means pretty soon. If I should be lucky enough to contract a fatal disease, I can do the right thing by eschewing expensive medical care that might extend my life. If that doesn’t happen, and I enter a slow and costly decline, then in the interests of the greater good I should take the Hemingway solution.

That’s pretty much the message of David Brooks’s column in today’s New York Times. “This fiscal crisis is about many things,” he writes, “but one of them is our
inability to face death — our willingness to spend our nation into bankruptcy
to extend life for a few more sickly months.”

Here’s how Brooks comes by his position: To begin with, he says: “The fiscal crisis is driven largely by health care costs.” Never mind two futile wars and ten years of tax relief for millionaires—it’s primarily health care that’s driving us into national penury.

Furthermore, Brooks argues, the reason for these soaring health care costs is that very old and very sick people insist on clinging on to their miserable lives, when they ought to be civic-minded enough to kick off. It’s not the insurance companies, which reap huge profits by serving as useless, greed-driven middlemen. It’s not the drug companies, which are making out like bandits with virtually no government regulation. It’s not the whole corrupt, overpriced system of medicine-for-profit, which delivers the 37th best health care in the world, according to the WHO, at more than twice the cost of the best system (France). No. It’s all about us greedy geezers. We’re the ones who are placing an untenable burden on the younger, heartier citizenry, with our selfish desire to live a little longer.

Brooks cites the usual figures: “A large share of our health care spending is devoted to ill patients in the last phases of life,” he writes, and Alzheimer’s patients will soon cost us hundreds of billions. He continues: “Obviously, we are never going to cut off Alzheimer’s patients and leave them out on a hillside.” (Thanks, Dave.) “We are never coercively going to give up on the old and ailing.” Nonetheless, Brooks hopes than many “old and ailing” people will make the choice made by Dudley Clendinen, a man suffering from A.L.S., who wrote a moving essay in the Times about his decision to end his life before the disease takes its full course and renders him “a conscious but motionless, mute, withered, incontinent mummy of my former self.”

I have great respect for Clendinen’s decision. As I’ve written before in Mother Jones, I am a big supporter of what these days is called “choice in dying” or “death with dignity”—each person’s right to decide when and where and in what
circumstances they will die. But I don’t want anyone else making those decisions for me, or telling me when the time is right—not an insurance company or a Medicare bureaucrat, not Barack Obama or John Boehner, and certainly not
David Brooks. I have every intention of being my own one-man death panel. But I won’t be persuaded to die a moment sooner than I want to just because it might
save some money–money that could easily be saved by far more equitable and less draconian means.

Brooks writes that “it is hard to see us reducing health care inflation seriously unless people and their families are willing to do what Clendinen is doing —confront death and their obligations to the living.” But why is it “hard to see us reducing health care inflation” any other way? Because conservatives like Brooks don’t believe in challenging the profit-driven health care system, and the people who pass these days for liberals lack the moxie to stand up to them.

Based on models from countries like France and Canada, we could bring about whopping savings in health care expenditures through a single payer system without rationing or compromising the quality of care. Short of this, we could opt for much more regulation and still save more money than we could by pulling the plug on every geezer in the land.

If I have any “obligation to the living,” it’s to leave them with a better health care system than we have now—a health care system that values all human life above profits. But I know that’s not likely to happen before my death—which, if I listen to Brooks, could be right around the corner.

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How to Become Your Own One-Member Death Panel

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Meet the Real Death Panels: The Truth About Age-Based Health Care Rationing

The latest issue of Mother Jones includes an article by me about the controversy over age-based health care rationing, which got transformed by the right into government “death panels.” Unfortunately, liberals have fallen into a different trap, because they refuse to take on the real enemies of affordable health care for all: the insurance companies, drug manufacturers, and other profiteers of our private health care system.

As a result, old people are being asked if we would be willing to give up some expensive, life-sustaining treatment so that our grandchildren can have health care. This is a bogus question, and a bogus “choice.” The real question, as I say in the article, is whether we should give up the treatment “so some WellPoint executive can take another expensive vacation, so Pfizer can book $3 billion in annual profits instead of $2 billion, or so private hospitals can make another campaign contribution to some gutless politician.”

It’s a long article, and I’m including just the opening here, with a link at the end to continue reading at the Mother Jones web site. Or you can read the whole thing at MotherJones.com by clicking here. And if you’re one of those geezers who still likes reading print and turning pages, the July/August issue is on newsstands now.

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From Mother Jones, July/August 2010

There’s a certain age at which you cease to regard your own death as a distant hypothetical and start to view it as a coming event. For me, it was 67—the age at which my father died. For many Americans, I suspect it’s 70—the age that puts you within striking distance of our average national life expectancy of 78.1 years. Even if you still feel pretty spry, you suddenly find that your roster of doctor’s appointments has expanded, along with your collection of daily medications. You grow accustomed to hearing that yet another person you once knew has dropped off the twig. And you feel more and more like a walking ghost yourself, invisible to the younger people who push past you on the subway escalator. Like it or not, death becomes something you think about, often on a daily basis.

Actually, you don’t think about death, per se, as much as you do about dying—about when and where and especially how you’re going to die. Will you have to deal with a long illness? With pain, immobility, or dementia? Will you be able to get the care you need, and will you have enough money to pay for it? Most of all, will you lose control over what life you have left, as well as over the circumstances of your death?

These are precisely the preoccupations that the right so cynically exploited in the debate over health care reform, with that ominous talk of Washington bean counters deciding who lives and dies. It was all nonsense, of course—the worst kind of political scare tactic. But at the same time, supporters of health care reform seemed to me too quick to dismiss old people’s fears as just so much paranoid foolishness. There are reasons why the death-panel myth found fertile ground—and those reasons go beyond the gullibility of half-senile old farts.

While politicians of all stripes shun the idea of health care rationing as the political third rail that it is, most of them accept a premise that leads, one way or another, to that end. Here’s what I mean: Nearly every other industrialized country recognizes health care as a human right, whose costs and benefits are shared among all citizens. But in the United States, the leaders of both political parties along with most of the “experts” persist in treating health care as a commodity that is purchased, in one way or another, by those who can afford it. Conservatives embrace this notion as the perfect expression of the all-powerful market; though they make a great show of recoiling from the term, in practice they are endorsing rationing on the basis of wealth. Liberals, including supporters of President Obama’s health care reform, advocate subsidies, regulation, and other modest measures to give the less fortunate a little more buying power. But as long as health care is viewed as a product to be bought and sold, even the most well-intentioned reformers will someday soon have to come to grips with health care rationing, if not by wealth then by some other criteria.

In a country that already spends more than 16 percent of each GDP dollar on health care (PDF), it’s easy to see why so many people believe there’s simply not enough of it to go around. But keep in mind that the rest of the industrialized world manages to spend between 20 and 90 percent less per capita and still rank higher than the US in overall health care performance. In 2004, a team of researchers including Princeton’s Uwe Reinhardt, one of the nation’s best known experts on health economics, found that while the US spends 134 percent more than the median of the world’s most developed nations, we get less for our money—fewer physician visits and hospital days per capita, for example—than our counterparts in countries like Germany, Canada, and Australia. (We do, however, have more MRI machines and more cesarean sections.)

Where does the money go instead? By some estimates, administration and insurance profits alone eat up at least 30 percent of our total health care bill (and most of that is in the private sector—Medicare’s overhead is around 2 percent). In other words, we don’t have too little to go around—we overpay for what we get, and we don’t allocate our spending where it does us the most good. “In most [medical] resources we have a surplus,” says Dr. David Himmelstein, cofounder of Physicians for a National Health Program. “People get large amounts of care that don’t do them any good and might cause them harm [while] others don’t get the necessary amount.”

Looking at the numbers, it’s pretty safe to say that with an efficient health care system, we could spend a little less than we do now and provide all Americans with the most spectacular care the world has ever known. But in the absence of any serious challenge to the health-care-as-commodity system, we are doomed to a battlefield scenario where Americans must fight to secure their share of a “scarce” resource in a life-and-death struggle that pits the rich against the poor, the insured against the uninsured—and increasingly, the old against the young.

For years, any push to improve the nation’s finances—balance the budget, pay for the bailout, or help stimulate the economy—has been accompanied by rumblings about the greedy geezers who resist entitlement “reforms” (read: cuts) with their unconscionable demands for basic health care and a hedge against destitution. So, too, today: Already, President Obama’s newly convened deficit commission looks to be blaming the nation’s fiscal woes not on tax cuts, wars, or bank bailouts, but on the burden of Social Security and Medicare. (The commission’s co-chair, former Republican senator Alan Simpson, has declared, “This country is gonna go to the bow-wows unless we deal with entitlements.”)

Old people’s anxiety in the face of such hostile attitudes has provided fertile ground for Republican disinformation and fearmongering. But so has the vacuum left by Democratic reformers. Too often, in their zeal to prove themselves tough on “waste,” they’ve allowed connections to be drawn between two things that, to my mind, should never be spoken of in the same breath: death and cost.

Click here to the rest at MotherJones.com.

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Robert N. Butler, 1927 – 2010: Visionary Psychiatrist and Champion of Elders

If you’re like most people, you may find that at about age 70, life begins to close in on you. You’re supposed to be retired by then with an adequate pension and/or a 401K–only you don’t have a pension, your 401K went down in the big recession, and to tell the truth, you  don’t want to retire anyway. You want to work, but there the job market is tight, age discrimination is rampant, and thanks to the Supreme Court, there’s virtually no way to fight it. You don’t have the money, or maybe the nerve, to strike out on your own, unless you call flipping burgers striking out on your own.

The advertisements for retirement investments and hair color keep telling you that 70 is the new 40, that you’re only as young as you feel. AARP’s magazines say the same thing–but the world they depict seems unreal and, to tell the truth, somewhat revolting. Because you don’t feel young–you feel old. And in today’s America, that’s hardly a happy feeling. You feel shoved aside, irrelevant, a relic waiting to hurry up and die. You realize you can’t remember things as well as you once did, have more and more of the proverbial “senior moments,’’ and start wondering how long it will be until you sink into dementia, maybe Alzheimer’s, at which point your life will really be over.

There’s precious little in our society that acts as an antidote to any of these thoughts. But for the last half-century, there has been one man: Dr. Robert N. Butler. A psychiatrist, activist, and visionary, Butler died on Sunday at the age of 83, and is being eulogized in the obituaries as the founder of modern gerontology, the man who coined the word “ageism.’’ Butler founded the National Institute of Aging at the NIH, and helped found the American Association for geriatric Psychiatry and the Alzheimer’s Disease Association; he also launched the first medical department devoted to geriatrics at Mount Sinai Hospital in New York.  He wrote influential books, advised politicians, counseled the World Health Organization, and he founded and ran the International Longevity Center in New York. 

Through all of this work, Butler inspired thousands, perhaps millions of people to think differently about growing old, and to treat aging and the aged differently. For old people, that transformation is even more profound, because it means thinking differently about yourself. I am one of those people whose thinking was changed, in some significant way, by Robert Butler and his work.

I was lucky enough to meet Butler a few weeks ago at a week-long series of seminars his International Longevity Center put on annually for a small group of journalists, called the Age Boom Academy. That one week produced some of the most astute briefings on every aspect of health policy and the challenges ahead that one could hope to take in–from research on Alzheimers, to the political assault on Medicare and Social Security currently underway in the administration and Congress, to the day-to-day work on the ground across the City of New York. What I had feared might consist of a bunch of self-serving medical and psych professionals was instead an immersion into the real world of the politics and economics  of medicine, tempered always by Butler’s vision. Despite his concerns for the scandalous lack of funding for research on Alzheimer’s and the aging brain, as well as the growing shortage of doctors trained in gerontology or even general practitioners, he approached his work with unyielding  optimism. I had no idea he was battling a life-threatening illness.

On Monday I was on a train on my way to New York, where I had an appointment this week to sit down with him to further discuss his ideas, when I received an email and learned that he was gone. Although he had acute leukemia, Butler reportedly had been working until three days before his death. At 83, he had seemed like he was in the prime of life–not because he acted like he was 40, but because he had succeeded in redefining 83 as a different kind of prime, for himself and for others.

 In a speech not long ago at the American Academy of aging, Butler quoted Proust from In Search of Lost Time, “If we mean to try to understand this self, it is only in our innermost depths, by endeavoring to reconstruct it there, that the quest can be achieved.” He saw that quest as part of the journey into old age, and gave it significance and dignity. He said in his speech:

In the 1950s, psychology, psychiatry and gerontology textbooks devalued reminiscence and memories. Reminiscing was condescendingly called “living in the past,” and phrases like “wandering of mind,” “boring” and “garrulous” were used to describe elders who looked back. Actually, reminiscence was thought to be an early diagnostic sign of senile psychosis–what is known today as Alzheimer’s disease. However, I was seeing a different picture in vibrant, healthy individuals who were engaging in a fascinating inward journey.

More than fifty years later, Butler’s ideas are widely respected by psychologists and social workers, many physicians and research scientists, and even some policymakers. As far as they have caught on at all with the general public, it is thanks to his tireless work. He like to point out that demographics was on his side: More and more, elders will outnumber youth, and the voice of the geezers will grow stronger and stronger.

I was pleased to see, this morning, an eloquently written obituary in the New York Times by Douglas Martin. Fittingly, it included some remembrances of Butler’s past. As Martin notes, “Dr. Butler’s mission emerged from his childhood.” His parents split up less than a year after he was born, and he went to live with his grandparents on a New Jersey chicken farm. 

He came to revere his grandfather, with whom he cared for sick chickens in the “hospital” at one end of the chicken house. He loved the old man’s stories. But the grandfather disappeared when Robert was 7, and nobody would tell him why. He finally learned that he had died.

Robert found solace in his friendship with a physician he identified only as Dr. Rose. Dr. Rose had helped him through scarlet fever and took him on his rounds by horse and carriage. The boy decided he could have helped his grandfather survive had he been a doctor. He also concluded that he would have preferred that people had been honest with him about death.

From his grandmother, he learned about the strength and endurance of the elderly, he wrote. After losing the farm in the Depression, she and her grandson lived on government-surplus foods and lived in a cheap hotel. Robert sold newspapers. Then the hotel burned down, with all their possessions.

“What I remember even more than the hardships of those years was my grandmother’s triumphant spirit and determination,” he wrote. “Experiencing at first hand an older person’s struggle to survive, I was myself helped to survive as well.”

Butler spent his life passing on that painful but profound gift to thousands of other people. I feel fortunate to have been one of them.

Robert Byrd, 1917 – 2010: Will the Circle Be Unbroken

Reader Response: How About Going After the Real “Fat Cats” Before Attacking Elders?

This morning I received a comment from Elizabeth Rogers in response to my posts about Senator Alan Simpson, the octagenarian elder-basher who co-chairs Obama’s Deficit Commission. Simpson has been making news with his comments about “fat cat” geezers who cling to their government handouts while younger generations suffer. I want to share it with everyone because Ms. Rogers gets to the heart of the whole entitlements question in a simple and direct way.

There’s a good chance this commission will end up proposing cuts in Medicare, along with steps towards privatizing  parts of Social Security. These have been heartbeat issues for conservatives running all the way back to the creation of Social Security in the New Deal, and has only grown since Congress created Medicare in the 1960s, after some arm twisting by LBJ. Doing away with these entitlement programs has been a cherished conservative idea, right alongside ridding the nation of  ties to the UN, ending the income tax, and abolishing the Department of Education, to name but a few.

In addition to destroying the social safety net, the war on entitlements serves to distract attention from the real causes of the inflated deficit. Elizabeth Rogers suggests some other sources of deficit-reduction that our politicians might want to consider before they start dipping into our Social Security checks. 

Retired Senator Simpson must travel in a very different crowd of older Americans than my husband and I do! We live in a compact 2 BR condo in the Pacific Northwest. Yes, there’s a gate, but our complex is very definitely occupied by middle class workers and retirees like us. At 73 I’m still working part time and thank my lucky stars that I have a job. My husband, now 80, worked until four years ago (he started working at age 14).

Lexuses? I don’t think so. Our small SUVs are over 10 years old and we hope they last as long as we do. Fat cats? Not exactly, although we do have an overweight feline in our family.

Seriously, although we have some additional resources, Social Security is a significant source of income for us, as I suspect it is for most recipients. That said, we get that the nation’s huge budget deficit is a serious problem.

We’d be willing to pay more taxes if the amount is fair and reasonable, but FIRST, how about: (1) pursuing the offshore bank accounts of billionaire tax evaders, (2) allowing the Bush tax cuts for the wealthiest 2% of Americans to expire, (3) ending the UNfunded wars in Iraq and Afghanistan that are now costing in the trillions; (4) changing our culture’s views on end-of-life care so that Medicare doesn’t continue to spend huge sums on “heroic” measures to “save” those in their last 6 months of life. I have multiple advance directives in place because I have no desire to fall into the hands of the medical-pharmaceutical complex at the end of my life, but even so, I can’t be certain that I won’t. We need to get real about this issue!

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