The revelation in The New York Times that Medicare chief Donald Berwick had done an end-run and revived Section 1233 of the health care reform bill passed last year—otherwise known as the “death panels” provision—restarted a debate that had gone cold (even though that decision has now been reversed on procedural grounds). Here at The Gospel Coalition, Rob Moll confessed that he is “dumbfounded as to why Christians aren’t vocally supportive” of the rules to pay Medicare doctors for end-of-life counseling.
Moll’s examination has two broader points. First, he argues that as Christians we need to die well, which involves deliberation and careful planning. He sets out to recover this tradition, known as the ars moriendi, in his excellent and important book The Art of Dying—and he can count me as an ally in his efforts. Jesus’ triumph over death means Christians can approach it without the fear that so often undergirds efforts to extend life as long as possible, but also (I would argue) without the peculiar theatricality of John Donne. We should treat death with the sort of contemplative, cheerful deliberation that might mark someone at the beginning of a long voyage, for the journey into the far country is the beginning, not the end.
Yet Moll also suggests that this tradition should prompt Christians to support the Medicare provisions paying doctors to provide end-of-life counseling. And what Moll has joined together, we should definitely separate. While end-of-life consultation is clearly a good idea, Moll’s hasty dismissal of the “scare of big government” ignores the troubling trajectory that the (since reversed) decision would have inaugurated. As Avik Roy wrote last year:
What conservatives are objecting to is the involvement of the state in end-of-life counseling. It comes down to this: if the government is funding health care, and simultaneously funding end-of-life counseling, the government has a conflict of interest. The government has a financial incentive to encourage people to “pull the plug on granny,” regardless of whether or not that is consistent with granny’s, or her family’s, wishes. It is, at bottom, the same reason we insist on a free, independent press (and free speech in general): when the government controls the media, it has a conflict of interest; i.e., an incentive to promote journalism that is favorable to the government.
This conflict of interest is, it seems to me, a significant problem that should make Christians wary of endorsing government-funded end-of-life care. Political decisions like this never happen in isolation—they shape future problems and possibilities. Government-subsidized end-of-life planning for the sake of the government’s financial burden may appear benign—but so will the next step, and the next step. The technocratic state in the 21st century tends toward expansion, but as Christians within a democratic republic we have every reason to use what freedom and authority we have as citizens to keep the state small and the church large.
If I might close with a slightly broader point about Christian discourse on this issue, as Christians our political imagination has been stunted by our adherence to contemporary discourse. With respect to health care, the question within the last year has always been what the government should—or should not—do. If end-of-life planning for Medicare patients is a good that would ease our government’s financial burden and improve the welfare of its people, then as Christians we should spend less time being preoccupied with whether the government should pay for it and instead get down to the business of providing it.