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The Medicare “mandatory counseling” controversy in the Obamacare debate laid bare a realistic fear that compensated counseling under Medicare could easily become subtle (or not so subtle) persuasion to refuse treatment—particularly since the primary point of the clause is to cut costs.

Here is an example of why I believe that the fear is realistic. The Center for Practical Bioethics has published a “Caring Conversations” workbook, in which intimate issues and details of life, death, and end of life options are raised.  Nothing wrong with that, in and of itself, of course.  It all depends on how it is done.

In this regard, it is worth nothing that workbook contains an advance medical directive that has a default position of refusing life-sustaining treatment and participating in medical experimentation when the person will not be restored to health. These are the boilerplate instructions in the “Healthcare Treatment Directive”:


  • I always expect to be given care and treatment for pain or discomfort even if such care may affect how I sleep, eat, or breathe.

  • I would consent to, and want my agent to consider my participation in federally regulated research related to my disorder or condition.

  • I want my doctor to try treatment/interventions on a time -limited basis when the goal is to restore my health or help me experience a life in a way consistent with my values and wishes. I want such treatments/interventions withdrawn when they cannot achieve this goal or become too burdensome for me.

  • I want my dying to be as natural as possible. Therefore, I direct that no treatment (including food or water by tube) be given just to keep my body functioning when I have: a condition that will cause me to die soon, or a condition (including brain damage or brain disease) that I have no reasonable hope of achieving a quality of life that is acceptable to me...


  • (Among the “quality of life” examples that are suggested to be listed by the document signer are, able to “take care of myself, able to  “feed myself,” and able to “be responsive to my environment.”

    The lexicon of the document is far from neutral and presumes that people will not want their lives sustained if they are in a dependent state. If one disagrees with these default positions, the signer must take action:
    If you do not agree with one or the other of the above statements, draw a line through the statement and put your initials at the end of the line.

    In the wrong hands, end of life counseling could easily be subtly or overtly outcome directed, as studies have shown often happens with genetic counseling of pregnant women testing positive for a Down fetus. Thus, there is much about which to be concerned when Medicare pays practioners to engage in counseling about end of life, and indeed, authorizes part of the counseling to consist of referrals to outside organizations that might have ideological agendas (such as Compassion and Choices). That is why, if the counseling provision remains in the bill, I believe protections against such abuse should be added, as I suggested in this post.

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