Among all of the discussions taking place regarding Medicare financing these days, my mind has been wandering back to 2009, when there was an escalating and embarrassing incident regarding the idea of Death Panels.

It turns out that Death Panels were in the news again earlier this year with author Wendell Potter of The Huffington Post pointing out that insurance companies do, in fact, already make decisions about who can receive certain advanced medical interventions.

Remember that the original issue in 2009 had to do with a provision from last year’s health care reform bill that would have allowed Medicare to pay doctors to counsel patients regarding end-of-life medical decisions. Some got anxious and/or tried to use this provision for political gain, and well, you know the rest.

Like a lot of things that happen in human group behavior, an important issue that could have led to productive discussion got lost in a torrent of political drama, anxiety and anger.  A critical conversation about what we all can do to take care of ourselves when we are really ill has yet to take place.

In this country, patients get to make a lot of decisions regarding care that can extend life.  Interestingly, in the United Kingdom, there is a long tradition of limiting dialysis for the elderly, a treatment that extends life for patients with end stage renal disease. Though this may have changed, check out two links (here and here), with the first link providing some history and current research on the issue in the United Kingdom and the second providing a fascinating discussion about dialysis and the risks and benefits from a facility in England.  Contrast the latter link with this one from the U.S. based, National Kidney Foundation; the tone is much different.

In case you don’t want to read all of that, let me tell you my take. In the United States, we allow people all kinds of choices regarding care when seriously ill. At some point, the politicians will have to confront the fiscal ramifications of end-of-life care. At that point, there might be some painful discussions about what we want the government to pay for. And we will be reminded, once again, that medical care is often based on class and financial resources. This is not new information, as the Huffington Post article suggests.

Although class differences in medical care are upsetting, I am equally interested in all of us being able to think about the culture of medicine in the United States and how medical advances have allowed us to have the fantasy that we can all live a long life without suffering. This matters to me because my patients have taught me that there is often no free ride when it comes to modern medicine and advanced lifesaving technology.

Medical technology colludes with our inherent and understandable difficulties in thinking about vulnerability and death. Who wouldn’t want to think that the next great scientific discovery can keep us alive forever?  However, advanced lifesaving procedures have risks as well as limitations in terms of  quality of life. Ask anyone on dialysis. But it is our choice to sign up for all kinds of treatments that may extend life. Since we get to have options, we need to think about what we want.

The real problem with the Death Panel discussions is that fear and anxiety take over and we can’t consider what we would really want for our loved ones or ourselves. Think about what you want. Tell those you love. Complete advanced directives. This means not just thinking about dialysis, but if you want to be resuscitated if your heart stops or if you would you want drugs or antibiotics to keep you alive in an intensive care unit. Advance directives allow you to take control. You may not need them anytime soon, but if and when you do, you will be happy that you overcame your fear to think about how you want to live the end of your life.