Health-care overhaul debate puts VA in the spotlight

WASHINGTON — While Republicans are calling a Department of Veterans Affairs (VA) health-planning booklet a "death book" that encourages veterans to kill themselves or forgo care, ethicists and legal and medical experts say it's a reasonable attempt to help veterans plan for the end of their lives.

Jim Towey, former director of President George W. Bush's White House office of faith-based initiatives, wrote in The Wall Street Journal last month that the VA's "Your Life, Your Choices" booklet encourages veterans to "hurry up and die." Republican National Committee Chairman Michael Steele said the VA effort aimed at veterans was "encouraging them to commit suicide."

"There is nothing in this pamphlet or in any of the VA effort in this area that is aimed at asking that veterans be allowed to die to save money," said the University of Pennsylvania's Arthur Caplan, one of the nation's leading bioethicists. "To say otherwise is just an exercise in ludicrous, inflammatory rhetoric."

VA chaplains said "Your Life" is helpful.

"I read it thoroughly again last night," said the Rev. Anthony Beazley, chief chaplain of the VA medical center in West Palm Beach, Fla., and a Southern Baptist minister. "I was very meticulous. I would not say that it encourages suicide."

The booklet "did not sound negative to me," said Rabbi Lowell Kronick of the VA's chaplain service.

"Your Life" was developed in 1997 for use in Seattle-area VA facilities, and later was made available on the VA's Web site. The booklet is designed to help veterans plan for the care they'd like if they become too sick or injured to communicate. It was being revised when it became a lightning rod in the health-care debate.

"At the time, it was the first advance-care planning workbook — and it was a groundbreaking step forward," said Charlie Sabatino, director of the American Bar Association's Commission on Law and Aging.

The booklet contains exercises that ask veterans to ponder whether, for example, life would be worth living in a wheelchair or in a nursing home. It offers a range of options that start with life being "difficult but acceptable" and ends with "not worth living."

"Where is the positive option?" Towey asked. "When you frame the discussion in this fashion, you corner people with bad choices."

Critic a competitor

VA supporters noted that Towey was trying to sell to the VA a competing book he helped write.

Matthew Wynia, director of the Institute for Ethics at the American Medical Association, said the statements are meant to persuade veterans to think about their place in life — and to realize that family members often consider it an honor, not a burden, to care for them.

VA critics, however, say the book advocates physician-assisted suicide because a VA physician and ethics official helped write it.

Robert Pearlman, the book's lead author, joined three dozen other physicians and scholars in a 1996 brief arguing that the Supreme Court should recognize the right to physician-assisted suicide. Yet, "I am not an advocate for physician-assisted suicide," Pearlman said.

"I have studied the subject and done research to try to understand what motivates people to consider it," he said. "I stay away from making any kinds of statements advocating for or against physician-assisted suicide. It's impermissible in the VA, and I support that position."

Nothing about suicide

Ellen Fox, the VA's chief ethics-in-health-care officer, oversees the "Your Life" project. She said she's never heard Pearlman "say anything to advocate for assisted suicide."

"And there is no way that any language advocating for assisted suicide would find its way into a nationally distributed book for veterans," she added.

The book was used through the Bush years and was being expanded into an online, interactive tool in 2007. That's when Towey learned about it and alerted White House officials.

"They were shocked by it," he said. "This wasn't a mainstream document." It "pushes people toward denial of care" and is "fatally flawed," he said.

Experts contacted by McClatchy said the booklet — while in need of updated language — is mainstream. Among them was Sabatino, who served as a reviewer for the VA booklet and for the competing booklet that Towey developed through a nonprofit association.

Sabatino said both booklets are valuable. Some veterans might prefer "Five Wishes," while others opt for "Your Life," he said.

According to the VA, the printed booklet was pulled in 2007, and the project to update it to an online resource was enhanced to include more outside reviewers. That was partly a response to Towey's concerns. Fox of the VA ethics division, said the VA has adopted some of Towey's suggestions, such as including a positive option for some of the workbook exercises.

By summer 2008, Fox said, the VA had greenlighted the project again, and in November was reviewing the project with disabled veterans, rehabilitation experts and VA chaplains.

Gerald Cross, a top VA health official in the Bush and Obama administrations, said this week that the VA continued to work on the "Your Life" project throughout 2007 and 2008. He said he had a "productive dialogue" with Towey and incorporated his concerns into the review, but the project was never abandoned during the Bush administration.

The original 1997 print version of the booklet was put back on the VA Web site this year as a result of new Obama administration policies that call for projects funded by federal grants — as "Your Life" was — to remain in the public domain. It starts with a disclaimer that the booklet is being revised.