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2011-01-05

Return of the "Death Panel" Myth is a "Travesty," Says Dr. Atul Gawande

Guests

Dr. Atul Gawande, associate professor at Harvard School of Public Health and is a practicing surgeon at the Brigham and Women’s Hospital in Boston. He’s also a staff writer at The New Yorker magazine. He is the author of three books; the most recent is The Checklist Manifesto: How to Get Things Right.

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As Republicans take control of the House today, GOP leaders say they will immediately try to repeal President Obama’s signature healthcare law. Even before the repeal vote takes place, Republicans can lay claim to a key victory in the healthcare battle. This week the Obama administration said it would reverse a regulation that would have covered end-of-life planning for Medicare beneficiaries during their annual checkups after Republicans revived the specter of so-called "death panels." We spend the hour with one of the most influential health policy writers in the country, renowned surgeon and author Dr. Atul Gawande. [includes rush transcript]

Transcript

This is a rush transcript. Copy may not be in its final form.

SHARIF ABDEL KOUDDOUS: Republicans take control of the House today with the swearing-in of the 112th Congress. It’s their first majority in the lower chamber since 2006, and Republican leaders say they’ll immediately take aim at President Obama’s signature healthcare law. Debate on a measure to repeal the bill will begin on Friday, with a final vote expected a week from today.

Several portions of the healthcare law took effect over the weekend, including one that provides discounts to Medicare beneficiaries for the purchase of prescription drugs. In addition, co-pays on preventive care are now prohibited, and health insurers must spend a higher percentage of the cost of premiums on actual medical care.

Republicans have promised the healthcare repeal effort since their gains in November’s midterm elections. One day after the vote, House Republican leader John Boehner, who today becomes House Speaker, denounced the healthcare bill.

REP. JOHN BOEHNER: I believe that the healthcare bill that was enacted by the current Congress will kill jobs in America, ruin the best healthcare system in the world, and bankrupt our country. That means that we have to do everything we can to try to repeal this bill and replace it with commonsense reforms that will bring down the cost of health insurance.

SHARIF ABDEL KOUDDOUS: With 242 Republicans in the House, the repeal measure is expected to pass, but Democrats still hold enough of a majority in the Senate to protect the healthcare law. Republicans have countered by saying they’ll circumvent Democratic opposition to a broad repeal by targeting the healthcare law’s individual provisions.

Speaking on Fox News Sunday, Republican Congressmember Fred Upton of Michigan discussed the Republican strategy.

REP. FRED UPTON: We have 242 Republicans. There will be a significant number of Democrats, I think, that will join us. You will remember, when that vote passed in the House last March, it only passed by seven votes.

CHRIS WALLACE: But you’re not going to repeal it. I mean, if you vote in the House, it’s not going to happen in the Senate.

REP. FRED UPTON: Just wait. Just wait. It passed — if you switched four votes from last March, that bill would have gone down. So we’ll take the Democrats that voted no, we’ll take other Democrats who probably agree with Speaker Pelosi’s statement — remember when she said we want to pass this thing because then we’ll learn what’s in it? Well, now the American public does know what’s in it. Unpopularity numbers are as high as 60 percent across the country. I don’t think we’re going to be that far off from having the votes to actually override a veto. Remember President Clinton? It took him three times before he signed welfare reform. If we pass this bill with a sizable vote — and I think that we will — it’ll put enormous pressure on the Senate to do perhaps the same thing.

But then, after that, we’re going to go after this bill piece by piece. We’ll look at the 1099 issue in Dave Camp’s committee, Ways and Means, to look at the $600 1099 that has to be processed for every business-to-business action. We’ll look at the individual mandate requirement. We’ll look at all those as individual pieces. We’re going to take up early, I think, the Pitt-Stupak language — no funds shall be spent on abortion — as a separate bill early on, and we’ll look at these individual pieces to see if we can’t have the thing crumble.

SHARIF ABDEL KOUDDOUS: Even before the repeal vote takes place, Republicans can lay claim to a key victory in the healthcare battle. On Tuesday, the Obama administration said it would reverse a regulation that would have covered end-of-life planning for Medicare beneficiaries during their annual checkups. Government coverage of end-of-life care has sparked Republican accusations that Democrats are effectively imposing "death panels" that will determine who is worthy of treatment. It’s the second time the Obama administration has dropped the end-of-life coverage provision after excluding a similar regulation from the bill signed by President Obama in March.

AMY GOODMAN: As the healthcare debate continues in Washington, well, today we have our own doctor in the house. We spend the hour with one of the most influential health policy writers in the country. Dr. Atul Gawande is an associate professor at Harvard School of Public Health, a practicing surgeon at the Brigham and Women’s Hospital in Boston. He’s also a staff writer at The New Yorker magazine. Dr. Gawande is the author of three books. His most recent is The Checklist Manifesto: How to Get Things Right. It’s out today in paperback.

Welcome to Democracy Now! It’s very good to have you with us.

DR. ATUL GAWANDE: Thanks for having me.

AMY GOODMAN: Why don’t we start off with this change in the Obama administration this week that the Republicans were pushing for?

DR. ATUL GAWANDE: Well, this change, which is to remove provisions that would have allowed for doctors to have additional payments to have end-of-life discussions with their patients, is an example of the mistake that repeal represents as a whole. End-of-life discussions are not death panels. But you say it over and over again, you brand it over and over again, and you begin to define what the meaning is of a major policy that’s passed. Being able to provide funding for discussions that have been shown to have a huge difference in improving the quality of life patients have and, in a recent study published in the New England Journal, also generated longer life for patients by helping them make better decisions about when to stop therapies that have become harmful to them, like that fourth round of chemotherapy and so on, those kinds of studies indicate we need more, longer and better discussions with doctors, overall. Repeal is a major mistake. Our choices are stalemate on making any kind of progress on healthcare at a time that the costs are going to be disastrous for our country over the next decade and at a time when more and more Americans are simply without health insurance.

AMY GOODMAN: Well, let’s talk about what these end-of-life discussions are about. You wrote a very moving piece and also, I think, surprising piece called "Letting Go: What Should Medicine Do When It Can’t Save Your Life?" It appeared in The New Yorker magazine in August. You looked at a number of cases of people at the end of life, and you also looked at studies, like the Aetna study. You looked at La Crosse, Wisconsin. You looked at what happens when people start talking about the end of life.

DR. ATUL GAWANDE: Yeah, it started for me with a recognition that I was not doing a great job with my patients who had a terminal illness. And I centered the story I wrote around a 35-year-old patient of mine, Sara Monopoli, who was diagnosed with metastatic lung cancer, an incurable lung cancer, in her eighth month of pregnancy.

AMY GOODMAN: With her first child.

DR. ATUL GAWANDE: With her first baby. And I took care of her as one of a whole team of doctors, none of us quite ever being willing to sit down with her and say very clearly what she actually kind of already knew, which is that this cancer would not be cured, that — and how things would go towards the end, so she could plan for it. And so, right into the last days, she was onto her fourth round of chemotherapy into her — on to brain radiation, in and out of the hospital, suffering through the end. I’m not convinced, especially for our late stages of therapy, that we did any good. But the choice at every point along the way was, do you want to try this experimental therapy? Do you want to try this next treatment, for the lottery ticket chance that maybe you’d get a little bit more time out of it? And what we weren’t willing to discuss was the most likely thing, which is, you wouldn’t win the lottery ticket, that time would pass. And so, when she finally woke up one morning unable to breathe, that was the moment nobody was prepared for, including leading to the one thing she didn’t want, which was to die in the hospital.

SHARIF ABDEL KOUDDOUS: You write in the piece about how the approach to dying has changed over time and what you call "the art of dying." Explain what you mean by that.

DR. ATUL GAWANDE: So, we’ve had a millennium of developing the way that people die, with last rites and a kind of bedside vigil for people. You know, death used to be a brief unpredictable process. And now it is a long unpredictable process. Virtually everybody who passes away does not do so with a sudden heart attack, and that’s that. It is a months-long dealing with a terminal cancer or a congestive heart failure and so on. And we do not have the rituals for how to even talk about what that process is like. What we do know is that patients want not only their best chance of living as long as possible, but a variety of other things medicine is really bad at helping people with, like reducing their suffering; maintaining — offering the chance for them to maintain as much control over their life, as their disease progresses, as possible; being able to spend time at home and with family. And this is where the — our failure comes from.

The ability to even talk about this in the face of death panels is what troubles me. The idea that discussion, that trying new policies that might help people to make this stage of life and the way our healthcare system works for people when they have a terminal illness, make it work better — yes, there is no perfect solution off the shelf, but we start with what we know from great evidence. Only a quarter of patients have a decent discussion with their doctor who has a terminal cancer. Of those patients that have the discussion, they are less likely to die in the intensive care unit, more likely to have a better quality of life and less suffering at the end, do not have a shorter length of life, and six months later their family members are markedly less likely to be depressed. And this is what we don’t want to talk about?

AMY GOODMAN: We’re going to go to break. I was just astounded by some of the studies in your article that show that people who actually start to deal with hospice care at the end, a different way of dealing with death, actually lived longer, and also the issue of cost, because that’s what we’re seeing in Congress right now as the major issue, what this means. We’re talking with Atul Gawande. He is a surgeon at Brigham and Women’s Hospital in Boston and staff writer at The New Yorker. His book, The Checklist [Manifesto], is out in paperback, How to Get Things Right. Stay with us.

[break]

AMY GOODMAN: We’re speaking for the hour with Dr. Atul Gawande, a surgeon at the Brigham and Women’s Hospital in Boston, a staff writer at The New Yorker magazine and associate professor at Harvard Medical School. His latest book, out today in paperback, is called The Checklist Manifesto: How to Get Things Right.

SHARIF ABDEL KOUDDOUS: Well, the talk of "death panels" was revived in recent weeks after the Obama administration issued a regulation covering end-of-life planning in annual examinations. Before the White House ultimately said it would reverse the directive on Tuesday, a number of right-wing media pundits and politicians took aim, accusing the government of rationing care. This is a sampling of voices in recent weeks from the right-wing networks Fox News and Fox Business, with hosts Dana Perino, Andrew Napolitano and Tucker Carlson.

TUCKER CARLSON: Remember those infamous death panels that were supposed to have died before the passage of the Democrats’ healthcare bill? Looks like they’re alive and kicking. The Democrats took end-of-life planning, what critics called "death panels," out of the healthcare bill, but now they’ve been made part of a federal regulation — the old idea, if you can’t legislate it, enforce it.

DANA PERINO: Are the so-called "death panels" revived? After furious, hot debate months ago, the end-of-life planning that was in the healthcare bill was dropped. But could it be back?

ANDREW NAPOLITANO: Without getting too much into the weeds and the how it would actually happen, can the Congress rescind this decision by Secretary Sebelius to create these death panels?

TUCKER CARLSON: The federal bureaucrats and planners and the people who imagine they’re in control of our medicine are going to have to figure out ways to convince old people, the elderly and the sick, to forgo treatment and instead choose to shorten their lives.

SHARIF ABDEL KOUDDOUS: Those are some of the voices on Fox News and Fox Business talking about death panels, reviving the specter of so-called death panels. What’s your response to this kind of language in the media?

DR. ATUL GAWANDE: This is a travesty. This is about a healthcare problem for millions of Americans who all face, at some point in their course of their life, terminal illness. We have now an immense number of studies showing that discussions with doctors are beneficial, they are too short, and being able to have time to have real, careful discussion about what people’s goals, fears and concerns are, as they face the prospect that treatment is no longer working, is absolutely crucial. This is not about a discussion of whether you will get that $100,000 treatment versus not get that $100,000 treatment. I’m a cancer surgeon. We’re going to give that to you. I give that to patients every day. When it reaches a point we’re actually doing more harm than good, we have been unwilling to have those discussions. And the idea that you can brand an entire set of policies around trying to make forward progress on these kinds of issues — take discussion off the table, is harmful to people.

AMY GOODMAN: Now, explain exactly what was cut out — these annual checkups that would include what kind of discussion?

DR. ATUL GAWANDE: Yeah, the irony here is this is a tiny portion of what’s needed to make care better for people. At an annual —- at your annual physical, the provision would have allowed for the physician to get extra payments to spend the extra time needed to discuss with you end-of-life issues. It could be up to once a year, doesn’t have -—

AMY GOODMAN: You can be perfectly healthy.

DR. ATUL GAWANDE: You could be perfectly healthy and have a discussion about what your goals for a living will might be. Now, the truth of the matter is, for a primary care doctor sitting down with you for an annual physical, if you’re 40 years old and there’s no issues going on, this is not going to be topic A. But when you are 40 years old but have an incurable lung cancer, like my 35-year-old patient did, or you are 78 years old and have a congestive heart failure and you’re on oxygen at home and it’s a typical 20-minute visit, there are a number of barriers to why that discussion doesn’t happen. One is that paying for the extra time that these discussions take, emotions get opened up, and there’s a need for a really good professional to walk through these moments with you, and no one wants to face them. The cost barrier is one. It’s a tiny one. The big barriers that also play into it are the fact that neither the doctor nor the patient are comfortable with these discussions, and we’re not good at them. Learning how to get good at them, getting that cost barrier out of the way, and making it simply part of our professional responsibility that we can help people just — even when we don’t necessarily have great treatments for them, that’s crucial.

SHARIF ABDEL KOUDDOUS: Well, let’s look at the bigger picture for a moment. So the Republicans are taking control of the House today, as we mentioned, and they’ve said that one of the top things on their agenda is to repeal the healthcare reform bill. You wrote, after the bill was signed — you made an analogy to what happened in 1965 when Johnson signed Medicare into law. Explain what happened then and what the analogy is to now.

DR. ATUL GAWANDE: Yeah, the week that the health reform bill passed, I wrote that we should be prepared for the war to come. We remember Medicare passing in 1965 as this historic accomplishment that then went smoothly into becoming a healthcare program for everybody over 65, without any troubles along the way. But in fact, it was severely under attack from the moment it passed. Ten thousand physicians in the Ohio State Medical Association announced they would boycott any elderly patients who would come to them who had Medicare. And then you had the requirement that now that this was a federal program, that hospitals in the South would have to be integrated in order to get paid under Medicare. And so, 50 percent of the hospitals in the South were announcing they’d boycott, including George Wallace, the governor of Alabama, announcing that he would lead that boycott and repeal effort.

Johnson did a combination, over the next few months, of both confrontation and conciliation. The confrontation: he sent a thousand inspectors into the South and ensured that black patients could be admitted to the doors of white hospitals and even be in the same wards that white patients were on, which was considered impossible. He went so far as make — enforcing that blood could no longer be labeled white blood versus black blood. This was thought to be the kind of thing that would put people into the streets. It was not popular. But he pushed, because it was the right thing to do. And by the time the law actually — one year later, the cards started landing in people’s mail to get their Medicare coverage, 90 percent of the hospitals in the South had signed up. With the doctors, on the other hand, he compromised. About nine months after the bill passed, there was a series of improving amendments that represented some compromises, that, you know, not everybody was happy with. Some of them actually did improve the program. But they made sure that passage could go in.

And ultimately, we’re in that beginning phase. We are in that — you know, the battle of trying to see that nothing happens. But stalemate is a disaster here for the healthcare system. We have to have ways to move forward, and finding ways through this is going to be an immense test of presidential leadership.

AMY GOODMAN: And the argument, aside from integrating the hospitals, like of the Ohio establishment, why were they opposed to Medicare? Simply because government was spending money on healthcare for older people?

DR. ATUL GAWANDE: The rhetoric is markedly familiar. It’s government takeover. It is socialism. It is "It’s going to be harming people. Your grandmother will not get the treatment that she needs." It’s fascinating, the entire basis of argument is not strikingly different. And here, this is a bill that’s not even bringing in a government insurance program. This is a bill that’s providing subsidies to private insurers to make it possible for 32 million people to receive insurance who didn’t have it, plus start putting in some billions of dollars for experiments in communities across the country in improving quality of care while trying to lower the costs of care. That’s the — you know, the meaning of this kind of legislation is something that is under — this is the core source of debate: people trying to determine what it means to put such a complex package together. Medicare was not exactly simple as a program, either. And this is an effort to define it, even, you know, by repeating the words "death panel" over and over and over again.

SHARIF ABDEL KOUDDOUS: Well, I mean, you bring up an interesting point. There are critics of the bill from across the political spectrum. You know, many thought that this just expanded an already broken system, that it forced people to buy a faulty products — health insurance — that it didn’t include a public option, which many said was essential to real reform. What’s in the bill that you like? Why do you think it’s a good piece of legislation?

DR. ATUL GAWANDE: You’re absolutely right. There are concerns from both the left and the right. And what is essential is that we are an experimenting and innovating society, that we are trying new things when we face problems and breakdown. We reached — we were able to reach an agreement that could get through Congress, when people have tried for half a century to get passage of coverage for the uninsured and for improving the delivery system for care. And we have finally accomplished it. It will represent now our next decade of work, seeing how well it works, seeing where the problems are. And if, for example, private insurers simply prove to worsen care, to only add on layers of cost, this is a test that the insurers have to end up measuring up to or failing. And if they fail, then it’s every reason that the left will be correct, that government insurance programs are in fact better than private insurance programs. This is the test and the question that we can actually try out. Or, we just go into stalemate.

AMY GOODMAN: One of the key provisions of the healthcare law targeted by Republicans bars insurance companies from denying coverage based on pre-existing conditions. Former Arkansas governor Mike Huckabee, who’s considered one of the top contenders for the Republican presidential nomination in 2012, mocked the provision in a speech before the Value Voters Summit last September.

MIKE HUCKABEE: And then a lot of this, it sounds so good, and it’s such a warm message to say, "And we’re not going to deny anyone from a pre-existing condition." Look, I think that sounds terrific. But I want to ask you something from a commonsense perspective. Suppose we apply that principle, that you can just come on with whatever condition you have and we’re going to cover you at the same cost we’re covering everybody else, because we want to be fair. OK, fine. Then let’s do that with our property insurance. And you can call your insurance agent and say, "I’d to buy some insurance for my house." He’d say, "Tell me about your house." "Well, sir, it burned down yesterday, but I’d like to insure it today." And he’ll say, "I’m sorry, but we can’t insure it after it’s already burned." Well, no pre-existing conditions. How would you like to be able to call your insurance agent for your car and say, "I want to insure my car"? "Well, tell me about your car." "Well, it was a pretty nice vehicle, 'til my 16-year-old boy wrecked it yesterday. Totaled the thing up, but I'd like to get it insured so we could get it replaced." Now, how much would a policy cost if it covered everything? About as much as it’s going to cost for healthcare in this country.

AMY GOODMAN: That was former Arkansas governor Mike Huckabee, considered a top contender for the Republican presidential nomination in 2012. Dr. Atul Gawande, your response?

DR. ATUL GAWANDE: Well, what’s fascinating is that the argument here is exactly the case for what — for the individual mandate. That is, if you’re going to have a private insurance system. The Republicans have attacked and want to strip out of the bill the thing that allows a private insurance system to survive, if you’re going to provide care and get rid of pre-existing conditions for people, which is that everybody would obtain private insurance coverage, and if they couldn’t afford it, have subsidies for that insurance. If you — yes, of course, if we had a system that said "no mandate for having to have insurance of some kind," then no one would have insurance and only would activate their insurance the minute that they got sick.

You know, I wish this were a matter of arguing about the key detail points back and forth. But the core issue here is that, on the one hand, attack the provision that pre-existing conditions are — there’s a regulation, you’ll call it "bureaucracy," and it’s regulation to ban pre-existing conditions, and then attack the bill for not — for mandating that insurance be required, but then also attack the idea that you’re going to — because the only alternative to that would then be single payer. If you do not have the basic provisions in place for insurance regulation, then the only other option for insuring the public would be government insurance.

AMY GOODMAN: What’s amazing from all the studies that have been done, everything from Social Security to Medicare, I mean, it shows that the population is so different than the very small circle of know-nothing pundits we get on television. It is remarkable even on the issue of single payer. The polls show, when explained, when not talked about as — you know, Fox put out that memo that you’re not supposed to refer to it as a "public" option, but a "government" option — when people actually explain what it is, most people are for it.

But I wanted to go back to this critical discussion about end of life, because it’s something we don’t deal with until we are in crisis. And that’s when people are struggling to get information, and they have the least ability to get the information, and that’s when they have to deal with these issues. The piece that you wrote in The New Yorker goes through many different cases. But you talk about two studies, one that was run by Aetna and another, the whole community in La Crosse, Wisconsin. Why don’t we go to La Crosse, Wisconsin, and talk about what happened there?

DR. ATUL GAWANDE: La Crosse, Wisconsin is a typical Midwestern community where the local doctors and a bioethicist there decided that they wanted to improve the care for people with terminal illness. And they did it by working to make sure that everybody in the town had a living will — and not by forcing anybody to have a living will, but simply by teaching everybody, from chaplains to social workers to doctors, how to have good conversations and to take the time to have good conversations with people about the kind of choices that they will face when, as all of us will, when they become sick.

AMY GOODMAN: And a "living will" means what?

DR. ATUL GAWANDE: And a living will means being able to say in advance what you desire when it comes time for treatment, everything from would I want to have my — would I want — if my heart stops, would I want to be resuscitated, and if I had a pneumonia, would I want to treat it. For most of us, in our phases of life, the obvious answer is "Yes, please." But we will all reach a phase where we will reach a point where the suffering of treatment for the sake of prolonging life will have trade-offs that we begin to struggle with, especially as we become ill and disabled by chronic illness.

So, in La Crosse, Wisconsin, they had a community effort. And the result was, over 90 percent of the population ended up having what they call advanced directives, a living will. The doctors actually paid attention to what they had written down, which often gets ignored. And it was not a matter of follow what this piece of paper says. The power of it proved to be that for people with terminal illness, they had thought about what might happen as they got sicker, whether they wanted to be at home or in a hospital when the end came, how much control they wanted over their life.

And by being able to articulate their values and concerns about facing that kind of illness, two things happened in La Crosse. First of all, the number of people who died in intensive care units and being kept alive on ventilators and on machines, past the point of being even conscious of what’s going on, declined markedly. The costs of people in the last year of life went down markedly. There was no change in how long people lived in La Crosse, Wisconsin. And it really became a model community for the entire country. They were the ones. They said the one barrier we have left in La Crosse is that the doctors don’t have the time to talk to patients, because they’re only paid for a short visit. Having the time to talk at length to people who are really, really sick, facing a few months to live, they needed to be compensated for that. And that led — they were the starters of the very provision that could help people decide, do they want hospice care versus hospital care, and having the dollars in place to make those conversations less of a burden on the medical community.

AMY GOODMAN: We’re going to continue this discussion in a minute. Dr. Atul Gawande is our guest. His latest book, The Checklist Manifesto: How to Get Things Right, is out in paperback today. This is Democracy Now!, democracynow.org, The War and Peace Report. If you’d like a copy of today’s show, you can go to our website at democracynow.org. Back in a minute.

[break]

AMY GOODMAN: Our guest for the hour, Dr. Atul Gawande, surgeon at Brigham and Women’s Hospital in Boston, staff writer at The New Yorker magazine, also has written the book The Checklist Manifesto: How to Get Things Right.

The whole discussion of how people deal, when they’re dealing with terminal illness, and having control of their lives, having a humane ending is something doctors have not been trained to deal with, and certainly people just in general have had trouble with and do not have the experience, until it’s too late. There was an Aetna study that was done that was fascinating, Dr. Gawande.

DR. ATUL GAWANDE: Yeah, this was a powerful study — of all things, an example of an insurance company doing an innovative program, where the usual rule to get hospice care — and hospice care, usual rule to get hospice care is that you have to be in the last six months of your life, certified by a doctor, and give up all other treatments, in order to be — to see a hospice nurse, who comes to your home and helps make sure that, on a daily basis, you’re not in pain, you’re not in suffering, and helping your family cope with a dying patient.

Aetna did an experiment where they said, "You know what? You don’t have to give up the chemotherapy. You don’t have to give up the radiation. And we’ll still have the hospice nurse visit." And what they found is that those patients who had care at home to help them in their last months ended up being less likely to end up in the hospital. They chose less treatment for — through chemotherapy and radiation. And they didn’t live shorter. They, in fact — in further studies that have been done, when people have received palliative care, which occurs even before those dying few months, but just trying to get attention to the symptoms that occur with a terminal illness, receiving palliative care lengthened people’s lives at the time that they were choosing to reduce their use of hospitals and aggressive therapies. And so, these kinds of programs are very powerful and have become unequivocal examples of needing to move forward in changing the way we deliver care for these kinds of patients.

AMY GOODMAN: Now, this is amazing, that patients at the end of life, in terminal cancer, actually, when they went through hospice or they decided not to prolong their lives through artificial means, lived longer than they would have if they had gone through the treatments.

DR. ATUL GAWANDE: A Medicare study of the hospice benefit found that the patients who took the hospice option — and these were people who were forced to give up the aggressive treatments and so on — that those hospice patients lived longer. And the examples were in colon cancer, breast cancer. Congestive heart failure patients lived on average three months longer than the group who continued the aggressive therapy right to the very last day of their life.

SHARIF ABDEL KOUDDOUS: I want to switch gears for a moment. You wrote a remarkable piece about the effects of solitary confinement on prisoners, on people who have been held in isolation for a long time. On this issue, I just want to turn to the case of the four prisoners in a supermax prison, the Ohio State Penitentiary. This week they launched a hunger strike to protest what they call their harsh mistreatment under solitary confinement. The prisoners — Bomani Shakur, Siddique Abdullah Hasan, Jason Robb and Namir Abdul Mateen — were sentenced to death for their involvement in the 1993 prison uprising in Lucasville, Ohio. For over 17 years, they’ve been held in 23-hours-a-day solitary lockdown. On Monday, the four began refusing to eat meals until they are moved out of solitary confinement and onto death row, where they say they’ll get better treatment. Yesterday I spoke — Amy spoke with the longtime peace activist, historian and lawyer, Staughton Lynd. He wrote the definitive history of the 1993 Ohio prison uprising at Lucasville. He described the prisoners’ conditions. Let’s take a listen.

STAUGHTON LYND: They are held in more restrictive confinement than the more than 100 other death sentence prisoners in the same prison. Now, why is this? It’s precisely because the system thinks of them as leaders. So, it will let them watch television. They even let Bomani Shakur use a typewriter. But what they don’t let any of the four men do is to be in the same space as another human being other than a guard at the same time. And this means that while other death sentence prisoners can wander about the pod, can have collective meals outside their cells, and especially can have semi-contact visits with their friends and families, the four are always obliged to encounter the world either through a solid cell door or, when they go out on a visit, through a solid pane of glass. So that, again, Bomani has a niece and nephew aged eight and three that he loves and would wish to touch. If he were on death row, he could do that. But he’s been told by the prison authorities he will never be on death row, because they’re going to keep him in social isolation until they kill him.

AMY GOODMAN: So, that is Staughton Lynd, the longtime peace activist, lawyer, talking about these four men who have now gone on a hunger strike at the Ohio State Penitentiary, demanding to be put on death row, where they say that they will be treated better.

And then we’ve got the case of the alleged WikiLeaks Army whistleblower Bradley Manning, who’s being held in solitary confinement. Twenty-two years old, U.S. Army private, arrested in May, has been in detention ever since. For the past five months, he’s been held at the U.S. Marine brig at Quantico, Virginia, before that, held for two months in a military jail in Kuwait. Last month, we spoke to Glenn Greenwald, the political and legal blogger at Salon.com. Glenn reported that Manning is being held under conditions that constitute cruel and inhumane treatment, and even torture. This is what Glenn Greenwald said.

GLENN GREENWALD: He’s been held for seven months without being convicted of any crime. And the conditions that I recently discovered he’s being held in are really quite disturbing. And this has been true for the entire seven-month duration of his detention. He is in solitary confinement, and he’s not only in solitary confinement, which means that he’s in a cell alone, but he’s there for 23 out of 24 hours every day. He is released for one hour a day only. So, 23 out of the 24 hours a day he sits alone. He is barred from even doing things like exercising inside of his cell. He’s constantly supervised and monitored, and if he does that, he’s told immediately to stop. There are very strict rules about what he’s even allowed to do inside the cell. Beyond that, he’s being denied just the most basic attributes of civilized imprisonment, such as a pillow and sheets, and has been denied that without explanation for the entire duration of his visit, as well. And there is a lot of literature and a lot of psychological studies, and even studies done by the U.S. military, that show that prolonged solitary confinement, which is something that the United States does almost more than any other country in the Western world, of the type to which Manning is subjected, can have a very long-term psychological damage, including driving people to insanity and the like. It clearly is cruel and unusual; it’s arguably a form of torture. And given that Manning has never been convicted of anything, unlike the convicts at supermaxes to whom this treatment is normally applied, it’s particularly egregious.

SHARIF ABDEL KOUDDOUS: That’s Glenn Greenwald, the political and legal blogger at Salon.com. In his piece that he wrote about Manning, he actually cited your article "Hellhole," which you document what happens to people held in isolation. Explain why this is thought of as a form of torture in many places.

DR. ATUL GAWANDE: Well, I was interested in whether it really was torture, and I was interested because this has become, I think, a generationally defining question for us. In the 1980s, during the Reagan administration, solitary confinement was very unusual. Today, we have over 50,000 people in long-term solitary confinement in our American prisons now. You know, in states like New York —- it’s across every -— red and blue states. We have — New York has over eight percent of its prison population in long-term solitary confinement. A large proportion — some think a majority — are not there for violent offenses, either. It’s a method of control that we regard as increasingly routine. And so, what my puzzle was, is it torture, or is it not?

And what I looked back to was the experience and the literature, which is much richer, around what hostages and prisoners of war — our Vietnam veterans, for example — experienced when they went through solitary confinement. And what’s found is that people experience solitary confinement as even more damaging than physical torture. Vietnam veterans who received physical torture — John McCain had two-and-a-half years in solitary confinement, had his legs and arm broken during his imprisonment, but described the two-and-a-half years that he spent in solitary as being the most cruel component and the most terrifying aspect of what he went under. You also look at studies that show that people held in isolation from other human beings —- we actually need social, friendly interaction with other people to be sane, to be absolutely -—

SHARIF ABDEL KOUDDOUS: Right. You document how people actually reach a level of psychosis.

DR. ATUL GAWANDE: That’s right. Not everybody.

SHARIF ABDEL KOUDDOUS: They begin to lose their minds, right?

DR. ATUL GAWANDE: Not everybody. The people who become psychotic in solitary confinement are people who often have attention deficit disorder or low IQ or issues of prior mental illness. Well, guess who is in our prisons? And there’s a very high rate of psychosis and people flat-out going crazy under the confinement conditions. And so, then what I puzzle over is, does it actually reduce our violence in our prisons? The evidence from multiple studies now is that not only that it has not reduced violence, it’s increased the costs of being in prison. And my finding was that we have decided that when it is political — when it is a prisoner of war or a hostage, that it is absolutely torture when other countries do this to people, and that there is no discernible difference in the experience of what people go through in our prisons, when they’re in solitary confinement for 14 years, in the case of one person who I documented, that this is torture.

AMY GOODMAN: Dr. Atul Gawande, in this last minute, we spent an hour with you talking about The Checklist Manifesto: How to Get Things Right, when it first came out. It’s out in paperback today, and we appreciate that you’re back. What have you most learned? And for people who aren’t familiar with this idea of the checklist, you’ve just got a short amount of time, so go through all those —that list and check off all the points.

DR. ATUL GAWANDE: Yeah, the key concept here is we think checklists are for the lowest people in healthcare or in other places in society, but never for the top dogs. But under the complexity we’re under to make things go right, whether it’s in aviation or in skyscraper construction or government programs or in a law office or in healthcare, having people think hard and make actual checklists to go through is producing some striking improvements. In surgery, I introduced a checklist based on some work that other people had been doing in surgery, that when I published the book, we had shown a 40-plus percent reduction in mortality in operating rooms when surgeons use the checklist. They have now adopted it in the Netherlands, in the U.K. and in France. In the Netherlands, they cut their death rate 50 percent.

AMY GOODMAN: By just going through a series of —

DR. ATUL GAWANDE: A two-minute checklist.

AMY GOODMAN: — lists that you have to get accomplished before you engage in whatever act in whatever profession.

DR. ATUL GAWANDE: That’s right, a two-minute pilot’s checklist. In the U.S., we’ve only embraced it in about a quarter of our hospitals. And our evidence is that even there, it’s skipped.

AMY GOODMAN: We’re going to continue this discussion after the show. You can go to our website at democracynow.org for our website exclusive. Dr. Atul Gawande has been our guest. If you’d like a copy of our show, you can also go to democracynow.org. Dr. Atul Gawande’s book, The Checklist Manifesto: How to Get Things Right, is out in paperback right now. He’s a Harvard Medical School — a Harvard professor.

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