To what lengths to prolong life?

In a New York Times column last summer, the late Dudley Clendinen, who suffered from Lou Gehrig's disease, wrote that Americans "don't talk about how to die."

We don't? For years, Americans have been discussing how to die. Most of this discussion exalts hospice care and deplores aggressive, life-prolonging medical treatment -- often in a manner reminiscent of the "Four legs good, two legs bad" slogan of Orwell's "Animal Farm."

Consider "The Long Goodbye," Joe Klein's cover story in the June 11 issue of Time. The cover says: "How to Die: What I Learned from the Last Days of My Mom and Dad."

You can learn plenty from Klein's story.

You can learn about the opposition faced by sick old people who want to prolong their lives.

Klein decries "unnecessary expenditures." Here is his account of one expenditure that he considers unnecessary. "At the age of 80, my mother insisted on having a heart-valve operation to fix a murmur she'd had since birth. 'It's getting worse,' she said. "I'm feeling more tired than I used to.' "

Klein says the operation cost more than $100,000. He says Medicare paid for it. He does not say whether it relieved his mother's symptoms or prolonged her life, although elsewhere his article indicates that she lived into her 90s.

Klein's omission suggests that he considers the medical effect of the operation irrelevant to whether it was worth the expense. But should we begrudge an operation that offers significant benefits? Aren't there more-humane ways to alleviate our country's financial woes?

Like most writers addressing this subject, Klein blames his mother's "unnecessary" operation on fee-for-service medicine. He extols the system of Pennsylvania's Geisinger medical organization, where "doctors are paid salaries and outcomes-based performance bonuses rather than by the services they perform."

Moreover, if Geisinger doctors "can improve service while cutting Medicare costs, [they] get to keep a portion of the savings."

This arrangement obviously provides a financial incentive to withhold expensive, life-prolonging treatment from Medicare patients whose quality of life is deemed low.

But many incurably ill and debilitated patients want their lives prolonged. For example, a Critical Care Medicine article about a study of 244 patients with various end-stage illnesses reports that most wanted medical treatment that would prolong life for even as little as a week.

Geisinger doctors learn how to win trust and overcome resistance. Geisinger "schools them in basic procedures like shaking hands with members of the patient's family, looking them in the eye and introducing themselves."

These procedures are good in their own right, of course. But Klein endorses them as aids in manipulation. He praises them as "especially important in a system in which doctors sometimes must try to deny care requested by patients or their families that is deemed unnecessary."

Geisinger doctor Charles Maxin won Klein's trust. He convinced Klein to sign a DNR (do not resuscitate) order for his father. Maxin's strategy involved stressing that resuscitation would probably break all of Klein's father's ribs.

"It was becoming clear to me that in the gentlest possible way, these Geisinger doctors did not mess around," Klein says approvingly.

Are broken ribs worse than death?

Klein's father did not seem to think so. Although this old man had broken two ribs in a fall the previous week, Klein admits that his father "probably would want to be resuscitated." This admission is disquieting to people who believe that medical treatment should accord with a patient's own values rather than those of his children or his doctors.

Also not messing around was Dr. Charles Dalton, Klein's father's urologist, a fee-for-service doctor who nevertheless gains Klein's praise for "Geisinger-like candor." Dalton told Klein, "Renal failure is a good way to go. ... Your dad's kidneys are pretty much shot. You may revive him, but he'll be back here in a month, six weeks."

Why would anyone want that extra month? Well, maybe to enjoy his daydreams, his memories or his family.

Whose life is it, anyway? This slogan is conventionally used to support the right to die. It applies just as much to a sick old person who wants to stay alive. Such a person deserves better than to have well-schooled manipulators coax his family into signing his death warrant.

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Felicia Nimue Ackerman is a professor of philosophy at Brown University. She wrote this article for the Providence Journal.