Illustration by Peter Schrank

THE first patient Dr Sherwin Nuland ever treated died horribly in front of him. James McCarty, a 52-year-old construction boss, had eaten too much red meat, smoked too many Camels and suffered a heart attack. Dr Nuland, then but a student, was asked to keep an eye on him while he recuperated. Suddenly, McCarty threw his head back, bellowed out a wordless roar and hit his own chest with balled fists. His face turned purple, his eyes bulged out of his head, he took “an immensely long gurgling breath”—and he died. Since this was half a century ago, Dr Nuland did what the textbooks then recommended. He cut open his patient's chest and tried, unsuccessfully, to massage his heart back to life with his bare hands. It felt like “a wet, jellylike bag of hyperactive worms”. And it did no good. The “dead McCarty… threw back his head once more [and gave] a dreadful rasping whoop that sounded like the hounds of hell were barking.”

That story is one of several that make up “How We Die”, a book Dr Nuland wrote in 1993, after a lifetime of watching the effects of terminal illness. Because modern life is so clean and orderly, he argued, people expect to die with dignity. But this may be wishful thinking: death can be dirty, ugly and often involves the “disintegration of the dying person's humanity”. Despite its gloominess, “How We Die” was a huge success, because it addressed with excruciating honesty mankind's greatest fear.

The current debate about health-care reform is in part a debate about death, which is why it evokes such fear. Some of this fear is absurd. Outside a town-hall meeting in Reston, Virginia, last week, a few buffoons likened Barack Obama to Hitler. But most of the protesters are sane. Mr Obama plans to cover millions of uninsured people, says Brittany Tomaino, a young would-be oncologist. He will have to find the money somewhere. That means cuts to Medicare, the government health plan for the elderly, which covers her 95-year-old grandfather, she reckons. “If he needs care, they're going to give it to someone younger,” she predicts.

A slim majority of Americans support Obamacare. But that majority is declining, and the passion is mostly on the other side. Pro-lifers, for example, worry that reform will mean taxpayer-funded abortions. Half of all Americans believe this will happen. Democrats point out that the bills in question do not mention abortion. Pro-lifers respond that the language is vague enough to allow bureaucrats to add abortion funding after the bill is passed. They also fret, like Ms Tomaino, that Mr Obama will deny life-saving treatment to Grandpa to save money. This possibility alarms Grandpa, too. Americans over 65 currently receive, through Medicare, fantastically generous health insurance for which they pay only a small fraction of the cost. Only 23% of them think Obamacare will make them better off, while a growing plurality think it will hurt them.

Health reformers always smash up against two unpalatable truths. We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean? Should doctors seek to save the largest number of lives, or the largest number of years of life? Even in America, resources are finite. No one doubts that $1,000 to save the life of a child is money well spent. But what about $1m to prolong a terminally ill patient's painful life by a week? Also, who should pay?

There are no easy answers. Unfortunately for Mr Obama, some of his academic chums have pondered seriously and publicly about the questions. Cass Sunstein, an adviser, has written extensively about which life-saving rules are most cost-effective. Ezekiel Emanuel, a doctor whose brother is Mr Obama's chief of staff, wrote a paper for the Lancet, a medical journal, in which he proposed a system for determining who should be first in line for such things as liver transplants or vaccines during an epidemic. Among other factors, he suggested taking age into account, with adolescents and young adults getting priority, because they have fully developed personalities and many years of life ahead. This may be philosophically defensible, but it is political poison—Dr Emanuel even included a graph showing voters above and below the ideal age how much less their lives are worth. Conservative talk radio predictably dubbed him “Dr Death”. Republicans vowed last week to outlaw the rationing of care by age.

Blithe and distrustful

Mr Obama's supporters say that objections to his reforms are largely based on misunderstanding, fuelled by Republican scaremongering. They have a point. But the Democrats' bigger problem is that most Americans have pretty good health insurance and no idea how much it costs. Taxpayers foot the bill for the old. Most workers with employer-provided health insurance imagine that their employer is paying for it, when in fact it comes out of their wages. Soaring medical inflation depresses Americans' standard of living and threatens to bust the budget. The system is riddled with waste. Yet most Americans feel little urge to make it more efficient. When asked if insurance firms should be obliged to pay for expensive treatments that have not been proved more effective than a cheaper alternative, 56% say yes.

Few Americans have a clear idea how Obamacare will affect them—unsurprisingly, since even quite basic details are undecided. The uninsured have the most to gain, but they are only 15% of the population. Everyone else has something to lose. Many Americans do not trust the government to do anything much, let alone make decisions about life and death. Small wonder Mr Obama finds the headwind against health reform so blustery.





Economist.com/blogs/lexington