The death panels are back.

Excised from the statutory text, death panels — or that thing that got wrongly called "death panels" — returns by way of regulations:

The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves....

Get ready to be prompted to sign a document that will sound helpful and reasonable. The advance directive. Don't you want the autonomy and control that comes from deciding in advance that you don't want people to try to save your life?

“While we are very happy with the result, we won’t be shouting it from the rooftops because we aren’t out of the woods yet,” [said the office Representative Earl Blumenauer of Oregon*] in an e-mail in early November to people working with him on the issue. “This regulation could be modified or reversed, especially if Republican leaders try to use this small provision to perpetuate the ‘death panel’ myth.”

Moreover, the e-mail said: “We would ask that you not broadcast this accomplishment out to any of your lists, even if they are ‘supporters’ — e-mails can too easily be forwarded.”

The email said email can be too easily forwarded. Ha ha ha. And now, here it is, quoted in the NYT, cut and pasted into blogs.

The e-mail continued: “Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch and may be calling on you if we need a rapid, targeted response. The longer this goes unnoticed, the better our chances of keeping it.”

In the interview, Mr. Blumenauer said, “Lies can go viral if people use them for political purposes.”

But it's not a lie. You may not like the label — no labels! — attached to the policy, but the policy itself is understood — understood and presented in an inflammatory way that precisely counterbalances the soothing, lulling tones used by people who like it.

Sarah Palin, the 2008 Republican vice-presidential candidate, and Representative John A. Boehner of Ohio, the House Republican leader, led the criticism in the summer of 2009. Ms. Palin said “Obama’s death panel” would decide who was worthy of health care. Mr. Boehner, who is in line to become speaker, said, “This provision may start us down a treacherous path toward government-encouraged euthanasia.” Forced onto the defensive, Mr. Obama said that nothing in the bill would “pull the plug on grandma.”

Well, you will pull the plug on grandma, but only after grandma has signed the document the doctor explained to her long before she got into the situation she's in now, back when it seemed like autonomy and control.

“Using unwanted procedures in terminal illness is a form of assault,” [said Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Service]. 

The question is what do patients want and how what they want will be determined. It seems to me that the effort is to get people to commit in advance to death-hastening choices, by getting everyone to sign these documents. Now, all the new regulation seems to do is to authorize Medicare reimbursements for the time health care professionals spend counseling patients about the value and importance of signing the document. It's hard to see what's wrong with that. If treatments are covered but advice about forgoing treatment is not covered, then there's an incentive to do expensive things.

In a recent study of 3,700 people near the end of life, Dr. Maria J. Silveira of the University of Michigan found that many had “treatable, life-threatening conditions” but lacked decision-making capacity in their final days. With the new Medicare coverage, doctors can learn a patient’s wishes before a crisis occurs.

Treatable? You have a condition that can be treated, but you can't think well enough anymore to decide whether you'd prefer to die? If you've signed the document, the answer is you'd rather let the condition kill you, because you allowed the doctors to "learn [your] wishes before" this "crisis" occurred. You didn't know what the crisis would be or how you would feel when it happened, but you had "wishes" then and these will be taken as your "wishes" now.

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*Oregon, the assisted suicide state.