The student will:

• Identify and support their personal position on rationing end-of-life health care
• Understand that health care costs in the United States have become a growing part of the overall economy and how rising costs will affect Medicare, the government health insurance program for Americans over 65.
• Compare and contrast different views on providing health care to all segments of society.
• Analyze the different positions on the issue of rationing end-of-life health care
• Formulate an end-of-life health care policy

Teacher Note: The topic of end-of-life health care can be a sensitive issue for the classroom. Before conducting this lesson, please review all its components to see if any parts might be emotionally difficult for any of your students.

It's a sensitive issue. Should someone who has a terminal illness or is in their advanced years and debilitating health be given life-supporting treatment?  Should the government or private health insurance companies be required to pay this cost? For some, the question is almost ludicrous. Of course you provide the treatment! Who can put a price on a human life, even if it is for only a few months?

For others who note the growing cost of health care and the impending bankruptcy of the Medicare program, the question isn't so easy to answer. The topic is the subject of a Miller Center Debate with experts.

Some difficult decisions need to be made or everyone will suffer. Should health care be rationed? Should people in their last few months of life be allowed all the care and treatment money can buy? Should the young be given a greater priority for limited funds over the oldest old (over 85 years old)?

Often times, these questions get addressed in headline stories of young patients on life support with family members facing the agonizing question of continuing treatment or letting go; of facing astronomical medical expenses or providing release. During the debates on health care reform, the issue became very politicized with one side insisting that there would be no rationing of any kind, and others claiming that any government plan would target the elderly or those most dependent on expensive treatments with federal government run "death panels."

And yet, as distasteful as it is for some, and as dangerous for politicians who rely on the votes of older Americans, the issue of end-of-life-care needs to be addressed. It won't go away and it will only get worse as the "baby-boomer" generation becomes older. The questions are should end-of-life-care be provided with no restrictions or should some fair and honest approach to rationing care be mandated?

In this lesson, students will explore this very sensitive issue from several different angles. They will begin by being asked their views on rationing health care. Then they will examine the present financial condition of health care with rising costs and dwindling funds for Medicare. They will breakdown the complex issues surrounding end-of-life-care and address some of the tougher questions. They will then develop a policy for end-of-life health care. Each of the activities in this lesson can be adapted to the abilities of your students and your class schedule.

Opening Activity:

1. To begin this lesson, post the following statement on the front board or overhead:

Would you support rationing care and treatment for those who have little time to live in order to preserve money for those who have long to live?

1. Draw a continuum line on the classroom floor with masking tape or up on the front board that looks like this:

Strongly Support---------------------Neutral------------------------Strongly Oppose

• Tell students that the far left end of the line designates those who strongly support a policy that rations care for those who have little time to live in favor of those who do and the far right side end designates those who strongly oppose such a policy.
• Ask students to think about their position on the proposition. Then ask them to place themselves on the continuum line in the position they feel best matches their view. Tell them that the "neutral" or middle position is off limits.
• After students have placed themselves on the line, ask students to explain their reasoning to the class.
• Allow students to move their position on the line as other students explain their answers.

Main Activity
Part 1: Understanding the Concern about Health Care Spending

Now tell student that they are going to explore the issue of end-of-life health care. To begin this exploration, share with students the two charts in student Handout 1. (This handout can be made as a transparency.) From the first chart, point out to students that the cost of health care as gone up tremendously since 1960 when health care was 5 percent of the U.S. gross domestic product (GDP). Now it is over 16 percent and is projected to be over 20 percent by 2018. Then point out on the second chart that if nothing is done to contain current costs, the Medicare trust fund will be depleted by 2019.

After reviewing the charts, discuss the following questions:

• What does the chart titled "U.S. Healthcare Spending" tell you?
• Why do you think the cost of health care in the United States has risen at such a dramatic rate in the past 50 years?
• Do you feel this rise in cost is a problem or the just price we have pay for a good health care system? If you feel this steep rise in cost is a problem, what do you think should be done about it?
• Medicare is a government program designed to help pay the medical costs for people 65 years old and over. What is the current condition of Medicare and what are the projections for solvency over the next ten years?
• What reasons do you think account for this condition?
• What do you think should be done about this?

Part 2: Should medical care be provided to all?
To give students an overview of the issues surrounding rationing health care, have students view the news story from Religion and Ethics Newsweekly. Tell students that this video segment focuses on the ethical question of rationing medical care from people without medical insurance to ensure funds will be available for those who do. Some of these people are American citizens and some are undocumented workers from Mexico. But the financial effect on the cost of medical is the same: It is becoming increasingly difficult to treat all patients the same way.

• Place students in small groups of two to three.
• Distribute Student Handout 2 to all students. Have students complete the questions on the handout. (This can be done as homework)
• When students have completed the handout, briefly review the following questions with the class.
  • Summarize the problems hospitals face when treating patients who have no insurance?
  • Summarize the views expressed by the two doctors on whether hospitals should treat patients who have to ability to pay for their medical care.
  • Should hospitals and doctors
    • Deny or ration care for patients who have no health insurance?
    • Deny or ration care to patients with terminal illness?
    • Deny or ration care to patients who are undocumented immigrants?
    • What is your reasoning for each group?

Part 3: Research Project: Rationing Health Care at end-of-life. Yes? No? Some?
This next activity has students explore in depth the issue of rationing health care. They will examine the issues raised in the Miller Center for Public Affairs Public debate "End-of-Life-Care" white paper. Students will review a spectrum of positions raised in the white paper concerning whether to ration end-of-life-care and articles that delve deeper into each position. Some of the articles are lengthy, so you may want to review prior to assigning this activity.

• Divide students into six groups. Assign each group one of the positions outlined in the student Handout 3, "Rationing Health Care at the End of Life."
• Distribute the handout and review the directions with students. 
• Provide time for each group to their review position's main points and the related article from the online resources. Have students develop a presentation for the class on their assigned position. (Reading the article can be assigned as homework)
• After all groups have presented, debrief the activity with the following questions:
• Is it financially practical to provide advanced health care to someone who is terminally ill? Is it ethical or moral not to provide such care? Explain.
• Should doctors and hospitals ration health care for people who are terminally ill in order to bring medical costs down? Explain.
• Medicare is projected to go broke in the next seven to nine years. Should the federal government ration Medicare benefits to some now so that others may have health care in the future? If yes, what criteria should the federal government use? If no, how should the federal government address the impending bankruptcy of Medicare?
• The possibility of rationing end-of-life-care is being considered for government sponsored health care programs and by private insurers. Who would you prefer making these decisions, the government or private insurers or neither? Explain why.
• Summarize the program known as "comparative effectiveness research." How does it work? Why is it seen as a viable alternative to rationing? How does it have components of rationing and rational care in it?
• Do you think the government should reimburse doctors and hospitals that provide advanced directives to patients even though such a proposal was accused of creating a government "death panel?" Explain.

Part 4: Culminating Activity Develop a Rational End-of-Life Health Care Policy
Pose the central question again from the opening activity:

Would you support rationing care and treatment for those who have little time to live in order to preserve money for those who have long to live?

and have students position themselves along the continuum line. Ask students to explain whether they changed their view and the reasons why or why not.  Then tell students they have been selected to be on a task force to look into the issue of rationing health care. Once students have completed their plans, consider having them send their ideas to federal or state political and medical officials.

• Divide the class into small groups or keep students in their same groups from the previous activity. (This activity can also be assigned to students for individualized assessment.)
• Distribute Student Handout 4, "A Rational End-of-Life Health Care Policy." Review the directions with students.
• Give them time to develop their health care policies. Then have them present their summaries to the class and/or turn in for assessment.

Assessment
Assess student performance based on how closely their policy plan covers the questions listed in their handout and how well they support their position with information covered in the other activities.