Our surprise finding: Whatever a doctor's political views, end-of-life care is the same

It’s no secret that we live in an era of historic political polarization.

Almost daily we’re reminded of the corrosive consequences of Americans drifting apart: Polarization affects how we work, where we live, what we buy and who we marry.

As doctors and health policy researchers, we worry about the effect of polarization not only for our political system, but also for our health system — and most importantly, for the care that our patients receive.

From Obamacare and “death panels” to abortion and stem cells, health care has grown into one of the most divisive issues of our time. This is perhaps unsurprising: Health affects us all and raises fundamental questions of values, equality, meaning and life — with a massive price tag to boot.

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As Americans have grown ideologically segregated, so too have doctors. A generation ago, most doctors were Republicans. Today, they’re split evenly between the parties and cluster along familiar lines: men, older physicians and higher-paid specialists favor Republicans, while women, younger doctors and lower-paid specialists lean Democrat. These political affiliations influence how doctors feel about a variety of health issues, including gun control, abortion, the Affordable Care Act and whether the medical profession is obligated to care for the uninsured.

What does this mean for how patients and families are cared for?

In a new study published in The BMJ, we analyzed whether doctors’ political preferences affect the care patients receive at the end of life — a heavily politicized and value-laden area of medicine and one that prior research has shown is influenced by how doctors counsel patients.

Let’s say you’re admitted to the hospital with a terminal condition. You and your family are trying to make important, agonizing decisions about what you want in your final days — weighing complex trade-offs of quality and quantity of life. The doctor caring for you is either strongly Democrat or strongly Republican and has donated to political candidates in recent elections.

Are you more or less likely to get a breathing tube? To be admitted to the I.C.U. or, instead, be discharged to hospice? To receive a feeding tube for artificial nutrition? Will the health system spend any more or any less?

The answer to each of these questions is: No.

We combined data on political donations made by physicians with data on the type of care they provide to Medicare patients at the end of life, and found no differences in the end-of-life care patients receive depending on the political affiliation of the doctor treating them.

Among patients who die in the hospital, patients treated by Republican doctors don’t get more feeding or breathing tubes, don’t receive dialysis more often and don’t have higher end-of-life spending compared to patients treated by Democratic doctors. For patients who survive hospitalization but are expected to die within months, those treated by Democratic doctors aren’t any less likely to be discharged from the hospital directly to hospice care. Total end-of-life medical spending is the same whether doctors are Democrats, Republicans or neither.

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Our findings are surprising in some ways and less so in others. Politics now seems to bleed into every area of life (but not, apparently, into death). And end-of-life care — like politics — is imbued with questions of values, identity and spirituality. Our research also differs from a recent, widely-read study examining whether doctors’ political affiliation influences how they would counsel patients on politically-charged health issues like firearm safety, abortion and marijuana, which did find significant differences between Democrats and Republicans. (This study evaluated doctors’ hypothetical recommendations, not their actual behavior, and did not ask about end-of-life care.) 

At the same time, medicine — particularly complex, end-of-life care — is delivered in teams, so an individual doctor’s political beliefs, even if he or she is in charge, may not sway the totality of care. And some decisions about the care patients want when they’re dying are made before they’re admitted to the hospital.

Surprising or not, our findings are reassuring. In an increasingly polarized era, when conservatives and liberals can’t seem to agree on what color the sky is, our research suggests there are still de-politicized zones. It suggests that, at least in this case, medical professionalism trumps political ideology. And it reflects a belief that doctors and patients of both parties share: Patients and their families should dictate the care they receive at the end of life.

Benjamin Franklin once wrote that nothing in this world is certain, except death and taxes. Democrats and Republicans, it seems, can agree on how to approach death. Taxes are another story.

Dhruv Khullar is a physician and researcher at Weill Cornell and director of policy dissemination at the Physicians Foundation Center for Physician Practice and Leadership. Anupam B. Jena is an economist, a physician and the Ruth L. Newhouse Associate Professor at Harvard Medical School. Follow them on Twitter: @DhruvKhullar and @AnupamBJena.