Is Ezekiel Emanuel Really Evil?

Posted on September 15, 2009
Filed Under Gekkonian Rationing, General Rationing Issues, Healthcare Reform |

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DrRich has criticized those on the left of the political spectrum for their vociferous and systematic demonization of Sarah Palin (for instance, here and here).  Attacks on Ms. Palin began the moment she was picked to be Senator McCain’s running mate last year, and have continued to the present moment. And while DrRich himself is not sold on Ms. Palin as a prospective leader of the free world, he finds most of the attacks on her from the left not to be based on substance, but instead on a visceral dislike of her gun-toting, Bible-thumping, baby-bouncing ways, her down-home North-country accent, and her decidedly unsophisticated style of hair, dress and manner, all of which wrap her baseline conservative political views in a particularly alarming package. The very thought of Ms. Palin as the first female Vice-President (or, perish the thought, President) gives our left-leaning intelligentsia apoplexy. Hence, demonization by any means necessary - however fair or unfair they may be - appears to be the order of the day.

DrRich has disparaged these efforts. Attack Ms. Palin on substantive grounds if you must (there’s bound to be plenty of material there if you look for it), but tone down the ad hominem attacks. Behaving this way demeans you, insults your purported audience, and ultimately undermines the legitimacy of your position.

So DrRich perked up his ears when he began hearing, a couple of months ago, similar-sounding attacks, this time by those on the right of the political spectrum, against Ezekiel Emanuel, MD, PhD. Dr. Emanuel is a bioethicist at the National Institutes of Health, and a fellow at The Hastings Center (a bioethics research institution). He is the brother of White House Chief of Staff Rahm Emanuel. He himself has been brought in to the Obama administration as a high-ranking advisor on healthcare reform, and is slated to serve as an important member of FECCER.

Emanuel became a person of interest earlier this summer, after an anti-Obama healthcare article by Betsy McCaughey appeared in the New York Post, which labeled him as a “deadly doctor,” who would undoubtedly head up those death panels which (some assert) are to decide who gets what in our coming Brave New World of healthcare. Subsequently, right-wing talk show hosts have ganged up on Dr. Emanuel, and in a manner reminiscent of the left-wing attacks on Sarah Palin, have vilified him as a virtual Dr. Mengele. Dr. Emanuel himself has been taken aback by such attacks, and insists his views are being taken out of context and exaggerated.

DrRich was intrigued. For reasons not entirely devoid of selfishness, DrRich asked himself this question: How much of the demonization of Ezekiel Emanuel is related to some sort of ethical bankruptcy (or some other variety of “wrongness”) in his actual views, and how much is simply related to the fact that he has had the temerity to propose actual systems for openly rationing healthcare? As one who has himself proposed a detailed system for openly rationing healthcare, DrRich was curious to know.

So he spent some time digging up and reading several of the articles the prolific Dr. Emanuel has published in peer-reviewed medical Journals (and elsewhere) over the past 10 - 15 years, in an effort to reach his own conclusions on the matter. As a result of this effort, DrRich has some observations.

On at least three counts, DrRich finds himself in strong agreement with Emanuel.

First, judging from his writings, Emanuel is not an ideologue, but rather seems to be entirely reasonable, rational and straightforward (at least, for an academic). Unlike many medical ethicists whose musings DrRich has studied, his writings are clearly expressed and logically developed, and are devoid of most of the incomprehensible jargon medical ethicists like to toss around (to throw the uninitiated off their trails, one suspects).

Second, Emanuel is an unlikely participant in actual death panels (if such were to be formed), since he has been a vocal opponent of euthanasia and of physician-assisted suicide. Emanuel has argued (as did DrRich in his book), that rather than reduce pain and suffering at the end of life, the availability of euthanasia and routine assisted suicide would “be a way of avoiding the complex and arduous efforts required of doctors and other healthcare providers to ensure that dying patients receive humane, dignified care.” (Wall Street Journal, January 7, 1997). That is, not only would they undermine a moral society that fundmentally values human life, euthanasia and assisted suicide would be counterproductive to good, dignified, humane end-of-life care.

Third, Emanuel recognizes that healthcare needs to be rationed, and is not afraid to publicly engage in discussions about how to do it. Furthermore, he asserts that healthcare rationing “must be legitimate. Legitimacy requires that people see the allocation system as just and accept actual allocations as fair. Consequently, allocation systems must be publicly understandable, accessible, and subject to public discussion and revision.” (The Lancet, Vol. 373, January 31, 2009).

That is, Emanuel seems to be in favor of a system of open healthcare rationing, as is DrRich, and agrees that “open” means completely transparent and understandable to the public. So, even to the extent that we might disagree with some of his proposals for healthcare rationing, DrRich is encouraged by the fact that someone so intimately tied to the Obama administration seems to be committed to gaining a broad consensus on the methods of rationing.

DrRich cannot be entirely sanguine about Emanuel’s views, however.

A chief piece of evidence cited against Emanuel by the right-wingers comes from an article he co-authored in The Lancet, in January, 2009, which proposed a system of healthcare rationing based on what Emanuel and co-authors called the “complete lives system.” The complete lives system “discriminates against older people” (The Lancet, Vol 373, p 429). Based on this fact, Emanuel has been labeled a “deadly doctor.”

This label ignores a possibly subtle but important distinction. The typical argument for discriminating against the elderly in a rationing system is a utilitarian one. Saving the life of a 90-year-old might “buy” him only an extra two or three years of life, whereas spending the same amount of money to save a 10-year-old might buy him another 70 - 80 years of life - so it is better for society to spend the money where it will save more years of life. This reasoning ignores the fundamental equivalence of any two human lives. It also opens the door for discrimination between individuals for other reasons. That is, if you can devalue the elderly to optimize the public good, then you can also devalue the disabled, the stupid, the  lazy, and the obese (for instance) to optimize public good.

But Emanuel’s complete lives system uses a different reasoning than a utilitarian one. He would favor treating the 10-year-old over the 90-year-old not to maximize public good, but to maximize the opportunity of individuals to enjoy “complete lives” over the entire age spectrum. So, all individuals are of equal intrinsic value, and during the course of their lives, everyone experiences an equal spectrum of priorities - first, the priority of a 10-year-old, and later (if lucky enough to live that long) the priority of a 90-year-old. While in practical terms this still means discriminating against the elderly, it does so in a way that cannot be extended to other groups of people (i.e, the disabled and so forth), and that, in fact, yields equal age-based priorities across individuals through the course of their complete lives.

DrRich understands this reasoning because he proposed something entirely similar, in his book, as an option for dealing with the age issue in a rationing system. Since writing his book he has come to the conclusion that such a rationale is too subtle for public consumption, and would be seen as out-and-out hatred of the old. (Just look at the response Emanuel has received to the idea). So DrRich has come up with an entirely non-age-based method of dealing with the infirmities of aging within a system of open rationing (which he will describe at a later time).

Suffice to say that if Emanuel had left it at that, DrRich would not find much to criticize in the complete lives system.

The problem is that Emanuel’s system also discriminates against the very young, and the rationale for this discrimination is, in fact, entirely utilitarian:

“Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritising adolescents and young adults over infants (figure). Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, in contrast, have not yet received these investments.” (The Lancet, vol 373, p. 428)

livessavedSo, Emanuel holds that it is OK to discriminate against infants, toddlers and young children on the grounds that society has not “invested” very many resources on them yet. This provision is extremely disturbing, to DrRich at least. For it essentially discards the notion that all human lives are of equal intrinsic value, in favor of some set of rules to determine which individual lives are valuable enough to save, and which are not. Note that the rationale for discriminating against the elderly in the complete lives system is framed specifically to avoid having to do this.

In DrRich’s view, this provision against the young entirely negates the ethical premise of “complete lives.” This provision is what finally places the state, the insurers, or FECCER in the position of assigning intrinsic value to individual human lives, from a distance, as a matter of policy. If this can be done based on extreme youth, then it can also be done based on any other factor which some empowered panel decides will influence the worth of individuals to society.

This provision is what finally causes DrRich to break from Dr. Emanuel. The fact that Emanuel is willing to devalue the worth of very young humans because society has not yet invested much in them is so fundamental, for DrRich, as to wreck any other legitimacy his rationing system might otherwise have.

Defenders of Dr. Emanuel point out, correctly, that the paper in The Lancet on the complete lives system is meant to address only those specific circumstances where rationing is necessary because there is a strict limitation on certain medical services - such as the number of hearts available for transplantation - and that it is not overtly proposed as a general rationing system. Fair enough. But the authors certainly hold out the possibility of using the complete lives system as a more general framework for rationing at some point in the future. “Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending.” (The Lancet, vol 373, p. 429).

For DrRich, the complete lives system as described by Emanuel would justify establishing rules for determining the intrinsic value of individual people for the purposes of rationing. DrRich insists (and has proposed) that any open rationing system must treat every human as being fundamentally of equivalent intrinsic value. That all people are intrinsically equal, in fact, is the basic premise of the Great American Experiment, and we should not throw it out for the sake of any mere healthcare system.

One other unfortunate aspect of Dr. Emanuel’s writings deserves attention.

Right-wing commentators have noted that Emanuel seems to disparage the Hippocratic oath as a guidepost for American physicians. DrRich was able to find two comments on the Hippocratic oath in Emanuel’s writings.

In the May 16, 2007 issue of the Journal of the American Medical Association, in an article entitled, “What Cannot Be Said on Television About Health Care,” Emanuel has the following complaint about American physicians: “Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life, akin to the economist who knew the price of everything but the value of nothing.”

In the June 18, 2008  issue of the same journal, in an article on healthcare “overutilization,” he discussed seven factors that drive the overuse of medical services. He identifies one of these factors as a  culture of unwarranted thoroughness on the part of American doctors, which serves to drive up cost. “This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to ‘use my power to help the sick to the best of my ability and judgment’ as an imperative to do everything for the patient regardless of cost or effect on others.”

So apparently, Emanuel  finds that a stubborn adherence to outdated medical ethics, which causes doctors to strictly place their individual patient’s interests above society’s interests, accounts for a substantial proportion of unnecessary healthcare costs.

DrRich is sympathetic with the complaints being made by right-leaning commentators about Emanuel’s position here. Patients, especially when they are sick and least able to fend for themselves, are in dire need of an advocate, a professional who will take their part and protect their individual interests against the often competing interests of a hostile and complex healthcare system, whose only concern is reducing costs. Patients abandoned in such a system without their rightful advocate are in a very dangerous position indeed. This is why the classic doctor-patient relationship is so critically important. And this is why Emanuel’s position is wrong. If we are to control healthcare costs, we need to find some way of doing it other than to expect (or, more likely, coerce) physicians to place the needs of society ahead of the needs of their individual patients.

But if we are to be honest, we must note that Emanuel’s position here is not particularly bizarre, remarkable, or even out of the medical mainstream (as it is portrayed by right-wingers). Indeed, Emanuel is merely espousing the official position already taken by respected medical organizations around the world. The classic doctor-patient relationship has been formally repealed, and covertly rationing healthcare by physicians at the bedside has  been officially declared ethical.

So Emanuel’s complaints regarding the Hippocratic Oath are actually not a petition for its repeal; that’s already happened. Rather, he is merely expressing his concern that too many doctors have refused to get the message. So while DrRich disagrees with Emanuel’s stance on the Hippocratic Oath and on the fundamental obligations of the physician, there is not anything particularly alarming, unusual, or even contrary to formal medical ethics here. If Emanuel deserves demonization on this point, then so does the medical establishment whose position he is supporting.

In summary, DrRich finds nothing really egregious in the actual writings of Ezekiel Emanuel, and believes  the right-wing is wrong for attacking him so vociferously. Emanuel seems to be a highly intelligent, rational and straightforward thinker, and there is much to like in his writings on healthcare rationing. If he is serious about requiring public “buy in” before healthcare rationing can be implemented, then any objectionable positions he has taken must necessarily be subject to negotiation.  DrRich believes that such a position can only be considered entirely reasonable.

To a large extent, it appears to DrRich that the attacks against Dr. Emanuel are based less on what he has actually said and written, and more on the fact that he is a very influential adviser who has openly and extensively addressed the need to ration healthcare, and has suggested ideas on how to do it. (Which makes DrRich glad he himself and his thoughts on healthcare rationing have remained almost completely unknown and unnoted.  Faced with the attacks Dr. Emanuel is enduring, DrRich would probably be reduced to curling up into a little ball, uttering great, gasping sobs.)

But at least one aspect of Emanuel’s writings remains quite disturbing to DrRich - the notion that healthcare rationing should be based at least partially on the intrinsic worth of individuals to society. This idea is not merely a minor detail. Rather, it must necessarily reflect a basic premise regarding the proper relationship of the individual to the collective. It is a premise that differs in a fundamental way from the premise of the Great American Experiment.

Perhaps DrRich is mistaken about Emanuel’s basic precepts. He hopes so. For it is one thing to be willing to negotiate, but effective negotiation between equals requires some meeting of the mind on fundamental, underlying principles.

DrRich’s synthesis of Dr. Emanuel’s positions on healthcare rationing reinforces a key point that has been emphasized here before - that before we can hope to effectively reform our healthcare system, we must first decide what kind of society we are to be. Is America’s foundational precept (which “inalienably” establishes the primacy of the individual) to hold sway, or are we instead to abandon that precept in favor of some other, newer one that awards primacy to the collective?

This is the fundamental question, and whether we answer it explicitly or implicitly (perhaps by means of the decisions we make as we reform our healthcare system), one way or another we are going to answer it, both for ourselves and for our posterity.

Comments

12 Responses to “Is Ezekiel Emanuel Really Evil?”

  1. Red Baron on September 15th, 2009 9:03 pm

    I hear your point but I think most people would be fair if they lumped you two together.

    I think the nuances you are making are far beyond the ability of any society to understand much less get agreement around.

    The idea of our society recognizing its cognitive dissonance and accepting rationing at all would be totally hitting a ball out of the park imo.

    The rest is just theological fine point- real, but trivial in comparison and likely to practically make a difference with only a very small number of people.

  2. not a panty waste on September 15th, 2009 9:14 pm

    Dr Emanuel makes perfect sense to me, a practicing MD. DrRich is a a buffoon and should shut his ignorant mouth.

  3. Jupe on September 16th, 2009 12:16 am

    Here’s a paper of his from 1996:

    http://www.ncpa.org/pdfs/Where_Civic_Republicanism_and_Deliberative_Democracy_Meet.pdf

    “This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources. Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity-those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic. Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia. A less obvious example is guaranteeing neuropsychological services to ensure children with learning disabilities can read and learn to reason.”

    I think he’s a creep.

  4. DrRich on September 16th, 2009 5:52 am

    Jupe,

    I agree that, once we give the central authority the power to determine which people are worthwhile and which are not, some very unpleasant outcomes can be easily imagined - and indeed, become almost inevitable. In in my view that’s the entire crux of the problem. If the good of the collective is really the paramount concern, if “redistributive justice” is to be the chief tool, then an all-powerful central authority is absolutely necessary, so that wealth and vital services (such as healthcare) can best be distributed to those individuals who best suit the needs of the collective.

    Rich

  5. DrRich on September 16th, 2009 6:07 am

    Not a PW,

    I have constructed a lengthy, detailed and dispassionate analysis of Dr. Emanuel’s writings, in the spirit of engaging in civil debate, expressly for the purpose of illustrating how one ought to take on the opposition without resorting to the much lower form of discourse known as ad hominem attacks, such as have been aimed at, for instance, Sarah Palin. In so doing, I have demonstrated (successfully, I think) that doing so: a) is a relatively difficult exercise, and b) may result in a product that many readers may not be able (or willing) to fully digest and/or appreciate.

    You, on the other hand, in your considered reply, have chosen to fire off a simple insulting statement that effectively dismisses any comment I might care to make, no matter how carefully and politely constructed, or how compelling the reasoning behind it might be.

    I actually find myself rethinking my premise on the benefits of civil debate. So let me try something a little different:

    You, sir, are a jackass.

    You know, that felt pretty good.

    Rich

  6. DrRich on September 16th, 2009 6:11 am

    Red,

    You are probably correct. And I (as others in this comment stream have so succinctly pointed out) am probably not the right person to try.

    But the point remains that if we allow the central authority to set up distributive policies based on its own determination of which individual Americans are intrinsically worthy and which are not, then we are giving up everything.

    I hope someone else can make this case to the people, or we are screwed.

    Rich

  7. Red Baron on September 16th, 2009 7:23 am

    Rich, you know I respect your opinion and on this but I think I may be a little more of a nihilist than you.

    While I see your point, at some level the collective is going to do what it is going to do regardless of what you and I think/want/believe in or think the collective should believe.

    … Personally, I am not always sure the collective itself always knows what it is doing ;-)

    There is an element of “shit happens” to life and human collective behavior that one just has to shake his head at in bewilderment from time to time

  8. Jupe on September 16th, 2009 12:33 pm

    Dr Rich,
    You know, it’s weird, because in the case of a limited supply of an effective vaccine during a deadly epidemic, it doesn’t weird me out to think of docs and nurses being prioritized over, say, me. Or a hypothetical situation of military leaders being prioritized in the event of bio warfare. So it’s not that collectivism inherently offends me across the board.

    In my mind there seems to be some sort of invisible line in there somewhere, but I can’t identify what it’s based on or exactly where it’s at, or why. I just know when it’s been crossed.(And “Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.” just screams “line WAY WAY WAY CROSSED! HOLY CRAP!” to me.)

    I know (well, deeply suspect) there actually is a fundamental difference between “doctors, nurses and military first to be immunized in the event
    of a bio-warfare attack” and “no antibiotics for the feeble minded” but I can’t pinpoint it outside of “it just intuitively seems right/wrong”.

  9. DrRich on September 16th, 2009 5:57 pm

    Jupe,

    Your question is a good one and deserves more than just a dash-off reply. I will try to compose a post that addresses your question in the next couple of days.

    Rich

  10. Reality Rounds on September 16th, 2009 11:16 pm

    “You, sir, are a jackass.”
    Tee hee. Dr. Rich is this a take on the POTUS and Kanye? You know who Kanye is right?

  11. DrRich on September 17th, 2009 5:04 am

    Reality Rounds,

    I’m pretty sure I viewed a video of a person by that name grabbing a microphone away from a waif who had been using it to inarticulately mutter some phrase of gratitude for something or other, then to use that microphone to loudly praise yet a third party in this little drama, while the waif stood by mutely grasping some sort of metallic utensil like it had been a favorite doll.

    My impression, judging from the voice-over from a news commentator, was that we in the viewing audience were to have heard of this Kanye even before this notable event. But I cannot imagine why that would be.

    And later I heard an audio of the President pronouncing some person a jackass, though it was unclear to me if this reference was toward this Kanye, Congressman Joe Wilson, or Glenn Beck. In any case, when I decided to stick my toe into the ad hominem attack waters, I felt relatively safe (on political correctness grounds) choosing a word favored by Mr. Obama.

    Rich

  12. Al Neustadter on September 24th, 2009 2:28 pm

    I agree that Zeke’s logic is derailed by his suggestion that the very young also be given less treatment because society’s investment in them has been minimal compared to, say, a high-schooler. If we allow such exceptions to contaminate our rationing there is no end to what might be equally appropriate. In my father’s case he lost a wife and 3-year old daughter in Auschwitz, which might work in his favor in terms of getting some extra health care brownie points. He also hit the ground running in this country at the age of 35, consuming no prior health care or educational resources here, while starting a business that generated jobs and tax payments almost immediately. Some extra credit for that too?

    From a purely secular point of view (not mine,) if the rationing criteria is based on age alone, ie that by allocating ‘x’ amount of our limited resources we are getting ‘x’ many more years of precious life with a 10-year-old than with a 90-year-old, I can accept it — provided there is transparency; provided the patient is told the truth up front and can at least potentially scramble to get more care if he so chooses.

    If my father had been given the opportunity pay for a premium level of service that he otherwise couldn’t have gotten by virtue of being above a FECCER-determined age cutoff, he would have accepted the situation and bought the most extensive and aggressive treatment available with his hard-earned money. In his particular case he would likely have survived his hospitalization and gone on to stimulate the economy with rehab, 24/7 home care, etc. This he would have gladly paid for out of pocket, as there were no painful or deal-breaking diseases, he was previously healthy and enjoyed being alive. Although he was a drain on Social Security, he received a generous restitution from Germany each month, and that, combined with willingness to spend his money on any supplemental health care denied him by his insurance would have been a strong net plus on the economy. And the fair and just thing. Covert rationing ruined it all.

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