Ezekiel Emanuel, Obama’s Rationing Czar, Says We Have Too Much Health Care
by Betsy McCaughey
August 28, 2009
LifeNews.com Note: Betsy McCaughey is chairman of the Committee to Reduce Infection Deaths and a former lieutenant governor of New York state. This opinion column originally appeared in the Wall St. Journal and does not necessarily represent the complete views of LifeNews.com.
Dr. Ezekiel Emanuel, health adviser to President Barack Obama, is under scrutiny. As a bioethicist, he has written extensively about who should get medical care, who should decide, and whose life is worth saving.
Dr. Emanuel is part of a school of thought that redefines a physicians duty, insisting that it includes working for the greater good of society instead of focusing only on a patients needs. Many physicians find that view dangerous, and most Americans are likely to agree.
The health bills being pushed through Congress put important decisions in the hands of presidential appointees like Dr. Emanuel. They will decide what insurance plans cover, how much leeway your doctor will have, and what seniors get under Medicare.
Dr. Emanuel, brother of White House Chief of Staff Rahm Emanuel, has already been appointed to two key positions: health-policy adviser at the Office of Management and Budget and a member of the Federal Council on Comparative Effectiveness Research. He clearly will play a role guiding the White House’s health initiative.
Dr. Emanuel says that health reform will not be pain free, and that the usual recommendations for cutting medical spending (often urged by the president) are mere window dressing. As he wrote in the Feb. 27, 2008, issue of the Journal of the American Medical Association (JAMA): "Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely ‘lipstick’ cost control, more for show and public relations than for true change."
True reform, he argues, must include redefining doctors’ ethical obligations. In the June 18, 2008, issue of JAMA, Dr. Emanuel blames the Hippocratic Oath for the "overuse" of medical care: "Medical school education and post graduate education emphasize thoroughness," he writes. "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."
In numerous writings, Dr. Emanuel chastises physicians for thinking only about their own patient’s needs. He describes it as an intractable problem: "Patients were to receive whatever services they needed, regardless of its cost. 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. . . . Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold down costs." (JAMA, May 16, 2007).
Of course, patients hope their doctors will have that single-minded devotion. But Dr. Emanuel believes doctors should serve two masters, the patient and society, and that medical students should be trained "to provide socially sustainable, cost-effective care." One sign of progress he sees: "the progression in end-of-life care mentality from ‘do everything’ to more palliative care shows that change in physician norms and practices is possible." (JAMA, June 18, 2008).
"In the next decade every country will face very hard choices about how to allocate scarce medical resources. There is no consensus about what substantive principles should be used to establish priorities for allocations," he wrote in the New England Journal of Medicine, Sept. 19, 2002. Yet Dr. Emanuel writes at length about who should set the rules, who should get care, and who should be at the back of the line.
"You can’t avoid these questions," Dr. Emanuel said in an Aug. 16 Washington Post interview. "We had a big controversy in the United States when there was a limited number of dialysis machines. In Seattle, they appointed what they called a ‘God committee’ to choose who should get it, and that committee was eventually abandoned. Society ended up paying the whole bill for dialysis instead of having people make those decisions."
Dr. Emanuel argues that to make such decisions, the focus cannot be only on the worth of the individual. He proposes adding the communitarian perspective to ensure that medical resources will be allocated in a way that keeps society going: "Substantively, it suggests services that promote the continuation of the politythose that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberationsare to be socially guaranteed as basic. Covering 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." (Hastings Center Report, November-December, 1996)
In the Lancet, Jan. 31, 2009, Dr. Emanuel and co-authors presented a "complete lives system" for the allocation of very scarce resources, such as kidneys, vaccines, dialysis machines, intensive care beds, and others. "One maximizing strategy involves saving the most individual lives, and it has motivated policies on allocation of influenza vaccines and responses to bioterrorism. . . . Other things being equal, we should always save five lives rather than one.
"However, other things are rarely equalwhether to save one 20-year-old, who might live another 60 years, if saved, or three 70-year-olds, who could only live for another 10 years eachis unclear." In fact, Dr. Emanuel makes a clear choice: "When implemented, the complete lives system produces a priority curve on which individuals aged roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get changes that are attenuated (see Dr. Emanuel’s chart nearby).
Dr. Emanuel concedes that his plan appears to discriminate against older people, but he explains: "Unlike allocation by sex or race, allocation by age is not invidious discrimination. . . . Treating 65 year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not."
The youngest are also put at the back of the line: "Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments. . . . As the legal philosopher Ronald Dworkin argues, ‘It is terrible when an infant dies, but worse, most people think, when a three-year-old dies and worse still when an adolescent does,’ this argument is supported by empirical surveys." (thelancet.com, Jan. 31, 2009).
Read the complete opinion column here.
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