The Doctor Is In
A Conversation With Ezekiel Emanuel, Number Cruncher, M.D.

Sunday, August 16, 2009

Before Ezekiel Emanuel joined his brother Rahm in the White House, he was director of the National Institute of Health's clinical bioethics programs and an oncologist specializing in breast cancer. Since he began advising President Obama's budget chief, Peter Orszag, on health care, he's become a surprisingly high-profile figure. A recent New York Post article dug through his academic papers and branded Emanuel one of Obama's "deadly doctors," accusing him of everything from wanting to refuse health care to the elderly to wanting to let the developmentally disabled perish. Reached in Italy last week, the man the New Republic called "the nicest" Emanuel brother struck back at his critics in a conversation with The Washington Post's Ezra Klein. Excerpts:

We've heard harsh accusations in the health-care debate lately, including Sarah Palin's contention that you want "death panels" and Rep. Virginia Foxx's charge that Democrats want "to put seniors in a position of being put to death by their government." So, do you want to euthanize my grandmother?

No. I've never met your grandmother. I'm sure she's a lovely lady.

Anybody else's grandmother?

No. I'm on record against legalizing euthanasia and assisted suicide for over a decade now.

The New York Post quoted a 1996 article you wrote saying that some people believe health-care resources shouldn't go to those "who are irreversibly prevented from being or becoming participating citizens." What was your point?

I was examining two different, abstract philosophical positions to see what they might offer in the context of redoing the health-care system and trying to reduce resource consumption in health care. It's as abstractly philosophical as you can get on a practical question. I qualified it in 27 different ways, saying it wasn't my view.

Before you joined the White House, you were a bioethicist. What does a bioethicist do?

Worries about some of the hardest questions society has to face. One of the quotes in the New York Post came from an article we recently published in the Lancet where the question we were confronting may be the most difficult question the health-care system faces every day. We don't have enough solid organs for transplantation; not enough kidneys, livers, hearts, lungs. When you get a liver and you have three people who need it, who should get it? We tried to come up with an ethically defensible answer. Because we have to choose.

Our system is expensive in part because we've refused to answer some of these questions, like how we deal with end-of-life care, or what minimum benefits should be guaranteed to every American. But isn't not answering those questions a sort of answer, too?

Yeah. You can't avoid these questions. Even if you don't provide an overt justification for them, you end up making decisions. Sometimes those aren't good decisions, or they're decisions you regret. We had a big controversy in the United States when there were 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.

Many see the health-care system as aimed at preventing death, and whenever someone dies, that's a failure. So we don't build in options around death because that would be admitting the possibility of failure.

Having been an oncologist and having cared for scores, if not hundreds, of dying patients, when you don't have a treatment that can shrink the tumor and the patient will die, it's a very difficult conversation. It's emotionally draining. Then to talk to the family and figure out how to give the best quality of life in the final weeks or months -- those are hard decisions.

You've argued that one of the reasons we've had trouble achieving universal health care is that we don't have an agreed-upon ethical system for health care. As such, we don't argue from common premises and no one trusts each other.

Issues that we cannot seem to resolve in our society reflect a lack of shared values. The situation around Terri Schiavo was a deeply held conflict over what to do if someone isn't going to return to consciousness or competence. Who will decide? Even there, where we had settled legal rules, we still had disagreement. We're torn about these things.

Are the bills under consideration dealing with these problems?

Fifteen years ago, I thought that cost growth meant we would have to confront the rationing question. But the more I studied it, the less I think rationing of health care is the key question. The bigger question seems to be improving the quality and efficiency of the system. We have a lot of unnecessary care. The big issue here is how to redesign the health-care delivery system so we're doing the appropriate data-driven care that we know will improve someone's life and not doing unnecessary, and potentially harmful, care.

So it's not rationing if you don't need it?

I think we have so much unnecessary care that's not improving quality of life or length of life, that our first order of business is to get rid of that. That, we can all agree on. We need to change incentives, change how doctors behave and make decisions, so they're more focused on what the data shows.

To switch gears, you're a foodie.

We're going from euthanasia and rationing to food?

Washington isn't known for being friendly to your kind. What's your favorite restaurant here?

A series of great meals at Cafe Atlantico. A quasi-Minibar they made for me was wonderful. I was there two weeks ago. They served about six or eight hors d'oeuvres, and then they had this series of small entrees that were spectacular. The crescendo was a duck confit that was brilliant.

I hear you're also trying to change how the federal government eats.

President Obama, about two months ago, had a number of CEOs of major American corporations explain how they improve the health and wellness of their workforce. I was charged with applying their ideas to the federal workforce. One of their ideas was to change the food and nutrition available to workers. Both at cafeterias and vending machines, giving them healthier options and subsidizing more nutritious foods, but also making available to them better foods they can bring home through farmers markets.

What is your brother Rahm's favorite food?

Good question. I don't know, actually.

I've heard it's the still-beating hearts of his enemies.

Oh, my brother is a lovely person. He doesn't do any of that.

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