Saturday, August 22, 2009
EZEKIEL EMANUEL, one of President Obama's top health advisers, is a respected bioethicist who opposes euthanasia and physician-assisted suicide. When the Supreme Court was considering the constitutionality of state laws that prohibit physician-assisted suicide, Dr. Emanuel was an outspoken opponent of the practice. He warned it could be abused "to justify using euthanasia for children, the incompetent, the mentally ill, and others who are suffering or who we imagine are suffering in some fashion." So it is grotesque that Dr. Emanuel has become the latest bogeyman -- the "Dr. Death" behind the "death panels" -- for opponents of the Obama administration's push for health-care reform.
The case against Dr. Emanuel, brother of White House chief of staff Rahm Emanuel, stems from his writings on how to allocate medical resources in cases of scarcity -- for example, who should get preferences for heart transplants or scarce flu vaccine. The furor was touched off when former New York lieutenant governor Betsey McCaughey, reprising her 1994 role as health-care misleader-in-chief, wrote an op-ed for the New York Post asserting that Dr. Emanuel advocates rationing care and believes "medical care should be reserved for the non-disabled." Dr. Emanuel's view, in Ms. McCaughey's caricature, boils down to: "Don't give much care to a grandmother with Parkinson's or a child with cerebral palsy." These statements distort Dr. Emanuel's thoughtful and nuanced positions. And they have even less to do with the pending health-care proposal.
In a 1996 essay for the Hastings Center Report, Dr. Emanuel struggled with the question of how to determine, in a system where everyone is guaranteed health coverage, what services patients are entitled to. Ms. McCaughey and other critics, including former Alaska governor Sarah Palin, cherry-picked from the piece to quote Dr. Emanuel writing that "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." This would be troubling if it were Dr. Emanuel's view; it isn't. "I never say this is the way we ought to go," Dr. Emanuel told us. "I never say this is the solution to the problem." In any event, Dr. Emanuel said he has since become convinced that there is enough waste in the health-care system that universal coverage can be achieved without rationing.
Critics also point to a January 2009 piece in the Lancet in which Dr. Emanuel and co-authors discuss how to determine which patients should obtain scarce resources such as organs for transplant. The authors consider various possibilities -- lotteries; first-come, first-served; sickest first -- and propose a combined "complete lives" approach that would consider age, prognosis and maximizing lives saved. Importantly, this would not apply to all health care -- only "when genuine scarcity makes saving everyone impossible." Ms. Palin misleadingly describes this as a "rationing system" that "would refuse to allocate medical resources to the elderly, the infirm, and the disabled who have less economic potential."
Dr. Emanuel's writings reveal him to be a thoughtful person grappling with difficult ethical issues. The same cannot be said of his critics, who seem less intent on discussing what is in the health reform proposal than in deploying scare tactics to defeat it.