Emanuel in June 2009
|Born||Ezekiel Jonathan Emanuel
|Fields||Medicine, medical ethics|
|Institutions||University of Pennsylvania|
|Alma mater||Harvard University (M.D., Ph.D.)
University of Oxford (M.Sc.)
Amherst College (B.A.)
Ezekiel Jonathan "Zeke" Emanuel (born 1957) is an American bioethicist and fellow at the nonprofit bioethics research institute The Hastings Center. He opposes legalized euthanasia, and is a proponent of a voucher-based universal health care. Before joining the National Institutes of Health in 1998 he was an associate professor at the Harvard Medical School, and as of September 2011 he serves as the Diane and Robert Levy University Professor at the University of Pennsylvania, where he holds a joint appointment at the University of Pennsylvania School of Medicine and the Wharton School.
Emanuel is the son of Benjamin M. Emanuel and Marsha (Smulevitz) Emanuel, and is a divorced father of three daughters. His two younger brothers are Chicago mayor Rahm Emanuel and Hollywood-based talent agent Ari Emanuel. He has an adopted sister, Shoshana Emanuel.  His father’s brother, Emanuel, was killed in the 1936 Arab Riots in the British Mandate of Palestine, after which the family changed its name from Auerbach to Emanuel in his honor.
His father, Benjamin M. Emanuel, is a Jerusalem-born pediatrician who was once a member of the Irgun, a Jewish paramilitary organization that operated in Mandate Palestine. He provided free care to poor immigrants and led efforts to get rid of lead paint due to its negative consequences for children. Emanuel’s mother, Marsha, a nurse and psychiatric social worker who was raised in the North Lawndale community on Chicago's West Side, was active in civil rights, including the Congress of Racial Equality (CORE). She attended marches and demonstrations with her children. Emanuel recalled in a 2009 interview that, in his childhood, "worrying about ethical questions was very much part and parcel of our daily routine."
As children, the three Emanuel brothers shared a bedroom, wrestled and played football in the family room, and spent summers together in Israel. All three brothers took ballet lessons in their childhood, which Emanuel says "hardened us and taught us that if you do something unusual, people will take potshots at you."
Emanuel and his brother Rahm frequently argue about healthcare policy. Emanuel mimics his brother's end of the conversation: "You want to change the whole healthcare system, and I can’t even get SCHIP [State Children’s Health Insurance Program] passed with dedicated funding? What kind of idiot are you?"
Emanuel has a sister with cerebral palsy. His daughter Gabrielle, a 2010 graduate of Dartmouth College, won a Rhodes scholarship in November 2010. Another daughter, Natalia, is a student at Yale University and former co-editor and chief of the Hoofbeat, the Northside Prep High School newspaper.
A straight-A student in his youth, Emanuel was so interested in science at an early age that his grandfather brought home a cow heart and lung from his meat business for his grandson to dissect.:2 Emanuel graduated from Amherst College in 1979 and subsequently received his M.Sc. from the University of Oxford in Biochemistry. He simultaneously studied for an M.D. and a Ph.D. in Political Philosophy from Harvard University, receiving the degrees in 1988 and 1989, respectively. Emanuel completed an internship and residency at Beth Israel Hospital in internal medicine. Subsequently, he undertook fellowships in medicine and medical oncology at the Dana-Farber Cancer Institute, and is a breast oncologist. Emanuel received dozens of honors and awards, including the Toppan Dissertation Prize, the Harvard award for best political science dissertation of 1988.
After completing his post-doctoral training, Emanuel pursued a career in academic medicine, rising to the level of associate professor at Harvard Medical School in 1997. He soon moved into the public sector, and held the position of Chief of the Department of Bioethics at the Clinical Center of the U.S. National Institutes of Health. Currently, Emanuel is acting as Special Advisor for Health Policy to Peter Orszag, the Director of the Office of Management and Budget. The Office of Management and Budget's role is to assist the White House in the preparation and administration of the federal budget. Emanuel entered the administration with different views from the president on how to reform health care, but is said by colleagues to be working for the White House goals. Since September 2011, Emanuel has headed the Department of Medical Ethics & Health Policy at the University of Pennsylvania, where he also serves as a Penn Integrates Knowledge Professor, under the official title Diane S. Levy and Robert M. Levy University Professor.
Portable health insurance
In articles and in his book Healthcare, Guaranteed, Emanuel said that universal health care could be guaranteed by replacing employer paid health care insurance, Medicaid and Medicare with health care vouchers funded by a value-added tax. His plan would allow patients to keep the same doctor even if they change jobs or insurance plans. He would reduce co-payments for preventive care and tax or ban junk food from schools. He criticized the idea of requiring individuals to buy health insurance. However, he supports Obama's plans for health care reform, even though they differ from his own.
In the article Why Tie Health Insurance to a Job?, Emanuel said that employer based health insurance should be replaced by state or regional insurance exchanges that pool individuals and small groups to pay the same lower prices charged to larger employers. Emanuel said that this would allow portable health insurance even to people that lose their jobs or change jobs, while at the same time preserving the security of employer based health benefits by giving consumers the bargaining power of a large group of patients. According to Emanuel, this would end discrimination by health insurance companies in the form of denial of health insurance based on age or preexisting conditions. In Solved!, Emanuel said that Universal Healthcare Vouchers would solve the problem of rapidly increasing health care costs, which, rising at three times the rate of inflation, would result in higher copayments, fewer benefits, stagnant wages and fewer employers willing to pay for health care benefits.
In an article co-written by Ezekiel Emanuel and Victor Fuchs, Emanuel co-wrote that employer-based health insurance has "inefficiencies and inequities", that Medicaid is "second-class" and that insuring more people without replacing those systems would be to build on a "broken system". He said, "in the short run they require ever more money to cover the uninsured, and in the long run the unabated rise in health costs will quickly revive the problem of the uninsured." He suggested that a federal agency be created to test the effectiveness of new health care technology.
As Emanuel co-wrote,
At $2 trillion per year, the U.S. health-care system suffers much more from inefficiency than lack of funds. The system wastes money on administration, unnecessary tests and marginal medicines that cost a lot for little health benefit. It also provides strong financial incentives to preserve such inefficiency.
By building on the existing health-care system, these reform proposals entrench the perverse incentives.
Moreover, even plans that reduce the number of uninsured today may find that those gains will disappear in a few years if costs continue to grow much faster than gross domestic product. As costs rise, many companies will drop insurance and pay the modest taxes or fees that have been proposed. States will find that costs exceed revenue and that cuts will have to be made.
Emanuel said that replacing employer-based health insurance and programs like Medicaid would "improve efficiency and provide cost control for the health-care system."
Emanuel and Fuchs reject a single-payer system, because it goes against American values of individualism. "The biggest problem with single-payer is its failure to cohere with core American values. Single-payer puts everyone into the same system with the same coverage and makes it virtually impossible to add amenities and services through the private market."
The ends of human life
In his book The Ends of Human Life Emanuel used the AIDS patient "Andrew" as an example of moral medical dilemmas. Andrew talked to a local support group and signed a living will asking that life sustaining procedures be withdrawn if there is no reasonable expectation of recovery. The will was not given to anyone but kept in his wallet, and no one was given power of attorney. There were questions about his competence since he had AIDS dementia when he signed the will. Still, Andrew's lover said that he had talked about such situations, and asked that Andrew be allowed to die. Andrew's family strongly disagreed that Andrew wanted to die. Dr. Wolf previously saved Andrew's life, but promised to help him avoid a "miserable death". The ICU wanted guidance from Dr. Wolf as to how aggressively they should try to keep Andrew alive, as his chances of surviving a cardiac arrest were about zero. Two other critical patients were recently refused admission because of a bed shortage. There was a question as to whether Andrew's lover was representing Andrew's wishes or his own. There was also a question as to whether Andrew’s parents knew Andrew better than others, or whether they were motivated by guilt from rejecting Andrew's identification as a gay male. The cost of aggressive treatment was $2,000.00 per day.
This dilemma illustrates the ethical challenges faced by even the most conscientious physicians, in addition to patient confidentiality, the meaning of informed consent, and the ethics of experimental treatments, transplanting genes or brain tissue. Also, while many agree that every citizen should be given adequate health care, few agree on how to define what adequate health care is. Many of these issues have become almost impossible to solve moral dilemmas. Babies that would be born with serious birth defects pose a serious moral dilemma, and medical technology makes it sometimes difficult to define what death is in the case of permanently brain damaged patients on respirators. There are also ethical questions on how to allocate scarce resources. However, the Hippocratic Oath is proof that medical technology is not the cause of medical questions about ethics.
Emanuel said the Hippocratic Oath and the codes of modern medical societies require doctors to maintain client patient confidentiality, refrain from lying to a patient, and keep patients informed and obtain their consent, in order to protect the patient from manipulation and discrimination. Emanuel said that a doctor’s oath would never allow him to administer a lethal injection for capital punishment as a doctor, although the issue would be different if he were asked to serve on a firing squad not as a doctor but rather as a citizen. He said that in the case of mercy killing there are rare cases where the medical obligation to relieve suffering would be in tension with the obligation to save a life, and that a different argument (an argument that intentional killing "should not be used to achieve the legitimate ends of medicine") would be required instead.
Emanuel said there is often a need to balance different values: As Emanuel said,
To know whether it is ethical to turn off the respirator for a quadriplegic patient requires conceptions of personal identity, a worthy human life, murder and suicide; to know how much information a doctor must provide a cancer patient to obtain proper informed consent for an experimental therapy requires conceptions of autonomy, coercion and the public good and how to balance these values; to know whether to break the AIDS patient’s confidentiality and inform his wife requires a framework for weighing the relative importance of competing individual rights as well as the public good.
One reason such issues seem impossible to solve is because of the belief that public policy should be neutral, without trying to select one definition of the public good over another. Emanuel believes that "liberal communitarianism" could be the answer. Citizens, according to this view, should be given rights needed to participate in democratic deliberations based on a "common conception of the good life". For example, vouchers could be granted through thousands of Community Health Programs (CHPs), each of which would agree on its own definition of the public good. Each CHP would decide which services would be covered as basic, and which services would not be covered.
Opposition to legalization of euthanasia
Emanuel said that legalizing euthanasia, as was done in the Netherlands, might be counterproductive, in that it would decrease support for pain management and mental health care. However, Emanuel does support the use of Medical Directives to allow patients to express their wishes when they can no longer communicate. Ezekiel, and his former wife Linda Emanuel, an M.D. Ph.D. bioethicist and geriatrician, created the Medical Directive, which is described as more specific and extensive than previous living wills and is a third generation Advance Directive. He claims the Hippocratic Oath debunks the theory that opposition to euthanasia is modern. Emanuel said that for the vast majority of dying patients, "legalizing euthanasia or physician-assisted suicide would be of no benefit. To the contrary, it would be a way of avoiding the complex and arduous efforts required of doctors and other health-care providers to ensure that dying patients receive humane, dignified care." Emanuel said that a historical review of opinions on euthanasia from ancient Greece to now "suggests an association between interest in legalizing euthanasia and moments when Social Darwinism and raw individualism, free markets and wealth accumulation, and limited government are celebrated."
Emanuel said that it is a myth that most patients who want to die choose euthanasia because they are in extreme pain. He said that in his own experience, "those with pain are more likely than others to oppose physician-assisted suicide and euthanasia." He said that patients were more likely to want euthanasia because of "depression and general psychological distress ... a loss of control or of dignity, of being a burden, and of being dependent." He also said that the kind of legalized euthanasia practiced in the Netherlands would lead to an ethical "slippery slope" which would make it easier for doctors to rationalize euthanasia when it would save them the trouble of cleaning bedpans and otherwise caring for patients who want to live. He said that legalized euthanasia in the Netherlands did not adhere to all the legal guidelines, and that some newborns were euthanised even though they could not possibly have given the legally required consent. As Emanuel said, "The Netherlands studies fail to demonstrate that permitting physician-assisted suicide and euthanasia will not lead to the nonvoluntary euthanasia of children, the demented, the mentally ill, the old, and others. Indeed, the persistence of abuse and the violation of safeguards, despite publicity and condemnation, suggest that the feared consequences of legalization are exactly its inherent consequences."
Emanuel also expressed the concern that budgetary pressures might be used to justify euthanasia if it were legal. As Emanuel said,
There is one final matter to consider: the possibility that euthanasia not only would be performed on incompetent patients in violation of the rules—as an abuse of the safeguards—but would become the rule in the context of demographic and budgetary pressures on Social Security and Medicare as the Baby Boom generation begins to retire, around 2010. Once legalized, physician-assisted suicide and euthanasia would become routine. Over time doctors would become comfortable giving injections to end life and Americans would become comfortable having euthanasia as an option. Comfort would make us want to extend the option to others who, in society's view, are suffering and leading purposeless lives. The ethical arguments for physician-assisted suicide and euthanasia, advocates of euthanasia have maintained, do not apply to euthanasia only when it is voluntary; they can also be used to justify some kinds of nonvoluntary euthanasia of the incompetent.
Emanuel said that while there might be some exceptions to the rule, legalizing euthananasia would be too dangerous. As Emanuel said (emphasis in the original),
The proper policy, in my view, should be to affirm the status of physician-assisted suicide and euthanasia as illegal. In so doing we would affirm that as a society we condemn ending a patient's life and do not consider that to have one's life ended by a doctor is a right. This does not mean we deny that in exceptional cases interventions are appropriate, as acts of desperation when all other elements of treatment—all medications, surgical procedures, psychotherapy, spiritual care, and so on—have been tried. Physician-assisted suicide and euthanasia should not be performed simply because a patient is depressed, tired of life, worried about being a burden, or worried about being dependent. All these may be signs that not every effort has yet been made. 
Emanuel said that claims of cost saving from assisted suicide are a distortion, and that such costs are relatively small, including only 0.1 percent of total medical spending.
The controversy surrounding Emanuel is due to claims by Betsy McCaughey and Sarah Palin accusing Emanuel of supporting euthanasia. Emanuel has opposed euthanasia. These claims have been used by Republicans opposing health care reform.
Betsy McCaughey described Ezekiel Emanuel as a "Deadly Doctor" in a New York Post opinion article. The article, which accused Emanuel of advocating healthcare rationing by age and disability, was quoted from on the floor of the House of Representatives by Representative Michele Bachmann of Minnesota. Sarah Palin cited the Bachmann speech and said that Emanuel's philosophy was "Orwellian" and "downright evil", and tied it to a health care reform end of life counseling provision she claimed would create a "death panel". Emanuel said that Palin's death panel statement was "Orwellian". Palin later said that her death panel remark had been "vindicated" and that the policies of Emanuel are "particularly disturbing" and "shocking". On former Senator Fred Thompson's radio program, McCaughey warned that "the healthcare reform bill would make it mandatory—absolutely require—that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner." She said those sessions would help the elderly learn how to "decline nutrition, how to decline being hydrated, how to go in to hospice care ... all to do what's in society's best interest or in your family's best interest and cut your life short." As The New York Times mentioned, conservative pundits were comparing the Nazi T4 euthanasia program to Obama’s policies as far back as November 2008, calling them "America's T4 program—trivialization of abortion, acceptance of euthanasia, and the normalization of physician assisted suicide."
The nonpartisan Politifact.com Web site described McCaughey's claim as a "ridiculous falsehood." FactCheck.org said, "We agree that Emanuel’s meaning is being twisted. In one article, he was talking about a philosophical trend, and in another, he was writing about how to make the most ethical choices when forced to choose which patients get organ transplants or vaccines when supplies are limited." An article on Time.com said that Emanuel "was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources ... 'My quotes were just being taken out of context.'" A decade ago, when many doctors wanted to legalize euthanasia or physician-assisted suicide, Emanuel opposed it. Emanuel said the "death panel" idea is "an outright lie, a complete fabrication. And the paradox, the hypocrisy, the contradiction is that many of the people who are attacking me now supported living wills and consultations with doctors about end-of-life care, before they became against it for political reasons." "I worked pretty hard and against the odds to improve end-of-life care. And so to have that record and that work completely perverted—it's pretty shocking."
Rep. Earl Blumenauer, D-Ore., who sponsored the end-of-life provision in H.R. 3200 section 1233, said the measure would block funds for counseling that presents suicide or assisted suicide as an option, and called references to death panels or euthanasia "mind-numbing". Blumenauer said that as recently as April 2008 then-governor Palin supported end-of-life counseling as part of Health Care Decisions Day. Palin's office called this comparison "hysterically funny" and "desperate". Republican Senator Johnny Isakson, who co-sponsored a 2007 end-of-life counseling provision, called the euthanasia claim "nuts". Analysts who examined the end-of-life provision Palin cited agreed that it merely authorized Medicare reimbursement for physicians who provide voluntary counseling for advance health care directives (including living wills).
According to Emanuel, the most important life-saving cancer drugs are rationed not by "death panels" but by The Medicare Prescription Drug, Improvement and Modernization Act of 2003, signed by President George W. Bush. The act limits Medicare payments for generic cancer drugs, which cuts profits from producing them and results in shortages.
Emanuel's previous statements on rationing were about the "allocation of very scarce medical interventions such as organs and vaccines" such as who should get a "liver for transplantation". Ezekiel said that McCaughey's euthanasia claims were a "willful distortion of my record". Jim Rutennberg said that Emanuel's critics oversimplified complex issues, such as who should get a kidney. Such rationing was said to be unavoidable because of scarcity, and because a scarce resource such as a liver is "indivisible". Emanuel said that McCaughey took words out of context, omitting qualifiers such as "Without overstating it (and without fully defending it) ... Clearly, more needs to be done ..." Emanuel once compared the word "rationing" to George Carlin’s seven words you can't say on television. In 1994 Emanuel said in testimony before the Senate Finance Committee, "Just because we are spending a lot of money on patients who die does not mean that we can save a lot of money on end of life care." According to PolitiFact, private health insurance companies ration health care by income, by denying health insurance to those with pre-existing conditions and by caps on health insurance payments. Rationing exists now, and will continue to exist with or without health care reform.
Emanuel wrote Where Civic Republicanism and Deliberative Democracy Meet (1996) for the Hastings Center Report. In this article Emanuel questioned whether a defect in our medical ethics causes the failure of the US to enact universal health care coverage. The macro level of the issue is the proportion of total gross national product allotted to health care, the micro level is which individual patient will receive specific forms of health care, e.g., "whether Mrs. White should receive this available liver for transplantation." In between are the basic or essential health care services that should be provided to each citizen. The end-stage renal disease program is an example of a service that increases the total cost of health care, and reduces the amount that can be spent on basic or essential health care.
Emanuel distinguished between basic services that should be guaranteed to everybody from discretionary medical services that are not guaranteed. The result would be a two tiered system, where those with more money could afford more discretionary services. He saw a failure to define basic services as the reason attempts at universal health care coverage have failed. As a result, the belief that universal health care would require unlimited costs makes any attempt at providing universal health care seem likely to end in national bankruptcy. Instead of universal coverage of basic health care, those who are well insured have coverage for many discretionary forms of health care and no coverage for some basic forms of health care. Emanuel said that while drawing a line separating basic and universal health care from discretionary health care is difficult, the attempt should be made. Emaniel mentioned the philosophies of Amy Gutmann, Norman Daniels and Daniel Callahan when arguing that there is an overlap between liberalism and communitarianism where civic republicanism and deliberative democracy meet. According to The Atlantic, Emanuel is describing the philosophy of John Rawls in arguing that society is choosing one value (equality) over another (a healthy society), and this substitution may be responsible for limited choices in health care. PolitiFact says that Emanuel was describing the fact that doctors often have to make difficult choices, such as who should get a liver transplant. PolitiFact also said, "Academics often write theoretically about ideas that are being kicked around. And they repeat and explore those ideas, without necessarily endorsing them."
As Emanuel wrote,
Without overstating it (and without fully defending it) not only is there a consensus about the need for a conception of the good, there may even be a consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues. Communitarians endorse civic republicanism and a growing number of liberals endorse some version of deliberative democracy. Both envision a need for citizens who are independent and responsible and for public forums that present citizens with opportunities to enter into public deliberations on social policies.
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. Clearly, more needs to be done to elucidate what specific health care services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services 
When asked if those who are not "participating citizens" should be denied health care, Emanuel said "No" and "The rest of the text around that quote made it made it pretty clear I was trying to analyze it and understand it, not endorse it."
In 2009, Govind Persad, Alan Wertheimer and Ezekiel Emanuel co-wrote another article on a similar topic in the journal The Lancet. Ezekiel was one of three authors who co-wrote Principles for allocation of scarce medical interventions, which examines eight theoretical approaches for dealing with "allocation of very scarce medical interventions such as organs and vaccines." All eight approaches were judged to be less than perfect, and the Complete Lives system combines most of them.
Treating people equally could be accomplished by lottery or first come first served. A lottery system is simple and difficult to corrupt, but blind in that it would treat saving forty years of life the same as saving four months. A first come first served system seems fair at first, but favors the well off, those who are informed, can travel easily and who push to the front of a line.
Favoring the worst off could be accomplished by favoring the sickest first or by favoring the youngest first. Favoring the sickest appeals to the rule of rescue, but organ transplants don’t always work well with the sickest patients. Also, a different patient could become equally sick in the future. Favoring the youngest saves the most years of life, but a twenty year old has a more developed personality than an infant.
Maximizing total benefits or utilitarianism can be accomplished by saving the most lives or by prognosis (life years). While saving the most lives is best if all else is equal, all else is seldom equal. Going by prognosis alone might unfairly favor improving the health of a person who is healthy to begin with.
Promoting and rewarding social usefulness can be accomplished through instrumental value or by reciprocity. Social usefulness is difficult to define, in that going by conventional values or favoring church goers might be unfair. Instrumental value, such as giving priority to workers producing a vaccine, cannot be separated from other values, like saving the most lives. Reciprocity (favoring previous organ donors or veterans) might seem like justice, but is backward looking and could lead to demeaning and intrusive inquiries into lifestyle.
When resources (organs, vaccines and so forth) are scarce, the Complete Lives systems blends five different approaches (excluding first come first served, sickest first and reciprocity) but is weighted in favor of saving the most years of life. However, it also emphasizes the importance of saving the large investment of nurture and education spent on an adolescent. It would not favor the young when the prognosis is poor and the number of years of life saved would not be great, when dealing with scarcity.
The complete lives system discriminates against older people. Age-based allocation is ageism. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. 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.
When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated (figure).78 It therefore superficially resembles the proposal made by DALY advocates; however, the complete lives system justifies preference to younger people because of priority to the worst-off rather than instrumental value. Additionally, the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them. Conversely, DALY allocation treats life-years given to elderly or disabled people as objectively less valuable ...
Ultimately, the complete lives system does not create "classes of Untermenschen whose lives and well being are deemed not worth spending money on" but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.
Emanuel said the Complete Lives system was not meant to apply to health care in general, but only to a situation where "we don’t have enough organs for everybody who needs a transplant. You have one liver, you have three people who need the liver - who gets it? The solution isn’t ‘We get more livers.’ You can’t. It’s a tragic choice."
Of the 1996 Hastings Center Report, Emanuel said, "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." He also said, "As far as rationing goes, it's nothing I've ever advocated for the health system as a whole, and I've talked about rationing only in the context of situations where you have limited items, like limited livers or limited vaccine, and not for overall health care."
Emanuel said that his words were selectively quoted, and misrepresent his views. He said, "I find it a little dispiriting, after a whole career's worth of work dedicated to improving care for people at the end of life, that now I'm 'advocating euthanasia panels.'" Emanuel spent his career opposing euthanasia and received multiple awards for his efforts to improve end of life care. Emanuel said, "It is incredible how much one's reputation can be besmirched and taken out of context" and "No one who has read what I have done for 25 years would come to the conclusions that have been put out there."
The perfect storm
In The Perfect Storm of Overutilization (Journal of the American Medical Association, June 18, 2008) Emanuel said, "Overall, US health care expenditures are 2.4 times the average of those of all developed countries ($2759 per person), yet health outcomes for US patients, whether measured by life expectancy, disease-specific mortality rates, or other variables, are unimpressive." He said that expensive drugs and treatments that provide only marginal benefits are the largest problems. Fee-for-service payments, physician directed pharmaceutical marketing, and medical malpractice laws and the resultant defensive medicine encourage overutilization. Direct-to-consumer marketing by pharmaceutical companies also drives up costs.
Emanuel co-wrote the following,
At least 7 factors drive overuse, 4 related to physicians and 3 related to patients. First, there is the matter of physician culture. Medical school education and postgraduate training emphasize thoroughness. When evaluating a patient, students, interns, and residents are trained to identify and praised for and graded on enumerating all possible diagnoses and tests that would confirm or exclude them. The thought is that the more thorough the evaluation, the more intelligent the student or house officer. Trainees who ignore the improbable "zebra" diagnoses are not deemed insightful. In medical training, meticulousness, not effectiveness, is rewarded.
This mentality carries over into practice. Peer recognition goes to the most thorough and aggressive physicians. The prudent physician is not deemed particularly competent, but rather inadequate. 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.
According to TIME, Betsy McCaughey said that Emanuel "has criticized medical culture for trying to do everything for a patient, 'regardless of the cost or effects on others,' without making clear that he was not speaking of lifesaving care but of treatments with little demonstrated value." Emanuel made a related comment during a Washington Post interview, when he said that improving the quality and efficiency of healthcare to avoid unnecessary and even harmful care would be a way to avoid the need for rationing.
One reason the high cost of health care yields disappointing results is because only 0.05 percent of health care dollars are spent on assessing how well new health care technology works. This is largely because health care lobbyists oppose such research. For example, when the Agency for Health Care Policy and Research found that there was little evidence to support common back operations, orthopedic and neurosurgeons lobbied to cut funding for such research.
Emanuel said that fee-for-service reimbursements encourage spending on ineffective health care. However, more should be spent on fraud detection, coordinating health services for patients with multiple doctors, and evaluating the effectiveness of new medical technologies such as genetic fingerprints for cancer and better ways of managing intravenous lines.
As Emanuel wrote,
Also, the care that the system delivers is of much poorer quality than Americans realize. Use of unproven, non-beneficial, marginal or harmful services is common. The list of offending interventions that are paid for and widely used but either unproven or of marginal benefit to patients is vast – IMRT and proton beam for early prostate cancer, CT and MRI angiograms, Epogen for chemotherapy induced anemia, Erbitux and Avastin for colorectal cancer, and drug eluting stents for coronary artery disease. Stanford researchers recently showed that between 15 and 20 percent of prescriptions are written for indications for which there is absolutely no published data supporting their use. The Dartmouth study for variation in practices demonstrate that for many interventions, more services are not better. For instance, heart attack patients in Miami receive vastly more care than similar patients in Minnesota at 2.45 times the cost, yet have slightly worse outcomes.
In a Washington Post article Emanuel co-wrote with Shannon Brownlee, Emanuel described our health care system as "truly dysfunctional, often chaotic", "spectacularly wasteful" and "expensive".
As Emanuel co-wrote,
We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name. Life expectancy at birth? We rank near the bottom of countries in the Organization for Economic Cooperation and Development ...
According to the Centers for Disease Control, 1.7 million Americans acquire an infection while in the hospital and nearly 100,000 of them die from it. Laboratory imaging tests are routinely repeated because the originals can't be found. Patients with such chronic illnesses as heart failure and diabetes land in the hospital because their physicians fail to monitor their condition. When patients have multiple doctors, there's often nobody keeping track of the different medications, tests and treatments each one prescribes.
Our doctors and hospitals are failing to provide us with care we need while delivering a staggering amount that we don't need. Current estimates suggest that as much as 20 to 30 percent of what we spend, or about $500 billion, goes toward useless, potentially harmful care.
There are two bright spots. One: We can improve the quality of care and cut costs without rationing. There are models out there for how to do it right -- the Mayo Clinic, the Geisinger Clinic in Pennsylvania, the Cleveland Clinic and California's Kaiser Permanente are just a few of the organized group practices that are doing a better job for less. Their doctors are better than average at using the best medical evidence available. They're more likely to be using electronic medical records, which can help keep track of patients who have multiple physicians and need complex care. And they're less likely to provide unnecessary care.
In What Cannot Be Said on Television About Healthcare Emanuel said,
Life expectancy in the United States is 78 years, ranking 45th in the world, well behind Switzerland, Norway, Germany, and even Greece, Bosnia, and Jordan. The US infant mortality rate is 6.37 per 1000 live births, higher than almost all other developed countries, as well as Cuba ...
The US health care system is considered a dysfunctional mess. Conventional wisdom has been turned on its head. If a politician declares that the United States has the best health care system in the world today, he or she looks clueless rather than patriotic or authoritative.
To many, the specialness of health care meant that cost should not be a consideration in care. Ethical physicians could and should not consider money in deciding what they should do for sick patients. 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, akin to the economist who knew the price of everything but the value of nothing. Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold costs down.
The tipping point came when the media began reporting that the high cost of pharmaceuticals forced some elderly to choose between drugs and food ... When health care began compromising access to other important goods--food, heating, and education--it ceased to be so special it was beyond cost. Today, saying that health care is so special that its cost is irrelevant serves to discredit the source ...
Increasingly, Americans are beginning to be skeptical about whether new health care technologies are better. The tipping point probably came with the withdrawal of rofecoxib from the US market. Today, the list of drugs and technologies for which new might not be better (and may be even worse) has expanded rapidly: postmenopausal hormone therapy, bare-metal stents, megadose antioxidants, selective serotonin reuptake inhibitors for adolescents, Swan-Ganz catheters, gabapentin for bipolar disorder, erythropoietin for anemia, and the list goes on ...
Americans are increasingly aware that structural and systemic problems – lack of electronic medical records, computerized physician orders, and coordination among various clinicians and health care systems – mean these problems affect the rich and the poor alike, that people cannot really buy their way out of unsafe and unreliable care no matter how much money they have.
Conflicts of interest
In the slideshow Conflicts of Interest, Emanuel said that there were conflicts of interest between a physician's primary responsibilities (providing optimal care for patients, promoting patient safety and public health) and a physician's secondary interests (publishing, educating, obtaining research funding, obtaining a good income and political activism). Emanuel said that while it is difficult to know when conflicts of interest exist, the fact that they do is "the truth". When there is no doubt of a conflict, the issue is not a mere conflict of interest but fraud. For example, the makers of Celebrex published only six months of data favoring their drug when twelve months of data was available and indicated that the drug is ineffective.
In Conflict of Interest in Industry-sponsored Drug Development Emanuel said that there is a conflict between the primary interests of drug researchers (conducting and publishing good test results and protecting the patient) and secondary concerns (obligations to family and medical societies and money from industries). However, industry sponsored tests are more likely to use double-blind protocols and randomization, and more likely to preset study endpoints and mention adverse effects. Also, there is no evidence that patients are harmed by such studies. However, there is evidence that money influences how test results are interpreted. Emanuel mentioned the Selfox study on the use of calcium channel blockers in treating hypertension, in which authors with a financial interest in the results reported much better results than the rest. Worse yet, test results sponsored by industry are likely to be widely published only if the results are positive. For example, in a Whittington study for data on selective serotonin reuptake inhibitors, negative results were much less likely to be published than positive results. However, in The Obligation to Participate in Biomedical Research the authors Schaefer, Emanuel and Wertheimer said that people should be encouraged to view participation in biomedical research as a civic obligation, because of the public good that could result.
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- FRESH-Thinking Project Director, FRESH-Thinking Project at Stanford University