Dr. Ezekiel Emanuel, the health-policy adviser at the White House’s Office of Management and Budget — who has been caricatured by conservatives as a “Dr. Death” seeking to pull the I.V.s out of your grandparents’ arms in the name of cost containment – is not happy.
Asked by ABC News in an interview about the thoroughly discredited claim by former Alaska Gov. Sarah Palin to paint his philosophical writings as evidence – along with a provision providing optional end of life counseling in the House Democrats’ health care reform bill – that President Obama wants to set up “death panels” to deny medical treatments to seniors and the disabled, including her son Trig, Emanuel, brother of White House chief of staff Rahm Emanuel, does not hold back.
“It’s an absolute outrage that you would take first of all a provision written in the bill,” Emanuel says, a provision allowing for “doctors to talk to patients about end of life care, and turn it into the suggestion that we’re going to have euthanasia boards – that’s a complete misreading of what’s there. It’s just trying to scare people.”
Emanuel says as an oncologist he’s had hundreds of discussions with patients about what to do when treatment doesn’t work.
“It’s wrenching,” he says.
The provision in the House Democrats’ bill is “an acknowledgment doctors should be compensated for making that conversation available,” he says. “It’s not forced – it’s voluntary.”
As for Palin’s vision of “Obama ‘death panels,’” Emanuel argues “there’s no basis for that claim either in any of my writings or the legislation. It has no grounds in reality. It’s surreal and Orwellian, the idea that this legislation or my writings suggest that her son Trig shouldn’t get health care.”
He notes that his sister has Cerebral Palsy, so he is not without personal sympathy for those with disabilities.
An opponent of euthanasia, Emanuel says he “abhor”s people “cavalierly distorting those writings and the work that I’ve done over 25 years to help improve medical care in America for vulnerable people who often have no voice.”
In fact, as an academic he looked into the notion of euthanasia when the “Right to Die” movement started gaining attention and he says he’s been “very solidly consistently against it.” The misperception was prevalent, he says, that those seeking assisted suicide did so because they were “writhing in pain,” when in fact the main motivation for those seeking voluntary euthanasia was depression.
One of the passages written by Emanuel and used as evidence by Palin and others that he would favor withholding medical care from those who aren’t productive members of society include a 1996 contribution to the Hastings Center Report, in which he said that under the “civic republican or deliberative democratic” construct, “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."
Is he saying, as Palin and others have suggested, that those who aren’t “participating citizens” should have no guarantee to health care?
“No,” Emanuel says, “and I think I made it pretty clear I wasn’t endorsing that view, I was analyzing that perspective and what it might mean in practical terms. 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.”
Emanuel acknowledges that philosophical treatises can be difficult to consume and might lend themselves to this kind of misinterpretation. People in the world of academia “tend to know your whole body of work, and when they make a response it tends to be to one line of argument in context.” But that said, “a lot of philosophy can sometimes seem extremely abstract to people and hard to follow — even well-educated people.” He says sometimes he has trouble following a philosophical article. “They’re not necessarily the easiest thing to read.”
(See also our blog “When Academic Words Become Political Ammunition,” July 28.)
In another article used as grist for his critics, in Lancet in January 2009, Emanuel and two co-authors discussed rationing care. But Emanuel cautions the goal of the article was not to apply his views of rationing onto providing health care in general.
“We were examining a very particular situation,” he said.
The situation: “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.” It’s a decision made in the story in the context of “absolute scarcity.”
“it doesn’t apply generally to health care services more broadly,” Emanuel underlines. “Only by ignoring what we say there could anyone come to a different conclusion. Only by taking two sentences out of their complete context.”
In that article Emanuel analyzed eight different views that have been advocated and, with his co-author, argued none are adequate. They combined five views to create the “Complete Life” theory. One of the arguments it that the younger patient should get the liver before the older patient – though Complete Life theory makes exceptions to that rule.
Emanuel points out that there is some support for the positions he takes in that article from public polling, and that none of these discussions are removed from the world – as with the prioritization by the Centers for Disease Control and Prevention for those who are health care workers, or pregnant women, to get the H1N1 vaccine.
“Throughout my career I’ve taken on those kinds of questions,” he says, “ones that people don’t like confronting.” They’re difficult issues, he says, but society already makes decisions, one way or another, about who gets the liver, and how to care for dying patients. “I understand it can make people queasy but there’s no way of escaping it. I hope at the end of the day I can make things better for people, especially vulnerable people.”
The oncologist suggests that his words are being twisted because opponents “don’t have a solution” to the health care reform debate. “Maybe the only tactic is to sow fear and use whatever means you have to attack whether that’s grounded in reality or not… If you don’t have good arguments you use whatever you got, I guess, to say things that are distortive and untrue.”
He says “there have been previous attempts to come after me and after some of my colleagues, but this is certainly on a completely different scale and magnitude. I’ve never been mentioned on Sunday shows in this light and certainly never on the floor of Congress. The distortions are much larger than I’ve ever seen or would have believed could happen.”
Much of the last quarter century he’s spent as an oncologist, he says, has been devoted to improving end of life care in America. He was told when he began exploring some of these issues in the 1980s not to do it.
About 15 years ago he did think rationing was necessary because of cost issues but he has come to change his mind. “The more I’ve looked into it the less I think it’s true,” he says. “We spend a lot of money and resources — hundreds of billions of dollars — for unnecessary care, care that doesn’t help patients,” and in some case might make them sicker by exposing them to hospital-acquired infections.
“We don’t have to raise the issue of denying care, or choosing which people gets services,” he says.