Q: Does Ezekiel Emanuel advocate sacrificing medical care for senior citizens and disabled youths for the good of society?
A: No. Critics of health care legislation are distorting the meaning of Emanuel’s academic writings on medical ethics. And Emanuel tells us, "I am not advocating this."
Is it true that Dr. Ezekiel J. Emanuel, Rahm Emanuel’s older brother and health adviser to President Obama, has advocated "the elderly with dementia and the young who have neurological disorders should be sacrificed for the common good"?
The introduction of Dr. Ezekiel Emanuel, head of the Department of Bioethics at The Clinical Center of the National Institutes of Health, into the health care reform debate came with an opinion piece written by Betsy McCaughey and published in the New York Post on July 24. Dr. Emanuel is also a health care policy adviser for the Office of Management and Budget and brother of President Obama’s chief of staff, Rahm Emanuel.
McCaughey, a former New York lieutenant governor, claimed that Ezekiel Emanuel advocated that "medical care should be reserved for the non-disabled, not given to those ‘who are irreversibly prevented from being or becoming participating citizens.’ " She interprets his words to mean: "Don’t give much care to a grandmother with Parkinson’s or a child with cerebral palsy."
Dr. Emanuel strenuously objects to this interpretation. "This is certainly untrue and a distortion of my record," he told FactCheck.org in a telephone interview. He said that his academic work is being taken completely out of context.
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.
What Emanuel Really Said
McCaughey cites an article Emanuel wrote nearly 15 years ago in the Hastings Center Report, a journal devoted to discussion of ethical issues in medicine. There Emanuel discusses possible philosophical justifications to "distinguish basic from discretionary health care services." Emanuel argued that thinkers on both the left and right were beginning to converge on a single answer when it comes to allocating medical resources. Here’s the quote in full context:
Emanuel, Hastings Center Report, 1996: Communitarians endorse civic republicanism and a growing number of liberals endorse some version of deliberative democracy. … 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. … 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.
Emanuel conceded that the article is "pretty abstract" and may be difficult to follow for those who are not academics, but he said that one should not then "take two sentences out of context."
"This is clearly not written in my own voice," he said. "I am not advocating this."
We’ll leave it to you to determine the merits of Emanuel’s philosophical observations. But the context makes it clear that Emanuel is describing the implications of a particular philosophical trend, not offering a policy prescription.
We’ll also note that Emanuel’s article actually said that children with learning disabilities should get medical help to ensure that they "can read and learn to reason." We’re not sure how McCaughey interpreted this to mean that services should be withheld from "a child with cerebral palsy."
McCaughey also pushes the idea that Emanuel would want to ration care for seniors by quoting from a January 2009 article that Emanuel coauthored in The Lancet journal. Here, McCaughey says, he "explicitly defends discrimination against older patients."
What Emanuel and his two coauthors were actually writing about was how to decide which patients are to receive organ transplants, vaccines or other "very scarce medical interventions" when there are not enough to go around. The three authors advocated favoring younger patients over older patients as part of a "complete lives" decision-making system aimed at saving the most years of life using the available resources. Age would be only one factor, however. Also weighing in the "complete lives" system would be such factors as a patient’s likelihood of full recovery (prognosis) and the use of a lottery when deciding between two "roughly equal" patients.
The authors disputed the idea that this system discriminates against older people in the way that favoring one race or one sex over another would discriminate. "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 authors stated that the complete lives system "empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible."
Emanuel told us that allocating health care services when there is an "absolute scarcity" is "one of the hardest decisions that a physician has to make." He said that he and his fellow authors were pondering "the most ethically coherent way to do that."
There She Goes Again
McCaughey also claims in her article that "presidential appointees" will be deciding "your care" and that Dr. Emanuel should "never be trusted with that power." She’s echoing an earlier false claim about health care rationing that she first trotted out back in February. It’s no more true this time around. A version of the health care bill in Congress, H.R. 3200, does mention creating a comparative effectiveness research center (and a comparative effectiveness commission to oversee the center) to conduct research into how sickness "can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically." A summary of the Senate Health, Education, Labor and Pensions Committee bill also mentions the establishment of a center for similar purposes. But the research wouldn’t be used to dictate health care coverage. The House version of the bill specifically states that the information can’t be used to mandate any policies for either private insurance coverage or for government health insurance:
H.R. 3200: Nothing in this section shall be construed to permit the Commission or the Center to mandate coverage, reimbursement, or other policies for any public or private payer.
So whether or not one might choose to trust Dr. Emanuel with the power to decide "your care," the fact is that no such power is being proposed in the legislation now being considered.
Note: For more on bioethics, please see our FactCheck Wire post, "When Philosophy Meets Politics."
– D’Angelo Gore
McCaughey, Betsy. "Deadly Doctors." New York Post. 24 Jul 2009.
Emanuel, Ezekiel. "Where Civic Republicanism and Deliberative Democracy Meet." The Hastings Center Report. Vol. 26, No. 6. (1996).
Persad, Govind, et al. "Principles for allocation of scarce medical interventions." The Lancet. Vol. 373, No. 9661 (2009).
Tapper, Jake. "When Academic Words Become Political Ammunition." ABC News Political Punch Blog. 28 Jul 2009.
Tapper, Jake. "Zeke Emanuel on Sarah Palin’s Accusation of ‘Death Panels': ‘It’s An Absolute Outrage’." ABC News Political Punch Blog. 13 Aug 2009.
Scherer, Michael. "Ezekiel Emanuel, Obama’s ‘Deadly Doctor,’ Strikes Back." Time.com. 12 Aug 2009.
Emanuel, Ezekiel. Interview with FactCheck.org. 13 Aug 2009.