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<DIV><FONT face=Arial color=#0000ff><A
href="http://online.wsj.com/article/SB10001424052970203706604574374463280098676.html">http://online.wsj.com/article/SB10001424052970203706604574374463280098676.html</A></FONT></DIV>
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<H1>Obama's Health Rationer-in-Chief </H1>
<H2 class=subhead><FONT size=4>White House health-care adviser Ezekiel Emanuel
blames the Hippocratic Oath for the 'overuse' of medical care.</FONT></H2>
<H2 class=subhead><FONT size=2>By </FONT><A
href="http://online.wsj.com/search/search_center.html?KEYWORDS=BETSY+MCCAUGHEY+&ARTICLESEARCHQUERY_PARSER=bylineAND"><FONT
color=#093d72><FONT size=2>BETSY MCCAUGHEY</FONT> </FONT></A></H2>
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<P>Dr. Ezekiel Emanuel, health adviser to President Barack Obama, is under
scrutiny. As a bioethicist, he has written extensively about who should get
medical care, who should decide, and whose life is worth saving. Dr. Emanuel is
part of a school of thought that redefines a physician’s duty, insisting that it
includes working for the greater good of society instead of focusing only on a
patient’s needs. Many physicians find that view dangerous, and most Americans
are likely to agree. </P>
<P>The health bills being pushed through Congress put important decisions in the
hands of presidential appointees like Dr. Emanuel. They will decide what
insurance plans cover, how much leeway your doctor will have, and what seniors
get under Medicare. <FONT size=5><STRONG>Dr. Emanuel, brother of White House
Chief of Staff Rahm Emanuel, <U>has already been appointed to two key
positions</U>: health-policy adviser at the Office of Management and Budget and
a member of the Federal Council on Comparative Effectiveness Research. <U>He
clearly will play a role guiding the White House's health
initiative</U></STRONG>. </FONT></P>
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src="http://s.wsj.net/public/resources/images/ED-AK071A_mccau_NS_20090826172955.jpg"
width=359 border=0> <CITE>"Principles for Allocation of Scarce Medical
Interventions" The Lancet, January 31, 2009</CITE>
<P class=targetCaption>The Reaper Curve: Ezekiel Emanuel used the above chart in
a Lancet article to illustrate the ages on which health spending should be
focused.</P></DIV></DIV></DIV>
<P>Dr. Emanuel says that health reform will not be pain free, and that the usual
recommendations for cutting medical spending (often urged by the president) are
mere window dressing. As he wrote in the Feb. 27, 2008, issue of the Journal of
the American Medical Association (JAMA): "Vague promises of savings from cutting
waste, enhancing prevention and wellness, installing electronic medical records
and improving quality of care are merely 'lipstick' cost control, more for show
and public relations than for true change."</P>
<P>True reform, he argues, must include redefining doctors' ethical obligations.
In the June 18, 2008, issue of JAMA, Dr. Emanuel blames the Hippocratic Oath for
the "overuse" of medical care: "Medical school education and post graduate
education emphasize thoroughness," he writes. "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."</P>
<P>In numerous writings, Dr. Emanuel chastises physicians for thinking only
about their own patient's needs. He describes it as an intractable problem:
"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. . . . Indeed, many physicians were willing to lie to get patients what
they needed from insurance companies that were trying to hold down costs."
(JAMA, May 16, 2007).</P>
<P>Of course, patients hope their doctors will have that single-minded devotion.
But Dr. Emanuel believes doctors should serve two masters, the patient and
society, and that medical students should be trained "to provide socially
sustainable, cost-effective care." One sign of progress he sees: "the
progression in end-of-life care mentality from 'do everything' to more
palliative care shows that change in physician norms and practices is possible."
(JAMA, June 18, 2008).</P>
<P>"<U>In the next decade every country will face very hard choices about how to
allocate scarce medical resources</U>. There is no consensus about what
substantive principles should be used to establish priorities for allocations,"
he wrote in the New England Journal of Medicine, Sept. 19, 2002. <U>Yet Dr.
Emanuel writes at length about who should set the rules, who should get care,
and who should be at the back of the line</U>. </P>
<P>"You can't avoid these questions," Dr. Emanuel said in an Aug. 16 Washington
Post interview. "We had a big controversy in the United States when there was a
limited number of dialysis machines. <U>In Seattle, they appointed what they
called a 'God committee' to choose who should get it</U>, and that committee was
eventually abandoned. Society ended up paying the whole bill for dialysis
instead of having people make those decisions." </P><A name=U10139252926ALC></A>
<P>Dr. Emanuel argues that to make such decisions, the focus cannot be only on
the worth of the individual. He proposes adding the communitarian perspective to
ensure that medical resources will be allocated in a way that keeps society
going: "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. Covering
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."
(Hastings Center Report, November-December, 1996) </P>
<P>In the Lancet, Jan. 31, 2009, <U>Dr. Emanuel and co-authors presented a
"complete lives system" for the allocation of very scarce resources</U>, such as
kidneys, vaccines, dialysis machines, intensive care beds, and others. "One
maximizing strategy involves saving the most individual lives, and it has
motivated policies on allocation of influenza vaccines and responses to
bioterrorism. . . . Other things being equal, we should always save five lives
rather than one.</P>
<P>"However, other things are rarely equal—whether to save one 20-year-old, who
might live another 60 years, if saved, or three 70-year-olds, who could only
live for another 10 years each—is unclear." In fact, Dr. Emanuel makes a clear
choice: "<U>When implemented, the complete lives system produces a priority
curve on which individuals aged roughly 15 and 40 years get the most substantial
chance</U>, whereas the youngest and oldest people get changes that are
attenuated (see Dr. Emanuel's chart nearby).</P>
<P>Dr. Emanuel concedes that his plan appears to discriminate against older
people, but he explains: "Unlike allocation by sex or race, allocation by age is
not invidious discrimination. . . . <U>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</U>." </P>
<P><STRONG>The youngest are also put at the back of the line</STRONG>:
"Adolescents have received substantial education and parental care, investments
that will be wasted without a complete life. <STRONG>Infants, by contrast, have
not yet received these investments</STRONG>. . . . As the legal philosopher
Ronald Dworkin argues, 'It is terrible when an infant dies, but worse, most
people think, when a three-year-old dies and worse still when an adolescent
does,' this argument is supported by empirical surveys." (thelancet.com, Jan.
31, 2009).</P><A name=U101392529269WB></A>
<P>To reduce health-insurance costs, Dr. Emanuel argues that insurance companies
should pay for new treatments only when the evidence demonstrates that the drug
will work for most patients. <U>He says the "major contributor" to rapid
increases in health spending is "the constant introduction of new medical
technologies, including new drugs, devices, and procedures.</U> . . . With very
few exceptions, both public and private insurers in the United States cover and
pay for any beneficial new technology without considering its cost. . . ." He
writes that one drug "used to treat metastatic colon cancer, extends medial
survival for an additional two to five months, at a cost of approximately
$50,000 for an average course of therapy." (JAMA, June 13, 2007).</P>
<P>Medians, of course, obscure the individual cases where the drug significantly
extended or saved a life. <FONT size=5><U>Dr. Emanuel says the United States
should erect a decision-making body similar to the United Kingdom's rationing
body</U>—the National Institute for Health and Clinical Excellence (NICE)—to
slow the adoption of new medications and set limits on how much will be paid to
lengthen a life. </FONT></P>
<P>Dr. Emanuel's assessment of American medical care is summed up in a Nov. 23,
2008, Washington Post op-ed he co-authored: "The United States is No. 1 in only
one sense: the amount we shell out for health care. We have the most expensive
system in the world per capita, but we lag behind many developed nations on
virtually every health statistic you can name." </P>
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width=262 border=0></A></DIV><CITE>Associated Press</CITE> </DIV>
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<P><STRONG><FONT size=4>This is untrue, though sadly it's parroted at town-hall
meetings across the country. </FONT></STRONG>Moreover, it's an odd factual error
coming from an oncologist. According to an August 2009 report from the National
Bureau of Economic Research, <U>patients diagnosed with cancer in the U.S. have
a better chance of surviving the disease than anywhere else</U>. The World
Health Organization also rates the U.S. No. 1 out of 191 countries for
responsiveness to the needs and choices of the individual patient. That
attention to the individual is imperiled by Dr. Emanuel's views. </P>
<P>Dr. Emanuel has fought for a government takeover of health care for over a
decade. In 1993, he urged that President Bill Clinton impose a wage and price
freeze on health care to force parties to the table. "The desire to be rid of
the freeze will do much to concentrate the mind," he wrote with another author
in a Feb. 8, 1993, Washington Post op-ed. Now he recommends arm-twisting Chicago
style. "Every favor to a constituency should be linked to support for the
health-care reform agenda," he wrote last Nov. 16 in the Health Care Watch Blog.
"If the automakers want a bailout, then they and their suppliers have to agree
to support and lobby for the administration's health-reform effort." </P>
<P>Is this what Americans want?</P>
<P><STRONG>Ms. McCaughey is chairman of the Committee to Reduce Infection Deaths
and a former lieutenant governor of New York state.</STRONG> </P><!-- article end --></DIV></DIV></DIV></DIV></DIV></BODY>
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