[Apologetics] Obama's Health Rationer-in-Chief

[Art Kelly]

http://online.wsj.com/article/SB1000142405297020370660457437446328009867
6.html

Obama's Health Rationer-in-Chief 


White House health-care adviser Ezekiel Emanuel blames the Hippocratic
Oath for the 'overuse' of medical care.


By BETSY MCCAUGHEY
<http://online.wsj.com/search/search_center.html?KEYWORDS=BETSY+MCCAUGHE
Y+&ARTICLESEARCHQUERY_PARSER=bylineAND> 


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. 

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. Dr. Emanuel, brother of White
House Chief of Staff Rahm Emanuel, has already been appointed to two key
positions: health-policy adviser at the Office of Management and Budget
and a member of the Federal Council on Comparative Effectiveness
Research. He clearly will play a role guiding the White House's health
initiative. 

  "Principles for Allocation of Scarce Medical Interventions" The
Lancet, January 31, 2009 

The Reaper Curve: Ezekiel Emanuel used the above chart in a Lancet
article to illustrate the ages on which health spending should be
focused.

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."

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."

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).

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).

"In the next decade every country will face very hard choices about how
to allocate scarce medical resources. 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. 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. 

"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. In Seattle,
they appointed what they called a 'God committee' to choose who should
get it, and that committee was eventually abandoned. Society ended up
paying the whole bill for dialysis instead of having people make those
decisions." 

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) 

In the Lancet, Jan. 31, 2009, Dr. Emanuel and co-authors presented a
"complete lives system" for the allocation of very scarce resources,
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.

"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: "When implemented, the complete lives
system produces a priority curve on which individuals aged roughly 15
and 40 years get the most substantial chance, whereas the youngest and
oldest people get changes that are attenuated (see Dr. Emanuel's chart
nearby).

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. . . . 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 youngest are also put at the back of the line: "Adolescents have
received substantial education and parental care, investments that will
be wasted without a complete life. Infants, by contrast, have not yet
received these investments. . . . 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).

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. 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. . . . 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).

Medians, of course, obscure the individual cases where the drug
significantly extended or saved a life. Dr. Emanuel says the United
States should erect a decision-making body similar to the United
Kingdom's rationing body-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. 

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." 

View Full Image

 
Associated Press 
 
 

This is untrue, though sadly it's parroted at town-hall meetings across
the country. Moreover, it's an odd factual error coming from an
oncologist. According to an August 2009 report from the National Bureau
of Economic Research, patients diagnosed with cancer in the U.S. have a
better chance of surviving the disease than anywhere else. 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. 

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." 

Is this what Americans want?

Ms. McCaughey is chairman of the Committee to Reduce Infection Deaths
and a former lieutenant governor of New York state. 




-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://gathman.org/pipermail/apologetics/attachments/20090827/5020acd7/attachment.html>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: ED-AK071A_mccau_NS_20090826172955.jpg
Type: image/jpeg
Size: 6397 bytes
Desc: ED-AK071A_mccau_NS_20090826172955.jpg
URL: <http://gathman.org/pipermail/apologetics/attachments/20090827/5020acd7/attachment.jpg>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: OB-EI132_McCaug_D_20090826184842.jpg
Type: image/jpeg
Size: 19855 bytes
Desc: OB-EI132_McCaug_D_20090826184842.jpg
URL: <http://gathman.org/pipermail/apologetics/attachments/20090827/5020acd7/attachment-0001.jpg>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: BTN_insetClose.gif
Type: image/gif
Size: 625 bytes
Desc: BTN_insetClose.gif
URL: <http://gathman.org/pipermail/apologetics/attachments/20090827/5020acd7/attachment.gif>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: OB-EI132_McCaug_G_20090826184842.jpg
Type: image/jpeg
Size: 68012 bytes
Desc: OB-EI132_McCaug_G_20090826184842.jpg
URL: <http://gathman.org/pipermail/apologetics/attachments/20090827/5020acd7/attachment-0002.jpg>