Monday, August 17, 2009

Ezekiel Emmanuel clarifies some comments he made on health care

Sarah Palin, the ex-governor of Alaska who started the whole "death panel" nonsense, based her stance on some comments made by Ezekiel Emmanuel, health policy adviser at the Office of Management and the Budget. Emmanuel made some comments in a piece by the Hastings Center that at first glance seemed to call for rationing. However, Emmanuel clarified himself in an interview with ABC News:

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.

As it turns out, I took a glance at the report mentioned in the article. I used to be interested in philosophy but quit because I found the writing confusing and impenetrable; that was the case with the article in question. I was initially taken aback based on the paragraph I read, but upon a re-read, Emmanuel is indeed describing a particular philosophical stance, not endorsing it.

We shouldn't blame Palin for making a mistake in interpreting a densely-worded article. However, public figures need to make sure their comments are accurate. If they turn out to be incorrect, they need to issue a retraction. If Palin wants to oppose increased government regulation of healthcare, that's her right, but she needs to retract her comment on Emmanuel's article.

Editor: An earlier version of this article said Emmanuel's paper was published by the Brookings Institution, a think tank. Brookings' health policy center is known as the Engelberg Center for Health Reform; I got confused here. The Hastings Center is an independent bioethics think tank.

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