Zeke Emanuel, The Death Panels, And Illogic In Politics

For political charges to stick, they've got to correspond to some discernible reality. They have to track with what an average voter experiences -- or believes -- is within the realm of the possible. During the presidential campaign, voters rejected John McCain's contention that President Obama was a radical socialist who palled around with terrorists because the Obama voters knew from the campaign and the primary did not seem like a rabble-rousing Eugene Debs.

Over the weekend, Gov. Sarah Palin, former Speaker Newt Gingrich and others seized on a few lines from one of the major health care bills to try and encapsulate the Democratic Party's entire approach to health care. As Palin wrote on her Facebook page,

The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's "death panel" so his bureaucrats can decide, based on a subjective judgment of their "level of productivity in society.

There are several immediate problems with this, not the least of which is Palin's chosen format. Facebook is not generally a place where serious political charges are lobbed. And Palin, having abdicated her elected executive position a few weeks ago, lacks the automatic standing to be a valued participant in the health care debate. If you're Sarah Palin, and you face an American public that is skeptical about your intellectual bona fides, you've got to choose your spots more carefully. Reading the post, it's hard to see what Palin actually meant. Her political spokesperson later confirmed that Palin was referring to the principle of "community standards," which she linked to a New York Post piece about Dr. Ezekiel Emanuel, a noted cancer physician an a presidential adviser on health care economics and the brother of the Chief of Staff. (Emanuel is also an occasional contributor to the Atlantic.)

Emanuel, in a few journal articles and an Atlantic feature, has written about the enormously complex emotional, social and economic decisions that individuals and the health care system confront whenever someone begins to die from a terminal illness. Emanuel's thesis adviser at Harvard was Prof. Michael Sandel, a noted communitarian who has argued that our political debates bracket gut-level values to our detriment.  Emanuel writes in the tradition of a communaritan who believes that procedural liberalism -- the reigning philosophy of government today -- does not allow for priorities among health care services because it "cannot appeal to a conception of the good."  Emanuel writes: "But without appealing to a conception of the good, it is argued, we can never establish priorities among health care services and define basic medical services."  Emanuel sketches out a "civic Republicanism" telos -- that is -- our health care decisions as a society should be yoked to a system that "promote[s] 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."  He notes that such a system would deny "services provided to individuals who are irreversibly prevented from being or becoming participating citizens."

Emanuel is setting up a contrast: our health care system today treats everyone equally -- as if they ought to have equal access to every possible procedure or treatment. To most of us, the status quo seems intuitively right. Everyone is equal -- equal under God -- Emanuel doesn't say this, but he might as well -- and therefore it would be evil to make distinctions.  What Emanuel is arguing, here, is that this liberalism substitutes one goal -- equality -- for another -- a healthy society -- and that substitution may be responsible for the limited choices that policy-makers confront. He also points out a trade-off between providing a basic level of coverage for all and providing the opportunity for anyone with some coverage to get every possible benefit, treatment and procedure.

Sarah Palin and Newt Gingrich aren't debating the moral philosophy of John Rawls, whose formulations Emanuel borrows. They're taking Emanuel's academic point about health care values, assigning it to Emanuel as if Emanuel were advocating for something he isn't, then jumping over the entire health care colossus, and they assign this distorted belief to  Barack Obama by implying an argument that actually disproves the linkage they are trying to make. 

On This Week with George Stephanopoulos, Gingrich, who hasn't always defended Palin, decided to take the bait. Didn't matter that the "death panel" about which Palin spoke wasn't in the health care bill -- (not even in any of the four or five bills that Gingrich subsequently referenced.)  Didn't matter that the provision in question simply allows the government to pay for end-of-life and Hospice discussions with your doctor -- something that virtually everyone with Medicare wants because they often can't pay for lawyers to advise them about the process, specific language about which that was written by a pro-life Republican.

 "I think people are very concerned when you start talking about cost control," Gingrich said.
"You're asking us to believe that government can be trusted. Communal standards historically is a very dangerous concept."

Gingrich is conflating Palin's tertiary fear about Emanuel with the provision in the health care bills that would establish panels of experts to evaluate procedures for their effectiveness. (As Harold Pollack notes, end of life care would not be a priority for these panels anyway.)

Gingrich alleged that Emanuel is an advocate of euthanasia and wants doctors to bring cost-benefit decisions into their end-of-life counseling sessions."  Actually, Emanuel's research shows the opposite. 

Let's say a doctor begins to counsel a patient with terminal pancreatic cancer. Right now, the health care system incentivizes doctors to keep that patient in a hospital and on chemotherapy until the day she dies. Late-stage pancreatic cancer is almost always fatal, and the chances that the patient will go into remission are very slim.  The doctor has no incentive to tell the patient that hospice care may well be a better alternative.  The last few months of life would be much more comfortable. Hospice care costs more than hospital care in most circumstances, Emanuel found -- and so the end-of-life counseling that a doctor provides has little to do with saving money. If there is any cost-benefit analysis in this scenario, it's simply that the patient may value comfort at the end of her life over aggressive, painful treatments that aren't likely to work (and might actually hasten death if they don't).  
Even if you're familiar with the facts -- Emanuel opposes euthanasia, he favors giving families more information about end of care decisions (because families often want this information and don't know enough about the future to ask about it), he understands the difficulty in convincing people to think about the costs and benefits of treating their dying loved one at the end of their life, and he is not writing the health care bill -- Gingrich's follow-on to Palin's attack is simply an exercise in unreality.