Dr. Ezekiel Emanuel, the medical ethicist and oncologist who advises President Obama, does not own a television, and if you catch him in a typically energized moment, when his mind speeds even faster than his mouth, he is likely to blurt out something like, "I hate the Internet." So it took him several days in late July to discover he had been singled out by opponents of health-care reform as a "deadly doctor," who, according to an opinion column in the New York Post, wanted to limit medical care for "a grandmother with Parkinson's or a child with cerebral palsy."
"I couldn't believe this was happening to me," says Emanuel, who in addition to spending his career opposing euthanasia and working to increase the quality of care for dying patients is the brother of White House chief of staff Rahm Emanuel. "It is incredible how much one's reputation can be besmirched and taken out of context."
It would only get worse. Within days, the Post article, with selective and misleading quotes from Emanuel's 200 or so published academic papers, went viral. Minnesota Representative Michelle Bachmann, a fierce opponent of Obama's reform plans, read large portions of it on the House floor. "Watch out if you are disabled!" she warned. Days later, in an online posting, former Alaska Governor Sarah Palin attacked Emanuel's "Orwellian thinking," which she suggested would lead to a "downright evil" system that would employ a "death panel" to decide who gets lifesaving health care. By Aug. 10, hysteria had begun to take over in places. Mike Sola, whose son has cerebral palsy, turned up at a Michigan town-hall meeting to shout out concerns about what he regarded as Obama and Emanuel's plans to deny treatment to their family. Later, in an interview on Fox News, Sola held up the Post article. "Every American needs to read this," he declared.
By this point, Emanuel, who has a sister who suffers from cerebral palsy, had arrived in northern Italy, where he planned to spend a week on vacation, hiking in the Dolomites. Instead, he found himself calling the White House, offering to book a plane home to defend his name. "As an academic, what do you have? You have the quality of your work and the integrity with which you do it," he said by phone from the Italian Alps. "If it requires canceling a week's long vacation, what's the big deal?"
The attacks on Emanuel are a reminder that there is a narrow slice of Americans who not only don't trust government, but also have come to regard it as a dark conspirator in their lives. This peculiar brand of distrust helps create the conditions for fast-moving fear-mongering, especially on complex and emotionally charged topics like the life and death of the elderly and infirm. Prairie fires of that kind are hard to douse when the Administration's own plan for health care remains vague, weeks away from being ready for a public rollout. The health-care bill that recently passed the House does not contain, as some have suggested, any provisions that would deny treatment to the elderly, infirm or disabled like Sola's son. One provision allows doctors to be reimbursed for voluntary discussions of so-called living wills with patients, but does not in any way threaten to deny treatment to dying patients against their will. The legislation anticipates saving hundreds of billions of dollars by reforming the health-care system itself, a process that would try to increase the efficiency of medical care by better connecting payments to health outcomes and discouraging doctors from unnecessary tests and procedures. The Obama Administration hopes that many of these reforms will be made in the coming years by independent panels of scientists, who will be appointed by the President and overseen by Congress.
This is where the criticism of Emanuel enters the picture, since he is just the sort of scientist who might be appointed to one of those panels. For decades, Emanuel has studied the ethics of medical care, especially in situations where a scarcity of resources requires hard decisions to be made. His work sometimes deals with the hardest possible decisions, like how to choose who gets a single kidney if there are three patients in need, or the reasons that doctors order tests with little medical value. Emanuel's reputation ranks him among the top members of his field. He is published often in the best journals; he has been given multiple awards for work to improve end-of-life care. At the White House, he has taken a free-floating role at the Office of Management and Budget, advising on a wide range of health issues.
But in a country where trust is in short supply, Emanuel has become a proxy for all the worst fears of government efforts to rein in costs by denying care. "The fundamental danger is that the American people are being asked to delegate all these life-influencing decisions," explains Betsy McCaughey, the conservative scholar who wrote the New York Post attack on Emanuel. "There is a lack of transparency here."
In her Post article, McCaughey paints the worst possible image of Emanuel, quoting him, for instance, endorsing age discrimination for health-care distribution, without mentioning that he was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources. She quotes him discussing the denial of care for people with dementia without revealing that Emanuel only mentioned dementia in a discussion of theoretical approaches, not an endorsement of a particular policy. She notes that he has criticized medical culture for trying to do everything for a patient, "regardless of the cost or effects on others," without making clear that he was not speaking of lifesaving care but of treatments with little demonstrated value. "No one who has read what I have done for 25 years would come to the conclusions that have been put out there," says Emanuel. "My quotes were just being taken out of context."
For Emanuel, the entire experience has been a painful education in the sometimes brutal ways of politics, something his brother has long endured and doled out. "I guess I have a better appreciation for what Rahm had to go through for years and years," Emanuel says. But that appreciation does not solve the question raised by the controversy. There is universal understanding that the nation's fiscal course is doomed without major changes to health care, but whom will the American people trust to carry it out?
Emanuel, for his part, plans to continue his work, which is focused on finding the most equitable and ethical way for this reform to be carried out, even if he has opted against returning from the Italian Alps. "I am an Emanuel," he says. "We are pretty thick-skinned. I am not going to change my colors. I am not going to crawl under a rock."