# Ezekiel Emmanuel says we need to ration care **URL:** \ **Category:** Great Debates\ **Created:** [August 12, 2009, 8:01am UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153 "2009-08-12T08:01:23Z")\ **Posts on this page:** 20\ **Page:** 1
**Author:** ![mswas](https://avatars.discourse-cdn.com/v4/letter/m/e99b99/32.png) [@mswas](https://boards.straightdope.com/u/mswas)\ **Post date:** [August 12, 2009, 8:01am UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/1 "2009-08-12T08:01:23Z")
[http://www.nypost.com/seven/07242009/postopinion/opedcolumnists/deadly\_doctors\_180941.htm?&page=0](http://www.nypost.com/seven/07242009/postopinion/opedcolumnists/deadly_doctors_180941.htm?&page=0) > [@](#): > > Emanuel bluntly admits that the cuts will not be pain-free. “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality are merely ‘lipstick’ cost control, more for show and public relations than for true change,” he wrote last year (Health Affairs Feb. 27, 2008). > Savings, he writes, will require changing how doctors think about their patients: Doctors take the Hippocratic Oath too seriously, “as an imperative to do everything for the patient regardless of the cost or effects on others” (Journal of the American Medical Association, June 18, 2008). > > Yes, that’s what patients want their doctors to do. But Emanuel wants doctors to look beyond the needs of their patients and consider social justice, such as whether the money could be better spent on somebody else. > > Many doctors are horrified by this notion; they’ll tell you that a doctor’s job is to achieve social justice one patient at a time. > > Emanuel, however, believes that “communitarianism” should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those “who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia” (Hastings Center Report, Nov.-Dec. '96). > > Translation: Don’t give much care to a grandmother with Parkinson’s or a child with cerebral palsy. > > He explicitly defends discrimination against older patients: “Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years” What do people make of this? We’ve been hearing that it’s absolutely ridiculous that care would be rationed, but how can it not be? Right now it’s rationed, those who can afford it monetarily get it, whereas those who cannot don’t. If we went to another system how is that it wouldn’t be rationed by some other means? Particularly as we are moving faster and faster toward a time where medicine can keep you alive far longer than before. What happens when it can keep you alive indefinitely? ---
**Author:** ![Bryan\_Ekers](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/bryan_ekers/32/183_2.png) [@Bryan\_Ekers](https://boards.straightdope.com/u/Bryan_Ekers)\ **Post date:** [August 12, 2009, 8:09am UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/2 "2009-08-12T08:09:21Z")
I don’t know why Emmanuel thinks doctors aren’t already _very_ familiar with the concept of “triage”, deciding how to allocate medical resources for the greatest good, including giving only minimal care to hopeless cases. ---
**Author:** ![mswas](https://avatars.discourse-cdn.com/v4/letter/m/e99b99/32.png) [@mswas](https://boards.straightdope.com/u/mswas)\ **Post date:** [August 12, 2009, 8:11am UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/3 "2009-08-12T08:11:11Z")
> [@Bryan\_Ekers](#): > > I don’t know why Emmanuel thinks doctors aren’t already _very_ familiar with the concept of “triage”, deciding how to allocate medical resources for the greatest good, including giving only minimal care to hopeless cases. Yes. but a concept of triage on an administrative level is exactly what people mean by the term, “Death Panel”. People like Ezekiel Emmanuel sitting in an office performing triage with a spreadsheet. ---
**Author:** ![DanBlather](https://avatars.discourse-cdn.com/v4/letter/d/f4b2a3/32.png) [@DanBlather](https://boards.straightdope.com/u/DanBlather)\ **Post date:** [August 12, 2009, 11:08am UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/4 "2009-08-12T11:08:22Z")
This just got me thinking. I wonder how many of the cases where people near death are given expensive treatments that may only keep them alive for a short while, are given to interns as learning excersises: “Dr Gnu hasn’t done an aortic plasmosis yet, maybe he should do the one on Mr Oldes. If the knife slips it’ll only kill him a few days earlier”. ---
**Author:** ![Der\_Trihs](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/der_trihs/32/233_2.png) [@Der\_Trihs](https://boards.straightdope.com/u/Der_Trihs)\ **Post date:** [August 12, 2009, 11:17am UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/5 "2009-08-12T11:17:21Z")
[Ezekiel Emanuel](http://www.time.com/time/nation/article/0,8599,1915835,00.html) however calls the accusations against him a smear campaign ( link courtesy of **RedFury** in the [Pit](http://boards.straightdope.com/sdmb/showthread.php?t=527720) ). > [@](#): > > 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.” ---
**Author:** ![njtt](https://avatars.discourse-cdn.com/v4/letter/n/ecd19e/32.png) [@njtt](https://boards.straightdope.com/u/njtt)\ **Post date:** [August 12, 2009, 11:24am UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/6 "2009-08-12T11:24:44Z")
Care is rationed now, always has been rationed (in all nations and historical epochs), and always will be. Insurance rations care now in America (and could not avoid doing so, even if the whole system was run by saints). In a system where people pay directly for their health care, you only get it until your money runs out. It is rationed by available cash. There is no question about whether we _should_ ration health care: we do, we must, and we will. The only question is about _how_ we should ration it. ---
**Author:** ![Jackmannii](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/jackmannii/32/311_2.png) [@Jackmannii](https://boards.straightdope.com/u/Jackmannii)\ **Post date:** [August 12, 2009, 12:12pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/7 "2009-08-12T12:12:53Z")
To me a key to the article is this (if poor Emanuel was not being misquoted again): “Emanuel bluntly admits that the cuts will not be pain-free. “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality are merely ‘lipstick’ cost control, more for show and public relations than for true change,” he wrote last year (Health Affairs Feb. 27, 2008).” How many Administration officials have been openly honest about this? In fact, no one to my knowledge has admitted that “enhancing prevention and wellness” (involving lots more screening tests, which leads to lots more screening tests and biopsies) and installing electronic medical records (which have to be expensively maintained with appropriate security, beyond initial installation costs) will considerably _increase_ health care costs. What “triage” currently takes place due to cost/insurance company decisions will have to occur (or more likely, be expanded) under a single payer plan. A big question - have health care reform advocates in Congress and the Administration decided that they cannot afford to be honest about the cost/consequences of the current (and future) proposals, or do they really not know what’s at stake? ---
**Author:** ![Lumpy](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/lumpy/32/446_2.png) [@Lumpy](https://boards.straightdope.com/u/Lumpy)\ **Post date:** [August 12, 2009, 12:33pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/8 "2009-08-12T12:33:49Z")
So just how is health care managed in countries that do have socialized universal health care? Do they openly have “death panels”? I haven’t researched it in depth but from what I remember from discussions on this board, the rationing is done mainly by long wait times for all but the most urgent emergencies, and by using the most conservative treatment possible. Maybe there’s a bit more focus on “end-of-life” hospice care for the terminally ill rather than heroic treatment, but I don’t actually know. Also, how is malpractice liability handled in socialized health care? Is there less “let’s order a zillion tests just to cover our [del]asses[/del]bases”? ---
**Author:** ![msmith537](https://avatars.discourse-cdn.com/v4/letter/m/d9b06d/32.png) [@msmith537](https://boards.straightdope.com/u/msmith537)\ **Post date:** [August 12, 2009, 1:22pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/9 "2009-08-12T13:22:10Z")
All the problems with health care in this country will be solved once we can provide every single person in the US with as much medical treatment as they can ever want absolutely free of cost. ---
**Author:** ![tagos](https://avatars.discourse-cdn.com/v4/letter/t/bbe5ce/32.png) [@tagos](https://boards.straightdope.com/u/tagos)\ **Post date:** [August 12, 2009, 1:46pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/10 "2009-08-12T13:46:51Z")
> [@Lumpy](#): > > So just how is health care managed in countries that do have socialized universal health care? Do they openly have “death panels”? I haven’t researched it in depth but from what I remember from discussions on this board, the rationing is done mainly by long wait times for all but the most urgent emergencies, and by using the most conservative treatment possible. Maybe there’s a bit more focus on “end-of-life” hospice care for the terminally ill rather than heroic treatment, but I don’t actually know. > > Also, how is malpractice liability handled in socialized health care? Is there less “let’s order a zillion tests just to cover our [del]asses[/del]bases”? It depends. In the UK waiting times vary from area to area and procedure by procedure. [Analysis here](http://www.nhs.uk/news/2009/03March/Pages/NHSwaitingtimesQA.aspx) > [@](#): > > The average wait for treatment for patients admitted to hospital is now just 8.6 weeks. Outpatients waited an average of 4.6 weeks at January 2009 I wouldn’t know how to factor in the uninsured/uncovered into comparative figures for the USA. And no - we do not have Death Panels :rolleyes: but yes, there are judgments made on terms of cost against efficiency. Just like has to be done in any un-rationed system. In the UK though it is done openly and not by bottom-line private insurance bandits or by denying anything but minimum emergency care for a large segment of the population. Or for the insured by what treatment your insurer is prepared to pay for. I much prefer an open public system that does its best to cover everyone to the job-tied, and/or potluck lottery US system and if I didn’t I could have the benefit of both by taking out private insurance with BUPA. The French health system makes the UK one look third world. ---
**Author:** ![gonzomax](https://avatars.discourse-cdn.com/v4/letter/g/e8c25b/32.png) [@gonzomax](https://boards.straightdope.com/u/gonzomax)\ **Post date:** [August 12, 2009, 2:00pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/11 "2009-08-12T14:00:55Z")
The system pays doctors for every procedure they do. That is why they do so many. The payoffs are not patient or results oriented. We have assembly line medical care with doctors having little time to consult with patients. Their time is money. Your time is irrelevant. Many doctors hate what our medical care has become. The insurance companies are between you and your doctor. They are thinking profits. ---
**Author:** ![Jackmannii](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/jackmannii/32/311_2.png) [@Jackmannii](https://boards.straightdope.com/u/Jackmannii)\ **Post date:** [August 12, 2009, 2:18pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/12 "2009-08-12T14:18:54Z")
> [@gonzomax](#): > > The system pays doctors for every procedure they do. That is why they do so many. The payoffs are not patient or results oriented. The obvious solution to this, once we vastly expand preventative care is to only pay the doctors for the simplest screening. Further procedures to confirm a malignant or benign lesion, or to remove them won’t be reimbursed. Problem solved. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [August 12, 2009, 2:20pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/13 "2009-08-12T14:20:55Z")
He’s making a valid point. Health care rationing will come, regardless of the system in place. The only question is how you want it allocated. Under UHC it will be by bureaucratic decision, and under the current system it will be by money. Although there will be some monetary influence even under UHC, since the really really rich will always have private coverage. As I see it, the impact of UHC will be taking away from the middle class and giving to the poor. The fact is that health care expenditures have been increasing as a percentage of GDP for some time. This cannot continue forever, otherwise the entire GDP and then some would have to be allocated to health care. What has to happen is that fewer and fewer people get “top quality” medical care. Question is who these people are. Under the current system, what will inevitably happen is that “top quality” care becomes more and more expensive, and people and their employers will increasingly be shunted to second tier plans, and second tier health care. Under the proposed UHC systems, this happens to virtually everyone. [One other issue is if you have UHC HC rationing but no tort reform. I guess doctors will continue to try to practice “defensive medicine”, but will have their hands tied by the system, and this will itself lend itself to their defense in tort lawsuits. Nonetheless, it would suggest that an increasingly important factor in health care will be the extent to which a doctor knows how to “work the system”.] ---
**Author:** ![elucidator](https://avatars.discourse-cdn.com/v4/letter/e/8edcca/32.png) [@elucidator](https://boards.straightdope.com/u/elucidator)\ **Post date:** [August 12, 2009, 2:27pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/14 "2009-08-12T14:27:41Z")
> [@msmith537](#): > > All the problems with health care in this country will be solved once we can provide every single person in the US with as much medical treatment as they can ever want absolutely free of cost. Do I detect a note of sarcasm? And a whole symphony of cynicism? ---
**Author:** ![zamboniracer](https://avatars.discourse-cdn.com/v4/letter/z/e9a140/32.png) [@zamboniracer](https://boards.straightdope.com/u/zamboniracer)\ **Post date:** [August 12, 2009, 2:36pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/15 "2009-08-12T14:36:51Z")
> [@njtt](#): > > Care is rationed now, always has been rationed (in all nations and historical epochs), and always will be. Insurance rations care now in America (and could not avoid doing so, even if the whole system was run by saints). In a system where people pay directly for their health care, you only get it until your money runs out. It is rationed by available cash. There is no question about whether we _should_ ration health care: we do, we must, and we will. The only question is about _how_ we should ration it. This is exactly right. This is anecdotal evidence from a friend of mine, but he says that his 95 year old mother’s doctor recently recommended that she have a pacemaker installed. His mother refused, saying she’s led a long, full life and is ready to die. Rationing care means that she wouldn’t have been offered that option, as indeed logic suggests that she shouldn’t have been. No offense to any 95 year olds, but as a taxpayer I don’t want to pay for their brand new pacemakers, anymore than I’d want to pay for a new engine for a 1975 Ford Pinto. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [August 12, 2009, 2:47pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/16 "2009-08-12T14:47:10Z")
> [@zamboniracer](#): > > No offense to any 95 year olds, but as a taxpayer I don’t want to pay for their brand new pacemakers, anymore than I’d want to pay for a new engine for a 1975 Ford Pinto. The problem with this is that you’re addressing the situation that will exist _after_ UHC is instituted, while we’re discussing whether it _should be_. Yeah, if UHC is in place then whether someone gets to live or die becomes a question of what other people want “as a taxpayer”. Question is if this is the best situation to be in. Of course, as above some rationing goes on already and will undoubtedly increase in the future under the current situation or any other conceivable one. But still, it’s likely that a middle class person who has a different attitude to end-of-life scenarios, and wants to pay for a plan that would allow them to adhere to this approach, would have fewer options and a more difficult time of it under a UHC approach than under the present one. ---
**Author:** ![tagos](https://avatars.discourse-cdn.com/v4/letter/t/bbe5ce/32.png) [@tagos](https://boards.straightdope.com/u/tagos)\ **Post date:** [August 12, 2009, 2:49pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/17 "2009-08-12T14:49:36Z")
Regarding indemnity/liability - the NHS not the practitioner bears the legal liability and any associated costs. This I imagine saves a doctor a packet on personal liability insurance and cuts out the need for expensive ‘defensive’ medicine. ---
**Author:** ![C\_K\_Dexter\_Haven](https://avatars.discourse-cdn.com/v4/letter/c/b2d939/32.png) [@C\_K\_Dexter\_Haven](https://boards.straightdope.com/u/C_K_Dexter_Haven)\ **Post date:** [August 12, 2009, 2:58pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/18 "2009-08-12T14:58:28Z")
> [@Lumpy](#): > > So just how is health care managed in countries that do have socialized universal health care? Do they openly have “death panels”? > [@Fotheringay-Phipps](#): > > Health care rationing will come, regardless of the system in place. The only question is how you want it allocated. Under UHC it will be by bureaucratic decision, and under the current system it will be by money. \*\*Fotheringay-Phipps:\*\*First, I disagree with your verb that rationing “will” come – rationing has always been here. Medical care is a limited and costly resource, and there will always be decisions made about who can and who can’t receive care. The “solution” to health care would be a system that provides immediate care to everyone, using the latest technology and most sophisticated procedures, at no cost. That’s just not possible. So, it’s always a case of rationing (“resource allocation” sounds better, of course.) The question is who makes such decisions, and based on what principles. At present, in the US, those decisions are made mostly by insurance companies and partly by the medical profession, and the principle is $$$$$ – the rich get what they want, the poor don’t. It’s hard to generalize, but under most government-provided health care systems (to answer **Lumpy** ), the decisions are made by some medical board (including doctors, patient-representatives, and government) based on clearly established principles. It’s not “bureaucratic” – it’s administrative decision, based on defined standards. As an example, we were treated in a London emergency room a few years back. On the wall was a sign, saying that priorities are given first based on medical emergency (life-threatening, etc), and after that, priority would be given to children, the elderly to get home before dark, etc. (I don’t remember the entire list, just those sections.) When it comes to life-saving situations, a 93-year old who needs a heart transplant is told by the board: no, sorry, society is not willing to pay for you to have a heart transplant. Most 93-year olds in other countries accept that, and accept that when a heart comes available, it should go to a 30-year old in need, instead. There’s slightly more emphasis on the welfare of all, and some willingness to sacrifice if necessary, than in the US. Compare that to the US and Mickey Mantel’s liver transplant – wouldn’t that liver have served better and longer in a younger and more able patient? Wasn’t it simply wasteful to give Mickey Mantel another (I forget) three months, when it could have given someone else thirty years? (By the way, even under government-run plans, those rich enough to afford it can almost always go outside the system, of course. ) I tend to like the analogy of the police department. Police services are rationed (prioritized, if you prefer) and always have been, based on societal standards. My next-door neighbor who found a bird had flown down her chimney called the police and was told that she’d not be a high priority, they’d get the animal wossname to her when they could. She accepted that, understanding the need for resource allocation and prioritization. Most government-medical systems work the same way, based on the astounding notion that health care is a SERVICE to be provided to all and paid for by all (like the roads, police, etc) … unlike the US, where health care is viewed as a profit-making COMMODITY to be bought and sold on the open market, like potatoes or cellphones, to those who can afford it. ---
**Author:** ![tagos](https://avatars.discourse-cdn.com/v4/letter/t/bbe5ce/32.png) [@tagos](https://boards.straightdope.com/u/tagos)\ **Post date:** [August 12, 2009, 3:00pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/19 "2009-08-12T15:00:30Z")
> [@Fotheringay-Phipps](#): > > Of course, as above some rationing goes on already and will undoubtedly increase in the future under the current situation or any other conceivable one. But still, it’s likely that a middle class person who has a different attitude to end-of-life scenarios, and wants to pay for a plan that would allow them to adhere to this approach, would have fewer options and a more difficult time of it under a UHC approach than under the present one. Why? On what basis are you making that assertion given that there are no age restrictions on pacemakers in the UK NHS system? ---
**Author:** ![zamboniracer](https://avatars.discourse-cdn.com/v4/letter/z/e9a140/32.png) [@zamboniracer](https://boards.straightdope.com/u/zamboniracer)\ **Post date:** [August 12, 2009, 3:03pm UTC](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153/20 "2009-08-12T15:03:38Z")
> [@Fotheringay-Phipps](#): > > The problem with this is that you’re addressing the situation that will exist _after_ UHC is instituted, while we’re discussing whether it _should be_. Not quite. The pacemaker in question would’ve been paid for by Medicare as it exists now, not under a future UHC system. [Next page](https://boards.straightdope.com/t/ezekiel-emmanuel-says-we-need-to-ration-care/506153.md?page=2)