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Published On: Tue, Jul 23rd, 2019

Ezekiel Emanuel Quotes

Dr. Ezekiel J. Emanuel was the special adviser for health care at the Office of Management and Budget and the brother of Obama aide, now Chicago mayor, Rahm Emanuel.

photo Will O’Neill via Flickr

In articles and in his book Healthcare, Guaranteed, Emanuel said that universal health care could be guaranteed by replacing employer paid health care insurance, Medicaid and Medicare with health care vouchers funded by a value-added tax.

“Yes, you will be the first” in the region with a proton beam center, said Ezekiel Emanuel, an oncologist and bioethicist at the University of Pennsylvania’s Perelman School of Medicine to Radiation Oncologists on photo beam technology. “You may also be the first to close it, you may be the first to lose money on it. There are a lot of firsts here to be had.” – July 2019

“Once I have lived to 75, my approach to my health care will completely change. I won’t actively end my life. But I won’t try to prolong it, either.” – in his attention-getting piece in The Atlantic, Emanuel identified the age of 75 as a personal cut-off point for health interventions

FROM A 2018 INTERVIEW

Are we too focused on living longer?  

Yes, and I think we delude ourselves about the wonderfulness of living long, and I think the advertising industry and others want us to be somewhat deluded… I think when you start thinking that you’ll make it to 100, that may be a recognition that my previous or current life wasn’t that valuable or meaningful, and I sort of squandered it. Be focused more on living a rich life rather than trying to get to 120 — that might be more valuable in my opinion.

How should public and private payers evaluate the returns on their investment in treatment and care?

An evaluation on care that does not prolong life over disease symptoms is hard to measure, and that could be very helpful to people at the end of life. We don’t want to waste money, so the return is either prolonging life, reducing symptoms, increasing convenience or reducing costs. We need to see those things from our medical interventions.

As a society, are we getting closer to or further from an honest conversation about aging?

I think in general we’re getting further away from honest conversations about everything in our society, because we’re unwilling to look at the facts and too willing to dismiss people with ad hominems and overall charges like ageism or discrimination.

photo LaDawna Howard via Flickr


“Whatever your metric – if your metric is access, if your metric is cost, quality, job growth, innovation … the Affordable Care Act has been a positive force in this country and it costs less than what was anticipated” – Oct, 2018. 
“Predicting the future is very, very risky,…Making predictions are hard, and we all learned that in a cruel way in the 2016 elections.”

Emanuel says he sees a shift toward bundled payments instead of a traditional fee-for-service system, where “everything is separate”: “You don’t buy a car, carburetor, chassis, etc. and put it together in your backyard. We want a bundle: I want a hip (replacement) and I want one price for the whole thing and (have the) whole thing coordinated.”

It is incredible how much one’s reputation can be besmirched and taken out of context. – describing his feeling about the “deadly doctor” label – speaking March 11 at the American Medical Association’s annual conference in Washington

No one who has read what I have done for 25 years would come to the conclusions that have been put out there. My quotes were just being taken out of context. – describing the public outcry against himself and Obamacare -speaking March 11 at the American Medical Association’s annual conference in Washington

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. – 2008

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. – 1996 Hastings paper

Ezekiel Emanuel interview by John Donnelly, July 17, 2010


Ezekiel J. Emanuel, head of the Department of Bioethics at The Clinical Center of the National Institutes of Health and a breast oncologist, is on extended detail as a special advisor for health policy to the director of the White House Office of Management and Budget.

But that doesn’t speak to his impact. He is one of the architects of the Obama administration’s Global Health Initiative, and he has been a lightning rod of criticism for activists who want a much more vigorous global AIDS response from the administration.

Emanuel spoke to John Donnelly on Saturday about how the Obama administration now needs better ideas for making global health programs more efficient, and how he won’t shy away from taking on AIDS activists. “I have two brothers and all we do is disagree,’’ he said.

Q: You haven’t been shy in pushing back on criticism from AIDS activists about the Obama administration’s smaller increases in the global AIDS budgets than under the Bush administration. What really upsets you?

A: We can have disagreements about the right policy, which way we are going forward, but we can’t have a disagreement about the facts – the facts of the budget. A number of advocates are saying we are cutting the PEPFAR budget. The fact is funding for HIV and our work on PEPFAR is going up – in 2009 2010 and 2011. That is matter of fact. You may not like the allocation we have made, or not like the pot we are putting it in, but (saying we are) cutting the budget is wrong.

The second thing is [the notion] that somehow I am `anti-HIV,’ or `anti-work-we-are-doing-on-HIV,’ is absolutely wrong. This development of the [Global Health Initiative (GHI)] is building on everything we have done, using what our work in HIV and malaria has shown us. One of the things that we have shown is that you can take complicated medical interventions, get them working in rural areas — including sophisticated techniques like measuring T cell and viral loads — and monitor people. A lot of what we have put into the GHI is built on the foundation of PEPFAR. We want to broaden it.

And (another thing) is that we have a moral obligation to the people we are trying to help that if we are spending money on things that are not efficient, we have to be more efficient. There is a moral obligation from the community (working in AIDS issues) not to just ask for more money, but to say, `We have this pot of money, how are we going to do the most with it?’

We’re not doing this because we are green-eyeshade, no-morals people. It’s because we want to save lives and spend money most efficiently.

Q: Still, Ambassador Eric Goosby told Science Speaks this week that even with efficiencies, there will be a `mismatch’ between funds and the need.

 

A: The United States has been a leader in the global HIV fight. President Obama is dedicated to that fight. He said there has to be a freeze in our spending and for everything that gets an increase, there has to be a decreases. In the 2011 budget, he increased global health funding by 8 percent. That should speak volumes to his dedication.

Q: But back to the Ambassador Goosby’s statement …

A: This is a shared responsibility. It’s not for the US alone to do everything for the world. It’s too big a problem. There are some numbers from UNAIDS (to be released Sunday) that show of all money for AIDS globally, (more than 50 percent) is American dollars, dwarfing by fivefold the next country. We are not shirking out duty. Everyone has to contribute, developing countries and developed countries.

Q: You challenged an audience in Vienna yesterday to identify cost-effective programs as well as inefficient ones. But what have you and others in the administration already identified as both winners and losers?

A: I am too distant from particular projects or programs to tell you what is working and what isn’t. When I ran a research group at the NIH, we would look at projects we were spinning our wheels on, and we would say, `Let’s kill it now.’ We have to do the same thing on the HIV implementation side. What’s going well, great. But what’s not going well, let’s cut it.

I have been told of some examples that we are thinking about, but this is really far beyond my expertise. One thing, on monitoring patients on antiretrovirals, instead of monitoring them every month to stretching it out to four months, then checking on that, and perhaps then stretching it out to six months.

The reason I issued my challenge is I am not the expert on the ground. I want to know what the community knows. I got a very loud non-answer (Friday) about what is effective and what isn’t effective. I do expect the community to come back and be frank. This is a collective effort, this isn’t one person and their judgment alone deciding things.

Q: Evidence-based recommendations are now putting more pressure on AIDS budgets – for instance, the WHO recommendation to start treatment when a person’s CD4 count falls below 350, instead of 200. Even with efficiencies, how are you going to meet that need with small percentage increases in budget?

A: In the whole area of global health, you have to recognize that we have millions upon millions of preventable deaths each year – not just in HIV, but in pneumonia, malaria, in maternal health. Every single one of those deaths is a tragedy. We have 2.2 million children die each year because of pneumonia. We have a vaccine for pneumonia, and it costs $1 — doesn’t that eat away at you? That eats away at me. The fact we have 2.5 million people die of HIV. That doesn’t eat away at you? It does me. The need clearly outstrips what the world is willing to contribute to this area. All of it is a tragedy. It’s why we want GHI to make a bigger impact than we have so far. We have to keep out eye on the ball. From 2003 to 2008, we spent $19 billion on HIV – for the five years. Now we are spending $6.9 billion a year – roughly one third that total.

Q: What area of PEPFAR’s work most easily translates into GHI? Where do you expect results?

A: Two things. One is prevention of maternal-child transmission. If transmission at birth is not zero, (it should be.) We have an intervention that works. Two, we want to integrate HIV/TB treatment. So many people with HIV have TB, and vice versa. Integrating those programs are going to be critical. But I am not a good micromanager. Eric (Goosby) and I discuss strategy, directions, but I don’t tell him what programs to do. It’s just like I don’t tell Raj Shah (USAID administrator) what programs to support. You are not going to see me designing particular programs.

Q: After an update on GHI recently at Kaiser Family Foundation, a leader in the US government on global health programs turned to me and whispered, `This is all fine, but PEPFAR is where the money is. GHI has no money — relatively.’ How are you going to manage this transition to GHI when nearly all the money is in PEPFAR?

A: There is no doubt that PEPFAR retains 70 to 75 percent of the funding. That is just the case. My point to the community has been to get off the dollars as a measure of success, or off dollars as a major scorecard. Our assessment has to be on impact on health. Are we decreasing mortality and morbidity, are we saving people’s lives. We have set goals on GHI … are we doing all we can with the funding that is projected?

One of the things I’m preoccupied by now, quite reasonably, is that there is a vaccine out there for pneumonia, and for rotavirus, and we have to make sure they are implemented. We are not the only game in town on this. We are working with Gates Foundation and with GAVI to make sure it works, to save the hundreds of thousands of lives we know we can save with these vaccines.

Underlying your question, I think, is the thought that since we have come to office, we haven’t done anything in the last 18 months. That is completely false. One of the things we’ve done is change how business is being done. We’ve pushed the notion of integration. Ambassador Goosby, Raj Shah and Tom Friedan at CDC meet regularly. Their deputies meet weekly, there’s better coordination on programs. A lot of this is less about the money and how are we going to do this in better fashion.

Q: How are things going at Vienna?

A: Oh, we had a few protestors yesterday — five out of 150 people or so. I don’t mind people disagreeing with me. I have two brothers and all we do is disagree. I’m used to argument, vigorous discussion. I think it is quite healthy. I do object to two things. One is disagreement not being fact based. The second is the HIV community has its own responsibility here. They need to be responsible, too. They have to come up with some positive ideas. How can we be more efficient? How can we integrate our programs with other ones so that everyone benefits? Activists did not come to their positions of power just by whining. They did because they were creative.

Ezra Klein interview with Ezekiel Emanuel, August 14, 2009

Before Ezekiel Emanuel joined his brother Rahm in the White House, he was director of the National Institute of Health’s clinical bioethics programs and an oncologist specializing in breast cancer. Since he began advising President Obama’s budget chief, Peter Orszag, on health care, however, he’s become a surprisingly high-profile figure. A recent New York Post article dug through his academic papers and branded Emanuel one of Obama’s “deadly doctors,” accusing him of everything from wanting to refuse health care to the elderly to wanting to let the developmentally disabled perish. Reached in Italy this week, the man the New Republic called “the nicest” Emanuel brother struck back at his critics, explained what a bioethicist does and revealed his foodie side. An edited transcript of our conversation follows.

We’ve heard harsh accusations in the health-care debate lately, including Sarah Palin’s contention that you want “death panels” and Rep. Virginia Foxx’s charge that Democrats want “to put seniors in a position of being put to death by their government.” So, do you want to euthanize my grandmother?

No. I’ve never met your grandmother. I’m sure she’s a lovely lady.

Anybody else’s grandmother?

No. I’m on record against legalizing euthanasia and assisted suicide for over a decade now. As you know from my Atlantic article.

I actually read that article in preparation for this interview. It made me rethink my position on euthanasia.

Wow! I’ve succeeded as an academic. That’s fantastic!

So how did all this get started?

You’re asking me? I’m just the victim here. All I know is the New York Post ran a article attacking me. I think lots of people decided it might be an easy way to kill health-care reform.

The New York Post quoted a 1996 article you wrote saying that some people believe health-care resources shouldn’t go to those “who are irreversibly prevented from being or becoming participating citizens.” What was your point?

I was examining two different, abstract philosophical positions to see what they might offer in the context of redoing the health-care system and trying to reduce resource consumption in health care. It’s as abstractly philosophical as you can get on a practical question. I qualified it in 27 different ways, saying it wasn’t my view.

Before you joined the White House, you were a bioethicist. What does a bioethicist do?

Worries about some of the hardest questions society has to face. One of the quotes in the New York Post came from an article we recently published in the Lancet where the question we were confronting may be the most difficult question the health-care system faces every day. We don’t have enough solid organs for transplantation; not enough kidneys, livers, hearts, lungs. When you get a liver and you have three people who need it, who should get it? We tried to come up with an ethically defensible answer. Because we have to choose.

Our system is expensive in part because we’ve refused to choose, because we’ve refused to answer some of these questions, like how we deal with end-of-life care, or what minimum benefits should be guaranteed to every American. But isn’t not answering those questions a sort of answer, too?

Yeah. You can’t avoid these questions. Even if you don’t provide an overt justification for them, you end up making decisions. Sometimes those aren’t good decisions, or they’re decisions you regret. We had a big controversy in the United States when there were 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.

Many see the health-care system as aimed at preventing death, and whenever someone dies, that’s a failure. So we don’t build in options around death because that would be admitting the possibility of failure.

Having been an oncologist and having cared for scores, if not hundreds, of dying patients, when you don’t have a treatment that can shrink the tumor and the patient will die, it’s a very difficult conversation. It’s emotionally draining. Then to talk to the family and figure out how to give the best quality of life in the final weeks or months — those are hard decisions.

You’ve argued that one of the reasons we’ve had trouble achieving universal health care is that we don’t have an agreed-upon ethical system for health care. As such, we don’t argue from common premises and no one trusts each other.

Issues that we cannot seem to resolve in our society reflect a lack of shared values. The situation around Terri Schiavo was a deeply held conflict over what to do if someone isn’t going to return to consciousness or competence. Who will decide? Even there, where we had settled legal rules, we still had disagreement. We’re torn about these things.

Are the bills under consideration dealing with these problems?

Fifteen years ago, I thought that cost growth meant we would have to confront the rationing question. But the more I studied it, the less I think rationing of health care is the key question. The bigger question seems to be improving the quality and efficiency of the system. We have a lot of unnecessary care. The big issue here is how to redesign the health-care delivery system so we’re doing the appropriate data-driven care that we know will improve someone’s life and not doing unnecessary, and potentially harmful, care.

So it’s not rationing if you don’t need it?

I think we have so much unnecessary care that’s not improving quality of life or length of life, that our first order of business is to get rid of that. That, we can all agree on. We need to change incentives, change how doctors behave and make decisions, so they’re more focused on what the data shows.

To switch gears, you’re a foodie.

We’re going from euthanasia and rationing to food?

Washington isn’t known for being friendly to your kind. What’s your favorite restaurant here?

A series of great meals at Cafe Atlantico. A quasi-Minibar they made for me was wonderful. I was there two weeks ago. They served about six or eight hors d’oeuvres, and then they had this series of small entrees that were spectacular. The crescendo was a duck confit that was brilliant.

I hear you’re also trying to change how the federal government eats.

President Obama, about two months ago, had a number of CEOs of major American corporations explain how they improve the health and wellness of their workforce. I was charged with applying their ideas to the federal workforce. One of their ideas was to change the food and nutrition available to workers. Both at cafeterias and vending machines, giving them healthier options and subsidizing more nutritious foods, but also making available to them better foods they can bring home through farmers markets.

What is your brother Rahm’s favorite food?

Good question. I don’t know, actually.

I’ve heard it’s the still-beating hearts of his enemies.

Oh, my brother is a lovely person. He doesn’t do any of that.

One last question: If you’re lying and you do create any death panels, can you put in a good word for me?

Ezra, you’re at the top of my list.

I guess that can mean a lot of different things.

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About the Author

- Stories transferred over from The Desk of Brian where the original author was not determined and the content is still of interest of Dispatch readers.

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