Monday, August 31, 2009

Nothing is more useful than silence

[Attributed to Menander of Athens]

The Deafening Silence blog is doing yeoman work taking a detailed look at some of Dr. Ezekiel Emanuel’s writings. The blogger there started with a New York Post article by Betsy McCaughey, tracked down three of the five Emanuel writings McCaughey cites, and is taking a detailed look at them. I think her review of Emanuel’s 1996 Hastings Center writing - the article which most damns him in conservative eyes - is particularly good and she is right on the money when she says:

Fortunately, according to Dr. Emanuel, this rigid insistance on moral neutrality in liberal philosophy is now changing, allowing liberal philosophers to declare what is 'good.'

"Fortunately, many, including many liberals, have come to view as mistaken a liberalism with such a strong principle of neutrality and avoidance of public discussion of the good. Some think the change a result of the critique provided by communitarianism; others see it as a clarification of basic liberal philosophy. Regardless, a refined view has emerged that begins to create an overlap between liberalism and communitarianism."

This new "refined view" appears to solve the problem for Dr. Emanuel. And from here, what might have been a very well-intentioned essay becomes increasingly myopic and narrow-minded.

I have read that Emanuel claims he was explaining a viewpoint he himself did not hold; I have also read he claims he has changed his mind about rationing since writing that article. I simply do not see how you can interpret Dr. Emanuel’s “Fortunately” paragraph as anything other than an endorsement of this more “refined” approach. So while I’m willing to accept that he has now changed his mind about the necessity for rationing (he did write this 13 years ago and, hey, when I was 17 I thought The Population Bomb was brilliant) I am not willing to accept that he never thought this view was a good one.*

That said, I also think Dr. Emanuel is getting a bum rap. Not from Deafening Silence: she seems even-handed and her willingness and ability to dig into the numbers behind the numbers are impressive. (I’m particularly glad she took a closer look at Dr. Emanuel’s rather selective chart in his June 18, 2008, JAMA article.) Furthermore, Deafening Silence is doing exactly what those attacking Dr. Emanuel are not doing: providing links and context.

This lack is really making me see red. I’ve gone through the New York Post article Deafening Silence began with and I’ve also gone through McCaughey’s very similar Wall Street Journal article. I was particularly intrigued by McCaughey’s claim that

Now he recommends arm-twisting Chicago style. "Every favor to a constituency should be linked to support for the health-care reform agenda," he wrote last Nov. 16 in the Health Care Watch Blog. "If the automakers want a bailout, then they and their suppliers have to agree to support and lobby for the administration's health-reform effort."

I cannot find this. I ran through about a half-dozen of the 130,000+ hits I got when searching for the string beginning “Every favor”: none of them contain a link, most of them simply quote McCaughey (some without mentioning her), and one of them even attributes the sentiment to Rahm Emanuel rather than Ezekiel.

This is insane. If there’s one thing the Internet is supposed to be about it’s allowing everyone access to all the data possible. I understand that McCaughey may be writing on dead trees but how hard would it be for the papers themselves to provide links? McCaughey has already found copies of these articles. Perhaps some of them are not available on-line or are behind firewalls but Deafening Silence managed to track down three of them. Surely with all her expertise in the medical field McCaughey could have managed the same feat. But then again her claims work far, far better if she can just rip out all that nasty context and cherry-pick which words she repeats and which words she hides.

The other thing that makes me see red is that not one article or blog or comment I have read attacking Ezekiel Emanuel cites what I think is his most important work: his 1997 Atlantic article arguing against the legalization of physician-assisted suicide and euthanasia. Of course, this makes perfectly good sense: it’s a lot easier to claim Ezekiel Emanuel is a soulless technocrat who wants to kill off everyone except perfectly healthy people between the ages of 15 and 45 if you manage to keep your audience from ever reading what Dr. Emanuel had to say in this article. Go, read - and remember this was published just a few months after his Hastings article.

Do I think Ezekiel Emanuel is beyond reproach? No. I believe his view of the Hippocratic Oath is seriously flawed and I’ll have more to say about that in my next post. In terms of what he does in general though I want to leave you with two thought experiments.

First, imagine that a war-geek journal - say the US Army War College Quarterly - devotes an article to discussing a hypothetical terrorist attack. The scenario is that a biological weapon has been unleashed on the Midwest city of Lincoln, Nebraska. Various articles in the journal discuss possible options to keep the disease from spreading outside of Lincoln. One writer suggests we may have to cordon off the city and let it struggle on its own; another suggests we may have to destroy the city ourselves to keep the disease from spreading. (No laughing from my military readers.) I think it’s good that someone is willing to consider the full range of options and ask some hard questions and even better that they’re doing so now before we’re in the midst of a crisis. Do you agree or do you think it’s horrible that anyone would even consider such a thing?

Second, imagine that terrorists have actually attacked the United States biologically. The disease is brutally effective: it takes a week to kill its victims so they require lots of medical care and it spreads by contact so those providing the care are infected when they try to help. Through heroic efforts the CDC has managed to develop a vaccine. It’s been rushed into production but we simply are not going to be able to produce more than about a million doses a day for the foreseeable future. I’d vaccinate health care workers and the military first. What would you do?


* I will give Dr. Emanuel a bit of a break here. What he is claiming was not his view was the part of his article that begins:

We may go even further. Without overstating it (and without fully defending it) not only is there a consensus about the need for a conception of the good, there may even be a consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues.

Most of what people quote as objectionable - “not guaranteeing health services to patients with dementia” - falls after this caveat. What Dr. Emanuel considers “fortunate” is the overturning of the argument that:

we lack sufficiently detailed ethical intuitions and principles to establish priorities among the vast array of health care services.

So what Dr. Emanuel is distancing himself from is the particular form the “conception of the good” would take. He has not - so far as I know - distanced himself from his distaste for the “moral skepticism” that “suggests there can be no principled mechanism to define basic health care services” and that therefore defining which health care services are basic - and how their cost should be balanced against the cost of other goods - should be left to the democratic process. Nor has he distanced himself from his preference for a “just allocation of health care resources” which - as Deafening Silence so cleverly points out - will be arrived at by a rather limited group.

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