Wednesday, August 12, 2009

Ezekiel Emanuel: COMPLETE LIVES SYSTEM

ObamaCare means rationing of health care services.

Obama dodges and weaves on that, trying to avoid admitting that care will indeed be rationed.

He, of course, doesn't want the public to understand what government-run health care would really entail.

At his alleged town hall meeting in Portsmouth, New Hampshire yesterday, (actually, it was more like a campaign rally), Obama extolled the wisdom of "expert health panels" and their role in government-run health care.

OBAMA: In terms of these expert health panels -- well, this goes to the point about "death panels" -- that's what folks are calling them. The idea is actually pretty straightforward, which is if we've got a panel of experts, health experts, doctors, who can provide guidelines to doctors and patients about what procedures work best in what situations, and find ways to reduce, for example, the number of tests that people take -- these aren't going to be forced on people, but they will help guide how the delivery system works so that you are getting higher-quality care.

Obama touts the judgment of these "expert health panels."

One such "health expert" is Dr. Ezekiel Emanuel, a top adviser to Obama.

Ezekiel Emanuel has a system for determining how to allocate health services. (Allocating, in effect, is rationing.)

Emanuel promotes the "Complete Lives System" as a way to decide who gets treatment and who is denied.

From
The Lancet, Volume 373, Issue 9661, Pages 423 - 431, 31 January 2009, Emanuel writes:
The complete lives system

Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles: youngest-first, prognosis, save the most lives, lottery, and instrumental value. As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.” Although there are important differences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the defining feature of the complete lives system.

Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritising adolescents and young adults over infants. Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments. Similarly, adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfilment requires a complete life. As the legal philosopher Ronald Dworkin argues, “It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does”; this argument is supported by empirical surveys. Importantly, the prioritisation of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo. Consequently, poor adolescents should be treated the same as wealthy ones, even though they may have received less investment owing to social injustice.

The complete lives system also considers prognosis, since its aim is to achieve complete lives. A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life. Considering prognosis forestalls the concern that disproportionately large amounts of resources will be directed to young people with poor prognoses. When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable. Some small benefits, such as a few weeks of life, might also be intrinsically insignificant when compared with large benefits.

Saving the most lives is also included in this system because enabling more people to live complete lives is better than enabling fewer. In a public health emergency, instrumental value could also be included to enable more people to live complete lives. Lotteries could be used when making choices between roughly equal recipients, and also potentially to ensure that no individual—irrespective of age or prognosis—is seen as beyond saving. Thus, the complete lives system is complete in another way: it incorporates each morally relevant simple principle.

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated. It therefore superficially resembles the proposal made by DALY advocates; however, the complete lives system justifies preference to younger people because of priority to the worst-off rather than instrumental value. Additionally, the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them. Conversely, DALY allocation treats life-years given to elderly or disabled people as objectively less valuable.

Finally, the complete lives system is least vulnerable to corruption. Age can be established quickly and accurately from identity documents. Prognosis allocation encourages physicians to improve patients' health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates.

Objections
We consider several important objections to the complete lives system.
The complete lives system discriminates against older people. Age-based allocation is ageism. 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. Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

Age, like income, is a “non-medical criterion” inappropriate for allocation of medical resources. In contrast to income, a complete life is a health outcome. Long-term survival and life expectancy at birth are key health-care outcome variables. Delaying the age at onset of a disease is desirable.

The complete lives system is insensitive to international differences in typical lifespan. Although broad consensus favours adolescents over very young infants, and young adults over the very elderly people, implementation can reasonably differ between, even within, nation-states. Some people believe that a complete life is a universal limit founded in natural human capacities, which everyone should accept even without scarcity. By contrast, the complete lives system requires only that citizens see a complete life, however defined, as an important good, and accept that fairness gives those short of a complete life stronger claims to scarce life-saving resources.

Principles must be ordered lexically: less important principles should come into play only when more important ones are fulfilled. Rawls himself agreed that lexical priority was inappropriate when distributing specific resources in society, though appropriate for ordering the principles of basic social justice that shape the distribution of basic rights, opportunities, and income.1 As an alternative, balancing priority to the worst-off against maximising benefits has won wide support in discussions of allocative local justice. As Amartya Sen argues, justice “does not specify how much more is to be given to the deprived person, but merely that he should receive more”.

Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending. The complete lives system explicitly rejects waste and corruption, such as multiple listing for transplantation. Although it may be applicable more generally, the complete lives system has been developed to justly allocate persistently scarce life-saving interventions. Hearts for transplant and influenza vaccines, unlike money, cannot be replaced or diverted to non-health goals; denying a heart to one person makes it available to another. Ultimately, the complete lives system does not create “classes of Untermenschen whose lives and well being are deemed not worth spending money on”, but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.

Legitimacy
As well as recognising morally relevant values, an allocation system must be legitimate. Legitimacy requires that people see the allocation system as just and accept actual allocations as fair. Consequently, allocation systems must be publicly understandable, accessible, and subject to public discussion and revision. They must also resist corruption, since easy corruptibility undermines the public trust on which legitimacy depends. Some systems, like the UNOS points systems or QALY systems, may fail this test, because they are difficult to understand, easily corrupted, or closed to public revision. Systems that intentionally conceal their allocative principles to avoid public complaints might also fail the test.

Although procedural fairness is necessary for legitimacy, it is unable to ensure the justice of allocation decisions on its own. Although fair procedures are important, substantive, morally relevant values and principles are indispensable for just allocation.

Conclusion
Ultimately, none of the eight simple principles recognise all morally relevant values, and some recognise irrelevant values. QALY and DALY multiprinciple systems neglect the importance of fair distribution. UNOS points systems attempt to address distributive justice, but recognise morally irrelevant values and are vulnerable to corruption. By contrast, the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives. In pandemic situations, it also allocates scarce interventions to people instrumental in realising these four principles. Importantly, it is not an algorithm, but a framework that expresses widely affirmed values: priority to the worst-off, maximising benefits, and treating people equally. To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo.

Age-based priority for receiving scarce medical interventions under the complete lives system



Emanuel, WHITE HOUSE HEALTH CARE POLICY ADVISER, has some very scary ideas about who's fit to live and who's life has been full enough.

Look at the chart. Determining whether to permit medical intervention on a curve?

Should older Americans be concerned about this? I think so. The very young are also targeted.

At his event in Portsmouth yesterday, Obama tried to convince Americans that rationing won't occur under his single payer plan.

But we've seen how socialized medicine works. It doesn't raise the standards of care for everyone. It creates scarcity. Quality care? Forget it.

Obama mocked opponents who point out that a government-run health care system bent on trimming expenses will mean cutting services.

OBAMA: Let me just be specific about some things that I've been hearing lately that we just need to dispose of here. The rumor that's been circulating a lot lately is this idea that somehow the House of Representatives voted for "death panels" that will basically pull the plug on grandma because we've decided that we don't -- it's too expensive to let her live anymore. And there are various -- there are some variations on this theme.

The Complete Lives System does "pull the plug on grandma."

Emanuel is an "expert" Obama admires.

As Obama said in Portsmouth, "[W]e've got a panel of experts, health experts, doctors, who can provide guidelines to doctors and patients about what procedures work best in what situations."


These same experts also will provide guidelines to doctors about what procedures will not be allowed.

Remember what Obama said on ABC during his health care infomercial in response to this question from Jane Sturm:



OBAMA: We're not going to solve every difficult problem in terms of end-of-life care. A lot of that is going to have to be we as a culture and as a society starting to make better decisions within our own families and for ourselves.

But what we can do is make sure that at least some of the waste that exists in the system, that's not making anybody's mom better, that is loading up on additional tests or additional drugs, that the evidence shows is not necessarily going to improve care, that at least we can let doctors know, and your mom know, that you know what, maybe this isn't going to help. Maybe you're better off not having the surgery but taking the painkiller.

If the "expert health panel" deems certain treatments not cost effective, the government will be pulling the plug on "grandma."
_________________

Related post:

Ezekiel Emanuel: 'Thinking has Evolved'

18 comments:

Anonymous said...

What an unfair, misleading post. Dr. Emmanuel's article was limited to the special case where transplant organs or lifesaving vaccines are in short supply and there are more eligible recipients than there are organs or vaccines. Why did you deliberately choose not to mention that? You also neglect to note that severe, unfair, arbitrary rationing occurs every single day in the American health care system because millions of American families do not have health insurance. Lose your job, and you lose your access to medical care. How can you possibly defend the justice of such a system? How could it possibly be more just than the current reform proposals?

Anonymous said...

good thought annonymous. I do not agree with most liberal thinking. However, that is something worht chewing on for a while.

Anonymous said...

Wow - just crickets here - no one cares to defend the original post.

Mary said...

I've written nothing unfair or misleading. I provide all links and sources.

Read the article. Look at Emanuel's priority curve.

I'm not on defense.

Anonymous said...

Mary - you certainly are on defense. Dr. Emanuel's article was expressly limited to the special case of scarce medical interventions - such as a limited supply of transplant organs or new vaccines where there there are more qualified recipients than there are donors. It says so in the very first sentence of the article. (Anyone who doubts me can easily find the article on the net.) You deliberately ignored Dr. Emanuel's limiting context. You chose to leave out of your post the fact that his article was limited to organ donations and scarce vaccines. In so doing you mislead Americans seeking clarity about an important topic of current debate. You also libeled the reputation of a distinguished oncologist. In all fairness, don't you think you should reexamine your views and apologize to Dr. Emanuel? And, by the way, if you have a better, more ethically justifiable system of dealing with the allocation problem that Dr. Emanuel has so manfully grappled with, I would be delighted to hear it. So would he.

Mary said...

I've written nothing unfair or misleading. I provide all links and sources.

Read the article. Look at Emanuel's priority curve.

I'm not on defense.

MrLeon said...

I'm not so sure Mary is off the mark.

Granted Dr. Emmanuel's original article dealt with transplants and epidemics, but he has written quite extensively on the broader topic of "overutilization of health care". (e.g. JAMA, June 18, 2008)

Much of his writing appears to be well-researched, "constructive", and does nothing to avoid the fact: Health care will need to be provided with consideration for the cost -- and benefit to patient AND society, in his words: "greater health care value". In a really simple, honest word: rationed. Not rationed in the sense of rationing a quart of water in a life boat at sea, but rationed in the sense of providing ONLY necessary, beneficial, [cost-effective] care to those who [need] it.

Realistically, we need to define the meaning of "cost-effective" and "need". That's where the debate comes. Some say a mother "needs" an abortion. Some say a person should stay on a ventilator as long as there is any possible hope of recovery. Some say their loved-one "needs" the new high-cost experimental treatment as their last hope of survival. Who is right? Unfortunately, a national plan would create the scenario that (in any one person's view) either the Democrats or Republicans are "right" (at least until the next election cycle). Gee, that just doesn't sound like the United States of America to me -- at least as it would relate to healthcare.

Insurance companies and the Medicare program are always trying to figure out how to spend less. If we're all forced (eventually) into one National plan, "rationing" -- or whatever you'd like to call it -- is simply inevitable. And you should also investigate some writings on "personal lifestyle choices" as they relate to health care costs. Don't be surprised when someone starts questioning yours!

Also -- I just have to add that the oft-trumpeted talking point: "Lower the cost of health care" is either: a) indicative of sweeping and drastic changes to be made in the care provided or the payment to physicians or hospitals for it; or b) based on someone who is hopelessly uninformed or trying to manipulate the audience.

Please keep the debate civil and investigate thoroughly what is REALLY at stake. Make sure you really want what is being considered. It will change all of our lives significantly.

I'm writing from 25 years' experience in the managed healthcare financial analysis and provider contracting.

David said...

My mother, age 87, suffers from dementia. I drive 180 miles to visit her for an hour each week. I would not {"pull the plug") on her, but she wisely provided written instructions limiting the intervention of medical procedures which might be used to prolong her life without significant benefit to the quality of her life. That was her decision well before she began to suffer from dementia and it is my decision for myself. She was then, in her loving way, wanting to pass on her limited estate to her children and grandchildren without unreasonably diminishing it for no real (in her opinion) benefit to anyone including herself. It could be termed rationed care, I suppose. Is that choice not rational, loving, and inspiring? Is it wrong for our society to consider a generalization from my mother's choice:? I think Mary is misleading herself if she thinks otherwise.

pat said...

There's nothing unfair here. Emanuel is merely applying his personal philosophy to this specific problem. Complete Lives is a philosophy that would be applied to all examples.

I'm not sure if you're the same Anon all the time, but I wholeheartedly doubt that Dr Emanuel would like to hear alternative ideas. He is neck-deep in "complete lives."

Stuck in Ohio said...

David, your mother's choice is completely valid and entirely her right. The key word there, though, was "choice." It is not the position of "society," the government, or a panel of select "experts" to "generalize" that choice to any other person or family. As MrLeon pointed out, there is no way we as a broader culture can--or should--decide those types of things collectively. So, Anonymous (good job on that, by the way), here's your requested "better, more ethically justifiable system": let people decide for themselves. Period.

To throw around accusations of libel and demand an apology is absurd and demeaning. We live in a country where one is allowed to express dissent and criticism freely...for now at least.

Anonymous said...

N......A.......Z.......I
How soon we forget.

Elle said...

It's easy to talk about the logic of either side of a plan when it's not happening to you. That's why our founding fathers based this country's survival on the wisdom and clarity of God.

What Dr. Emanuel and others seem to forge is that inscribed into permanent fixures of our nation's capital are the 10 commandments - one of which says "Thou shalt not kill."

Now, sometimes as in war killing is a harsh necessity, but this is people discussing whose lives are worthy and whose are not - not based on crimes or any reasonable threat - but on age, medical condition, and contribution value to society. Money over LIVES.

Under ANY scenario, this is wrong. Is it econically sound? Sure, but no amount of money is worth selling out our values and God given rights to "LIFE, liberty and the pursuit of happiness" over. No amount of money is worth selling out your fellow citizen.

If you allow this kind of thing - what some may see as a small price to pay compared to "the planet" - to take root, you're opening the gates for other scenarios in which whatever group in power decides who's worthy and who's not.

Just ask my mother-in-law who would get targeted on HER panel should she get power over the White House. lol I joke ... but you get the point. The value of lives should be left to God ... not flawed humans who naturally have opnions on who is and is not significant.

Little compromises lead to bigger ones. Look back to our founding fathers and "stay the course".

Be careful about this plan ...
Think it through ...
Today it's grandma on oxygen ... tomorrow it could be you.

Anonymous said...

The whole issue for me is WHY do we want the Government making any choices in OUR lives. i understand some people will not be able to afford certain care that sucks for them but it is not your or my tax dollars that should pay for it.It is not and should not be the governments job to pay for healthcare for anyone period.

Michael Civitella keep govt. out said...

Key word here is "choice" it was your mothers choice to do what she desires. Individuals make choices for themselves not governments

Anonymous said...

Yes, I agree with the other Anonymous, we should all just stick our heads back up our backsides, and just keep repeating "there are no death panels, there are no death panels..." over and over and over again until we can convince ourselves to accept it in lieu of the truth...

Ponyexpress said...

Supply of any commodity is limited. When it is not, it is free. Like air.
Since all medical care , services and products will always be limited, who gets what and when has been decided by market forces, price versus supply and demand.Once a third party, with no skin in the game, gets to decide price and eligibility supply invariably becomes limited, and black markets flourish.
National healthcare under any guise invariably leads to shortages and rationing. ALWAYS

Anonymous said...

Distributive justice? Social justice. Workers of the world unite!
Uh huh, all from the same commie playbook. No doubt there are two "whole life" curves. One for democrats and one for the rest of us.
If the government will have "death panels" the people will too.
Let's face it, there is nothing affordable about the "affordable care act." It is just another liberal scheme of wealth transfer but it is the biggest one ever and it is going to prove to be unworkable, unpopular and doomed to fail. Certainly some people like a few of the ideas but what insurance company can stay in business with the pre-existing conditions exclusion? Maybe if they raise the yearly deductible to $500,000.00 it could work. You want to stay healthy? There are life choices you can make to increase your chances but they require a bit of self restraint and discipline. Get rid of alcoholism, drug abuse and tobacco and I would wager that the overall health of this country would inprove by 40 to 50%.
Remember the US Constitution? The key phrase is "promote the general welfare." It is not "guarantee the general welfare.

Anonymous said...

I wonder if the progressive defenders of 'Dr. Death Panel' are still so sanguine about their 'high minded' acceptance of pushing grandma off a cliff to make a better world for the 'socially productive'.

With all the hemming an hawing Zeke the Wonder Euthanizer did on Chris Wallace's show, its definitely not Mary on the defensive anymore.