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Saturday, August 01, 2009



I'm not completely sure what your point is, but you seem to be attempting to make it through the use of innuendo. The article has nothing to do with health insurance discussions currently taking place in Congress. It's about how to ethically make choices about allocating scarce medical resources like organs and vaccines under current conditions. These are procedures where the market has failed to meet demand for the past fifty years. The article reviews three frameworks in use and their core ethical principles, suggests a fourth, and discusses advantages and disadvantages along the way. First come first serve has been shown in practice to treat people unequally. The authors do discuss the weaknesses of a youngest-first approach, but you neglect to mention that they still suggest keeping that as a core principle in their suggested framework. That is not their sole core principle however, and the tenuous connection to the Obama wants to kill old people meme is disingenuous. This year there will not be enough swine flu vaccine to go around. How best to allocate the vaccine to benefit public health is an important question.


As I understand the entire article, what you are implying is taken totally out of context. The article deals only with allocation of medical resources that are inherently scarce relative to need--a new vaccine or organs for transplant are examples. There simply are not enough to meet demand and they thus must be allocated. So under those circumstances, who better to receive the limited resource: someone who has hardly developed, or a twenty-year old; someone who might live 20 more years or an 80 year-old; etc?

You seem to imply that Democrat's proposed health care reforms would make all medical interventions subject to the allocation method advocated in the article thus conflating what should be plentiful with what is by nature scarce. You also imply there are no allocation systems for scarce interventions being employed now. Neither is true. We prioritize who should receive certain care, hold our noses and live--or die--with the results. And some of the methods of prioritizing indeed seem inferior to what is proposed in the article.

In fact, we prioritize and allocate nearly all interventions, scarce or otherwise, by ability to pay. And we make interventions more scarce by allocating money to insurance industry profits instead of actual health care. So, if granny is too young to qualify for medicare and can't get good health insurance, it seems to me someone other than Democrats and their advisers are at least tacitly giving her a little nudge toward the precipice.

One other item of note, the article explicitly calls for taking all possible measures to reduce scarcity before implementing any allocation system.

P. Chirry

EE says in the article

"Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending."

This is evidence that EE and his lot have ambitions for eventually applying a similar system to health care as a whole. So Miranda is right, there is cause for concern.


I'm sorry I wasn't more clear Denature. It has everything to do with the policy decisions being made now, as Emanuel is one of Obama's top health care advisers. If he did not mean to bring the same ideas or values into Obama's future policies, then, yes, this article might be irrelevant. But it isn't.

I'm not the only one who thinks Emanuel is a little creepy. Here's an excerpt from a recent Washington Times piece:

"Presidential health care adviser Ezekiel Emanuel, brother of White House Chief of Staff Rahm Emanuel and chairman of the Department of Bioethics at the Clinical Center at the National Institutes of Health, has argued that independent government boards should decide policy on end-of-life care. He also has defended rationing care more strictly for older people because "allocation [of medical care] by age is not invidious discrimination."

Now, this may seem reasonable to you, but after the Democrats ran their ad showing Bush pushing old ladies off cliffs, one wonders why they are silent about this.
If they are truly concerned about the well-being of the elderly, they should be up in arms against this sort of discrimination. That is my point.

A.I, it would be out of context, except that Emanuel is now trying to work his views on end-of-life care into current health policy. This is the article that explains what he means.

P. Chirry: Thank you for your support.


I read that section as a warning that their framework is not currently applicable to health care as a whole since problems of access are more related to money and waste. Access to a prostate exam is different from access to the kidney that just became available. The elderly have medicare, so I can't picture an argument for that population having inherently less access to health care as a whole under any future plans. The authors explicitly state that the framework was "developed to justly allocate persistently scarce life-saving interventions" Any rational criticism of applying this system, whether as intended in the article or conflated to health care in general, must include a comparison to how things work in its absence if we are to reach a relevant conclusion of its utility. Finally, the paper points out that the proposed framework does not create classes of people "whose lives and well being are not deemed worth spending money on."


The value of the Washington Times article is obvious by their quote mining from the same article you used. They use it to imply he wants to ration care for the elderly when the article explicitly states that is not its subject. A quick look at Emanuel's bio shows that he has argued that there is no compelling evidence that legalizing euthanasia improves care (see his '99 article in Ethics for another balanced review of current views in the medical field) and his development of a living will (giving people the power to make their own decisions) was endorsed by Consumer Reports, the NYT, and the Wall Street Journal. It may be easier to discuss this topic if you fill in the steps of your slippery slope and tell us how Obama plans to implement his eugenics program.


I never indicated or implied that I thought Emanuel supported euthanasia. I applaud his efforts to stop it. However, I do think that the article I quoted shows that he values older people less than younger people. That is important, because the Democrats have, in the past, at least pretended to be concerned about the welfare of the elderly.
In the cartoon I linked to, Bush was shown pushing old ladies off cliffs, merely because he suggested that individuals could invest in personal retirement accounts, rather than the social security system.
Emanuel not only wants to scrap Medicare and Medicaid, in favor of a voucher system, but he wants to deny critical care to the elderly, so that it can be given to younger people. Therefore, I think it’s fair to say that he is more guilty than Bush of pushing old ladies off cliffs.


You say: "Democrats have, in the past, at least pretended to be concerned about the welfare of the elderly." Pretended? Who had to fight Republicans every step of the way to institute Social Security and Medicare? It was Democrats of course. And who fought to keep Social Security intact during both the Reagan and GW Bush administrations. Again, it was Democrats.

As a conservative, you are certainly entitled to argue the merits of either Social Security or Medicare as opposed to some other policies you might propose. But to suggest the party that fought to institute programs to ensure some semblance of financial and health security for older people doesn't care about the elderly is beyond the pale.

As denature and I have pointed out, your assertions are poorly supported. You assume EE will apply the same ethical standard for allocating scarce health care resources to those which are not, or at least should not be. You then assume that if that were true, EE's standard would be adopted by Democrats in congress and the Administration as they formulate health policy. In short you assume what is not clearly evident in an attempt to build a case against efforts to alleviate some of the very problems you say will be created or exacerbated. In so doing, you join the chorus of those who seek to scare the elderly into rejecting health care reform.

You attempt to say that is on a par with Democrats warnings about Bush Administration Social Security proposals. There is a big difference. What Democrats cited as the downside to privatization came to pass. What you warn of is nothing more than fear mongering with no basis in fact.

P. Chirry

A.I. you are wrong.

There is plenty of basis for concern. ALL medical resources are inherently scarce, EE realizes this and, as I've pointed out, even suggests that his discriminatory complete lives system, or at least the principles behind it, might one day be applied to health care as a whole. He said it, it's there, and ignoring it is simply wishful thinking.

You can see evidence of his willingness to implement it in the current health care reform legislation, where are buried things like mandatory counseling sessions for all seniors every five years regarding "end of life" decisions are buried in the hundreds of pages.

There is even more cause for concern when you look to places that already have government healthcare like Europe, specifically places like the Netherlands, where studies report there are about 1000 annual deaths due to _non-voluntary_ euthanasia.

That seems a reasonable basis enough for me to be wary, at least. But then again I don't drink kool-aid, so I might not have as the best grasp on what's reasonable.

P. Chirry

Meh, forget that last line there, that was out of line.


I don't even like Kool-Aid. I do like Coke though, which figures in another discussion I'm embroiled in here--but I digress.

This whole notion of Democrats, Obama, EE or whomever wanting to establish mechanisms that would counsel/cajole seniors into shuffling off this mortal coil are silly, crazy and sinister. Yes, some of the current proposals include provision for counseling people on living wills and end-of-life directives on a voluntary basis. That does not constitute what you and others imply: http://tpmmuckraker.talkingpointsmemo.com/2009/07/debunking_the_gops_phony_euthanasia_myth_--_since.php

There are many with much to gain politically and monetarily by promoting this myth. I would bet you have neither Miranda, so please, just stop. There are many real issues regarding health care warranting discussion, but this isn't real of one of them.


Obama has stated himself "Seniors my have to come to embrace hospice". Please explain to me, if this is not saying we are going to ration health care for the elderly what does it mean?



You are right, I have no political ambitions, and I have nothing to gain monetarily by expressing my opinion. But I do have the right to do so, and I think it is important that people question governmental choices that do not seem quite right to them. If I'm wrong, I'm wrong and I don't mind admitting it. On the other hand, if Emanuel does have the views I suspect he does and if he tries to work policies into Obama's plan that reflect these, we need to be on our toes.


If I am in the doctor's office waiting for a flu shot, and there are nine others there also waiting for the same kind of shot. but there are only nine shots left, it is my decision to either forgo my shot or to take my turn. The others may be younger or older, healthier of more frail; the decision is mine alone to make. It is not Obama's to make or even consider making==unless of course he is a control freak.


Thanks, Jaye. I agree.

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