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Cost effectiveness and Nazi Medecine,
the Chilling Example of Dr. Ezekiel Emanuel

In October 1939, Adolf Hitler issued a decree ordering the death of those who were considered “unworthy of life”, stating that patients considered incurable, be accorded a “mercy death”. The extermination started with the mentally ill, the terminally ill, invalids, and the disabled, and eventually spread to millions of Jews, Gypsies and other “undesirables”, who were worked to death or exterminated in concentration camps. This monstrous program was initially sold as a way of “easing the economic burden represented by people suffering from hereditary diseases”.

In today's debate about skyrocketing health care costs and health-care reform, the same type of “pragmatic” arguments are coming from top advisers in the Obama White House and the President himself – although couched in different terms.

A most egregious case is White House special health policy advisor Ezekiel Emanuel, who is also a member of the Federal Coordinating Council on Comparative Effectiveness Research, the 15 member panel that is to decide which medical care and medication will be permitted, and which will not. For those who might doubt the nazi parallels or the danger of systematic rationing of treatment, it is useful to consider what Dr Emanuel has written.

In the British medical journal Lancet, he elaborated a method for selecting which sections of the population should be denied health care in what order, in an article entitled, tellingly, "Principles for Allocation of Scarce Medical Interventions." That article was published on Jan. 31, 2009, which was 11 days after Barack Obama's inauguration. Then on March 19, Ezekiel Emanuel was appointed to the FCCCER – in spite of his well-documented positions on cutting costs for the most vulnerable sections of the population.

In the Lancet article, Dr. Emanuel describes his method of "Complete Lives System," saying it: "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." This may be justified by public opinion, since "broad consensus favors adolescents over very young infants, and young adults over very elderly people." He goes on to explain that the "death of a 20-year-old woman is intuitively worse than that of a 2-month-old girl". And so on ad nauseam.

Dr. Emanuel, a bioethicist (i.e. eugenicist), claims his system is preferable to such inhuman accounting methods as Quality-Adjusted Life Years and Disability-Adjusted Life Years: “the complete lives system is least vulnerable to corruption. Age can be established quickly and accurately from identity documents.” (And the designated victims carted away, he could have added.)

Ezekiel Emanuel has also called for a reinterpretation of the physician's Hippocratic Oath, in order to take account of “costs” and “effect on others”. In an article in the Journal of the American Medical Assocation (June 18, 2008), he wrote: “At least 7 factors drive overuse [of medical care], 4 related to physicians and 3 related to patients. First, there is the matter of physician culture. Medical school education and postgraduate training emphasize thoroughness. When evaluating a patient, students, interns, and residents are trained to identify and praised for and graded on enumerating all possible diagnoses and tests that would confirm or exclude them.... In medical training, meticulousness, not effectiveness, is rewarded.

“This mentality carries over into practice. Peer recognition goes to the most thorough and aggressive physicians. The prudent physician is not deemed particularly competent, but rather inadequate. This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic oath's admonition to 'use my power to help the sick to the best of my ability and judgment' as an imperative to do everything for the patient regardless of cost or effect on others." (emphasis added).

The potential savings from legalizing physician-assisted suicide has been a major area of interest for Ezekiel Emanuel. Fortunately for the terminally ill in over-crowded hospitals, he did, however, conclude in a 1998 article, that “Physician-assisted suicide is not likely to save substantial amounts of money in absolute or relative terms... for the nation as a whole.” So, at least he doesn't push that.

When Hitler set up his T4 program, to eliminate "useless eaters" from Germany's hospitals and nursing homes, he turned to a “non-political” body of medical experts to make the ugly decisions on who would die. Dr. Emanuel, in his 2008 book Healthcare, Guaranteed: A Simple, Secure Solution for America, called for phasing out Medicare, Medicaid, and the low-income children's health program SCHIP, and replacing them with government-paid private insurance. But the oversight on the approved payments, procedures, etc., he said, is to be made by an “independent” National Health Board, “to reduce political interference and allow the necessary tough choices to be made.” The Board should be nominated by the President, and confirmed by Congress, but otherwise not subject to objection from victims or voters, even being funded independently of Congressional appropriations.

It gets even worse, when one looks back to an essay co-published in the Hastings Center Report of Nov-Dec 1996) by Emanuel, in the context of so-called “academic” considerations. According to the “civic republican or deliberative democratic conception of the good”, he wrote, “services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.”

First exposed as “Dr. Death” by the LaRouche Political Action Committee, and then increasingly by others, Ezekiel Emanuel has made a vain attempt to convince the Washington Times that his thinking has changed. In an telephone interview from his vacation spot in Italy, Emanuel said that 20 years ago he thought rationing of care was an absolute necessity, and that there was a necessity to deny people care. But, now he has come to the conclusion that "if we got rid of unnecessary care, we would have absolutely no reason to even consider rationing except in a few cases.”

(Anton Chaitkin of Executive Intelligence Review confronted Dr. Ezekiel Emanuel with these accusations at an official hearing in Washington back on June 10. The video of his three minute intervention has been posted many times on youtube.com, and can be accessed by giving in search words “Chaitkin” and “Emanuel”.)

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