At it again: McCaughey distorts Ezekiel Emanuel's writings to smear him as "Rationer-in-Chief"

››› ››› MORGAN WEILAND

Serial health care misinformer Betsy McCaughey, who The New York Times reported has "largely quot[ed]" White House health care adviser Ezekiel Emanuel's "past writings out of context this summer," did so again -- and at length -- in an August 27 Wall Street Journal op-ed. Indeed, she distorted various passages of Emanuel's writings and interviews by cropping and misrepresenting his remarks -- some of which the Times had described in context only days earlier -- to smear him as "Obama's Health Rationer-in-Chief."

NY Times: McCaughey has "largely quot[ed]" Emanuel's "past writings out of context this summer"

Times: Emanuel's writings "are being condensed, oversimplified and distorted in the griddle-hot health care debate." In an August 24 article, the Times' Jim Rutenberg wrote:

Few people hold a more uncomfortable place at the health care debate's intersection between nuanced policy and cable-ready political rhetoric than President Obama's special health care adviser, Dr. Ezekiel J. Emanuel.

Largely quoting his past writings out of context this summer, Betsy McCaughey, a former lieutenant governor of New York, labeled Dr. Emanuel a "deadly doctor" who believes health care should be "reserved for the nondisabled" -- a false assertion that Representative Michele Bachmann, Republican of Minnesota, repeated on the House floor.

Former Gov. Sarah Palin of Alaska has asserted that Dr. Emanuel's "Orwellian" approach to health care would "refuse to allocate medical resources to the elderly, the infirm and the disabled who have less economic potential," accusations similarly made by the political provocateur Lyndon H. LaRouche Jr.

In fact, Dr. Emanuel has written more than a million words on health care, some of which form the philosophical underpinnings of the Obama administration plan and some of which have enough free-market elements to win grudging respect from some conservative opponents.

The debate over Dr. Emanuel shows how subtle philosophical arguments that have long bedeviled bioethicists are being condensed, oversimplified and distorted in the griddle-hot health care debate. His writings grapple with some of the most complex issues of medical ethics, like who should get the kidney transplant, the younger patient or the one who is older and sicker?

Despite backtrack, McCaughey still distorting Emanuel's "Hippocratic Oath" statement

McCaughey: "Dr. Emanuel blames the Hippocratic Oath for the 'overuse' of medical care." From her WSJ op-ed:

Dr. Emanuel says that health reform will not be pain free, and that the usual recommendations for cutting medical spending (often urged by the president) are mere window dressing. As he wrote in the Feb. 27, 2008, issue of the Journal of the American Medical Association (JAMA): "Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely 'lipstick' cost control, more for show and public relations than for true change."

True reform, he argues, must include redefining doctors' ethical obligations. In the June 18, 2008, issue of JAMA, Dr. Emanuel blames the Hippocratic Oath for the "overuse" of medical care: "Medical school education and post graduate education emphasize thoroughness," he writes. "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." [The Wall Street Journal, 8/27/09]

Emanuel did not "blame" the oath for the "overuse" of medical care. Rather, as Media Matters for America noted, Emanuel argued in his June 18, 2008, JAMA piece, co-authored by Victor R. Fuchs, that the "physician culture" in which "meticulousness, not effectiveness, is rewarded" has led physicians to interpret the Hippocratic Oath "as an imperative to do everything for the patient regardless of cost or effect on others." From his June 18, 2008, JAMA piece:

At least 7 factors drive overuse, 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. The thought is that the more thorough the evaluation, the more intelligent the student or house officer. Trainees who ignore the improbable "zebra" diagnoses are not deemed insightful. 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. [Journal of the American Medical Association, 6/18/08]

McCaughey's distortion is a backtrack from false claim that Emanuel wanted to "eliminate" the oath. On the May 11 edition of Fox Business' Cavuto, McCaughey claimed that Emanuel "said if you want to save money in health care, we're going to have to push doctors to eliminate the Hippocratic Oath and give more attention to costs when they're treating a patient." Media Matters has documented this and other instances in which McCaughey was caught making an outright false claim about health care reform and backtracked, but nonetheless continued to attack and distort progressives' policies without acknowledging her backtrack from her prior falsehood.

McCaughey suggests Emanuel supported cost concerns over "patient" need -- but he expressed concern for both

McCaughey claims Emanuel "chastises physicians for thinking only about their own patient's needs." From her WSJ op-ed:

In numerous writings, Dr. Emanuel chastises physicians for thinking only about their own patient's needs. He describes it as an intractable problem: "Patients were to receive whatever services they needed, regardless of its cost. Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life. ... Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold down costs." (JAMA, May 16, 2007). [The Wall Street Journal, 8/27/09]

Emanuel was making larger point that health care's "cost, quality, benefits, and value" should be considered because it is a "social good." McCaughey's claim that Emanuel "chastises physicians for thinking only about their own patient's needs" ignores the larger point that he was making in the article she cited -- that "the patient's needs" are broader than their need for health care alone. Emanuel argued that the cost of health care should be considered in part because of its impact on the patient's "other essential needs," pointing to the fact that "the high cost of pharmaceuticals forced some elderly to choose between drugs and food." He also argued that health care should be treated like other "social goods" that are measured by "cost, quality, benefits, and value." From his May 16, 2007, JAMA article, "What Cannot Be Said on Television About Health Care":

For decades it was accepted that health care was special. Indeed, it was so special it could not be considered a usual good or service to be traded on the market for other goods. As [Norman] Daniels, a leading bioethicist, once argued, "A theory of health care needs should ... illuminate the sense in which many of us think health care is special and should be treated differently from other social goods."

To many, the specialness of health care meant that cost should not be a consideration in care. Ethical physicians could and should not consider money in deciding what they should do for sick patients. Patients were to receive whatever services they needed, regardless of its cost. Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life, akin to the economist who knew the price of everything but the value of nothing. Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold costs down.

The tipping point came when the media began reporting that the high cost of pharmaceuticals forced some elderly to choose between drugs and food. Health care actually was being traded off against other goods both at the individual and social level. The implication was that for Americans, health care did not necessarily seem so special; other essential needs -- food, housing, or heating -- could be just as special. The same phenomenon began to play out in state budgets. Increasing costs of Medicaid and health insurance premiums for state workers meant cuts in Medicaid's discretionary services or, more commonly, in other state services, especially primary and secondary education and support for state colleges and universities.

Americans began to realize that, as the economists would say, spending on health care has opportunity costs. Too much money spent on health care reduced the ability to obtain other essentials of human life as well as some goods and services not essential to life but still of great value, such as education, vacations, and the arts. Indeed, experts in the social determinants of health emphasized that many of these other factors, from income to education, were integral and perhaps even more integral than health care services for improving health outcomes. When health care began compromising access to other important goods--food, heating, and education--it ceased to be so special it was beyond cost.

Today, saying that health care is so special that its cost is irrelevant serves to discredit the source. A New York Times reporter learned this lesson the hard way when he praised a study that claimed by "virtually any commonly cited value of a year of life, we found that if medical care accounts for about half the [6.97 year] gain in life expectancy [since 1960] then the increased spending has, on average, been worth it." In response, the reporter "received about 500 e-mail responses from readers, and the most common reaction was a version of a simple question: 'Why do Americans spend so much more than folks in most other developed countries while getting worse results?'"

Replacing the notion that cost is irrelevant is the notion of value. Just as consumers ask whether a car or a computer is worth the cost, health care consumers are beginning to ask whether a health care intervention is worth the cost. Increasingly, health care needs to be measured by the same metrics as other goods and services -- cost, quality, benefits, and value. It can no longer claim to be treated differently from other social goods. [Journal of the American Medical Association, 5/16/07]

McCaughey selectively crops Emanuel quotes to buttress "Rationer-in-Chief" smear

McCaughey misleadingly crops NEJM book review, WaPo interview to advance smear. From her WSJ op-ed:

"In the next decade every country will face very hard choices about how to allocate scarce medical resources. There is no consensus about what substantive principles should be used to establish priorities for allocations," he wrote in the New England Journal of Medicine, Sept. 19, 2002. Yet Dr. Emanuel writes at length about who should set the rules, who should get care, and who should be at the back of the line.

"You can't avoid these questions," Dr. Emanuel said in an Aug. 16 Washington Post interview. "We had a big controversy in the United States when there was 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." [The Wall Street Journal, 8/27/09]

McCaughey suggests Emanuel contradicted himself regarding allocation of "scarce medial resources." By cropping Emanuel's article, McCaughey suggested that his admission that "[t]here is no consensus about what substantive principles should be used to establish priorities for allocations" contradicts the fact that he has, according to McCaughey, "writ[ten] at length about who should set the rules, who should get care, and who should be at the back of the line." But in very next line, which McCaughey omitted, Emanuel provided a guiding principle for how to go about "allocat[ing] scarce medical resources," explaining that "[i]nstead, we will need fair procedures. Debate will focus on what those procedures should be." From his September 19, 2002, book review, "Setting Limits Fairly: Can We Learn to Share Medical Resources?" (subscription required; the portion McCaughey omitted is in bold):

In the next decade, every country will face very hard choices about how to allocate scarce medical resources. There is no consensus about what substantive principles should be used to establish priorities for allocations. Instead, we will need fair procedures. Debate will focus on what those procedures should be. Daniels and [James E.] Sabin's accountability for reasonableness and illuminating case studies will be invaluable in furthering that debate. [The New England Journal of Medicine, 9/19/02]

In WaPo interview, Emanuel explained resource allocation choices made implicitly as well. In purporting to quote from Emanuel's Post interview, McCaughey omitted both the question and Emanuel's explanation that even if decisions about how care is allocated are not explicitly made, they are made nonetheless implicitly. The full context of the August 16 Washington Post interview with Ezra Klein, with the question and the part of Emanuel's response that McCaughey omitted in bold:

Our system is expensive in part 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. [The Washington Post, 8/16/09]

McCaughey incorrectly attributes "consensus view" to Emanuel himself

McCaughey: Emanuel advocates the "communitarian perspective." From McCaughey's WSJ op-ed:

Dr. Emanuel argues that to make such decisions, the focus cannot be only on the worth of the individual. He proposes adding the communitarian perspective to ensure that medical resources will be allocated in a way that keeps society going: "Substantively, it suggests services that promote the continuation of the polity -- those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations -- are to be socially guaranteed as basic. Covering 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." (Hastings Center Report, November-December, 1996) [The Wall Street Journal, 8/27/09]

NYT: Emanuel said he was "describing a consensus" view, not his own. In the August 24 Times article, Rutenberg explained that in Emanuel's 1996 Hastings Center Report, which McCaughey cited, he "laid out what he called a growing consensus among competing political philosophies about how a society should allocate health care services. In clinical terms, he said that consensus held that those who 'are irreversibly prevented from being or becoming participating citizens' should not be guaranteed the same level of treatment as others." Rutenberg went on to report that "Dr. Emanuel said he was simply describing a consensus held by others, not himself." Additionally, Rutenberg noted that McCaughey had previously misrepresented the Hastings report. From the August 24 Times article:

Ms. McCaughey, Ms. Palin and others have based accusations that Dr. Emanuel would direct treatment away from the disabled on a 1996 paper he wrote for the Hastings Center bioethics institute.

In it, Dr. Emanuel did not assert that "medical care should be reserved for the nondisabled, " as the critics have said.

The paper laid out what he called a growing consensus among competing political philosophies about how a society should allocate health care services. In clinical terms, he said that consensus held that those who "are irreversibly prevented from being or becoming participating citizens" should not be guaranteed the same level of treatment as others.

He cited as an example, "not guaranteeing health services to patients with dementia."

Dr. Emanuel said he was simply describing a consensus held by others, not himself.

But even some colleagues said in interviews that the paper did not go far enough in repudiating the view.

"He doesn't ever endorse it, nor does he explicitly distance himself from it," said Thomas H. Murray, president of the Hastings Center. But, Mr. Murray added, "anyone who would attribute this isolated sentence to his convictions, it's just unfair." [The New York Times, 8/24/09]

McCaughey crops Emanuel to mislead on his standard for payment for new treatments

McCaughey: Emanuel claims new drugs should only be paid for when evidence shows it "will work for most patients." From her WSJ op-ed:

To reduce health-insurance costs, Dr. Emanuel argues that insurance companies should pay for new treatments only when the evidence demonstrates that the drug will work for most patients. He says the "major contributor" to rapid increases in health spending is "the constant introduction of new medical technologies, including new drugs, devices, and procedures. ... With very few exceptions, both public and private insurers in the United States cover and pay for any beneficial new technology without considering its cost. ..." He writes that one drug "used to treat metastatic colon cancer, extends medial survival for an additional two to five months, at a cost of approximately $50,000 for an average course of therapy." (JAMA, June 13, 2007). [The Wall Street Journal, 8/27/09]

Emanuel actually suggested treatments should only be paid for when benefits to that patient justify costs. In his June 13, 2007, JAMA article, Emanuel did not argue that "insurance companies should pay for new treatments only when the evidence demonstrates that the drug will work for most patients," but instead suggested that treatments should be paid for when the benefit to that patient justifies the cost. From the JAMA article, which Emanuel co-authored with Colleen C. Denny and Steven D. Pearson:

While some new medical innovations provide significant benefits to patients and even reduce overall health care costs, many new interventions do neither. By foregoing considerations of costs in relationship to benefits, current health insurance designs do little to distinguish health care interventions that are valuable from ones that offer little more than higher prices. Failing to explicitly include cost-benefit considerations in a framework for health benefits creates a pattern of imprudent and wasteful spending, fueling the escalation of health care costs. [Journal of the American Medical Association, 6/13/07]

Cost-benefit argument obscured by cropped quote. Indeed, Emanuel's argument would have been clear had McCaughey not cropped his words. From the June 13, 2007, JAMA article, with the portion McCaughey omitted in bold:

With very few exceptions, both public and private insurers in the United States cover and pay for any beneficial new technology without considering its cost in relation to the degree of additional benefit it provides over alternatives. [JAMA, 6/13/07]

McCaughey overstates power of possible "rationing body"

McCaughey misrepresents mandate NICE-like "rationing body" would have. From her WSJ op-ed:

To reduce health-insurance costs, Dr. Emanuel argues that insurance companies should pay for new treatments only when the evidence demonstrates that the drug will work for most patients. He says the "major contributor" to rapid increases in health spending is "the constant introduction of new medical technologies, including new drugs, devices, and procedures. ... With very few exceptions, both public and private insurers in the United States cover and pay for any beneficial new technology without considering its cost ... ." He writes that one drug "used to treat metastatic colon cancer, extends medial survival for an additional two to five months, at a cost of approximately $50,000 for an average course of therapy." (JAMA, June 13, 2007).

Medians, of course, obscure the individual cases where the drug significantly extended or saved a life. Dr. Emanuel says the United States should erect a decision-making body similar to the United Kingdom's rationing body -- the National Institute for Health and Clinical Excellence (NICE) -- to slow the adoption of new medications and set limits on how much will be paid to lengthen a life. [The Wall Street Journal, 8/27/09]

Emanuel: Group would "determin[e] the value of health care services by assessing their comparative clinical effectiveness and cost-effectiveness." McCaughey's claim that Emanuel supports a "rationing body" that would "slow the adoption of new medications and set limits on how much will be paid to lengthen a life" grossly distorts what Emanuel wrote in the June 13, 2007, JAMA article she appears to be citing. Emanuel actually stated only that the "United States currently lacks an authoritative, independent entity specifically charged with determining the value of health care services by assessing their comparative clinical effectiveness and cost-effectiveness," citing "the National Institute for Health and Clinical Excellence in England" as an "[i]nternational example" of a body that performs such assessments. From Emanuel's June 13, 2007, JAMA article:

The United States currently lacks an authoritative, independent entity specifically charged with determining the value of health care services by assessing their comparative clinical effectiveness and cost-effectiveness. International examples, such as the National Institute for Health and Clinical Excellence in England and the Pharmaceutical Benefits Advisory Committee in Australia, have demonstrated how this task can be successfully managed with rigor, objectivity, and transparency. [JAMA, 6/13/07]

Ignoring facts, McCaughey claims Emanuel's op-ed "untrue"

McCaughey: Emanuel's claim that U.S. "lag[s] behind" on "virtually every health statistic" is "untrue," "factual error." From her WSJ op-ed:

Dr. Emanuel's assessment of American medical care is summed up in a Nov. 23, 2008, Washington Post op-ed he co-authored: "The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed nations on virtually every health statistic you can name."

This is untrue, though sadly it's parroted at town-hall meetings across the country. Moreover, it's an odd factual error coming from an oncologist. According to an August 2009 report from the National Bureau of Economic Research, patients diagnosed with cancer in the U.S. have a better chance of surviving the disease than anywhere else. The World Health Organization also rates the U.S. No. 1 out of 191 countries for responsiveness to the needs and choices of the individual patient. That attention to the individual is imperiled by Dr. Emanuel's views. [The Wall Street Journal, 8/27/09]

McCaughey's claim is "untrue," a "factual error." In writing that Emanuel's claim is "untrue" and a "factual error," McCaughey ignores the evidence that Emanuel provided in his November 23, 2008, Washington Post op-ed to substantiate his claim that "we lag behind many developed nations on virtually every health statistic you can name." For instance, Emanuel correctly noted that the United States "rank[s] near the bottom of countries in the Organization for Economic Cooperation and Development" in terms of life expectancy at birth. He correctly noted that U.S. infant mortality is "6.8 per 1,000 births, more than twice as high as in Japan, Norway and Sweden." And he was right about the United States' ranking concerning efforts to reduce smoking rates, the obesity epidemic, and prostate cancer death rates. From Emanuel's Post op-ed, co-written with Shannon Brownlee:

Let's bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name. Life expectancy at birth? We rank near the bottom of countries in the Organization for Economic Cooperation and Development, just ahead of Cuba and way behind Japan, France, Italy, Sweden and Canada, countries whose governments (gasp!) pay for the lion's share of health care. Infant mortality in the United States is 6.8 per 1,000 births, more than twice as high as in Japan, Norway and Sweden and worse than in Poland and Hungary. We're doing a better job than most on reducing smoking rates, but our obesity epidemic is out of control, our death rate from prostate cancer is only slightly lower than the United Kingdom's, and in at least one study, American heart attack patients did no better than Swedish patients, even though the Americans got twice as many high-tech treatments. [The Washington Post, 11/23/08]

McCaughey: serial misinformer on health care

Betsy McCaughey is a serial misinformer who has perpetuated numerous falsehoods about health care reform. McCaughey has on numerous occasions propagated falsehoods about health reform proposals that were subsequently parroted by the conservative media. Most recently, McCaughey falsely claimed that the House health care reform bill would "absolutely require" end-of-life counseling for seniors on Medicare "that will tell them how to end their life sooner" -- a claim that many in the media subsequently repeated. McCaughey has repeatedly falsely claimed that the Senate Health, Education, Labor and Pensions Committee's bill "basically" "pushes everyone into an HMO-style plan." Additionally, McCaughey concocted the false claim, which was nonetheless widely repeated in the media, that a health IT provision in the economic recovery act enabled government bureaucrats to "monitor treatments" or restrict what "your doctor is doing" with regard to patient care.

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Betsy McCaughey
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