Right-Wing politics often leave me at a loss for words.  The attacks aimed at Ezekiel Emanuel before and after the passage of what is commonly called “Obamacare” is one of the most bizarre examples.  At the time, Emanuel was Special Advisor for Health Policy to Peter Orszag, acting director of OMB.

Emanuel struck me as a strange target.  In 1997, he wrote a strong essay against legalization of assisted suicide and/or euthanasia.  His latest essay opposing legalization of assisted suicide appeared on October 2012 in the NY Times.

Here’s what Wikipedia has to say about the attacks on Emanuel:

Betsy McCaughey described Ezekiel Emanuel as a “Deadly Doctor” in a New York Post opinion article.^[29] The article, which accused Emanuel of advocating healthcare rationing by age and disability, was quoted from on the floor of the House of Representatives by Representative Michele Bachmann of Minnesota.^[30]Sarah Palin cited the Bachmann speech and said that Emanuel’s philosophy was “Orwellian” and “downright evil”, and tied it to a health care reform end of life counseling provision she claimed would create a “death panel“.^{[10][31][32][33][34][35][36]} Emanuel said that Palin’s death panel statement was “Orwellian”.^[37] Palin later said that her death panel remark had been “vindicated” and that the policies of Emanuel are “particularly disturbing” and “shocking”.^[38] On former Senator Fred Thompson’s radio program, McCaughey warned that “the healthcare reform bill would make it mandatory—absolutely require—that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner.” She said those sessions would help the elderly learn how to “decline nutrition, how to decline being hydrated, how to go in to hospice care … all to do what’s in society’s best interest or in your family’s best interest and cut your life short.”^[39] As The New York Times mentioned,^[40] conservative pundits were comparing the Nazi T4 euthanasia program to Obama’s policies as far back as November 2008, calling them “America’s T4 program—trivialization of abortion, acceptance of euthanasia, and the normalization of physician assisted suicide.”^[41]

Here’s a summary of what fact-checkers had to say about the allegations:

The nonpartisan Politifact.com Web site described McCaughey’s claim as a “ridiculous falsehood.”^{[39][42][43][44]} FactCheck.org said, “We agree that Emanuel’s meaning is being twisted. In one article, he was talking about a philosophical trend, and in another, he was writing about how to make the most ethical choices when forced to choose which patients get organ transplants or vaccines when supplies are limited.”^[45][46] An article on Time.com said that Emanuel “was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources … ‘My quotes were just being taken out of context.'”^[10] A decade ago, when many doctors wanted to legalize euthanasia or physician-assisted suicide, Emanuel opposed it.^[4] Emanuel said the “death panel” idea is “an outright lie, a complete fabrication. And the paradox, the hypocrisy, the contradiction is that many of the people who are attacking me now supported living wills and consultations with doctors about end-of-life care, before they became against it for political reasons.” “I worked pretty hard and against the odds to improve end-of-life care. And so to have that record and that work completely perverted—it’s pretty shocking.”^[47]

To me, Ezekiel has been one of the “good guys” – pushing for better and more efficient health care for everyone, and staunchly opposed to legalization of assisted suicide and euthanasia.

Last Thursday – January 3 – Emanuel published another essay titled “Better, if Not Cheaper, Care.”  Here’s the opening:

IT is conventional wisdom that end-of-life care is an increasingly huge proportion of health care spending. I’ve often heard it said that people spend more on health care in the year before they die than they do in the entire rest of their lives. If we don’t address these costs, the story goes, we can never control health care inflation.

Wrong. Here are the real numbers. The roughly 6 percent of Medicare patients who die each year do make up a large proportion of Medicare costs: 27 to 30 percent. But this figure has not changed significantly in decades. And the total number of Americans, not just older people, who die every year — less than 1 percent of the population — account for much less of total health care spending, just 10 to 12 percent.

The more important issue is that just because we spend a lot on end-of-life care does not mean we can save a lot. We do know that costs for dying patients vary widely among hospitals, which suggests that we can do better. And yet no one can reliably say what specific changes would significantly lower costs. There is no body of well-conducted research studies that has proved how to save 5, 10, much less 20 percent.

Recent studies find that hospice may reduce costs in the last year of life for cancer patients by 10 to 20 percent. But they find no savings from hospice care for patients who die of other conditions, like emphysema or heart failure. No one is sure why hospice care doesn’t save more. It may be because patients are enrolled in hospice care too late, or because hospice services themselves are labor-intensive and not cheap.

Even if we can never save a dime, however, there are good reasons to think about changing end-of-life care practices. While end-of-life care has improved considerably over the last 30 years, many Americans still die in hospitals when they would rather die at home. Nearly 20 percent of deaths occur in an intensive care unit or immediately after discharge, and too many patients experience symptoms like pain that are controllable with appropriate palliative care.

Emanuel goes on to describe four changes in the delivery of care that could improve the lives of patients with serious medical conditions and their families.  They are well worth considering.

Over the next week, I’ll share some material regarding another professional who also has some great ideas about reforming “end of life” practice and is already implementing those changes on a “small” scale.

I’ll also share some other info that gives some pretty stark evidence of just how significant the barriers are to making changes that would make the practice of medicine safer and truly person-centered.