Emanuel has written cogently about the causes of overutilization -- Americans' addiction to unnecessary invasive, expensive procedures; the causal link between runaway healthcare costs and the rising number of uninsured; and criteria for making the hardest choices about allocating truly scarce medical resources, such as in organ donation. McCaughey falsely charges that he "blames the Hippocratic Oath" for U.S. doctors' propensity to prescribe unnecessary treatment (rather than a particular interpretation of that oath); that he wants to ration care generally rather than set criteria for allocating resources in the few situations of true scarcity; and that he falsely maligns the US healthcare system by charging that it's "number one in only one sense: the amount we shell out for health care" -- an absolutely true charge undented by the ratings she cherry-picks as counter-evidence.
Alas, even a demagogue can strike home on occasion, and a prolific academic will usually go on record with some disturbing ideas. McCaughey does flag one troubling strain in Emanuel's thought, and his protestations don't entirely hold water.
The trouble comes in a brief 1996 essay in the Hasting Center Report that questions whether American society can bring to bear on healthcare a "concept of the good" that will provide the broad framework enabling us to "develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially." The trouble, Emanuel suggests, is that liberalism resists justifying policy by appeals to the good because to do so "would violate the principle of neutrality and be coercive, imposing one conception of the good on citizens who do not necessarily affirm that conception of the good." He suggests that this "strong principle of neutrality" is a weakness and seems to approve of a "growing agreement between many liberals, communitarians and others" that "the just allocation of health care sources...can be addressed only by invoking a particular concept of the good." He suggests that "there may even be a consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues." He then defines that emerging consensus concept in a passage out of which McCaughey and others have made much hay:
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. Conversely, 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. A less obvious example is guaranteeing neuropsychological services to ensure children with learning disabilities can read and learn to reason.In defense of this passage, Emanuel told Jake Tapper that he was merely describing this allegedly emerging consensus, not endorsing it. His presentation of the "consensus" cited above is indeed couched in a disclaimer to this effect:
We may go even further. Without overstating it (and without fully defending it) not only is there a consensus about the need for a conception of the good, there may even be consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues.I take Emanuel at his word that he does not advocate failing to guarantee health care to those who lack or have lost the capacity to be active citizens. That parenthetical disclaimer is a pretty weak hedge, though. The whole tenor and structure of the article builds toward presenting the liberal-communitarian convergence on this utilitarian "concept" as a cornerstone of true healthcare reform. Early on, Emanuel suggests (again with a slight distancing gesture):
On this view, the reason the United States has failed to enact universal health coverage is not primarily political or economic; the real reason is ethical--it is a failure to provide a philosophically defensible and practical mechanism to distinguish basic from discretionary health care services.He then decries as "dangerous" a "moral skepticism" that rejects the possibility of defining a "concept of the good" that can attract consensus. He lauds as "fortunate" the alleged fact that many liberals have abandoned such skepticism and alleges "consensus between communitarians and liberals that policies regarding opportunities, wealth and matters of the common good can only be justified by appeal to a particular conception of the good. " That is the buildup to his presentation (without overstating or defending...) of the possible consensus concept of the good. He concludes:
Clearly, more needs to be done to elucidate what specific health care services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services. Perhaps under this progress in political philosophy we can begin to...discuss the goods and goals of medicine.True, the "concept of the good" sketched out is just a beginning. But Emanuel plainly regards it as a good beginning, a viable basis for determining what gets covered and what doesn't. And that basis is utilitarian -- guaranteeing only those services that help develop and maintain active, participating citizens.
A "White House official" quoted by Tapper in a prior piece claims that Emanuel in fact ends the article by decrying the "concept of the good" around which the article is built. Here's how the "official" presents it:
After a long review of the pluses and minuses of using various schools of philosophical thought to being able to lead a theory of how to allocate health care, he describes the pluses and minuses of the civic republican/deliberative democracy school of thought,” says the official.On the other hand, the sentence introducing the 'concept of the good' in question asserts, "This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources." And while the conclusion acknowledges that "more needs to be done," it also assets that the emerging consensus "points to a way of introducing the good back into medical ethics."
The sentence that follows in Emanuel’s article, the official notes, is: “Clearly, more needs to be done to elucidate what specific services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services.”
“By the sentence that follows the one McCaughey quoted,” the official says, “it’s obvious that Zeke sees this as a fault in this approach that needs to be addressed in further discussion.”
If the assertion that "more needs to be done" constitutes a critique, it is a pretty flaccid one. If the 'concept of the good' leads to morally objectionable conclusions why not say so, and venture an amendment?
UPDATE: I should have noted that the New York Times' James Rutenberg, in an 8/24 article about McCaughey's smear campaign, addressed Emanuel's stance in this article as follows:
To my eye, 'shy advocacy' of the emerging 'consensus' seems to be exactly what this paper offers.
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.”
Dr. Emanuel said he understood some of the criticisms.
“Maybe if I had been a smarter, more careful thinker about how people could interpret it, I would have qualified it and condemned it more robustly,” he said. “In my 1.2, 1.3 million written words, you can’t find another sentence that even comes close to advocating that in my voice. When I advocate, I’m not shy.”
A final thought: I'm not party to the academic dialogue of which this essay is a part. But if anything in the article seems "abstract," as Emanuel characterized his argument, it's the alleged emerging consensus between "communitarian" and "liberal" philosophers. Are there really opposed camps of philosopher-ethicists who are converging on a "concept of the good" that would fail to guarantee services to those who lack the mental capacity for active citizenship?