Ezekiel Emmanuel's Reaper Curve

Ezekiel Emanuel has written extensively, before and after he helped draft ObamaCare, about who should get medical care, who should decide, and whose life is worth saving. Emanuel is part of a school of thought that redefines a physician’s duty, insisting that it includes working for the greater good of society instead of focusing only on a patient’s needs. Many physicians find that view dangerous, and most Americans are likely to agree.

True reform, Emanuel argues, must include redefining doctors' ethical obligations. In the June 18, 2008, issue of JAMA, 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."

In numerous writings, 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).

Of course, patients hope their doctors will have that singleminded devotion. But Emanuel believes doctors should serve two masters, the patient and society, and that medical students should be trained "to provide socially sustainable, cost-effective care." One sign of progress he sees: "the progression in end-of-life care mentality from 'do everything' to more palliative care shows that change in physician norms and practices is possible." (JAMA, June 18, 2008)

In the Lancet, Jan. 31, 2009, Dr. Emanuel and coauthors presented a "complete lives system" for the allocation of very scarce resources, such as kidneys, vaccines, dialysis machines, intensive care beds, and others.

"One maximizing strategy involves saving the most individual lives, and it has motivated policies on allocation of influenza vaccines and responses to bioterrorism. . . . Other things being equal, we should always save five lives rather than one.”

"However, other things are rarely equal -- whether to save one 20-year-old, who might live another 60 years, if saved, or three 70-year-olds, who could only live for another 10 years each -- is unclear…When implemented, the complete lives system produces a priority curve on which individuals aged roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated...”

Zeke has summarized his thinking in a very curious graph published in The Lancet on January 31, 2009. The Y-axis is labeled “probability of receiving an intervention” (medical treatment), and the X-axis is labeled “Age in years.” 

            “Principles for Allocation of Scarce Medical Interventions” The Lancet, January 31, 2009

If you are lucky enough to be born, you had better be very healthy, for it looks like you have to be alive for about 2 years before you have an even 25% chance of getting needed medical care. By the time you are 10 years old you just have a 50% chance for critical care. Too bad for you if you have an early or complicated birth. And you’d better live a pretty protected childhood.

Don’t get into too much trouble before you are about 18. This is coincidently when you can start to vote, and therefore when you begin to arrive in the zone of maximum probability of an intervention (i.e. getting some health care). But maximum probability does not mean a certainty of intervention at any time.

The period of maximum probability continues until you are about 33 years old. By 50 you are down to only a 75% chance of receiving a needed intervention. By your late 50s you are down to only a 50% chance of getting what you need. And just about the time you turn 65, the very time you would have expected to begin to be eligible for Medicare after having paid payroll taxes for years, you will only have a 25% chance (or less) of getting a needed intervention.

This is worthy of being repeated. You have paid your payroll taxes for 40 years or so in the expectation that you will receive full Medicare benefits for your health care needs. Then you discover that under Emanuel’s “Reaper Curve,” you will only have a 25% chance or less of receiving medical intervention when you reach a health crisis

The truth of Emanuel’s Reaper Curve and his writings are playing out now in ObamaCare’s implementation.  As more and more Americans are dropped from their healthcare plans and are forced to switch to an ObamaCare plan, as more people sign up for Medicaid and President Obama pushes more cuts in Medicare, American’s are faced with the reality of less choice in picking their doctors and health care plans and less health care for them in times of need as government bureaucrats look for ways to cut health care costs. 

But, as Ezekiel Emanuel points out in this graph, at the very age that you are most likely to need medical intervention, his “complete lives system,” will increasingly not provide it to you.  The older you are the more likely you will die from not receiving medical care.  Isn’t that comforting?     

Ezekiel Emanuel has written extensively, before and after he helped draft ObamaCare, about who should get medical care, who should decide, and whose life is worth saving. Emanuel is part of a school of thought that redefines a physician’s duty, insisting that it includes working for the greater good of society instead of focusing only on a patient’s needs. Many physicians find that view dangerous, and most Americans are likely to agree.

True reform, Emanuel argues, must include redefining doctors' ethical obligations. In the June 18, 2008, issue of JAMA, 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."

In numerous writings, 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).

Of course, patients hope their doctors will have that singleminded devotion. But Emanuel believes doctors should serve two masters, the patient and society, and that medical students should be trained "to provide socially sustainable, cost-effective care." One sign of progress he sees: "the progression in end-of-life care mentality from 'do everything' to more palliative care shows that change in physician norms and practices is possible." (JAMA, June 18, 2008)

In the Lancet, Jan. 31, 2009, Dr. Emanuel and coauthors presented a "complete lives system" for the allocation of very scarce resources, such as kidneys, vaccines, dialysis machines, intensive care beds, and others.

"One maximizing strategy involves saving the most individual lives, and it has motivated policies on allocation of influenza vaccines and responses to bioterrorism. . . . Other things being equal, we should always save five lives rather than one.”

"However, other things are rarely equal -- whether to save one 20-year-old, who might live another 60 years, if saved, or three 70-year-olds, who could only live for another 10 years each -- is unclear…When implemented, the complete lives system produces a priority curve on which individuals aged roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated...”

Zeke has summarized his thinking in a very curious graph published in The Lancet on January 31, 2009. The Y-axis is labeled “probability of receiving an intervention” (medical treatment), and the X-axis is labeled “Age in years.” 

            “Principles for Allocation of Scarce Medical Interventions” The Lancet, January 31, 2009

If you are lucky enough to be born, you had better be very healthy, for it looks like you have to be alive for about 2 years before you have an even 25% chance of getting needed medical care. By the time you are 10 years old you just have a 50% chance for critical care. Too bad for you if you have an early or complicated birth. And you’d better live a pretty protected childhood.

Don’t get into too much trouble before you are about 18. This is coincidently when you can start to vote, and therefore when you begin to arrive in the zone of maximum probability of an intervention (i.e. getting some health care). But maximum probability does not mean a certainty of intervention at any time.

The period of maximum probability continues until you are about 33 years old. By 50 you are down to only a 75% chance of receiving a needed intervention. By your late 50s you are down to only a 50% chance of getting what you need. And just about the time you turn 65, the very time you would have expected to begin to be eligible for Medicare after having paid payroll taxes for years, you will only have a 25% chance (or less) of getting a needed intervention.

This is worthy of being repeated. You have paid your payroll taxes for 40 years or so in the expectation that you will receive full Medicare benefits for your health care needs. Then you discover that under Emanuel’s “Reaper Curve,” you will only have a 25% chance or less of receiving medical intervention when you reach a health crisis

The truth of Emanuel’s Reaper Curve and his writings are playing out now in ObamaCare’s implementation.  As more and more Americans are dropped from their healthcare plans and are forced to switch to an ObamaCare plan, as more people sign up for Medicaid and President Obama pushes more cuts in Medicare, American’s are faced with the reality of less choice in picking their doctors and health care plans and less health care for them in times of need as government bureaucrats look for ways to cut health care costs. 

But, as Ezekiel Emanuel points out in this graph, at the very age that you are most likely to need medical intervention, his “complete lives system,” will increasingly not provide it to you.  The older you are the more likely you will die from not receiving medical care.  Isn’t that comforting?