Ezekiel Emanuel is the Chair of the Department of Bioethics at the Warren G. Magnuson Clinical Center at the National Institutes of Health. Dr. Emanuel is a well-known authority on the ethics of clinical research, end of life care issues, euthanasia and the ethics of managed care.
He has published in the New England Journal of Medicine, The Lancent, JAMA, and many other medical journals. His book The Ends of Human Life: Medical Ethics in a Liberal Polity received an honorable mention for the Rosenhaupt Memorial Book Award by the Woodrow Wilson Foundation. Dr. Emanuel was educated at Amherst College, Oxford University and Harvard University, from which he holds both an MD and PhD in political philosophy. He also served on the ethics section of President Clinton's Health Care Task Force, on the National Bioethics Advisory Committee, and on the bioethics panel of the Pan American Health Organization.
Question: What impact does your work have on the world?
Ezekiel Emanuel: Some of our work has had, I would say, generalized public importance. When I started working on end-of-life care in the 1908s, I was well advised by my professors at Harvard medical school that that was a career-ender. You know? We don’t talk about dying people in medicine. Well that turned out to be untrue, and one of the things I do think I’ve had a small part in contributing to was to try to change the language and the public discussion about end-of-life care. We changed the discussion about living wills and the kinds of living wills we should have.
I’ve had a big role – although I don’t know how much of an impact – on thinking about euthanasia and some of the complexities of that. Certainly in the research/ethics area we had a very big impact in setting the framework of how people think about it.
Some of our stuff is actually, ironically, being adopted in Nigeria, and Kenya, and Sri Lanka, and other countries as part of their regulation. And we’ll see about healthcare reform. We’re plugging away. We’re working hard. Early days, because I don’t anticipate healthcare reform to be a . . . I mean, we’re going to have a lot of debates ________; but it’s not going to be a serious issue until 2013. So there’s a little time.
Question: What is your proudest achievement?
Ezekiel Emanuel: My most proud thing is, of course, my three daughters. That goes without saying. They’re absolutely unbelievable kids, and I’m very, very proud of them. I’m not sure it’s my achievement, but to be said that I get associated with them, it’s to my benefit.
My proudest achievement--I don’t know what my proudest is.
One of the things I do like to take pride in is we have trained a number of tremendously talented young people who area going to be the future of the field.
The second is I have a tremendous number of great colleagues. So the department I work in, we have a core group of about 10 people who are just fabulous to work with and are really challenging intellectually. I have to get up on Monday morning at 4:00 in the morning to make my plane to go to Washington. And to do that for 10 straight years you have to really enjoy what you’re doing, and you have to enjoy who you’re working with. And that’s fantastic. And the fact that we’ve been able to build this ______ that’s really broken a lot of barriers, and brought new ideas, and really informed how people think about bioethical dilemmas – especially on research – I think is something I’m proud of.
I actually think our healthcare reform plan is; there’s no perfect plan, but I think it probably is the best out there. It’s more coherent with American values of equal opportunity and individualism. It’s the most lean in the sense that it has the fewest moving parts. So it’s actually the least corruptible, provides the right incentives. I think that’s something I’ll be proud of, I hope, in about five or six years.
Question: What is the biggest challenge your field faces?
Ezekiel Emanuel: Well medicine in the United States, I think, faces a real disaster in its delivery system. We know that we’re not delivering care well in that we can’t reliably guarantee Americans will get quality care when they enter the hospital. That in fact it’s almost a 50/50 flip of a coin for people, whether they get the right care or the not right care. That is a disaster.
And to change the system to make sure that delivery is better, and that we’re really doing better by people and actually doing it efficiently is a huge challenge at the moment. And I think that, without a doubt, is the biggest challenge facing American medicine.
And that’s really going to, in my view, require comprehensive change of the system. We can’t sort of fix a little here and a little there. I don’t even think getting all Americans ensured is a solution. That’s one small element, but we actually have to control costs. Otherwise in a few years, we’re going to have uninsured.
We also have to improve quality. So that’s a very complicated puzzle. And you just think that American healthcare system costs two trillion dollars – sixteen percent of the GEP – fixing that obviously is a huge, huge challenge. And so I think without a doubt, the medicine, that’s the biggest challenge.
Obviously there are lots of diseases we haven’t solved. Lots of diseases that we don’t even have therapies for. Those are big challenges, but nothing compared to delivering what we know works today efficiently and effectively to all Americans. That is a huge undertaking in management, really.
Bioethics, I would say there are problems which need to be addressed, but I also think there’s a sort of manpower problem. We do not have a very good training program in this country for bioethics. We don’t support it actually, despite the fact that it occupies a lot of media attention. Despite the fact that everyone says how important it is, you always hear this phrase: “Our technology is outrunning our values and our bioethical understanding.” And yet we have a very poor way of actually supporting it over the long run so people can take time and address big problems, and think for a while on some of these problems.
As I mentioned, some of the issues that we address, we can be sure that it’s going to take us two years to think through some of this stuff. And we don’t have a mechanism to really support that. And one of the consequences of that is we have not been good at training young people to come through, and to attract some of the smartest young people into the field. And I think that’s a huge, huge issues. Obviously there are lots of particular issues that we need to address better; but I think if we had a lot more smart people in the field with a lot more sustained support, those issues could be well addressed.
Recorded: July 5, 2007