Emanuel weighs competing values.

Question: Beyond a simple title, how would you describe what you do for a living?

Ezekiel Emanuel: I spend a lot of time thinking, a lot of time writing, and a lot of time talking about important problems in biomedicine.

Early in my career, I spent a lot of time worrying about how to improve end-of-life care in this country.

I’ve spent the last 10 years trying to think about how to do research studies and experiments better with people, more ethically, more fairly.

And in the last probably five to seven years, I’ve spent a lot more attention on healthcare reform and trying to figure out how to reform healthcare systems, and how to improve it because I think it’s in a terrible state.

But mostly what I do is any problem related to medicine, or biomedicine, or science that has an ethical component, I get a chance to think about it.

And if something crosses my desk that’s interesting; one of the things that crossed my desk probably around 18 months ago was how we’re preparing for pandemic flu. And I thought that many of the rationales for the preparation were not very good. And so I decided well, let’s write a paper and think about it and see if we can propose something better. So that created a whole other project. But it was serendipity. It came out of the blue; but I thought it was a serious public problem but not being well-handled in terms of ethics.

Question: What is the study of bioethics?

Ezekiel Emanuel: Well it’s really looking at ethical issues; anything related to biomedicine. So as I’ve said, issues like how do you manage with scarce medical resources in the case of pandemic flu? But it also applies to organs for transplant. What are the principles we use to allocate those scarce items? How do we think about prioritizing?

So it’s really thinking about the values that underlie decisions; how you weigh competing values; how do you justify them? That is, how do you give people reasons so that they ought to agree.

So one of the things which I like about it is it tends to be somewhat theoretical. You deal with abstract values, but it’s also practical. You have to know what’s going on in the world. You have to know what the real-life problems are. You have to know what are the practical solutions that you can actually implement.

Question: What is the joy in what you do?

Ezekiel Emanuel: The best thing that I do actually is train the next generation. We have about six new fellows a year. Some of them come right out of college. Some of them already have PhDs, or law degrees or medical degrees. And working with them – because they’re incredibly smart – is one of the great things that I do. That’s one of the pleasures.

Another pleasure is trying to influence public policy, and to sort of try to make a difference in how things are done in the world.

A third thing is, one of the great things about working for the National Institutes of Health is that we have interest and research all over the world; and we’ve been able to go and work in almost all continents – especially in Africa and Latin America and Asia – meeting new people, seeing how their healthcare systems work, seeing their challenges. Having them open up their houses, their hospitals, their clinics to us is a tremendous, tremendous privilege. And it really allows you to understand what’s common among people; and what’s also very culturally different; and I think also where certain practices that we still have might have come from hundreds – if not thousands – of years ago.

Question: What is the struggle in what you do?

Ezekiel Emanuel: The struggle? I think one of the big struggles is trying to get complicated both clear in my mind and then clearly expressed and communicated to other people. So let’s take this issue of how to allocate scarce resources like organs, or if we had a pandemic flu vaccine.

What are the values at stake? Well one of the things I can tell you a pretty definitive conclusion is there’s not a single value that is going to determine how you allocate those things. Well one of the challenges is how do you then balance multiple values? And how do you articulate how you’re balancing them and why other people should see it the same way? That is a very challenging thing.

We’ve got a paper we’ve been working on for about six or eight months, trying to really work this out. And I can see that we’ll work it out tentatively, but it’s probably going to be several years of really working on this one problem to really get it. And even then I’m not 100% sure if we’ll get it as clear.

Similarly, I’ve been working for a number of years now on a better plan for universal healthcare reform in the United States. And again, trying to figure out all the parts and how to communicate it to people clearly, and how to address a number of the sort of not very fine details, but other details that really might bore people, but are going to make a huge difference to the success or failure of reform.

And then again to communicate that to people who might not be experts is another big challenge, which I love. I like to talk. I like to lecture. I like to try to make complicated things clear to people.

Question: How does the media affect bioethics?

Ezekiel Emanuel: Oh just hugely! I mean what is a problem? How they address problems; how they can sometimes do tremendous job educating people about the complexities of the problem; how sometimes they can do a terrible job because of the shortness; that they don’t allow the complexities and the subtleties to get through. In general actually, I think reporters have really been very interested in trying to understand the details.

I would say that the second problem with the media is the attention span problem. That’s a general problem in our culture. You got to say it in 250 words or less; but also once you’ve said it--How much coverage do we now have today in July 2007 on pandemic flu? The threat hasn’t gone away. If anything, the threat has gotten worse. And yet, you talk to a reporter, “Well we did that last year.” And that, I think, is a terrible problem. Because some of these problems require a long-term focus on an issue.

Healthcare reform is another really big issue, which you’re not going to solve it in a year. You’re not going to solve it in the next five years. It’s going to take a long time to focus on the problem; and yet the media doesn’t have that attention span.

Recorded: July 5, 2007