Dr. Ezekiel J. Emanuel, the White House official targeted by Sarah Palin and other conservatives as an advocate for health care rationing and "death panels," said Thursday his "thinking has evolved" on the need to decide who gets treated and who does not.
"When I began working in the health policy area about 20 years ago ... I thought we would definitely have to ration care, that there was a need to make a decision and deny people care," said Dr. Emanuel, a health care adviser to President Obama in the Office of Management and Budget, during a phone interview.
"I think that over the last five to seven years ... I've come to the conclusion that in our system we are spending way more money than we need to, a lot of it on unnecessary care," he said. "If we got rid of that care we would have absolutely no reason to even consider rationing except in a few cases."
Dr. Emanuel, the elder brother of White House Chief of Staff Rahm Emanuel, spoke with The Washington Times from Italy, where he is on vacation. The White House made him available in an attempt to tamp down criticism from conservatives such as Mrs. Palin, the former Republican governor of Alaska, and former House Speaker Newt Gingrich, Georgia Republican.
These critiques have gained such steam that Mr. Obama on Tuesday told a town-hall meeting in New Hampshire that he has no intent to "pull the plug on Grandma."
Mrs. Palin drew national attention when she wrote on her Facebook page last Friday that President Obama's proposed health care reforms would put her parents and her 16-month-old son, Trig, who has Down syndrome, at risk of being denied health care by a "death panel."
The former governor and 2008 vice-presidential candidate says that under Democratic proposals, physicians who counsel patients on end-of-life decisions would be financially incentivized to pressure seniors into minimal care.
Mrs. Palin accused Dr. Emanuel of "Orwellian thinking," citing writings that she said discuss whether to deny health care based on an individual's "level of productivity in society."
Dr. Emanuel, a nationally renowned bioethicist who also has a doctorate in political philosophy from Harvard University, said he was not expressing his own opinion in a short article published in a bioethics journal in 1996.
He wrote then that "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," he wrote in the paper published by the Hastings Center, a nonpartisan, nonprofit bioethics research institute.
In another paper, published in January, Dr. Emanuel and two other medical ethicists recommended that in situations where there is a scarcity of a medical service or product, physicians should use "a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance" of receiving treatment, "whereas the youngest and oldest people get chances that are attenuated."
Dr. Emanuel said the Lancet medical journal piece was focused narrowly on extreme cases where medical resources are limited.
"We're analyzing a very small set of issues. They're real and they're very vexing and they're very tragic, but it's hardly all of health care," he said.
Such a scenario involving a vaccine likely will play out this fall, when the government expects a major outbreak of the H1N1 virus, or swine flu. The Centers for Disease Control and Prevention has issued guidelines for who will first receive vaccinations, starting with pregnant women, young children and health care workers.
Mrs. Palin has been widely panned by independent fact-checking groups for her talk of "death panels." Her attacks on Dr. Emanuel have led to charges that he is advocating euthanasia.
Dr. Emanuel, who has a track record of arguing against euthanasia, said the charges are "completely off the wall" and "can only be held by people who willfully don't read, jump to conclusions without checking the facts, or are completely distorting my record for ulterior motives."
"The idea that I would be out there portrayed as somehow wanting to knock people off, just is, I mean, that is completely surreal and Orwellian."
Art Caplan, who heads the University of Pennsylvania's bioethics center, called the attack ironic.
"You've got a guy who has been an outspoken critic of euthanasia getting dragged around as a proponent, which is just not true. And he's probably got a more market orientation in his personal view of paying for health care than others," Mr. Caplan said.
Mrs. Palin derives the idea of "death panels" from a provision in a bill under consideration in the House that would give doctors financial incentives to give counseling sessions on end-of-life care to older patients. Mrs. Palin's charge is that while the sessions are technically voluntary, physicians can and will initiate the conversation and senior citizens will be pressured to accept "minimal end-of-life care" because the sessions are "part of a bill whose stated purpose is 'to reduce the growth in health care spending.' "
Mr. Gingrich, who is considered even by critics to be deeply knowledgeable on policy issues, has defended the statements made by Mrs. Palin, a potential rival for the 2012 Republican nomination to run for president against Mr. Obama.
Mr. Gingrich thinks that some of the new bureaucracy created by current versions of health care legislation, combined with the explosion of another $1 trillion or so in government spending, will lead to greater government control of all health care. Once that happens, he said, the thinking expressed by Dr. Emanuel that quantifies the value of certain human lives over others will permeate the decision-making process.
"These bills establish many agencies, commissions and offices with substantial power to redefine health care," Mr. Gingrich said in a statement e-mailed by a spokesman. "As health care costs continue to rise, the government will look for ways to save money. It is reasonable to expect that many of the people this administration would appoint to these new government bodies would be sympathetic to the views described by Dr. Emanuel."
The charges of rationing, or concerns about his language in journal articles, Dr. Emanuel said, is somewhat understandable given that he was "writing really for political philosophers, and for the average person it's not what they're used to reading, even if they've had a good liberal education."
Nonetheless, a spokesman for Sen. Tom Coburn, Oklahoma Republican and a practicing physician, said the senator remains "concerned about the rationing provisions in the House and Senate bills."
Coburn spokesman John Hart said: "On three different occasions during the [Senate Health, Education and Labor and Pensions] committee markup, Dr. Coburn and other Republicans attempted to insert language prohibiting rationing.
"All three amendments were voted down, which suggests that Democrats do, in fact, want to preserve the ability to ration care," Mr. Hart said.