About this iReport
  • Not verified by CNN

  • Click to view Wavform's profile
    Posted July 31, 2009 by
    This iReport is part of an assignment:
    Breaking news: Share your story

    More from Wavform



    (ignore clip- wrong vid)


    The following has been composed by Ezekiel 'Dr Death' Emanuel -- a special adviser to Budget Director Peter Orszag and older brother of White House Chief of Staff Rahm Emanuel -- heads up the White House's health care reform efforts. Obama has appointed Dr. Ezekiel Emanuel to a top-level position as one of his top-level advisors, and Czars on health care reform.


    *Special Note: the term allocation refers to rationing.





    Coauthored by Dr. Ezekiel Emanuel


    Allocation of medical interventions is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.





    Allocation by lottery has been used, sometimes with explicit judicial and legislative endorsement, in military conscription, immigration, education, and distribution of vaccines. Lotteries have several attractions. Equal moral status supports an equal claim to resources. Even among only roughly equal candidates, lotteries prevent small differences from drastically affecting outcome. Some people also support lottery allocation because "each person's desire to stay alive should be regarded as of the same importance and deserving the same respect as that of anyone else". Practically, lottery allocation is quick and requires little knowledge about recipients. Finally, lotteries resist corruption. The major disadvantage of lotteries is their blindness to many seemingly relevant factors. Random decisions between someone who can gain 40 years and someone who can gain only 4 months, or someone who has already lived for 80 years and someone who has lived only 20 years, are inappropriate. Treating people equally often fails to treat them as equals. Ultimately, although allocation solely by lottery is insufficient, the lottery's simplicity and resistance to corruption suggests that it could be incorporated into a multiprinciple [Healthcare] system.


    First-come, first-served:


    Within health care, many people endorse a first-come, first-served distribution of beds in intensive care units or organs for transplant. The American Thoracic Society defends this principle as "a natural lottery—an egalitarian approach for fair [intensive care unit] resource allocation." Others believe it promotes fair equality of opportunity, and allows physicians to avoid discontinuing interventions, such as respirators, even when other criteria support moving those interventions to new arrivals. Some people simply equate it to lottery allocation.


    As with lottery allocation, first-come, first-served ignores relevant differences between people, but in practice fails even to treat people equally. It favours people who are well-off, who become informed, and travel more quickly, and can queue for interventions without competing for employment or child-care concerns. Queues are also vulnerable to additional corruption. As New York State's pandemic influenza planners stated, "Those who could figuratively (and sometimes literally) push to the front of the line would be vaccinated and stand the best chance for survival". First-come, first-served allows morally irrelevant qualities—such as wealth, power, and connections—to decide who receives scarce interventions, and is therefore practically flawed.

    Favouring the worst-off; prioritarianism:


    Franklin Roosevelt  argued that "the test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little". Philosophers call this preference for the worst-off prioritarianism. Some define being worst-off as currently lacking valuable goods, whereas others define it as lacking valuable goods throughout one's entire life. Two principles embody these two interpretations.


    Sickest first:


    Treating the sickest people first prioritises those with the worst future prospects if left untreated. The so-called rule of rescue, which claims that "our moral response to the imminence of death demands that we rescue the doomed", exemplifies this principle. Transplantable livers and hearts, as well as emergency-room care, are allocated to the sickest individuals first.


    Some people might argue that treating the sickest individuals first is intuitively obvious. Others claim that the sickest people are also probably worst off overall, because healthier people might recover unaided or be saved later by new interventions. Finally, sickest-first allocation appeals to prognosis if untreated—a criterion clinicians frequently consider.

    On its own, sickest-first allocation ignores post-treatment prognosis: it applies even when only minor gains at high cost can be achieved. To circumvent this result, some misleadingly claim that sick people with a small but clear chance of benefit do not have a medical need. Sick recipients' prognoses are wrongly assumed to be normal, even though many interventions—such as liver transplants—are less effective for the sickest people.


    If the failure to take account of prognosis were its only problem, sickest-first allocation would merely be insufficient. However, it myopically bases allocation on how sick someone is at the current time—a morally arbitrary factor in genuine scarcity.


    Preferential allocation of a scarce liver to an acutely ill person unjustly ignores a currently healthier person with progressive liver disease, who might be worse off when he or she later suffers liver failure. Favouring those who are currently sickest seems to assume that resource scarcity is temporary: that we can save the person who is now sickest and then save the progressively ill person later. However, even temporary scarcity does not guarantee another chance to save the progressively ill person. Furthermore, when interventions are persistently scarce, saving the progressively ill person later will always involve depriving others. When we cannot save everyone, saving the sickest first is inherently flawed and inconsistent with the core idea of priority to the worst-off.


    Youngest first:


    Although not always recognised as such, youngest-first allocation directs resources to those who have had less of something supremely valuable—life-years. Dialysis machines and scarce organs have been allocated to younger recipients first, and proposals for allocation in pandemic influenza prioritise infants and children. Daniel Callahan has suggested strict age cut-offs for scarce life-saving interventions, whereas Alan Williams has suggested a system that allocates interventions based on individuals' distance from a normal life-span if left unaided.


    Prioritising the youngest gives priority to the worst-off—those who would otherwise die having had the fewest life-years—and is thus fundamentally different from favouritism towards adults or people who are well-off.  Also, allocating preferentially to the young has an appeal that favouring other worst-off individuals such as women, poor people, or minorities lacks: "Because [all people] age, treating people of different ages differently does not mean that we are treating persons unequally." Prudent planners would allocate life-saving interventions to themselves earlier in life to improve their chances of living to old age. These justifications explain much of the public preference for allocating scarce life-saving interventions to younger people.


    Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect. The death of a 20-year-old young woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life. The 20-year-old has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects. Youngest-first allocation also ignores prognosis, and categorically excludes older people. Thus, youngest-first allocation seems insufficient on its own, but it could be combined with prognosis and lottery principles in a multiprinciple allocation system.


    Save the most lives


    ...However, other things are rarely equal. Some lives have been shorter than others; 20-year-olds have lived less than 70-year-olds. Similarly, some lives can be extended longer than others. How to weigh these other relevant considerations against saving more lives—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 10 years each—is unclear. Although insufficient on its own, saving more lives should be part of a multiprinciple allocation system.

    Prognosis or life-years:


    Rather than saving the most lives, prognosis allocation aims to save the most life-years.


    This strategy has been used in disaster triage and penicillin allocation, and motivates the exclusion of people with poor prognoses from organ transplantation waiting lists. Maximising life-years has intuitive appeal. Living more years is valuable, so saving more years also seems valuable.


    Instrumental Value Allocation:


    Instrumental value allocation prioritises specific individuals to enable or encourage future usefulness. Guidelines that prioritise workers producing influenza vaccine exemplify instrumental value allocation to save the most lives. Responsibility-based allocation—eg, allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation.


    This approach is necessarily insufficient, because it derives its appeal from promoting other values, such as saving more lives: "all whose continued existence is clearly required so that others might live have a good claim to priority". Prioritising essential health-care staff does not treat them as counting for more in themselves, but rather prioritises them to benefit others. Instrumental value allocation thus arguably recognises the moral importance of each person, even those not instrumentally valuable.






    For those who have no idea what the 'Good Doctor' is saying it's quite simple; Those who are healthy with a high ratio of life-years will receive priority and those who are not healthy *regardless* of a high or low life-years ratio will receive *federally cost effective, rationed, low priority* life-sustaining medical intervention-- In some cases, no medical intervention *at all.* The healthy will be treated and the unhealthy will be left to die. That is the most cost effective medical-costs model under proposed federal legislative policy. (see 'Medical Coverage Rationing' in Obama's own words http://www.ireport.com/docs/DOC-303237 for further consideration.)


    Nonetheless, for a man with such a brilliant mind and stellar education it's a tragedy of the highest degree to see how he uses it- what a waste; This animal and monster, Ezekial 'Dr. Death' Emanuel, is America's second nemesis. America's first nemesis is President Obama for promoting Dr Emanuel to position of Health Czar. Why health Czar you may ask? Simple. Czars circumvent Congressional-level vetting. That is, Dr Emanuel answers to none other than the President himself bypassing Congress altogether and Congress cannot hold him accountable nor can they hold Congressional hearings on him.








    *To read the document in its enitrety goto http://www.thelancet.com/, register, and pull up document entitled Principles for Allocating Scarce Medical Interventions by typing in 'Emanuel' in the 'search for' field then typing '2009' in the 'year' field and select document number 5 Department of Ethics . This report is Vol. 373, No. 9661, pp 423-431.

    Add your Story Add your Story