The Hastings Center was founded in 1969 as a nonpartisan bioethics institute. Dr. Emanuel is one of 200 fellows at the institute, which publishes a report 6 times per year.
The article I am about to examine, Where Civic Republicanism and Deliberative Democracy Meet, was published in 1996 as part of a Hastings Center Report titled In Search of the Good Society: The Work of Daniel Callahan.
Dr. Ezekiel Emanuel is credited as the sole author.
Where Civic Republicanism and Deliberative Democracy Meet
Dr. Emanuel begins this article with a question:
"Is there a relationship between defects in our medical ethics and the reason the United States has repeatedly failed to enact universal health coverage?"
His answer to this appears to be 'yes'. Most of this brief article is devoted to defining a workable system of ethics for "distributive justice for health care."
Dr. Emanuel divides health care itself into "basic" and "discretionary" services. In his model, "basic" services would be available to all, while "discretionary" services would be limited. He admits that deciding what should be "basic" and what should be "discretionary" is a problem:
"The fundamental challenge to theories of distributive justice for health care is to develop a principled mechansim for defining what fragment of the vast universe of...medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially."
Interestingly, Dr. Emanuel says that the failure to develop this 'mechanism' has been caused by fears that too much coverage will be offered to too many people:
"...rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services...and uninsured persons receive far fewer services."
(If this fear of 'too much coverage' seems wildly out of touch with today's concerns about health care rationing, take a moment to remember that this paper was written in 1996, during the Clinton Administration's attempt to establish national health care. Likely issues were being framed differently by both sides at that time.)
Dr. Emanuel cites two philosophical explanations for society's reluctance to identify 'basic' and 'discretionary' medical care. First, he quotes Amy Gutmann:
"I suspect that no philosophical argument can provide us with a cogent principle by which we can draw a line within the enormous group of goods that can improve health or extend life prospects of individuals..."
Gutmann appears to believe that mere philosophy is inadequate to make such life or death decisions. Dr. Emanuel decries this view:
"...this moral skepticism is extremely dangerous...It suggests we should just give up on a just allocation of health care resources because we can never succeed."
Dr. Emanuel then identifies a second reason no choices between 'basic' and 'discretionary' care have been made: the reluctance of liberal philosophy to define what is 'good.'
"To justify laws by appealing to the good would violate the principle of neutrality and be coercive, imposing one conception of the good on citizens who do not necessarily affirm that conception of the good. But without appealing to a conception of the good, it is argued, we can never establish priorities among health care services and define basic medical services."
Fortunately, according to Dr. Emanuel, this rigid insistance on moral neutrality in liberal philosophy is now changing, allowing liberal philosophers to declare what is 'good.'
"Fortunately, many, including many liberals, have come to view as mistaken a liberalism with such a strong principle of neutrality and avoidance of public discussion of the good. Some think the change a result of the critique provided by communitarianism; others see it as a clarification of basic liberal philosophy. Regardless, a refined view has emerged that begins to create an overlap between liberalism and communitarianism."
This new "refined view" appears to solve the problem for Dr. Emanuel. And from here, what might have been a very well-intentioned essay becomes increasingly myopic and narrow-minded.
In the remaining text, Dr. Emanuel acknowledges only the "consensus between communitarians and liberals" as a basis for allocating health care priorities. No other streams of thought are admitted to the discussion. He quotes Brian Barry:
"...There is no room for a complaint of discrimination simply on the ground that the policy by its nature suits those with one conception of the good more than it suits those with some different one. This is unavoidable."
It appears that in Dr. Emanuel's world, only communitarians and liberals would make decisions about the allocation of health care. Libertarians, conservatives, pragmatists and any others need not apply.
In fact, they would do well to shut up.
Dr. Emanuel soothingly points out that:
"Communitarians endorse civic republicanism and a growing number of liberals endorse some version of deliberative democracy."
Under this leadership he envisions:
"...public forums to deliberate about which health services should be considered basic and should be socially guaranteed."
There is a catch, however; only liberals and communitarians would set the agenda, and the topics discussed at such a forum would be limited to the concerns of the adult and able-bodied:
"Substantively, it suggests services that promote the continuation of the polity-- those that ensure healthy furture generations, ensure development of pratical reasoning skills, and ensure full and active participation by citizens in public deliberations-- are to be socially guaranteed as basic. Conversely, 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."
It is unfair to judge a man's views on the basis of one short document, but the picture presented by Where Civic Republicanism and Deliberative Democracy Meet is discomforting, to say the least. It appears to describe a society in which a central authority devoted to the principles of liberal and communitarian thinking picks winners and losers in assigning medical care-- and that the winners are intended to be "participating citizens" in the "polity."
Judging from the quoted paragraph, there would be no one to speak for those who have no voice: the infirm elderly, disabled children, those afflicted with terminal disease. They are not part of the "healthy future generations" or "participating citizens."
I can only hope Dr. Emanuel expressed himself poorly.
An Important Note
I have noticed that there seems to be some confusion about the terms 'communism' and 'communitarianism.' They are not the same school of thought, but the two words look so similar it is easy to mix them up. For a good overview of Communitarian principles, you can visit this link.
I'm not endorsing either philosophy here, just trying to clear up some confusion.