Friday, November 06, 2009

Grading PolitiFact: Michele Bachmann and Dr. Emanuel's health care policy

PolitiFact took another shot at Michele Bachmann recently. Two, actually, but I'll deal with the older one first.

The issue:

PolitiFact and I are getting better at spelling Bachmann's name (see update, below).

The fact checkers:

Writer, researcher: Robert Farley
Editor: Bill Adair


Barack Obama's top adviser, Rahm Emanuel, has a brother who is also a medical doctor. Coincidentally, that brother is also a health policy advisor at the Office of Management and Budget. Small world, eh?

Why would they need a health policy advisor at the OMB? Keep that question in mind as we evaluate this PolitiFact item.

After writer Robert Farley acquaints the reader with Bachmann's statement about Emanuel, we get a little more background on the man:
Emanuel is a well-known oncologist and bioethicist, which means he ponders such moral questions as "You have three people who need a liver, but you've got just one liver, who gets it?"
Hmmm. Sounds like a handy guy to have around at the OMB if the government needs to decide who gets the highest priority in receiving limited government health care.
Like other academics (see our article on claims about science czar John Holdren ), Emanuel has found that highbrow articles for academic journals make great fodder for opponents trying to score political points. Academics often write theoretically about ideas that are being kicked around. And they repeat and explore those ideas, without necessarily endorsing them.
Wow. Looks like Farley's solved this one before we even get acquainted with the facts. Emanuel's statement, whatever it was, is simply being used to score political points. And Emanuel didn't necessarily endorse whatever it was he may have written.

Farley gives us some additional background concerning other criticism of Emanuel's scholarly work. The key quotations start with Farley's ninth paragraph.
"Emanuel, however, believes that 'communitarianism' should guide decisions on who gets care. He says medical care should be reserved for the nondisabled, not given to those 'who are irreversibly prevented from being or becoming participating citizens. . . . An obvious example is not guaranteeing health services to patients with dementia.' (Hastings Center Report, Nov.-Dec. '96).

"Translation: Don't give much care to a grandmother with Parkinson's or a child with cerebral palsy."
The above is Farley's quotation of a New York Post op-ed by Betsy McCaughey. McCaughey attaches her use of the term "disabled" to a couple of passages in Emanuel's article. I find that important because it is not the standard use of the term, and Bachmann later uses the same word when she comments on Emanuel's views.

Farley continues:
Bachmann quoted heavily from McCaughey's op-ed in her floor statement, and sprinkled in her own two cents.

Here's what Bachmann said:

"The president's adviser, Dr. Emanuel, believes communitarianism should guide decisions on who gets care. He says medical care should be reserved for the nondisabled. So watch out if you're disabled."

If Bachmann had failed to distinguish her use of the term "disabled" from its everyday use, and I would count that against her. Fortunately for Bachmann, that is merely the impression left by Farley. In context, Bachmann's use of the term is sandwiched between quotations of McCaughey. That, I think, provides sufficient context to understand Bachmann in the same manner set forth by McCaughey. Farley's story is misleading on this point, for his sketch of the context lacks critical detail.

So does the article say what Bachmann claims it says?
The quote in question comes from an essay Emanuel wrote for the Hastings Center Report in the November-December 1996 issue. It ran under the title, "Where Civic Republicanism and Deliberative Democracy Meet." The title alone should give you an idea of the kind of academic, philosophical discussion that will ensue.
Academic and philosophical. That's nice.
In the article, he addresses the idea of what's good for society at large when it comes to allocating health care resources, and that it "suggests the need for public forums to deliberate about which health services should be considered basic and should be guaranteed." Under that philosophy, he writes, health services would be guaranteed to ensure the health of future generations as well as for "full and active participation by citizens in public deliberations."
I read the article. Farley appears to bend over backward to minimize Emanuel's role in advocating a position. More on that later after Farley completes his exposition.

That's the lead-in to the part that contains the stuff McCaughey cited:

"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. A less obvious example is guaranteeing neuropsychological services to ensure children with learning disabilities can read and learn to reason."

I think some of the nuance of Emanuel's piece is lost with Farley's edits. But I can appreciate the challenge of providing a fair yet edited account of the article. That "Conversely" at start of the Emanuel quotation serves a critical role in contrasting services guaranteed for one class of people and not guaranteed for a different class.
So the question is, is Emanuel saying that he thinks health services ought not to be guaranteed to patients with dementia?
The question is actually whether he thinks the guarantee should be withheld from those "irreversibly prevented from being or becoming participating citizens." But Farley's version of the question is serviceable, since Emanuel says the example is an "obvious" one.
No, said Kenneth Baer, a spokesman for the White House Office of Budget and Management. "He just unequivocally doesn't believe that."
If anybody would know, it would be Kenneth Baer.
In fact, he said, one need look only as far as the next paragraph:

"Clearly more needs to be done to elucidate what specific health care services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services."

Yeah, we sorta got lost there too.

What it means, Baer said, is that Emanuel was exploring different views of political theory as they apply to health care decisions and following one school of thought through to the point where he notes that it would lead to "potentially disturbing types of policy ramifications."
And if anybody would know, it's Kenneth Baer.
Furthermore, he said, you need to balance McCaughey's claim against Emanuel's 25-year record of caring for very sick people, and specifically providing quality care to very ill patients at the end of their life.
Emanuel's record is irrelevant compared to the text he wrote. It is one thing to receive payment for services rendered and another thing to determine wise government spending. Amazingly, Farley only gives us analysis courtesy of the spokesperson for the OMB. And we find that analysis well represented in Farley's conclusion:
(T)o make the sensational claim that Emanuel says health care should not be extended to the disabled is a gross distortion of his position, lifted out of context from an academic paper in which he poses philosophical ideas but doesn't necessary (sic) endorse them. Emanuel's hefty medical record also counts for something, as well his unequivocal public position against euthanasia and doctor-assisted suicide. We rule Bachmann's statement False.
Hook, line, sinker.

First, Bachmann's claim is not a gross distortion of Emanuel's position. She provided context from McCaughey's op-ed that explained the specialized meaning of "disabled."

Second, Emanuel's statements were not taken out of context. McCaughey and Bachmann both provided accurate background information and sufficient context to understand Emanuel's meaning.

Third, while Emanuel did not necessarily endorse the described view--I'm repeating those weasel-words for effect--he did use language that strongly suggests he did, in fact, endorse them.

Here's what Farley left out:

Emanuel does start out academically, asking what it is that explains the difficulty in advancing health care reform. He offers two competing models and rejects the first of them as "dangerous." Then he talks about a second explanation:
The second explanation holds that the problem with defining basic health services is not a general lapse of ethics, but a specific lapse of liberal political philosophy that informs our political discourse, including the allocation of health care resources.
Emanuel advocates the second explanation. That is, the neutrality of liberal political philosophy must give way to the determination of "the good" as in communalism.
This is Dan Callahan's view with which I agree:
... there can be no full discussion of equality in health care without an equally full discussion of the substantive goods and goals that medicine and health care should pursue ... [U]nless there can be a discussion of the goals of medi- cine in the future as rich as that of justice and health has been, the latter problem will simply not admit of any meaningful solution.
Could Emanuel simply have agreed that an appeal to "the good" is required to achieve a "meaningful solution." Perhaps, but it would be a stretch. Calling one solution meaningful while implying that the other ("dangerous") path is not a meaningful solution strongly implies advocacy. And Emanuel cinches it with his next sentence:
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.
No matter how "academic" or "scholarly" a work, even a journalist should be able to figure out that "fortunately" represents a value judgment. Emanuel's journal article was plainly advocacy if one bothered to read it--even with a limited understanding of philosophy and ethics. When Emanuel later describes an "obvious" example of the distribution of services according to the system he advocates, it is reasonable to conclude that he believes in the validity of that example.

It should have been impossible to rate Bachmann any worse than "Partially True." And her statement might be simply "True" and Emanuel's denial a lie. Farley doesn't do enough work to justify his conclusion. PolitiFact simply likes giving Bachmann poor grades, it seems.

The grades:

Robert Farley: F
Bill Adair: F

I find it particularly disturbing that Farley proved so inept at engaging the journal article, and that he apparently took the OMB spokesperson's account as some sort of gospel. As with some past entries from PolitiFact, this seemed more like an effort at rehabilitation rather than fact-checking.

Additional notes:

I found one positive aspect of failing to review this PolitiFact entry until it had hung on the vine for a time. PolitiFact added a link to Emanuel's response.

Most of the ABC interview deals with semi-related allegations. But some of it was close enough to warrant commentary:

Is he saying, as Palin and others have suggested, that those who aren’t “participating citizens” should have no guarantee to health care?

“No,” Emanuel says, “and I think I made it pretty clear I wasn’t endorsing that view, I was analyzing that perspective and what it might mean in practical terms. The rest of the text around that quote made it made it pretty clear I was trying to analyze it and understand it, not endorse it.”

Emanuel acknowledges that philosophical treatises can be difficult to consume and might lend themselves to this kind of misinterpretation.

Emanuel's explanation, matching as it does Baer's right down to the understanding journal articles is hard bit, fails the smell test. It is not clear when you call the increased acceptance of one of two views "fortunate" that you are not endorsing that view. And it is ridiculous to say that the increased acceptance of that view is "fortunate" if you can't even affirm the validity of an "obvious" application of said view.

My opinion? The White House knew it was caught by the short hairs. The strategy developed to put out the fire involved denial, the claim that writing it didn't mean he endorsed it, and discouraging investigation into the obvious falsehood of the former by reminding the public that journal articles are too hard to understand. Then hope the press buys it, because that will help immensely.

Farley's your man.

Update (11-6): Expanded on a couple of points and made minor modifications a few sentences. Also expanded the quotation of the ABC News interview to make the accuracy of my evaluation more clear. Lastly, fixed my misspelling of Bachmann's first name in the title.

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