Emanuel and the White House are attempting to reorganize the delivery and reimbursement systems of health care, changing what the types of procedures doctors rely on, making people more aware of disease prevention, encouraging insurance companies to expand coverage, and so on. It is a process rife with sensitivities, trickeries and, of course, the potential for failure. It is not, he insists, impossible.

“It is a complicated process and we have to try and make the choices clear and give people good reasons for making them,” Emanuel explains. “I don’t think that’s an impossible task and thankfully we have one of the great communicators, Barack Obama, at the helm of this ship of state.”

Emmanuel recently authored an article in the Lancet describing the various models of non-market health care rationing. Titled “Principles for allocation of scarce medical interventions”, its is co-authored with Govind Persad and Alan Wertheimer. In it the authors simply review the pros and cons of the various ways of deciding who gets treated and who doesn’t. The allocation mechanisms they discuss are divided into strategies and substrategies. The pros and cons of each are laid out.

Treating People Equally

1. Lottery
2. First-come, first served

Prioritarianism

1. Sickest first
2. Youngest first

Utilitarianism

1. Saving the most lives
2. Saving the most life-years
3. Saving the most socially useful
4. Reciprocity (paying back people who have ‘contributed’, such as organ donors)

The authors are not very satisfied with the current metrics used for making medical decisions based on saving the most life-years. Both the “Quality-adjusted life-years” model and the “Disability-adjusted life-years” have shortcomings which they believe can be addressed by another model of their own: “The complete lives system”, which takes all the factors into account. They write:

Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles: youngest-first, prognosis, save the most lives, lottery, and instrumental value. … When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated … the complete lives system is least vulnerable to corruption. Age can be established quickly and accurately from identity documents. Prognosis allocation encourages physicians to improve patients’ health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates.

Under this system, patients would receive scarce care according to the graph shown below.

The paper concludes: “the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives. In pandemic situations, it also allocates scarce interventions to people instrumental in realising these four principles. Importantly, it is not an algorithm, but a framework that expresses widely affirmed values: priority to the worst-off, maximising benefits, and treating people equally. To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo.”

What’s not mentioned anywhere in the discussion, except by implication is the identity of the narrator. Who is the “we” in “Principles for allocation of scarce medical interventions” that decides who gets scarce medical care? The answer is tangentially provided in the paper itself, which writes that “the complete lives system is least vulnerable to corruption”.The “we” is  a system; a system that can possibly be corrupted; hence Dr. Emmanuel’s efforts to design one in which such distortions will be held to a minimum.

Ultimately health care reform is as much about politics as it is about medicine. The discussion in Dr. Emmanuel’s paper is incomplete if limited to pure public health considerations. Politics is central to the whole issue. Whatever “guidelines” are chosen, however rational, however humane, can never implement themselves. Human beings in positions of power are required to do that. And while it is important to note that even under the current system these decisions are being made by someone or by some consensus, it is also vital to realize that in any “health care reform” effort, one of the principal outcomes is the shift power to make those decisions to someone else. That may not be a fit subject for the Lancet, but it is the elephant in the operating room in the national health care debate.

The idea that a certain amount of blood had to be used to grease the wheels of peace may have been a rational calculation under the shadow of the bomb. The ultimate proof of the efficacy of containment is that you are reading these words. The counterfactual argument is uncertain and speculative at best. But it was a profoundly corrosive and cynical idea whose moral ends could not be made to meet until Ronald Reagan found a way to win the Cold War in non-nuclear fashion. In a world which declares itself unwilling to even use the words “terrorism” any longer it is sometimes easy to forget for how long civilization was preserved by holding hundreds of millions on each side of the Iron Curtain hostage to destruction. The price of deterrence, for the sensitive at least, was a kind of moral damnation. Who knows to what extent McNamara’s subsequent career in the World Bank was driven by the need to shrive himself, yet of what sin that others were not guilty of, who can say, but himself?

Since then, at an uncertain hour,
That agony returns :
And till my ghastly tale is told,
This heart within me burns.

I pass, like night, from land to land ;
I have strange power of speech ;
That moment that his face I see,
I know the man that must hear me :
To him my tale I teach. …

He prayeth best, who loveth best
All things both great and small ;
For the dear God who loveth us,
He made and loveth all….

The Mariner, whose eye is bright,
Whose beard with age is hoar,
Is gone : and now the Wedding-Guest
Turned from the bridegroom’s door.

He went like one that hath been stunned,
And is of sense forlorn :
A sadder and a wiser man,
He rose the morrow morn.

President Obama has made his first mistake in Russia even before he arrives in Moscow today. His attempt to cast Vladimir Putin as yesterday’s man and to drive a wedge between the Prime Minister and President Medvedev demonstrates a misreading of relations in the Kremlin.

Mr Medvedev is in office but not in power and whether he becomes President in more than name depends on Mr Putin’s support and intentions. Mr Medvedev may represent a more accommodating face of Russia but this is only because Mr Putin wants him to.

Mr Obama declared: “I think that it’s important that even as we move forward with President Medvedev that Putin understand that the old Cold War approaches to US-Russian relations is outdated . . . Putin has one foot in the old ways of doing business and one foot in the new.” That suggests that Mr Medvedev’s outlook differs from that of his mentor despite a lack of evidence. Mr Putin is not known as a bad judge of character and he himself described his successor as “no less a Russian nationalist than I am”.

It’s not such a hard puzzle to solve. The “wedge” is for American consumption only. For Barack Obama to sell any agreement he reaches with the Russians, he must portray today’s Russia as being led by “new men”, reasonable men, men perceived to be unlike Vladimir Putin. In this way he can say that ‘new page’ has been turned; and America is now dealing with ‘people we can trust’. Obama probably knows that Medvedev only represents “a more accommodating face of Russia … only because Mr Putin wants him to”. But it suits his book to present Medvedev’s face or at the very least to portray Russia as a battlefield between “moderates and neo-conservatives”. The wool being pulled over isn’t over the President’s eyes but someone else’s.

With the recent news that Russia has agreed to let the US supply forces in Aghanistan through Moscow-controlled territory, look for “deep cuts” and “stand downs” vis a vis Moscow. The Reuters article says Obama “will also meet business chiefs and listen to the country’s embattled democratic opposition. But he faces a harder task in trying to achieve his aim of a ‘reset’ in overall relations between Washington and Moscow.” It may be easier than he lets on.

The parallels between the Philippines and Honduras are uncanny. As we all know very well [Gloria Macapagal Arroyo's] GMA’s allies in Congress have been assiduously pushing for charter change … Zelaya’s ouster was precipitated by his insistence on having a constitutional convention … Both moves are seen as attempts to extend the president’s term of office. GMA’s allies want to proceed with a con-ass [constitutional assembly] even without the Senate (clearly unconstitutional), while Zelaya wants a referendum on the convening of a con-con [constitutional convention] without congressional authorization as required by Honduras’s constitution. …

Going back to Honduras, it is disappointing to know that the international community - including the UN, Organization of American States, and the US - was quick to condemn the removal of Zelaya and announce its disapproval of the existing government, given the background of Zelaya and what prompted his removal. A review of what happened in Honduras shows that it was Zelaya who first committed constitutional shortcuts by disregarding the Honduran Congress in calling for a referendum to amend the constitution. The Honduran Supreme Court, backed by the attorney general, ruled that Zelaya’s call for a referendum was unconstitutional. Zelaya defied the Supreme Court ruling by firing the army chief who refused to support Zelaya’s self-initiated referendum. This prompted the military, in support of the Supreme Court’s ruling, to arrest Zelaya. As a result of this the Honduran Congress installed Roberto Micheletti, the constitutional successor to the president. …

Mr. Bautista’s piece might remind Washington that Third World Countries striving to become countries of “laws and not men” also have to struggle with problem of preserving their institutions even as they are tempted to take shortcuts to solve ’social justice’ problems. The idea that Zelaya ought to be supported by Washington because he is considered by some NGOs to be a “man of the people” may or may not have moral validity. But even if he were, restoring him in violation of Honduran laws also has a downside. Those who worked for years to restore the semblance of constitutional rule in a Third World after a dictator has torn them up know how that it is much easier to scramble an egg than to unscramble it. Once the laws of Honduras are circumvented with a wink and a nod the temptation to circumvent them again will be irresistible. Honduras and the Honduran constitution may not mean much beyond a narrow circle in Washington, but to the Hondurans, it is all they have.

There are probably a great many ambitious leaders in the Third World who are watching how Washington handles the Honduran crisis. It is all the more reason to act carefully and wisely.

Zelaya himself appears to be riding the ever present tide of resentment against the elite to position himself as a populist strongman. Whether or not he is a convinced Marxist, the success of the Chavez formula has probably encouraged others to copy his authoritarian methods, whatever their actual ideologies. Everybody who wants power — permanently — wants to be another Chavez. And there is no shortage of unrest in Latin American countries that a politician can’t appeal to in order to justify an extended grip on power. The AP cites an area expert as saying that Zelaya was moving towards an authoritarianism. That much seems clear. What is debatable is what he intended to do with power once he got it.

The Honduran coup last Sunday was swift and bloodless. But the tension that culminated in Zelaya’s overthrow had been building for months as his politics and rhetoric moved left, and he aligned himself closer to Venezuelan President Hugo Chavez.

Though Zelaya made no sweeping changes, his alliance with a president who abolished term limits and is making an economic shift toward socialism was unsettling to the business and political elite who still run Honduras — and from whose ranks Zelaya originally came.

“There’s a sense of Zelaya overstepping his power and confusion over this embracing Chavez,” said Peter DeShazo, who directs the Americas Program for the Washington-based Center for Strategic and International Studies.

Barack Obama has so far taken the position that Zelaya remains the President of Honduras and has acted to restore him through the Organization of American States (OAS) and by suspending bilateral military relations. The OAS recently threatened to expel Honduras, but the current Honduran government pre-empted them by withdrawing from membership. In response the OAS said that Honduras had no right to withdraw because it isn’t the legal government. They’re like the boss who won’t let you resign. They want to make a point of firing you.

The goal of the US is ostensibly to restore the status quo ante and use negotiations to resolve things from there. But with the positions between the two parties hardening, things may be moving towards a zero-sum game. In a winner-take-all scenario Zelaya either wins or loses. If Zelaya is kept out by the Honduran interim government, the new guys will have established themselves, baggage and all, in the saddle. If Zelaya returns it may represent a clear victory for the Chavez camp in Latin America. The new guys will be toast. My guess is that unless an amicable solution can be brokered quickly, the choices will be stark. Chavez’s bad (or not so bad) guy versus a bad (or not so bad) guy opposed to Chavez. How will the Hondurans fare? Poorly in any case. In power plays of this kind, no matter what anyone says, it is never about the poor. At the end of the day, they will be just as poor, or poorer, than ever.

MOSCOW (Reuters) – Russia will grant President Barack Obama permission next week to ship U.S. weapons supplies across its territory, or through its airspace, en route to Afghanistan, sources on both sides told Reuters on Saturday. The transit deal will open up an important corridor for the United States as it steps up its Afghan war against Taliban insurgents by sending in more troops. Routes via Pakistan have come under attack by militants …

Medvedev has repeatedly said he is ready to widen cooperation with U.S.-led coalition and NATO forces in Afghanistan, though Moscow has ruled out sending any of its own troops to fight. Russia has already granted Washington the right to transit ‘non-lethal’ supplies, such as food, overland via Russia — and Central Asia — to Afghanistan.

The Washington Post says a US sources has confirmed the deal and calls it a “step forward in cooperation on Afghanistan, which Russia views as a key area where both the former Cold War foes can work together to mend ties.”

This represents another kind of debt, one which will have to be repaid eventually. It is inconceivable that Russia will not demand linkage for its agreement to supply the Afghan campaign elsewhere. Whether this will take the form of payback in the Honduras, Iran, in Russian policy towards Europe, in money, in shared secrets or something else is not at the moment clear. But there will be some price. What’s clear is that Barack Obama has taken out a political loan to buy something in South Asia. Like any other debt, the question must be will America get it’s money’s worth. Will Obama’s strategy in South Asia (whatever it happens to be) yield returns commensurate to the price that will have to be paid. And by the way, what is that price? Surely the the State Department has some idea. Without a clear knowledge of how much one is borrowing in exchange for what investment plan, it’s hard to say whether this is good or bad. Maybe one shouldn’t worry. Why stint on debt when there are some visions that are too big to fail.

“Moscow is against imposing sanctions on Iran over the alleged crackdown on protests following the country’s controversial presidential elections, a spokesman for the Russia Foreign Ministry said on Thursday. “We believe that sanctions against Iran over its internal political problems would be unlawful and counter-productive,” Andrei Nesterenko told a regular press conference. Such a move would provoke unwelcome events in the country and the region, the spokesman said, adding that all disputes should be addressed through legal means. Italian Premier Silvio Berlusconi said earlier that the upcoming meeting of the Group of Eight leaders in central Italy would discuss possible sanctions against Iran for its crackdown on election protests.

The Haaretz report says:

The United States is opposed to enacting a new set of financial sanctions against Iran that are due to be discussed in the G8 summit next week, diplomatic officials in New York reported Friday. According to officials, sanctions against Iran are expected to top the G8’s agenda. Sources are also predicting a pointed debate between the heads of the industrialized nations over an appropriate response to Iranian authorities’ suppression of reformist demonstrations in Iran led by Mir Hossein Mousavi and other Iranian opposition leaders.

Italian Prime Minister Silvio Berlusconi hinted in a newspaper interview earlier in the week that the G8 is due to decide on new financial sanctions against the Islamic Republic. Berlusconi disclosed that he had spoken with the heads of the G8 nations and has discussed such steps with them.

If true, this raises the interesting question of where it puts US policy with respect to that of its long time transatlantic partner, the United Kingdom. The Times Online describes the rift within the EU over how to tackle Iran. After employees of the British embassy were arrested by Iranian authorities, the British pushed for a strong statement of condemnation from the EU, but was notably cold-shouldered by Germany and Italy. Berlusconi’s statements about the forthcoming debate suggest that there will be some kind of showdown over the issue. With the US, Germany, Italy and now the US (if Haaretz is accurate) moving to conciliate Iran, then the UK will to all intents and purposes be isolated. The Times Online article says:

The EU was very quick to condemn Iran for the way it cracked down on presidential election protests last month. But EU co-ordination began to break down with the arrest of nine British embassy staff.

Britain won a strong statement under the Czech EU presidency. A British request for the mass withdrawal of EU ambassadors remains on the table, but in some capitals this measure is seen as too aggressive.

The EU is Iran’s largest trading partner with exports worth €11 billion. The two biggest opponents of sanctions have been Germany and Italy, which do the most business with Iran.

As I’ve written before the momentum behind “engagement” is all the handshake deals that have already been done up to this point. Ironically, the elections in Iran are also about money; what was at stake was the economic dominance of two rival groups in Iran, both probably salivating over the possible lifting of sanctions. Recent events in Iran may mean that lifting sanctions must await a “decent interval”, but it’s easy to see how Iran’s “partners for peace” may be eager to keep further sanctions from being imposed.

One strategist who assumes she has aspirations to run for president called the decision to resign her office “puzzling,” another described it as “nutty.” “If this is about running for president, it’s about as odd a way as we’ve ever seen,” said John Weaver, a Republican strategist. …Yet, it has been obvious that Alaska is a difficult place from which to participate in the national debate — both because of its physical distance from the rest of the United States but also because of its unique culture and identity. Freed of the constraints of her office, Palin could, if she chooses, become a more engaged participant in the national debate.

“My contrarian take is almost everyone I talk to thinks it’s crazy but I wonder maybe it’s crazy like a fox,” said Bill Kristol, editor of the Weekly Standard, who has been out defending Palin this past week.

If Sarah Palin has resigned in order to focus on the 2012 it will have the effect of starting the election season early. Both President Obama and Republican Presidential hopefuls must consider whether they can stay on the starting blocks while the former of Governor of Alaska runs down the track at her own pace. If they leave it too long she may build up a significant start on them.  The President will probably try to ignore her; with his publicists portraying her as “looney” or trying to escape her responsibilities in Alaska. There may even be one or two exposes commissioned to allege that Palin had something to hide in the Great North and was running from it. By leaving her destruction to his public relations minions instead of taking her seriously, the incumbent can portray her as beneath his dignity to take seriously. But if Palin’s campaign begins to acquire momentum, then he and every other Presidential hopeful will be forced to respond whether they like it or not.

The word “campaign” must be used advisedly. The text of her announcement, as excerpted by the AP suggests that she may be aiming to position herself as the center of a movement — in effect going outside the system –  rather than aspiring to be just another one of the Republican Presidential candidates for 2012. Sarah Palin may be calculating that, with employment rates at their lowest point in decades and with polls showing a widespread fear for the country’s future, that a crisis is brewing or will soon burst.  A real crisis would seek a natural center, a point around which to rally; and she would be it.  For the Republican Party, a Palin at the center of “Tea Parties” and other unconventional protests would raise the risk of draining away support from the party, which to be fair, has done precious little to harness dissent  itself.

In a hastily arranged news conference at her home in suburban Wasilla, Palin said she will formally step down July 26, and Lt. Gov. Sean Parnell will be inaugurated at the governor’s picnic in Fairbanks. She said she had decided against running for re-election as Alaska’s governor, and believed it was best to leave office even though she had two years left to her term. …

Palin hinted she had a bigger role in mind, saying she wanted to make a “positive change outside government.” But she kept supporters in suspense, promising on Twitter: “We’ll soon attach info on decision to not seek re-election … this is in Alaska’s best interest, my family’s happy … it is good. Stay tuned.”

If something resembling a crisis does break out in the next six months then Sarah Palin’s “unconventional” or “puzzling” move will be retroactively described as an act of genius. But if nothing impends, then Sarah Palin will risk wearing herself out on the public stage even before the 2012 election season begins. Whether or not she has made the right move remains to be seen. In politics as in all else, “something must be left to chance; nothing is certain … [but] no captain can do very wrong if he places his ship alongside the enemy.”

Update: Predicting that the Left would go after Palin was an easy call (see above). Already Newsbusters is reporting “a blog just published at the Huffington Post is disgracefully titled Palin Will Run In ‘12 On More Retardation Platform.”  It was written by comedian Erik Sean Nelson. Some choice quotes are:

Her first act as President: To introduce a Pre-K lunch buffet that includes lead paint chips. Sort of a Large HEAD-START Program.

She will then encourage women to hold off on pregnancies until their 40’s just to mix up some chromosomes.

She now is in favor of abortion only in case of diploid birth.

Her policies will increase jobs because Wal-Mart is building new stores each day and someone has to be the greeter.

Ha ha ha ha. In case anyone takes offense, the defense will be “it was comedy”. But consider this. If they didn’t fear Palin why would they bother to focus every available “comedian” on her? Is it out of contempt, or fear?

[There is a video that cannot be displayed in this feed. Visit the blog entry to see the video.]

Or is it earth versus the flying saucers?

[There is a video that cannot be displayed in this feed. Visit the blog entry to see the video.]