August 27, 2025 • 29 mins
Dr. Michael Koren is joined by Dr. Ezekiel "Zeke" Emanuel, an oncologist, bioethicist, and former White House advisor. Dr. Emanuel talks about his enduring interest in bioethics and the importance of ethics in areas like clinical research. The two doctors also talk about shared experiences at Harvard Medical School and Dr. Emanuel's contributions to bioethics in healthcare and research over his career. They close Part 1 of this conversation with Dr. Emanuel laying out the disparities between US healthcare spending and health outcomes.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcer (00:00):
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts hosted bycardiologist and top medical
researcher, Dr.
Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence, and I
have a really super fun tasktoday to introduce my friend,
long-standing colleague and anincredible doctor, Ezekiel
Emanuel.
Zeke Thanks for being part ofthe MedEvidence family now.
And Zeke has had an absolutelystoried career in medicine that
(00:34):
goes way back to when we were inmedical school together.
I'm going to tell you ananecdote in a second about that,
but Zeke is the chair ofbioethics and health policy at
the University of Pennsylvania.
He's been advisor to the WhiteHouse, to the WHO, and he's
widely considered as a truethought leader in the areas of
bioethics and also in publicpolicy.
(00:55):
So again, Zeke, welcome toMedEvidence and I'm really
looking forward to ourconversation.
Dr. Ezekiel Emanuel (00:59):
It's great to be here.
Thanks for inviting me.
Dr. Michael Koren (01:02):
All right.
So I'm going to start off onthis anecdote that I just shared
with you, to remind you,because I think it's really
wonderful.
So Zeke and I were actually inthe same medical school class at
Harvard and we both chose thecurriculum that involved a more
rigorous scientific part ofmedicine that was run through
MIT, and so there's probablyabout 25 of us in that program,
(01:24):
something like that.
So I was late to go to schoolbecause of a family emergency
and I show up to one of thefirst sessions where we're
getting oriented to the othermembers of the class.
I don't really know who anybodywas at that point and there was
a professor that was goingaround trying to predict what
our specialty would be,literally as first week medical
students.
And again, this is what theprofessors did for fun.
(01:46):
I guess they wanted to see ifyou had the personality of a
pediatrician or an obstetricianor a surgeon or somebody in a
non-patient care specialty likeradiology.
So they went through the wholegroup and people raising their
hand yeah, I want to be asurgeon, I think I want to be a
pediatrician, I want to do OBGYN.
But Zeke didn't raise his hand.
So eventually the professorcomes over to Zeke.
(02:07):
He says I noticed, Zeke, youhaven't raised your hand.
Do you know what you want to be?
And he says I want to be amedical bioethicist.
And the whole class smiled andI didn't know him.
This was literally the firsttime I heard anything come out
of Zeke's mouth, but it soimpressed me that you knew
exactly what you wanted to do.
And it also fascinated mebecause I had no idea what a
(02:28):
medical bioethicist is.
And in fact you did exactlywhat you said you were going to
do, which is so impressive andreally part of our mission here
at MedEvidence is to helpphysicians understand career
paths and how people get tocertain places.
And, given your great success,I think the audience will be
super interested in usunderstanding how you went from
that statement in the first weekof our medical school class to
(02:51):
where you are now as a chairmanof a major department at a great
academic medical center.
So tell us the story, Zeke.
I'm super fascinated.
Dr. Ezekiel Emanuel (03:00):
Well, I did .
I was an undergraduate atAmherst College.
Dr. Michael Koren (03:06):
Great school.
Dr. Ezekiel Emanuel (03:07):
Double majored in chemistry and
philosophy and very interestedat that time in ethics and
political philosophy, and I wasalso, you know, pre-med.
But I really didn't want to goto med school.
On the other hand, as I like tosay, being a doctor was sort of
overdetermined.
(03:28):
My father's an immigrant.
My father was a pediatrician.
I was the eldest of animmigrant pediatrician and I was
very good at science and it'slike there's no alternative.
You got you know he was pushingmedicine, but I was very
(03:50):
hesitant.
I had worked a few summers inlabs.
I found the science interesting, but I didn't find spending my
time in the lab interesting.
So I applied to med school butI went to England to work in a
lab there for a couple of yearsto see if I really liked it, and
it was actually pretty good.
(04:10):
I did molecular immunology.
I got three papers, includingone in nature, done we
identified antibody complementinteraction sites but it really
wasn't exciting to me.
I didn't really like being inthe lab.
Um, and you know, this sort ofethics thing, uh was a pulling.
(04:34):
I came back to med schoolbecause I didn't have an
alternative plan, um, and thepart of the story that is
relevant is that at the end ofour first year of medical school
.
I hated medical school.
I liked my peers, but HSTbecause it was a small group of
(04:56):
people was actually great.
Dr. Michael Koren (05:00):
That's the MIT-Harvard combination
Dr. Ezekiel Emanuel (05:03):
Health, science and technology program
Right.
Dr. Michael Koren (05:05):
Just for the audience.
Yes, yep, go ahead.
Dr. Ezekiel Emanuel (05:07):
I, instead of doing the usual I think
everyone went to a lab to workfor the summer.
I went to Washington to internat a political newspaper, a
political magazine there calledthe New Republic, which was in
it.
That was one of its heydays ofabout 20 year stretch of great
(05:28):
reporting and stuff.
I spent the summer doing thatand I realized two things First,
there are plenty of people whowere way better writers than I
was I wasn't that great a writerand second, I didn't want to
report on what was happening.
I wanted to do what washappening.
So I came back again for thesecond year because I didn't
(05:49):
have a plan B.
I didn't, you know.
It wasn't clear to me what todo.
Alternatively, how to actuallyget this.
Medical ethics thing
Dr. Michael Koren (05:56):
And it really wasn't a terrible gig to be
going to Harvard Medical School.
Let's face it, but go ahead.
Dr. Ezekiel Emanuel (06:00):
For sure, for sure.
But so during that year someonesuggested actually one of my
brother youngest brother'scolleagues was going to Harvard
College and suggested that Ibecome a tutor at Harvard, and
(06:27):
so I don't know if you remember,but they had us explore
teaching opportunity or notteaching.
They had us explore differentlabs to see where people would
end up in the lab.
So we had an afternoon a weekoff and I'm like, well, maybe I
could teach an afternoon a weekat Harvard College instead of
being in a lab.
And that's what I did and Itaught a Harvard major called
social studies where you readeveryone from basically
Thucydides and Plato andAristotle to Freud and Durkheim,
(06:47):
and it was great, I loved itand I said you know this
teaching.
I really liked that.
So after our third year ofmedical school, I took off.
I got accepted to the Harvardpolitical science Department,
called the Gov Department, for aPhD, and I basically stopped
medical school and, you know,did the PhD.
(07:11):
The thing about it at Harvardwas that you only needed 15
months of clinical rotations tograduate and I had had the 15
months summer and by the time Istarted the PhD I basically
could have graduated.
But of course you can't becauseyou have to go into internship.
And then I did the PhD in fouryears and then I went back as an
(07:36):
intern and this may surpriseyou, because I'd sort of been
off the wards and forgotten alot of stuff.
While I was working on medicalethics related dissertation, I
asked to start in the CCU andevery time people who aren't
(07:58):
doctors think, well, that'scrazy.
You know, those are the sickestpatients in the hospital and I
said yeah, and they wouldn't leta fresh intern touch them.
Dr. Michael Koren (08:07):
That's right,
Dr. Ezekiel Emanuel (08:07):
they have experienced nurses, they have a
cardiology fellow.
I'd be there and I could learn.
I could remember how to take ahistory.
I could remember how to writethe order and after two weeks
I'd be up to speed which isexactly what happened and it was
, you know.
It was very good learning and Imet some of our classmates who
(08:29):
by that time were fellowsbecause I had taken off for a
PhD.
Harlan Krumholz, for example,was a cardiology fellow on the
service and I short trackbecause I was impatient and
after two years I went andbecame a Farber fellow at the
Dana Farber Cancer Institute anddid oncology.
(08:51):
And I chose oncology for threeor four reasons.
One coolest science going on incancer.
In the late 80s, early 90s, wewere really at the cutting edge.
Every patient had end-of-lifeissue crisis.
(09:12):
That was part of my research.
I was heavily focused onimproving end-of-life care.
And last, there was this wholeissue of allocation of resources
.
We were even back then, 25 yearsago 35 years ago, I mean
spending a fortune on cancer.
We had bone marrow transplantsat 100,000 a crack at that time
(09:34):
where we thought it wasoutrageously expensive, and so
it had all of these ethicalelements and there wasn't anyone
who was really systematicallydealing with them and they all
interested me.
So I chose oncology and theFarber was a fabulous place for
someone like me because everyoneknew that there were big
(09:59):
ethical dilemmas but they didn'thave anyone who was going to
address them.
So I started something calledthe Ethics Grand Rounds and
every month we had a big ethicscase that presented and we
brought in an expert andeveryone showed up.
Unlike the other Grand Rounds,everyone found these interesting
, personal.
Yeah, we had ones about doingthings on clinical trials the
(10:21):
ethics of phase one oncologytrial, and then the Journal of
Clinical Oncology, which is theprofessional journal of the
American Society of ClinicalOncology, began running these
articles.
So I got a lot of academiccredibility there and I think it
(10:42):
convinced people that ethicsand end-of of life care and
informed consent and thinkingabout research ethics and was
part of what they should bedoing.
And they just happened to haveme, so it was-
Dr. Michael Koren (10:55):
-f ascinating , yeah, so fascinating.
You really were a pioneer inthat space, quite frankly.
Dr. Ezekiel Emanuel (11:00):
Well, I, I was.
Uh, it is the case that, um,the history of bioethics is such
that it sort of took off in theUnited States in 1970, '71.
But a lot of the people whowere doing it were not
well-trained.
They were psychiatrists whowere doing it because of
whatever, or they were retiredsurgeons who, after retirement,
(11:25):
decided this was an interesting,important topic even though
they had no training.
So a lot of the early stuff wasnot particularly good.
At the end of the 70s there wasa Jimmy Carter appointed a
presidential commission onbioethics to look at a lot of
things like gene therapies andstuff, and it got a little more
professionalized.
(11:45):
But there still weren't peoplethat were.
There were only a handful ofpeople who were both physicians
and interested in this, who hadsome training and that were just
sort of talking based upontheir intuition and guts but
actually understood somethingabout ethical reasoning, and so
(12:06):
that's the area that was luckythat I had this overlap and I
was one of the few people whoboth you know, frontline
clinical back with oncology aswell as and I understood a lot
of the science and research aswell as highly trained in ethics
and political philosophy.
(12:27):
It gave me a kind of uniqueposition and it was a I would
say again, a time when theprofession did open up and did
say you know, this is core ofwhat we've got to be doing.
And so I was in that uniquemoment and it emphasized for me,
(12:51):
you know, a lot of careersuccess is luck.
Are you at the right place atthe right time and take
advantage of that luck.
And I did happen to be at theright place.
Dr. Michael Koren (13:01):
Yeah, tremendous.
So, as a quick summary, youmade your parents proud.
They can say my son theoncologist and you are a true
pioneer in a kind of a new partof science.
The Belmont Report that we'lltalk about came out in 1979.
Dr. Ezekiel Emanuel (13:17):
Yeah, I was part of that
So literally.
you know, within about a decadeof that we were starting to
understand how that applied toactual clinical practice and
getting people involved inclinical research.
And there were very, very fewpeople, as you point out, that
had knowledge both on theclinical side and the bioethics
side and know how to navigatethose tensions which are
actually super interesting.
So I'm not surprised you hadgreat attendance to the
(13:37):
bioethics grand rounds.
I'm sure there was somefascinating cases discussed.
So kind of give me the littlebit of the scoop from going from
training to ending up at Pennand ending up at the White House
.
That's kind of an interestingtransition.
Well, I was at the Farber for seven years
and then trying to figure outwhat the next job was.
Dr. Michael Koren (14:02):
So you were an attending physician there for
a while, treating cancerpatients.
Dr. Ezekiel Emanuel (14:06):
I would put that in quotes.
Yes, I was a classic academicphysician half a day, a week of
clinic.
Dr. Michael Koren (14:12):
Oh, wow, ok, All right, that counts.
Dr. Ezekiel Emanuel (14:14):
Most of my time was spent doing research.
I had a teeny, teeny tinyresearch group.
The biggest it ever got to wastwo people,
Dr. Michael Koren (14:24):
All right
In addition to me, and we wereincredible.
I mean, you know it.
Just let me say
yeah, Watson and Crick were a two-person team
.
Dr. Ezekiel Emanuel (14:33):
I had two research assistants and you know
we were focused on this sort ofmedical ethics issues, mainly
end-of-life care, but we alsofocused heavily on
physician-patient relationship.
We wrote a very important paperon how to understand the
(14:54):
physician-patient relationshipand I should say an interesting
thing happened to me at theFarber.
All of you who've worked inacademic centers know that the
coin of the realm is space.
There's never enough space andbecause of what I was doing, um
(15:15):
uh, after my second year, youknow, I needed to get a space of
my own.
Um, the head of my department,which happened to be the
epidemiology department, um uhtook me on a walk, says well,
Zeke, you know we're gonna findyou new space.
And he took me out of the mainbuilding at the farber to walk
(15:36):
across the parking lot and thenthere was this little building
in the shadow of a power plant.
It turned out that that littlebuilding housed all the unused
um iron lungs.
Dr. Michael Koren (15:50):
Oh geez .
Dr. Ezekiel Emanuel (15:50):
From Polio, from the 50s and he said you
know, there's this second floorsuite in the back there and you
know you can have four rooms.
And I realized this is theplace where they put all the
people who they're not actuallyfiring but want people to leave.
It turned out, you know, Ithought you know, basically this
(16:12):
is Siberia.
It turned out to be a blessingin disguise.
Sometimes Siberia can be coldand unproductive and a vast
wasteland.
But for me, I was out of theflow, out of the politics, out
of everyone.
You know, spending time,wasting time talking about this
and that and who was up, who wasdown, and I simply focused on
(16:35):
my work and it.
We turned out to have twopeople and me and we were
incredibly productive, um, justbanging out the papers, and
(16:55):
then in 1996, I believe '95 um,a job came up to.
Uh, they were looking for ahead of bioethics at the NIH,
not just the head.
They, the guy who was head ofthe clinical center, which is
the hospital at the at the NIH,was establishing a department
and he thought well, we neededyou know, the hospital needed to
have a bioethics department.
So I applied and, um, the twoother candidates were much more
(17:17):
senior than I.
I was, I think, uh, whopping,uh, uh, 38 years old or
something, um, and I didn't doany research ethics.
You know, since the hospital atthe NIH is purely research,
there's no routine patient carethere, and I had not done any
(17:42):
publications in the researchspace.
Uh, in immune, uh, deficiency,uh, diseases, um, chronic
granulomatosis, um, for whateverreason, we hit it off.
He went to Amherst.
I went to Amherst, we had avery nice meeting of
personalities and he gave me thejob, um, and you know it was a
(18:08):
wonderful opportunity to buildsomething from the ground up, uh
, and to, you know, invitepeople.
And it got me also interestedin research ethics.
At that time this is 1996, 97.
I was like, well, you know, allof that research ethics done.
We had the Belmont report, wehad the declaration of Helsinki,
(18:29):
we have federal regulationswhat more could there be to do?
And I scratched the surface.
I began reading these documentsand realized, you know, there's
a lot more to do.
These aren't.
They're heavily focused on onething autonomy and informed
consent.
But there's also much moreabout the ethics of research
(18:52):
that they're not addressing atall.
And, by the way, a lot of theliterature that had been
published, I thought, was againgiven my unique position as a
doctor, a researcher and abioethicist.
It's like I think they've gotit wrong and we could do a
better job, of sort of fixing itand putting it right.
(19:16):
And so it turned out to be awonderful, wonderful moment to
create a department and toreally I think we ended up
transforming how people thinkabout the ethics of clinical
research.
Dr. Michael Koren (19:32):
One super cool and absolutely spot on is
that there's been a huge changein the way we perceive ethics.
That we'll get into more detailin a moment, but that's just
wonderful story.
So tell me about the politicalpart of your career, how that
came aboard, and you're wellknown for those contributions,
(19:53):
so why don't?
You tell us a little bit moreabout that.
Dr. Ezekiel Emanuel (19:56):
So I worked at the NIH from 97.
And then, beginning around 2003, 2004, I could see I'd done
almost everything I wanted to doin the research ethics space.
Again, it was an incrediblygenerative from a productivity
standpoint, one of the bestexperiences you could imagine.
(20:19):
We had a fellowship, we hadpeople coming right out of
college, we had postdocs.
They were all brilliant, theywere great to work with.
But I could see that I was sortof getting to the end of all the
research ethics things I wantedto really write about.
Not like I covered everything,but that I wanted to write about
(20:40):
.
And I was like the thing that'ssort of uh, agitating me is
going back to my politicalphilosophy.
My government polsci roots was,you know, we don't have
universal coverage and we needto begin thinking about it and
lay the plans for it.
So I ended up writing somestuff and teaming up with one of
(21:03):
the uh I like to call them theuh uh three original health
economists in the country a guynamed Victor Fuchs who was a
professor at Stanford.
He had just retired and youknow we had talked about
collaborating and some of ourideas overlap and again, that
(21:25):
turned out to be incrediblygenerative.
So in '03, '04, '05, we beganreally publishing a lot.
Romney, uh, uh, Mitt Romney wasgovernor of Massachusetts and
and, uh, put in his Romney care,uh, a legislation that created
a way for people to getinsurance who didn't have
insurance and subsidize them.
(21:45):
And then, you know, presidentObama was his stuff and I was
again writing on this andtalking about it.
And when Obama was elected, heappointed Peter Orszag as head
of the Office of Management andBudget.
And Peter Orszag asked if Iwould come and work there as a
(22:09):
special assistant working on theAffordable Care Act.
And what was important aboutthat is because I was at the NIH
, I was a government employee, Icould go there and it wouldn't
cost the White House a penny,which is always and one of the
things you.
Let me just say two things youlearn very quickly.
First, the Office of Managementand Budget is the most powerful
(22:31):
agency you never heard of.
Actually, it controls all thebudgets, it controls all the
regulations.
It's really a magical place tobe.
The second thing is that thereare never enough people in the
White House to handle all theincoming, and so I always tell
(22:53):
students, if they ask you tocome and sweep the floors at the
White House, you say absolutelyI will do it because peas are
falling off issues.
You can do so much.
It doesn't get to thepresidential level, doesn't even
get to the chief of staff level, doesn't get to the National
Economic Council level.
There's things you can do.
(23:13):
So just give you one example Igot there and part of what Obama
was talking about was we got toreduce regulation.
So I said to Peter Orszag I saidyou know, there's a lot of
regulation around clinicalresearch that is not helping and
just creating a lot ofpaperwork that we could
streamline.
So he said he ran it up theflagpole.
(23:34):
He said okay, you can puttogether a group.
So I could put together a groupfrom HHS.
There's, for a variety ofreasons, labor and the feds
department involvement and weput together a group and within
six months we had a draft of thefirst ever revision of the
regulations of human subjectsresearch and it didn't get
(23:59):
passed till January 2017,literally as president Obama was
leaving the office.
But that's because I left andthey didn't have someone driving
it and it was being held up bysome people at the NIH,
ironically enough, but that'sthe kind of thing you can do at
the White House, and I alsohappened to work on the First
(24:22):
Lady Michelle Obama's let's Moveinitiative, the food, redoing
the food pyramid to make it afood plate.
So lots of possibilities, butthe main thing I was there for
was to work on the AffordableCare Act and that was a
thrilling, wonderful opportunity.
And I like to say, you know, 22, 25 million people got health
(24:46):
insurance.
If I was one of a thousandpeople working on that, you know
, okay, I take, you know, 0.1%of 25 million people.
There's 25,000 people.
I helped 25,000 people.
You can't do that every day ofyour life,
Dr. Michael Koren (25:00):
Yeah.
Dr. Ezekiel Emanuel (25:00):
And every year of your life.
It's a pretty lucky opportunity.
Dr. Michael Koren (25:05):
Well, thank you for those efforts, not
always widely appreciated, butcertainly people in the know do
appreciate them.
So thank you.
So tell us a little bit aboutfrom this incredible experience
obviously became well knownthrough your work on the
Affordable Care Act and thenending up at Penn and in your
current position and you tell usa little bit about what you do
day to day now.
Dr. Ezekiel Emanuel (25:26):
Well, at Penn I had again the same
wonderful opportunity to be atthe right place at the right
time.
They were creating, they had acenter for bioethics with Arthur
Kaplan headed, but they wantedto change it to make it a
department and merge it withhealth policy.
So there were PhDs and they hada lot of PhD health policy
(25:49):
people working in clinicaldepartments like primary care,
and it didn't make any sense.
So they wanted to merge or havethe bioethicists and the health
policy people in one departmentand make, you know, give it,
unlike a center that has noability to appoint or hire
faculty, it would haveappointment power.
(26:10):
And again, there you.
And again there were no peoplein the department.
So I came and started adepartment, which was again a
wonderful opportunity.
I think I was selected becauseI'm one of the few people again
who was both a bioethicist andhad expertise in health policy
Not everyone who whose bioethicscan do health policy and few
(26:33):
people who do health policy dobioethics.
So I actually was one of thefew people who had a leg in both
sides.
I had a great opportunity toattract two absolutely
outstanding people to head eachdivision Steve Jaffe, I
recruited from Boston Children'sHospital, and Dana Farber,
who's an oncologist and expertin bioethics, part.
(26:56):
And Kevin Volpe, who peopleknow because of his great work
on the role of behavioraleconomics and healthcare and
using incentives in the rightway to head the health policy
side.
I mostly do what I've alwaysdone, which is mostly uh, um,
research and it's what up in themorning, writing papers.
(27:19):
I'm at the moment, um, I've gotuh, uh, two books in the air.
One's going to be published inJanuary and I'm working, spent
the morning here working onchapter six of the next book,
which is the one really about.
I'd like to say why Americacan't achieve any one of the
(27:41):
goals of healthcare.
We can't get the universalcoverage at reasonable costs,
with consistent, high quality,reducing, if not eliminating
disparities and having highsatisfaction for both the
physicians and clinicians in thecare and patients.
We don't have any of the five.
Now.
Most other countries have manyof the five.
(28:01):
They have coverage, they havereasonable costs on it you know
12 percent of GDP going tohealth care.
They have more consistent, highquality and people actually
like their system, even theBritish, you know we always say
well, they've got to wait, andit's dirty hospitals and all of
this.
Well, it turns out you poll theBritish.
(28:21):
They're way proud of theirnational health service.
They may moan about variousparts, but we can't achieve, and
we have no path for achieving,those five.
You know what we're looking atis our health care spend to go
above 20 percent of GDP.
We're now at five trilliondollars on health care.
You know we and we're gettingfurther and further away from
(28:46):
universal comfort.
So the question is why is thatand is there a solution to that?
Dr. Michael Koren (28:56):
Well, definitely have to bring you
back to dig into those reallyimportant questions in a much
more detailed manner.
Dr. Ezekiel Emanuel (28:59):
I have absolutely no doubt.
Yeah.
Announcer (29:02):
To continue watching this podcast episode.
Head over to MedEvidence.
com.
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts hosted bycardiologist and top medical
researcher, Dr.
Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence, and I
have a really super fun tasktoday to introduce my friend,
long-standing colleague and anincredible doctor, Ezekiel
Emanuel.
Zeke Thanks for being part ofthe MedEvidence family now.
And Zeke has had an absolutelystoried career in medicine that
(00:34):
goes way back to when we were inmedical school together.
I'm going to tell you ananecdote in a second about that,
but Zeke is the chair ofbioethics and health policy at
the University of Pennsylvania.
He's been advisor to the WhiteHouse, to the WHO, and he's
widely considered as a truethought leader in the areas of
bioethics and also in publicpolicy.
(00:55):
So again, Zeke, welcome toMedEvidence and I'm really
looking forward to ourconversation.
Dr. Ezekiel Emanuel (00:59):
It's great to be here.
Thanks for inviting me.
Dr. Michael Koren (01:02):
All right.
So I'm going to start off onthis anecdote that I just shared
with you, to remind you,because I think it's really
wonderful.
So Zeke and I were actually inthe same medical school class at
Harvard and we both chose thecurriculum that involved a more
rigorous scientific part ofmedicine that was run through
MIT, and so there's probablyabout 25 of us in that program,
(01:24):
something like that.
So I was late to go to schoolbecause of a family emergency
and I show up to one of thefirst sessions where we're
getting oriented to the othermembers of the class.
I don't really know who anybodywas at that point and there was
a professor that was goingaround trying to predict what
our specialty would be,literally as first week medical
students.
And again, this is what theprofessors did for fun.
(01:46):
I guess they wanted to see ifyou had the personality of a
pediatrician or an obstetricianor a surgeon or somebody in a
non-patient care specialty likeradiology.
So they went through the wholegroup and people raising their
hand yeah, I want to be asurgeon, I think I want to be a
pediatrician, I want to do OBGYN.
But Zeke didn't raise his hand.
So eventually the professorcomes over to Zeke.
(02:07):
He says I noticed, Zeke, youhaven't raised your hand.
Do you know what you want to be?
And he says I want to be amedical bioethicist.
And the whole class smiled andI didn't know him.
This was literally the firsttime I heard anything come out
of Zeke's mouth, but it soimpressed me that you knew
exactly what you wanted to do.
And it also fascinated mebecause I had no idea what a
(02:28):
medical bioethicist is.
And in fact you did exactlywhat you said you were going to
do, which is so impressive andreally part of our mission here
at MedEvidence is to helpphysicians understand career
paths and how people get tocertain places.
And, given your great success,I think the audience will be
super interested in usunderstanding how you went from
that statement in the first weekof our medical school class to
(02:51):
where you are now as a chairmanof a major department at a great
academic medical center.
So tell us the story, Zeke.
I'm super fascinated.
Dr. Ezekiel Emanuel (03:00):
Well, I did .
I was an undergraduate atAmherst College.
Dr. Michael Koren (03:06):
Great school.
Dr. Ezekiel Emanuel (03:07):
Double majored in chemistry and
philosophy and very interestedat that time in ethics and
political philosophy, and I wasalso, you know, pre-med.
But I really didn't want to goto med school.
On the other hand, as I like tosay, being a doctor was sort of
overdetermined.
(03:28):
My father's an immigrant.
My father was a pediatrician.
I was the eldest of animmigrant pediatrician and I was
very good at science and it'slike there's no alternative.
You got you know he was pushingmedicine, but I was very
(03:50):
hesitant.
I had worked a few summers inlabs.
I found the science interesting, but I didn't find spending my
time in the lab interesting.
So I applied to med school butI went to England to work in a
lab there for a couple of yearsto see if I really liked it, and
it was actually pretty good.
(04:10):
I did molecular immunology.
I got three papers, includingone in nature, done we
identified antibody complementinteraction sites but it really
wasn't exciting to me.
I didn't really like being inthe lab.
Um, and you know, this sort ofethics thing, uh was a pulling.
(04:34):
I came back to med schoolbecause I didn't have an
alternative plan, um, and thepart of the story that is
relevant is that at the end ofour first year of medical school
.
I hated medical school.
I liked my peers, but HSTbecause it was a small group of
(04:56):
people was actually great.
Dr. Michael Koren (05:00):
That's the MIT-Harvard combination
Dr. Ezekiel Emanuel (05:03):
Health, science and technology program
Right.
Dr. Michael Koren (05:05):
Just for the audience.
Yes, yep, go ahead.
Dr. Ezekiel Emanuel (05:07):
I, instead of doing the usual I think
everyone went to a lab to workfor the summer.
I went to Washington to internat a political newspaper, a
political magazine there calledthe New Republic, which was in
it.
That was one of its heydays ofabout 20 year stretch of great
(05:28):
reporting and stuff.
I spent the summer doing thatand I realized two things First,
there are plenty of people whowere way better writers than I
was I wasn't that great a writerand second, I didn't want to
report on what was happening.
I wanted to do what washappening.
So I came back again for thesecond year because I didn't
(05:49):
have a plan B.
I didn't, you know.
It wasn't clear to me what todo.
Alternatively, how to actuallyget this.
Medical ethics thing
Dr. Michael Koren (05:56):
And it really wasn't a terrible gig to be
going to Harvard Medical School.
Let's face it, but go ahead.
Dr. Ezekiel Emanuel (06:00):
For sure, for sure.
But so during that year someonesuggested actually one of my
brother youngest brother'scolleagues was going to Harvard
College and suggested that Ibecome a tutor at Harvard, and
(06:27):
so I don't know if you remember,but they had us explore
teaching opportunity or notteaching.
They had us explore differentlabs to see where people would
end up in the lab.
So we had an afternoon a weekoff and I'm like, well, maybe I
could teach an afternoon a weekat Harvard College instead of
being in a lab.
And that's what I did and Itaught a Harvard major called
social studies where you readeveryone from basically
Thucydides and Plato andAristotle to Freud and Durkheim,
(06:47):
and it was great, I loved itand I said you know this
teaching.
I really liked that.
So after our third year ofmedical school, I took off.
I got accepted to the Harvardpolitical science Department,
called the Gov Department, for aPhD, and I basically stopped
medical school and, you know,did the PhD.
(07:11):
The thing about it at Harvardwas that you only needed 15
months of clinical rotations tograduate and I had had the 15
months summer and by the time Istarted the PhD I basically
could have graduated.
But of course you can't becauseyou have to go into internship.
And then I did the PhD in fouryears and then I went back as an
(07:36):
intern and this may surpriseyou, because I'd sort of been
off the wards and forgotten alot of stuff.
While I was working on medicalethics related dissertation, I
asked to start in the CCU andevery time people who aren't
(07:58):
doctors think, well, that'scrazy.
You know, those are the sickestpatients in the hospital and I
said yeah, and they wouldn't leta fresh intern touch them.
Dr. Michael Koren (08:07):
That's right,
Dr. Ezekiel Emanuel (08:07):
they have experienced nurses, they have a
cardiology fellow.
I'd be there and I could learn.
I could remember how to take ahistory.
I could remember how to writethe order and after two weeks
I'd be up to speed which isexactly what happened and it was
, you know.
It was very good learning and Imet some of our classmates who
(08:29):
by that time were fellowsbecause I had taken off for a
PhD.
Harlan Krumholz, for example,was a cardiology fellow on the
service and I short trackbecause I was impatient and
after two years I went andbecame a Farber fellow at the
Dana Farber Cancer Institute anddid oncology.
(08:51):
And I chose oncology for threeor four reasons.
One coolest science going on incancer.
In the late 80s, early 90s, wewere really at the cutting edge.
Every patient had end-of-lifeissue crisis.
(09:12):
That was part of my research.
I was heavily focused onimproving end-of-life care.
And last, there was this wholeissue of allocation of resources
.
We were even back then, 25 yearsago 35 years ago, I mean
spending a fortune on cancer.
We had bone marrow transplantsat 100,000 a crack at that time
(09:34):
where we thought it wasoutrageously expensive, and so
it had all of these ethicalelements and there wasn't anyone
who was really systematicallydealing with them and they all
interested me.
So I chose oncology and theFarber was a fabulous place for
someone like me because everyoneknew that there were big
(09:59):
ethical dilemmas but they didn'thave anyone who was going to
address them.
So I started something calledthe Ethics Grand Rounds and
every month we had a big ethicscase that presented and we
brought in an expert andeveryone showed up.
Unlike the other Grand Rounds,everyone found these interesting
, personal.
Yeah, we had ones about doingthings on clinical trials the
(10:21):
ethics of phase one oncologytrial, and then the Journal of
Clinical Oncology, which is theprofessional journal of the
American Society of ClinicalOncology, began running these
articles.
So I got a lot of academiccredibility there and I think it
(10:42):
convinced people that ethicsand end-of of life care and
informed consent and thinkingabout research ethics and was
part of what they should bedoing.
And they just happened to haveme, so it was-
Dr. Michael Koren (10:55):
-f ascinating , yeah, so fascinating.
You really were a pioneer inthat space, quite frankly.
Dr. Ezekiel Emanuel (11:00):
Well, I, I was.
Uh, it is the case that, um,the history of bioethics is such
that it sort of took off in theUnited States in 1970, '71.
But a lot of the people whowere doing it were not
well-trained.
They were psychiatrists whowere doing it because of
whatever, or they were retiredsurgeons who, after retirement,
(11:25):
decided this was an interesting,important topic even though
they had no training.
So a lot of the early stuff wasnot particularly good.
At the end of the 70s there wasa Jimmy Carter appointed a
presidential commission onbioethics to look at a lot of
things like gene therapies andstuff, and it got a little more
professionalized.
(11:45):
But there still weren't peoplethat were.
There were only a handful ofpeople who were both physicians
and interested in this, who hadsome training and that were just
sort of talking based upontheir intuition and guts but
actually understood somethingabout ethical reasoning, and so
(12:06):
that's the area that was luckythat I had this overlap and I
was one of the few people whoboth you know, frontline
clinical back with oncology aswell as and I understood a lot
of the science and research aswell as highly trained in ethics
and political philosophy.
(12:27):
It gave me a kind of uniqueposition and it was a I would
say again, a time when theprofession did open up and did
say you know, this is core ofwhat we've got to be doing.
And so I was in that uniquemoment and it emphasized for me,
(12:51):
you know, a lot of careersuccess is luck.
Are you at the right place atthe right time and take
advantage of that luck.
And I did happen to be at theright place.
Dr. Michael Koren (13:01):
Yeah, tremendous.
So, as a quick summary, youmade your parents proud.
They can say my son theoncologist and you are a true
pioneer in a kind of a new partof science.
The Belmont Report that we'lltalk about came out in 1979.
Dr. Ezekiel Emanuel (13:17):
Yeah, I was part of that
So literally.
you know, within about a decadeof that we were starting to
understand how that applied toactual clinical practice and
getting people involved inclinical research.
And there were very, very fewpeople, as you point out, that
had knowledge both on theclinical side and the bioethics
side and know how to navigatethose tensions which are
actually super interesting.
So I'm not surprised you hadgreat attendance to the
(13:37):
bioethics grand rounds.
I'm sure there was somefascinating cases discussed.
So kind of give me the littlebit of the scoop from going from
training to ending up at Pennand ending up at the White House
.
That's kind of an interestingtransition.
Well, I was at the Farber for seven years
and then trying to figure outwhat the next job was.
Dr. Michael Koren (14:02):
So you were an attending physician there for
a while, treating cancerpatients.
Dr. Ezekiel Emanuel (14:06):
I would put that in quotes.
Yes, I was a classic academicphysician half a day, a week of
clinic.
Dr. Michael Koren (14:12):
Oh, wow, ok, All right, that counts.
Dr. Ezekiel Emanuel (14:14):
Most of my time was spent doing research.
I had a teeny, teeny tinyresearch group.
The biggest it ever got to wastwo people,
Dr. Michael Koren (14:24):
All right
In addition to me, and we wereincredible.
I mean, you know it.
Just let me say
yeah, Watson and Crick were a two-person team
.
Dr. Ezekiel Emanuel (14:33):
I had two research assistants and you know
we were focused on this sort ofmedical ethics issues, mainly
end-of-life care, but we alsofocused heavily on
physician-patient relationship.
We wrote a very important paperon how to understand the
(14:54):
physician-patient relationshipand I should say an interesting
thing happened to me at theFarber.
All of you who've worked inacademic centers know that the
coin of the realm is space.
There's never enough space andbecause of what I was doing, um
(15:15):
uh, after my second year, youknow, I needed to get a space of
my own.
Um, the head of my department,which happened to be the
epidemiology department, um uhtook me on a walk, says well,
Zeke, you know we're gonna findyou new space.
And he took me out of the mainbuilding at the farber to walk
(15:36):
across the parking lot and thenthere was this little building
in the shadow of a power plant.
It turned out that that littlebuilding housed all the unused
um iron lungs.
Dr. Michael Koren (15:50):
Oh geez .
Dr. Ezekiel Emanuel (15:50):
From Polio, from the 50s and he said you
know, there's this second floorsuite in the back there and you
know you can have four rooms.
And I realized this is theplace where they put all the
people who they're not actuallyfiring but want people to leave.
It turned out, you know, Ithought you know, basically this
(16:12):
is Siberia.
It turned out to be a blessingin disguise.
Sometimes Siberia can be coldand unproductive and a vast
wasteland.
But for me, I was out of theflow, out of the politics, out
of everyone.
You know, spending time,wasting time talking about this
and that and who was up, who wasdown, and I simply focused on
(16:35):
my work and it.
We turned out to have twopeople and me and we were
incredibly productive, um, justbanging out the papers, and
(16:55):
then in 1996, I believe '95 um,a job came up to.
Uh, they were looking for ahead of bioethics at the NIH,
not just the head.
They, the guy who was head ofthe clinical center, which is
the hospital at the at the NIH,was establishing a department
and he thought well, we neededyou know, the hospital needed to
have a bioethics department.
So I applied and, um, the twoother candidates were much more
(17:17):
senior than I.
I was, I think, uh, whopping,uh, uh, 38 years old or
something, um, and I didn't doany research ethics.
You know, since the hospital atthe NIH is purely research,
there's no routine patient carethere, and I had not done any
(17:42):
publications in the researchspace.
Uh, in immune, uh, deficiency,uh, diseases, um, chronic
granulomatosis, um, for whateverreason, we hit it off.
He went to Amherst.
I went to Amherst, we had avery nice meeting of
personalities and he gave me thejob, um, and you know it was a
(18:08):
wonderful opportunity to buildsomething from the ground up, uh
, and to, you know, invitepeople.
And it got me also interestedin research ethics.
At that time this is 1996, 97.
I was like, well, you know, allof that research ethics done.
We had the Belmont report, wehad the declaration of Helsinki,
(18:29):
we have federal regulationswhat more could there be to do?
And I scratched the surface.
I began reading these documentsand realized, you know, there's
a lot more to do.
These aren't.
They're heavily focused on onething autonomy and informed
consent.
But there's also much moreabout the ethics of research
(18:52):
that they're not addressing atall.
And, by the way, a lot of theliterature that had been
published, I thought, was againgiven my unique position as a
doctor, a researcher and abioethicist.
It's like I think they've gotit wrong and we could do a
better job, of sort of fixing itand putting it right.
(19:16):
And so it turned out to be awonderful, wonderful moment to
create a department and toreally I think we ended up
transforming how people thinkabout the ethics of clinical
research.
Dr. Michael Koren (19:32):
One super cool and absolutely spot on is
that there's been a huge changein the way we perceive ethics.
That we'll get into more detailin a moment, but that's just
wonderful story.
So tell me about the politicalpart of your career, how that
came aboard, and you're wellknown for those contributions,
(19:53):
so why don't?
You tell us a little bit moreabout that.
Dr. Ezekiel Emanuel (19:56):
So I worked at the NIH from 97.
And then, beginning around 2003, 2004, I could see I'd done
almost everything I wanted to doin the research ethics space.
Again, it was an incrediblygenerative from a productivity
standpoint, one of the bestexperiences you could imagine.
(20:19):
We had a fellowship, we hadpeople coming right out of
college, we had postdocs.
They were all brilliant, theywere great to work with.
But I could see that I was sortof getting to the end of all the
research ethics things I wantedto really write about.
Not like I covered everything,but that I wanted to write about
(20:40):
.
And I was like the thing that'ssort of uh, agitating me is
going back to my politicalphilosophy.
My government polsci roots was,you know, we don't have
universal coverage and we needto begin thinking about it and
lay the plans for it.
So I ended up writing somestuff and teaming up with one of
(21:03):
the uh I like to call them theuh uh three original health
economists in the country a guynamed Victor Fuchs who was a
professor at Stanford.
He had just retired and youknow we had talked about
collaborating and some of ourideas overlap and again, that
(21:25):
turned out to be incrediblygenerative.
So in '03, '04, '05, we beganreally publishing a lot.
Romney, uh, uh, Mitt Romney wasgovernor of Massachusetts and
and, uh, put in his Romney care,uh, a legislation that created
a way for people to getinsurance who didn't have
insurance and subsidize them.
(21:45):
And then, you know, presidentObama was his stuff and I was
again writing on this andtalking about it.
And when Obama was elected, heappointed Peter Orszag as head
of the Office of Management andBudget.
And Peter Orszag asked if Iwould come and work there as a
(22:09):
special assistant working on theAffordable Care Act.
And what was important aboutthat is because I was at the NIH
, I was a government employee, Icould go there and it wouldn't
cost the White House a penny,which is always and one of the
things you.
Let me just say two things youlearn very quickly.
First, the Office of Managementand Budget is the most powerful
(22:31):
agency you never heard of.
Actually, it controls all thebudgets, it controls all the
regulations.
It's really a magical place tobe.
The second thing is that thereare never enough people in the
White House to handle all theincoming, and so I always tell
(22:53):
students, if they ask you tocome and sweep the floors at the
White House, you say absolutelyI will do it because peas are
falling off issues.
You can do so much.
It doesn't get to thepresidential level, doesn't even
get to the chief of staff level, doesn't get to the National
Economic Council level.
There's things you can do.
(23:13):
So just give you one example Igot there and part of what Obama
was talking about was we got toreduce regulation.
So I said to Peter Orszag I saidyou know, there's a lot of
regulation around clinicalresearch that is not helping and
just creating a lot ofpaperwork that we could
streamline.
So he said he ran it up theflagpole.
(23:34):
He said okay, you can puttogether a group.
So I could put together a groupfrom HHS.
There's, for a variety ofreasons, labor and the feds
department involvement and weput together a group and within
six months we had a draft of thefirst ever revision of the
regulations of human subjectsresearch and it didn't get
(23:59):
passed till January 2017,literally as president Obama was
leaving the office.
But that's because I left andthey didn't have someone driving
it and it was being held up bysome people at the NIH,
ironically enough, but that'sthe kind of thing you can do at
the White House, and I alsohappened to work on the First
(24:22):
Lady Michelle Obama's let's Moveinitiative, the food, redoing
the food pyramid to make it afood plate.
So lots of possibilities, butthe main thing I was there for
was to work on the AffordableCare Act and that was a
thrilling, wonderful opportunity.
And I like to say, you know, 22, 25 million people got health
(24:46):
insurance.
If I was one of a thousandpeople working on that, you know
, okay, I take, you know, 0.1%of 25 million people.
There's 25,000 people.
I helped 25,000 people.
You can't do that every day ofyour life,
Dr. Michael Koren (25:00):
Yeah.
Dr. Ezekiel Emanuel (25:00):
And every year of your life.
It's a pretty lucky opportunity.
Dr. Michael Koren (25:05):
Well, thank you for those efforts, not
always widely appreciated, butcertainly people in the know do
appreciate them.
So thank you.
So tell us a little bit aboutfrom this incredible experience
obviously became well knownthrough your work on the
Affordable Care Act and thenending up at Penn and in your
current position and you tell usa little bit about what you do
day to day now.
Dr. Ezekiel Emanuel (25:26):
Well, at Penn I had again the same
wonderful opportunity to be atthe right place at the right
time.
They were creating, they had acenter for bioethics with Arthur
Kaplan headed, but they wantedto change it to make it a
department and merge it withhealth policy.
So there were PhDs and they hada lot of PhD health policy
(25:49):
people working in clinicaldepartments like primary care,
and it didn't make any sense.
So they wanted to merge or havethe bioethicists and the health
policy people in one departmentand make, you know, give it,
unlike a center that has noability to appoint or hire
faculty, it would haveappointment power.
(26:10):
And again, there you.
And again there were no peoplein the department.
So I came and started adepartment, which was again a
wonderful opportunity.
I think I was selected becauseI'm one of the few people again
who was both a bioethicist andhad expertise in health policy
Not everyone who whose bioethicscan do health policy and few
(26:33):
people who do health policy dobioethics.
So I actually was one of thefew people who had a leg in both
sides.
I had a great opportunity toattract two absolutely
outstanding people to head eachdivision Steve Jaffe, I
recruited from Boston Children'sHospital, and Dana Farber,
who's an oncologist and expertin bioethics, part.
(26:56):
And Kevin Volpe, who peopleknow because of his great work
on the role of behavioraleconomics and healthcare and
using incentives in the rightway to head the health policy
side.
I mostly do what I've alwaysdone, which is mostly uh, um,
research and it's what up in themorning, writing papers.
(27:19):
I'm at the moment, um, I've gotuh, uh, two books in the air.
One's going to be published inJanuary and I'm working, spent
the morning here working onchapter six of the next book,
which is the one really about.
I'd like to say why Americacan't achieve any one of the
(27:41):
goals of healthcare.
We can't get the universalcoverage at reasonable costs,
with consistent, high quality,reducing, if not eliminating
disparities and having highsatisfaction for both the
physicians and clinicians in thecare and patients.
We don't have any of the five.
Now.
Most other countries have manyof the five.
(28:01):
They have coverage, they havereasonable costs on it you know
12 percent of GDP going tohealth care.
They have more consistent, highquality and people actually
like their system, even theBritish, you know we always say
well, they've got to wait, andit's dirty hospitals and all of
this.
Well, it turns out you poll theBritish.
(28:21):
They're way proud of theirnational health service.
They may moan about variousparts, but we can't achieve, and
we have no path for achieving,those five.
You know what we're looking atis our health care spend to go
above 20 percent of GDP.
We're now at five trilliondollars on health care.
You know we and we're gettingfurther and further away from
(28:46):
universal comfort.
So the question is why is thatand is there a solution to that?
Dr. Michael Koren (28:56):
Well, definitely have to bring you
back to dig into those reallyimportant questions in a much
more detailed manner.
Dr. Ezekiel Emanuel (28:59):
I have absolutely no doubt.
Yeah.
Announcer (29:02):
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