Q&A with Ezekiel “Zeke” Emanuel

“Are you interviewing me?” Ezekiel “Zeke” Emanuel bellows in his broad Chicago accent from the doorway of his office in College Hall.

Ezekiel “Zeke” Emanuel

Candace diCarlo

The commanding cadence of his voice, the way he whisks by, indicates that he’s a man on the move, with scarce seconds to spare.

Emanuel joined the Penn community in September as the University’s 13th Penn Integrates Knowledge Professor, the Diane v.S. Levy and Robert M. Levy University Professor, and the vice provost for global initiatives. Since then, he’s been as busy as the Schuylkill Expressway at rush hour.  

Trained as a medical doctor, Emanuel also serves as the inaugural chair of the Department of Medical Ethics and Health Policy in the Perelman School of Medicine. His appointment is shared between the Perelman School of Medicine and the Department of Health Care Management in the Wharton School.

Furthermore, he teaches a health policy course called “The Future of the American Health Care System: Health Policy and the Affordable Care Act.”

“As I like to say, I’m the eldest son of a doctor who had recently immigrated to the United States, so my being a doctor was over-determined,” Emanuel says. “And I was good at science, which my brothers were not.”

Emanuel is the oldest of three phenomenally successful brothers. Rahm, the middle brother, is the current mayor of Chicago and former chief of staff to President Barack Obama. Youngest brother Ari is the co-CEO and director of William Morris Endeavor Entertainment.

When Penn President Amy Gutmann announced Emanuel’s appointment, she remarked that Penn “is tremendously fortunate to have attracted to our faculty one of the most insightful and well-respected bioethicists of our time.”

“[Zeke Emanuel] has time and again demonstrated the vital importance of putting the broadest and deepest understandings to work in service of others,” she said. “I am delighted that he will join the ranks of our esteemed Penn Integrates Knowledge University Professors.”

In between an important meeting and an overseas phone call to China, Emanuel took the time to talk with the Current about his life, Penn, ethics, and why he doesn’t own a television.

Q. How are you enjoying Penn so far?
A. It’s great. It’s got a lot of the things I came for, which is a very collegial, very supportive environment that is striving to be the best. I love the fact that all the schools are on the same campus and I can actually go from the Medical School, to the College, to Wharton, to the Law School, to Nursing in five minutes. That really just makes a world of collaborations possible. And I love the fact that I have students from all those different schools in my class.

Q. I’m sure you could have had your choice of universities…
A. Yes, I had a few choices.

Q. What was it that attracted you to Penn?
A. It’s definitely the collaborative environment. One aspect, just as a matter of personality, is I realized I really couldn’t be on the West Coast, I had to be on the East Coast. I’m an East Coast kind of guy. Too much sun and good weather are probably not conducive to my being productive. Second is through the Penn Integrates Knowledge Professorships, Penn is more committed to integrating across the schools and within the schools. That’s not to say such collaboration doesn’t have its challenges, but Penn is definitely much more interested in fostering cross-school collaboration. I did talk to other schools; collaboration was going to be much more difficult. At one of the other Ivies that I talked to, all the people in health policy had never actually sat down in the same room together. Ever. That’s crazy. At Penn, I didn’t have to start that far behind the eight ball.
There are some challenges to working across schools. There are silos. There are issues of how projects are funded that I think can make it challenging to work across schools and to get some projects going. On the other hand, what I do find at Penn, which I think is really wonderful, is people want to work on those barriers and solve the problems. Being willing and open to looking at things anew I think is very much something that’s very attractive about Penn.

Q. You received your Ph.D. in political philosophy. Were you interested in politics in your younger days?
A. It was mostly ethics. As an undergraduate, I actually had completed all the requirements for a philosophy major, including the oral exam, except I didn’t take logic. I refused to take logic. I’ve had a longstanding interest, actually, in ethics and political philosophy, not politics per se. I leave politics to my brother; I stick to the high ground of political philosophy.

Q. Why did you refuse to take logic?
A. It was boring, as far as I was concerned.

Q. You earned your Ph.D. while you were also enrolled at Harvard Medical School?
A. I finished all the requirements for medical school in three years, and then basically stopped medical school and went across the Charles River to do the Ph.D. in Cambridge. I was not a big fan of my medical school experience.

Q. What didn’t you like about it?
A. First, I found it required way too much memorization. Second, I found it too hierarchical; whatever the senior doctor said went, rather than being open to the exchange of a lot of ideas. That sort of hierarchy didn’t go along with my personality.
I also saw a lot of practices at that time mainly related to end-of-life care that weren’t going so well and I thought that given my interest in ethics and given my training in medicine, I had clear, distinctive skills to address those issues.

Q. You were previously on the faculty at the Dana-Farber Cancer Institute. How did you become interested in cancer care?
A. Cancer care has all the interesting issues. If you are a bioethicist, all the issues are present in cancer care, whether it’s end-of-life care, informed consent, or what to do about high-cost treatment. Second, if you are interested in science, cancer care has been at the cutting-edge of gene research, defining what genes cause cancer, and personalized medicine, so it’s cutting-edge from a scientific standpoint. And last, if you’re interested in physician-patient interactions, your patients have a serious illness. They come to see you every other week or every four weeks, you get to know them very, very well, very intensely. It’s not like being a primary care physician and seeing your patients once a year for a routine annual physical. As a cancer doctor, you get to know your patients intimately; you get to know their families very intensely. Every aspect, whether it’s having meaningful clinical relationships with patients, scientific research, bioethics—cancer is the best medical field to be in.

If you are a bioethicist, all the issues are present in cancer care, whether it’s end-of-life care, informed consent, or what to do about high-cost treatment."

Q. You and your brothers sat down with Charlie Rose in June of 2008. During the interview, you mentioned that when you were younger, you used to tag along with your father while he made his rounds on the weekend. Did that have any influence on you becoming a medical doctor?
A. I don’t know that it had an influence on me becoming a doctor. I certainly got a sense of how my father practiced medicine. I would say at least this: We weren’t afraid of the hospital or afraid of sick patients. And I could see how much good a person could do by being a doctor. So I guess in those senses, it had an influence.

Q. And your mother was heavily involved in the Civil Rights Movement?
A. Very, very, very actively involved in civil rights. Growing up in the ‘60s, we were probably the only white family—certainly the only white family we knew—that had a lot of African-American friends. We had a helper in the house whose family we were very friendly with, and we would go to her West Side Chicago apartment once a month. We hung out on the West Side when no whites hung out on the West Side. We had a very close [African-American] family friend that my mom knew as a child, and they were active together in the Civil Rights Movement. Her two sons were very close friends.
Plus my brothers, especially Rahm, would get extremely dark in the summers from suntans and were very frequently confused with being African American, so we used to get a lot of racism directed at us. We certainly experienced that as young kids in the ‘60s. We were in a very different place than most whites growing up.

Q. Am I correct that your mother made you wear black armbands to school after the Rev. Martin Luther King, Jr. was assassinated?
A. I don’t know that she so much made us, as we just wore the armbands. She had gone to the March on Washington in 1963, and then she remained heavily involved in civil rights.

Q. Were you and your brothers competitive with each other when you were younger?
A. We had this funny situation where all of us were competitive with each other inside the house, and outside the house we were all pretty unified. I think that actually remains true today. My brothers can scream at me and I can scream at them, yet we can also dare anyone on the outside to try to put a wedge between us. It’s not a very good thing for them to attempt.

Q. Do you still compete? All of you are very successful.
A. I think it’s not a coincidence that we’re all in very different professional fields. We need a lot of room between us. Neither Rahm nor I are going to compete with Ari in media, TV, business deals. No one’s going to compete with Rahm in political success. They don’t try to compete with me in academic success. As a matter of fact, when their kids need help writing speeches, or science projects, or math problems, I get the call.

I think it’s not a coincidence that [my brothers and I are] all in very different professional fields. We need a lot of room between us."

Q. You and your brothers used to spend the summers in Israel in the late 1960s and early 1970s. What impact did those trips have on you?
A. We have a lot of identification with Israel from that period. It was very formative in making us the kind of people we are, but those summers also allowed us to forge a very strong bond between us because, as three American kids in Israel, we hung out together. We were each other’s playmates. It’s not like we went off to camp and were in different age groups. We spent a lot, a lot, a lot of time together, mostly lazing on a beach and swimming and surfing and bodysurfing.

Q. Your first trip to Israel was in June of 1967, right after the Six-Day War. How was the visit?
A. It was very funny because we were going to a place where there were terrorist attacks all the time. We get to Israel and it feels much safer than the streets of Chicago. The chance of being mugged in Israel was zero. A random bomb? Yes, a higher chance in Israel than in Chicago. But that’s probably not what’s really dangerous. The really dangerous stuff is are you going to be mugged or attacked? The chances of that were way higher in Chicago. If there was a real threat of injury in Israel, it was probably from driving in cars. The Israelis were lunatic drivers, much more lunatic than today. They were classic Third-World drivers. Traffic lights were merely suggestions.
All these adults were nervous as hell about our going to Israel, but from our standpoint it was wonderful. We could walk to the beach, we could walk all around Tel Aviv unsupervised. It was a very small country at that time, 2 million people. Everyone knew everyone else. It was very hard to go awry without someone noticing. We had, in some funny sense, much more freedom in Israel, even though a lot of our friends in the U.S. thought my parents were nuts to send us.

Q. You served on President Clinton’s Health Care Task Force in 1993 and as special advisor for health policy to President Obama from January 2009 to January 2011. You were involved in two contentious healthcare battles, one unsuccessful and one successful. Why do you think healthcare is such a divisive issue?
A. A huge amount of money, about 17 percent of the GDP, ergo lots of interest groups. It touches everyone. You have a very big ideological divide about the free market versus government interaction, and it’s incredibly complex. On the one hand, any little change is very big, and on the other hand, there aren’t that many people who really understand the system in detail. The large number of interest groups, the ideological issues, the complexity of it all,  make it hard.

Q. Do you think President Obama should have used so much political capital on healthcare reform?
A. I’m not the political brother---ask Rahm that question. But let me just say the following: Healthcare reform is a world historical event. We’ve been trying to get a universal system in this country for a hundred years, since 1912. It finally got enacted in March 2010. That is the first thing.
The second thing is, it is necessary. Now I know a lot of people will think healthcare reform was necessary because it extended access to uninsured Americans. That’s absolutely important. But reform is also necessary because it’s going to dramatically improve the quality of healthcare in America. It will lower costs and restructure the system in a way that is not going to add to the debt of this country. As a matter of fact, it will give us a better handle on getting our arms around the debt. So from almost any perspective, it’s a step in the positive direction.
Is it perfect? No bill that comes out of Congress is perfect. Is it a very good advance? Absolutely. Are there things we could have done to make it better? Absolutely. But you have to ask yourself also, ‘What was the alternative?’ It’s not like the Republicans had a coherent alternative, and the system was and remains deeply flawed, if not broken, and you had to do something to reform it. So I don’t think there’s any alternative.
And when we make major social change in America, whether it’s Social Security or civil rights, there is always going to be controversy. In a huge country like the United  States, these major social changes don’t go smoothly. It’s a big country with lots of diverse people and philosophies. That doesn’t mean you don’t try to make big changes. One of the things I learned about working with President Obama is that when he makes up his mind, you’re not going to move him. He doesn’t make up his mind fast, but when he makes up his mind, it’s really hard to get him to move off because he’s really thought about it in detail and he knows himself.

Q. Do you think the government has a responsiblity to provide healthcare for its citizens?
A. It has a responsibility to ensure that Americans can get the healthcare they need, which is short of unlimited healthcare, in my view. That’s a very different thing than socialized medicine or a government takeover of healthcare. Most of the American healthcare system is a private healthcare system. It’s funded in a variety of different ways, some governmental, some private.

Q. You developed The Medical Directive, a comprehensive living will that allows people to record their wishes regarding their medical treatment in various scenarios if they become too ill to think clearly. What were your motivations for creating the living will?
A. I had done a lot of work on end-of-life care in the mid to late 1980s, and clearly one of the problems was that the living will documents that we had—while there was a big movement to get people to sign them—were quite poor, and so we thought we could do better. We did, in fact, do better in many ways. The basic structure of our document has been copied by a lot of other people.
We tried to make it, among other things, comprehensive, but also to give people a chance to see, through scenarios, the various different, most common situations that they might confront. We also thought of the document more as a jumping-off point for discussions with family members, with doctors, and caregivers.

Q. You mentioned that you have had a longstanding interest in ethics. Do you think ethics is something you can teach?
A. You’re certainly not born with it. We may be born with some brain structures that enhance ethical thinking, and we clearly need to have ethics because it’s about the principles that regulate human interaction with other human beings, with animals, and the environment. But clearly we have issues where it’s not obvious what the right answer is, and we need to study and give reasons why one approach is better than another. That’s what I take our role as bioethicists to be, and we need to see how practices vary. People have a lot of, you might say, intuitions or assumptions about what’s going on in many situations that turn out either to be true only sometimes, or to be false. I’ve certainly confronted a number of cases in my career where people are sure they know the right answer and it turns out that it’s probably not the right answer.
Early in my career, when we began working on end-of-life care, people were like, ‘Patients don’t want to talk about this.’ Well, really? Have we talked to patients? Let’s find out what they want to do. We were among the first people to show that, in fact, patients were very interested in talking about end-of-life care, very interested in filling out advanced directives, and that the medical system was not responding. In another part of my career, a very common view was that if you’re a terminally ill patient and you have extreme pain, you would naturally want euthanasia. Well, really? Why don’t we ask patients? So we asked patients and it turns out, no, terminally patients who are in pain are not interested in euthanasia. Their interest is to get rid of the pain. It was patients who were depressed or hopeless who were interested in euthanasia. That puts a very different color on thinking about legalizing euthanasia …
I think in a lot of ethical issues, people think they know the right answer and part of my job is to say, ‘Are we sure we know the right answer? Maybe we should think this through again in a little more detail.’

Q. Is it true that you don’t own a television?
A. I don’t own a TV. I don’t have Netflix. I don’t do Hulu. I think I’ve seen about four, maybe five YouTube videos in my life. I don’t drive a car anymore. I don’t own a car. And I don’t spend a lot of time surfing the Web.

Q. Can I ask why?
A. I find it a waste of time. I don’t find TV, videos, surfing the Web particularly interesting, or intellectually or otherwise stimulating.

The job here at Penn is fantastic. There are things I can do here that I can’t do [in Washington]."

Q. If President Obama is reelected, would you have any interest in returning to work for the administration?
A. [Laughs] There are things you can do in Washington that you can’t do any other way. It’s a huge privilege to be able to work for the country in the government and try to make things better for the country. I thoroughly enjoyed my time working in the White House. I thought I made a contribution. It was a great honor to be able to be called upon to do that. If I could be of help again, I’d be more than happy to serve, but there are lots and lots of other interesting jobs to do. The job here at Penn is fantastic. There are things I can do here that I can’t do [in Washington]. There are amazing opportunities as well as challenges. I like to find places where there are challenges and opportunities and work with them.
On the other hand, as I said, there are certain things you can do in government that you can’t do anywhere else. It gives you a different kind of platform. And whatever the pressures, the heat, the abuse that you get as a result, it’s worth it because you can do good there. But I’m loving it here at Penn and have no plans to move. 

Originally published on February 16, 2012