Zeke Emanuel ’79 outside his office in the Eisenhower Executive Office Building. View the entire photo shoot here.
By Sarah Auerbach '96
“I should eat,” says Zeke Emanuel ’79 to his assistant.
“Yes. You should eat,” she says.
He has just hurried in—Dr. Ezekiel Emanuel always hurries—from a presentation to a group of doctors about health care reform. I am waiting for him in the scrappy conference room adjacent to his office, where Emanuel works on health care policy for the Obama administration. Emanuel tosses his lunch, three slices of crusty raisin bread and a grilled chicken breast, down on the table. “I have to eat while we talk,” he says. He uses both hands, ripping off chunks of grilled chicken and folding them into the bread, shoving food into his mouth and talking through it, wiping his mouth with a paper napkin between bites. This is classic Emanuel: even when he’s in eat-for-fuel mode, the food is homemade, gourmet and an all-out experience.
The rush-rush, too, is classic Emanuel, though it’s also the result of the role he has found himself in. A prominent bioethicist on leave from the National Institutes of Health, Emanuel is senior counselor on health policy at the Office of Management and Budget, part of the Executive Office of the President of the United States, which means he spends an enormous amount of time meeting with doctors and others in the health care industry to try to hammer out a workable solution to the nation’s health care woes. Emanuel reports to Peter Orszag, director of the OMB, which is based in the Eisenhower Executive Office Building, mere steps away from the White House. In addition to his work on health care reform, Emanuel collaborates with others in the administration to write policies governing everything from stem cell research to the distribution of U.S. resources to improve global health. When swine flu made headlines, Emanuel helped craft the administration’s response.
Even before his appointment, Emanuel was pulled in many directions—or perhaps it’s more accurate to say he has never walked away from an idea he is passionate about. Jan Dizard, Charles Hamilton Houston Professor in American Culture at Amherst, once tried to rein in Emanuel’s tendency to scatter himself. “At the end of my junior year, I went to him for some career advice, and he was so pissed off at me for fapping about between philosophy and biology or science research or a career in medicine, he said, ‘Just get off the pot and do something!’
“That was just, like, the worst advice,” Emanuel says.
He disregarded it. He spent two years earning a master’s in biochemistry at Oxford; a slew of years at Harvard, during which he moved back and forth across the Charles River between the medical school, where he was working on his M.D., and the political science department, where he was a Ph.D. candidate in political philosophy; even a summer at the New Republic, toying with the possibility of a career in journalism. “I did everything but settle down and do a career,” Emanuel says.
But Dizard’s advice kept echoing, and Emanuel says that, ultimately, being forced to contemplate why it sat so badly with him helped him figure out what he really wanted to do.
Instead of choosing a single career, he has melded the ideas that are important to him, which is how he came to be a leading opponent of legalizing euthanasia and assisted suicide, to build the NIH Clinical Center’s bioethics program from scratch into arguably the world’s most productive department and to catch the attention of the new presidential administration, which viewed his embrace of multiple disciplines—and his many publications on the subject of health care and health care reform—as a strength in writing health policy.
Emanuel has brought birthday cake to work this morning, a chocolate concoction he baked for a fellow staffer. He grabs the cake and starts to head upstairs. His assistant says, “You might want to wait until she gets there to show up with the cake.”
“Women think of these things,” Emanuel says, pausing.
He goes to a meeting, comes back and throws himself into his seat. “This is an awful day,” he says. “It’s a no-pee day.” I offer him a chance to take a bathroom break, but he shrugs me off: “No. Let’s do this. What do you want to know?”
Emanuel’s curriculum vitae, printed out, exceeds 50 pages. It includes stints on President Clinton’s Health Care Task Force, positions on nearly 20 advisory boards and associations, more than 20 awards and honors and page after page of books, chapters and articles. He co-authored, with his ex-wife, Linda Emanuel, the Medical Directive, a comprehensive living will endorsed by the Harvard Health Letter, The Wall Street Journal and many others. And if anything, he’s gathering momentum. Last year, he authored Healthcare, Guaranteed: A Simple, Secure Solution for America, about which Newsweek said:
[This] may be the most exciting book yet to come out of the country’s medical crisis. What it offers is a radical yet straightforward proposal, one a layperson can understand. If the complexities of health-care policy give you a headache, this book is aspirin. Read it twice and call your congressman in the morning.
Emanuel is the object of media attention not only in his own right but also for his part in an unusual triumvirate: he is the eldest of three brothers, all of whom wield enormous power in their respective realms. His brother Rahm is Obama’s chief of staff, arguably the second-most-powerful man in Washington. His youngest brother, Ariel, is a dominant Hollywood agent and the inspiration for the character Ari Gold on the TV series Entourage. Much has been made of the brothers. In 1997, Elizabeth Bumiller wrote in the New York Times Magazine that, “Of the three brothers, Rahm is the most famous, Ari is the richest, and Zeke, over time, will probably be the most important.” Her prediction is open for debate; meanwhile, the brothers are recovering from their shock that Zeke is now often billed as “Rahm Emanuel’s brother,” since Rahm’s academic performance in high school—especially in comparison to Zeke’s—left much to be desired.
Zeke Emanuel '79 at work in the Eisenhower Executive Office Building. View the entire photo shoot here.
The brothers’ most famous media appearance was probably their roundtable on Charlie Rose last year, during which they tried to answer the Emanuel Question: how did one family produce three such high-powered characters? The brothers credit parenting. Their father, an Israeli pediatrician, and mother, an American Jewish civil rights activist, made sure the boys were culturally literate and intellectually prepared. The Emanuel dinner table was a war zone for ideas. Shared Emanuel traits also play a role. The brothers have been described and portrayed as brusque, arrogant, aggressive, hyperactive, combative and crude—and that’s a short list. Over time, they’ve worked to minimize those traits and develop what Ari calls “bedside manner.” “Zeke’s got an unbelievable bedside manner,” Ari says. “Rahm probably does have a better bedside manner now. I’m not sure that, if you did polling in California, mine would be the greatest.” (Ari ended our brief phone interview by saying, “Can I go make some money? Thanks, honey.”)
On Charlie Rose, Rahm was lukewarm about his older brother’s book on universal health care. Healthcare, Guaranteed lays out a system in which everyone in the country would get a health care voucher. You could use your voucher to buy medical benefits from any insurer, and you could buy additional benefits out of your own pocket. Employers would no longer pay for health care, so, in theory, they could raise wages. From your higher wages, you would support the system by paying a special, dedicated tax. A National Health Board, similar to the Federal Reserve Board, would oversee the system. Two other government bodies would resolve disputes between you and your doctor or insurer and decide which tests, drugs and procedures were worth the money.
“Rahm didn’t want to slam me on national TV,” Zeke says. “I think he has said in public, ‘Zeke may be right that his plan is the best plan, all things considered, but we may not be able to get there.’” Getting there is the tough part. When President Clinton undertook health care reform in the 1990s, his legislation hit political roadblocks and ultimately foundered. The national climate is now more favorable to reform, and Obama seems determined to take a different approach than the Clintons did. Many believe that Clinton’s plan failed because the administration delivered it as a fait accompli to Congress. Obama has left the legislation-writing to Congress. He has spent his time wooing Republicans, convincing hospitals and other health care organizations to cut costs and building grassroots support for his vision.
Obama’s vision is not the same as Emanuel’s, though the two men agree on much. As the Senate Health and Finance committees began unveiling their plans, Obama moved away from discussing the details of how his goals should be achieved and focused on the goals themselves: reducing health care costs, protecting families from bankruptcy, improving quality of care, insuring all Americans, guaranteeing the portability of health care and making sure that Americans with pre-existing conditions are not excluded from care. Still, certain threads from his campaign declarations seemed alive and well: Like Emanuel in Healthcare, Guaranteed, Obama opposes a single-payer plan (in which the government insures all Americans) and supports having private insurers. Unlike Emanuel, Obama wants the responsibility for health care benefits to remain in the hands of employers, who could be fined for failing to insure their workers. There has been no sign that Emanuel’s vouchers or a dedicated health care tax are on the administration’s radar screen, but the president’s vision leaves room for other Emanuel ideas. For example, Obama’s calls for improved quality could be achieved in part through the dispute-resolution boards that Emanuel proposed. Emanuel has at times voiced support for two other key elements of Obama’s vision: a public insurer to compete with and drive up the quality of private insurers and a National Insurance Exchange, a marketplace where public and private insurers compete.
Emanuel with Office of Management and Budget Director Peter Orszag (left) and Deputy Director Robert Nabors (right). View the entire photo shoot here.
What ultimately emerges from the Senate committees may have little in common with the ideas brought to the table by Emanuel and his colleagues, including Jeanne Lambrew ’89, director of the Department of Health and Human Services’ new Office of Health Reform. And there are still many obstacles to overcome: the OMB’s Orzsag criticized an initial draft from the Senate Health Committee for its outsized budget requirements, and many in Congress will line up to take shots at various aspects of the legislation. In July, the Congressional Budget Office objected to House and Senate plans, saying they failed to reduce government health care spending. It remains to be seen whether Obama will succeed where Clinton failed and how much the results will bear the imprint of Emanuel’s ideas.
Emanuel has already shepherded theory to political reality in other realms. During the spring outbreak of swine flu, he took part in high-level meetings in the Situation Room in the basement of the West Wing, advising the head of the Homeland Security Council and cabinet members on how to deal with the new threat. In doing so, he called on theory he had expounded in articles such as “Who Should Get Influenza Vaccine When Not All Can?” and “The Lessons of SARS.” The latter outlines four lessons learned during the 2003 outbreak of Severe Acute Respiratory Syndrome. One is that nations must cooperate to contain infectious diseases. “SARS is a forceful reminder that everyone has a personal health interest in what happens in other countries,” he wrote. The lesson appears to have been learned: well before swine flu made its appearance outside Mexico, governments were braced for its arrival.
Idealist or pragmatist, Emanuel has an easy smile and a ready laugh; his face is expressive. When he isn’t jiggling his leg and pressing his fingers together as if the energy in his wiry body is just a little too much for him, he’s tipping his chair back, throwing his arms out to the sides, swearing freely or perching one foot up on his chair like an odd sort of flamingo. As Ben Richardson, the son of family friends, says, “I have this completely ineffable desire to impress him. There’s something about him—whenever he’s around, I want my jokes to be met with the big Zeke laugh, and my observations and arguments to be met with the most enthusiastic interest or analysis.... It’s almost as if eliciting his most fervent intellectual engagement is like a drug.”
Emanuel acts as if he wants to bring you into his mighty circle. He’ll tell you that he has a tremendous disregard for all forms of hierarchy, that just because someone’s in charge doesn’t make that person right, that that’s why he had few friends in medical school. He demonstrates his irreverence when he meets with a collection of top executives from Merck & Co., the pharmaceutical giant. Emanuel hurries out of his interview with me and into the Merck meeting. A moment later he calls out to me, “Come meet this guy! This guy had me as an intern. This is one of the guys I always argued with—I argued with him about the use of aspirin after a coronary.” The Merck executive wears an expression that suggests low-level irritation; the meeting is behind schedule, and who knows what he thinks of having his opinions of aspirin freely advanced to the public. But to Emanuel, what his former boss thinks of aspirin isn’t information to be carefully managed—it’s just another interesting idea whose value can only grow when it is discussed, dissected and bounced playfully around.
The biggest of Emanuel’s big ideas relates to the “good death.” Emanuel is passionate in his belief that people should die according to their own wishes and without avoidable suffering. In articles such as “Death and Dignity: Dogma Disputed,” Emanuel articulates his views on the matter and calls on other researchers and doctors to define terms such as suffering and to find better ways to measure concepts such as dignity.
Emanuel has spoken out forcefully against the legalization of euthanasia and physician-assisted suicide, but he does not always oppose the practices themselves; he believes they are sometimes the most or the only ethical options. What he opposes is their legalization. After surveying patients, doctors and the general public in 1996 and 1997, he concluded that far fewer cancer patients than previously believed actively wanted to die. He also concluded that depression, not pain, was most likely to cause patients to seek physician-assisted suicide or euthanasia—an argument for better mental health care for dying patients, not death made more accessible. In writing about legalized euthanasia in the Netherlands, he argues that legalization in the United States might be counterproductive: it might divert research, doctors, insurance reimbursements and reform away from improving pain management and mental health treatments.
Emanuel’s most concrete contribution to the notion of a “good death” is the Medical Directive, a form that lets you record, in detail, the treatments you want in case you become unable to express your wishes. The form asks you to imagine, for example, that you’re in a coma or persistent vegetative state and then to say whether you’d want to: (1) prolong life, treat everything; (2) attempt to cure, but reevaluate often; (3) limit interventions to the less invasive and less burdensome; (4) provide comfort care only; or (5) other. From there, the form asks whether you’d want specific interventions—cardiopulmonary resuscitation, major surgery, mechanical breathing.
In 1990, when the Boston Globe interviewed Emanuel for an article about end-of-life care, the head of the Dana-Farber Cancer Institute forbade him to talk about death using his affiliation with the hospital, Emanuel says. “The sub rosa was, Patients don’t die here, and we’re not going to advertise that patients die here and that we’re going to try to make it better for them,” Emanuel says.
Ultimately, the Medical Directive helped make palliative care and the notion of a good death part of the regular conversation that doctors have with terminally ill patients. It was also one of the things that snared the attention of John Gallin ’65, director of the NIH Clinical Center, in 1997. Gallin wanted to restore the center’s bioethics program to the stature it held in its heyday, when it was responsible for many of the federal regulations that now govern clinical research. The department had dwindled in the intervening decades. “My goal was to be the best in the country, if not the world,” Gallin says. “I went out and searched the world and came across Zeke Emanuel.”
The NIH Clinical Center is the nation’s largest hospital devoted entirely to clinical research. There, Emanuel quickly instituted a program of bioethical grand rounds, during which doctors and students gather to examine cases with thorny bioethical components. Some recent topics have included “Medical and Non-Medical Features of Execution by Lethal Injection,” “Financial Conflicts of Interest in Clinical Research” and “When Respecting Confidentiality is Risky.” A physician presents each case and an outside speaker—perhaps a journal editor—elaborates and fields questions.
Emanuel also took one look at the government-issue green-hued rooms where NIH scientists did their work and told Gallin, “That’s not the right environment for bioethicists.” Emanuel created a central common space. Under a giant conference table, he placed an Oriental rug, and on the walls, he hung “real art,” he says, including African masks from his many travels to that continent.
Emanuel tore down walls to expand the bioethics department’s territory, and he has colonized other NIH institutes to add faculty to his department. From his first days at the Clinical Center, he visited institute directors to recruit them to his cause. The effort paid off: Emanuel’s department was supposed to have 10 full-time-equivalent employees; in addition, it now shares six faculty members from other institutes.
Today, while Emanuel hurries around the OMB, shrugging off opportunities for a bathroom break, his former students and colleagues at bioethics are having a more relaxed experience. The bioethics department is buried in the heart of Building 10 at the NIH compound in Bethesda, Md. The corridors leading to it are narrow, bland and filled with pale greenish-yellow light, but in the sacred space that Emanuel created, eight men and women sit around the conference table clutching mugs. They’re having 3 p.m. tea, which Emanuel instituted to foster the exchange of ideas. The tea-drinkers are mostly young postdocs and fellows. They’re talking about everything but bioethics, until, suddenly, a voice rises out of the murmur. It belongs to Govind Persad, a former fellow in town for a visit. He wants to know if it would be ethical to vaccinate kids against smoking. This is how ideas rise to the surface.
Emanuel’s former students appear to have a love/hate relationship with him. One asks if his neighbors at the OMB are deaf yet and observes that even when Emanuel is talking to someone who’s sitting right in his office, he yells. They make fun of his rapid-fire, Chicago-inflected delivery and his propensity for barking words such as “Counterfactual!” Philosophy, says fellow Carla Saenz, is a contact sport. “An environment of combative collegiality” is how Gallin describes the world that Emanuel has created at bioethics.
The department has published nine books, including the first comprehensive textbook on the ethics of research. Each year, under Emanuel’s direction, it publishes 60 to 80 papers. One, “What Makes Clinical Research Ethical” (on which Emanuel is the lead author), is the fourth-most-cited bioethics paper in history, despite its relative newness on the scene.
Among the faculty and fellows who’ve left Emanuel’s fold, one directs the Harvard University Program in Ethics and Health, another the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital. Postdoctoral fellows have been appointed at Stanford, Harvard and Johns Hopkins. “No department in the world has come close to having this much influence and impact in terms of publications or placement of faculty,” says Gallin.
That said, Emanuel wrote last year, in an article titled “The NIH and Bioethics: What Should Be Done?,” that “the NIH’s overall support of bioethics can be described as small, if not minuscule.” He is not afraid to rock the boat.
Emanuel’s combative collegiality was once as much a liability as a blessing. He suffered at Amherst College. He’d been happy in high school, secure among a warm group of close friends who loved to argue. At Amherst, by contrast, someone once lobbed an M-80 firecracker at his door. Emanuel can remember no specific motive for the attack, but his Amherst friends have some ideas.
“For years,” says Andy Oram ’79, “I have dined out on being able to imitate his laugh and what I consider to be the defining expression of his college years—” Here, Oram’s voice rises several octaves and proceeds on fast forward: “‘You’re wrong, and you know it!’”
“People mistook his passion for personal invective,” Oram says.
Or ego, possibly. Oram says that once, in a biochem exam, Emanuel finished the exam first and told the professor—Oram’s words—“This exam sucks.” The professor said, “Well, write me a better one,” Oram remembers. “And Zeke was back before the last guy finished the test and gave the guy a better exam.”
Emanuel’s friends say he has since mellowed. Emanuel attributes the change to age, but Oram offers other guesses. He says Emanuel calmed down after he met his ex-wife, Linda. Zeke and Linda Emanuel were together 27 years, during which they were also research collaborators. (Zeke also gives Linda half-credit for his three adult daughters—“my best work,” he calls them.)
Oram thinks Emanuel’s stint on TV also may have helped, by giving Emanuel a glimpse of how others saw him. Emanuel does not watch television; he doesn’t own one, eschews them in hotel rooms and never let his daughters watch. People joke that Zeke is the only Emanuel brother without his own television character (Ari has Entourage’s Ari Gold, and The West Wing’s Josh Lyman is supposedly based on Rahm), but he did, in fact, have his moment, on the BBC television show Now Get Out of That. The show was an early experiment with reality television that pitted two teams—in Emanuel’s case, Cambridge and Oxford—against each other in a man-v.-nature race. Emanuel was the only American on the Oxford team. The original episodes are unavailable on YouTube, but Oram retells a highlight: At one point, trying to reckon with a padlocked strongbox standing between his team and victory, Emanuel picked up a huge rock and began smashing the box. As Oram recalls, one teammate said mildly, “I say, Zeke, I do believe that’s against the rules.” Oram says that Emanuel turned to the teammate and snarled, “There are no fucking rules!” Viewers wrote letters referring to Emanuel as the “obnoxious American.”
Whatever the reason, Emanuel is now much less likely to offend, and, Oram believes, much more likely to be effective. “All of us have certain gifts, and whatever they are, they’re always a double-edged sword,” Oram says. “Zeke is someone who has done a remarkable job of keeping himself whole and true to himself while learning how to moderate himself in such a way that he can get things done.”
During their hour on Charlie Rose, the brothers remarked that if you attack one Emanuel, you can expect the wrath of all three. That’s the kind of enormous, ferocious affection that Zeke Emanuel seems to extend to everyone he loves. When his daughters were young, he clambered around the playground with them, let them climb all over him. He talked them through their homework as they got older, often over the phone at a full-fledged yell. During the school year, he speaks to his youngest daughter every day as she walks from her dorm to breakfast. When she called him recently to see if he wanted to have dinner, he flew to New York to join her. It turned out to be a $500 dinner, if you count plane fare, but he didn’t mind.
A brief encounter with Emanuel can become a lifelong engagement. When he drove home with David Turetsky ’79 during college, he met Turetsky’s father for the first time, and within a few minutes, “the two of them were having a great debate,” says Turetsky. “I think there were times they may have switched positions, argued each other’s, because they were having such a good time. I eventually went to sleep and the two of them continued for a good while after I was gone. My dad became a big fan of his.”
When Turetsky’s father was dying of cancer, the family turned to Emanuel for a second opinion. Turetsky’s father’s doctor wanted to start another round of chemo. But his father had two big events coming up, an 80th birthday party and his grandson’s bar mitzvah. Emanuel suggested they delay the chemo. “It never would have changed the outcome and Zeke totally knew that, and I think we all knew it—but you know, he had a great time, my dad just had a great time at those family events.” Telling the story, Turetsky is choked up. “He knew my father and knew what was important to him.”
There have been other times when Emanuel has come for a visit and stayed for a lifetime, most notably with Mary Challinor and her husband, Henry Richardson. You might call them Emanuel’s landlords—but that’s not quite right. Emanuel met Richardson when they were TAs at Harvard. When Emanuel first started at NIH, Linda Emanuel had just taken a job in Chicago and was not yet ready to move with the kids to D.C. So Emanuel moved by himself into a room in the Challinor-Richardson house. As circumstances would have it, Linda never came to D.C., and Zeke never moved out of the Challinor-Richardson house. (He even moved with them to their current house).
“He’s become part of the family,” says Challinor, whose son, Ben Richardson, is the one who described his efforts to impress Emanuel as an addiction. Challinor is one of few people who know that Emanuel bakes when he’s stressed out—chocolate cherry biscotti, banana bread, cake. In the Challinor-Richardson-Emanuel household, Emanuel regularly cooks brunch. His food-related forays and restaurant outings find their way into his regular column on The Atlantic’s online food site, Everybody’s a Critic.
In return for Emanuel’s cooking, Challinor, who was raised Catholic, keeps a “Kosher-Catholic” kitchen. “I don’t really have separate pots or plates, but I don’t mix meat with milk or serve shellfish or pork,” she says. Emanuel describes himself as a “practicing atheist” who doesn’t believe in God but does go to synagogue every Saturday. He loves to discuss the Torah. He believes it offers important insights into how to live.
He doesn’t mean the kinds of insights you debate over a beer, musing about how it would be so nice if everyone could just live that way someday. To meet Emanuel is to be quite certain that, for at least one central thread in Jewish thought, he considers the idea to be a commandment: that belief must find its expression in deed. That there is no point in believing something if you can’t work toward its expression in the world. That if you believe everyone deserves good health, a good life and a good death, you don’t walk away from those ideas until you’ve wrestled them to the ground, squeezed policy out of them and, if the strength of your convictions is enough to change minds, delivered those rewards to your fellow citizens.
Sarah Auerbach is a freelance journalist based near Boston and a mother of two.
Photos by Samuel Masinter '04