Elbridge Gerry to President of Senate and Speaker of House of Representatives of Massachusetts (October 18, 1787)
Gentlemen : I have the honor to enclose, pursuant to my commission, the Constitution proposed by the Federal Convention.
To this system I gave my dissent, and shall submit my objections to the honorable legislature.
It was painful for me, on a subject of such national importance, to differ from the respectable members who signed the Constitution; but conceiving, as I did, that the liberties of America were not secured by the system, it was my duty to oppose it.
My principal objections to the plan are, that there is no adequate provision for a representation of the people; that they have no security for the right of election; that some of the powers of the legislature are ambiguous, and others indefinite and dangerous; that the executive is blended with, and will have an undue influence over, the legislature; that the judicial department will be oppressive; that treaties of the highest importance may be formed by the President, with the advice of two thirds of a quorum of the Senate; and that the system is without the security of a bill of rights . These are objections which are not local, but apply equally to all the states.
As the Convention was called for “the sole and express purpose of revising the Articles of Confederation, and reporting to Congress, and the several legislatures, such alterations and provisions as shall render the Federal Constitution adequate to the exigencies of government, and the preservation of the Union,” I did not conceive that these powers extend to the formation of the plan proposed; but the Convention being of a different opinion, I acquiesced in it, being fully convinced that, to preserve the Union, an efficient government was indispensably necessary, and that it would be difficult to make proper amendments to the Articles of Confederation.
The Constitution proposed has few, if any, federal features, but is rather a system of national government. Nevertheless, in many respects, I think it has great merit, and, by proper amendments, may be adapted to the “exigencies of government, and preservation of liberty.”
The question on this plan involves others of the highest importance: 1. Whether there shall be a dissolution of the federal government; 2. Whether the several state governments shall be so altered as in effect to be dissolved; 3. Whether, in lieu of the federal and state governments, the national Constitution now proposed shall be substituted without amendment. Never, perhaps, were a people called on to decide a question of greater magnitude. Should the citizens of America adopt the plan as it now stands, their liberties may be lost; or should they reject it altogether, anarchy may ensue. It is evident, therefore, that they should not be precipitate in their decisions; that the subject should be well understood;–lest they should refuse to support the government after having hastily accepted it.
If those who are in favor of the Constitution, as well as those who are against it, should preserve moderation, their discussions may afford much information, and finally direct to a happy issue.
It may be urged by some, that an implicit confidence should be placed in the Convention; but, however respectable the members may be who signed the Constitution, it must be admitted that a free people are the proper guardians of their rights and liberties; that the greatest men may err, and that their errors are sometimes of the greatest magnitude.
Others may suppose that the Constitution may be safely adopted, because therein provision is made to amend it. But cannot this object be better attained before a ratification than after it? And should a free people adopt a form of government under conviction that it wants amendment?
And some may conceive that, if the plan is not accepted by the people, they will not unite in another. But surely, while they have the power to amend, they are not under the necessity of rejecting it.
I have been detained here longer than I expected, but shall leave this place in a day or two for Massachusetts, and on my arrival shall submit the reasons (if required by the legislature) on which my objections are grounded.
I shall only add that, as the welfare of the Union requires a better Constitution than the Confederation, I shall think it my duty, as a citizen of Massachusetts, to support that which shall be finally adopted, sincerely hoping it will secure the liberty and happiness of America.
I have the honor to be, gentlemen, with the highest respect for the honorable legislature and yourselves, your most obedient and very humble servant,
To the Hon . Samuel Adams , Esq., President of the Senate, and the Hon . James Warren , Esq., Speaker of the House of Representatives, of Massachusetts.
The Chief Architect of Obamacare is Dr. Ezekiel Emanuel. Recently, Megyn Kelly has had him on her show, “The Kelly File”. Anyone who saw Dr. Emanuel on “Kelly File” knows he is an abrasive, arrogant, and downright nasty individual.
Ezekiel “Dr. Mengle” Emanuel’s views on Health Care is known as “The Complete Lives System”. Below is an excerpt from “Principles for Allocation of Scarce Medical Interventions” written by Govind Persad, Alan Wertheimer, Ezekiel J Emanuel which appear in “The Lancet” Vol 373 January 31, 2009 pages 423–31.
Do not be fooled by the rhetoric of the Marxists. As you read this excerpt from the article, you will immediately notice the Marxist “buzz words” of “social justice”,”fair”, “just”, et.al.
At its core, ” the complete lives system combines four morally relevant principles: youngest-ﬁrst, prognosis, lottery, and saving the most lives.”
(Formatting did not transfer over. I did my best to edit)
“The complete lives system”
Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates ﬁve principles (table 2): youngest-ﬁrst,prognosis, save the most lives, lottery, and instrumental value. 5 As such, it prioritizes younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.” 1,75,76 Although there are important diﬀerences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the deﬁning feature of the complete lives system.
Consideration of the importance of complete lives alsosupports modifying the youngest-ﬁrst principle byprioritising adolescents and young adults over infants(ﬁgure). Adolescents have received substantial educationand parental care, investments that will be wasted withouta complete life. Infants, by contrast, have not yet receivedthese investments. Similarly, adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfillment requires a complete life.77
As the legal philosopher Ronald Dworkin argues, “It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does”; 78 this argument is supported by empirical surveys. 41,79 Importantly, the prioritization of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo. Consequently, poor adolescents should be treated the same as wealthy ones,even though they may have received less investment owing to social injustice.
The complete lives system also considers prognosis,since its aim is to achieve complete lives. A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life. Considering prognosis forestalls the concern that disproportionately large amounts of resources will be directed to young people with poor prognoses. 42 When the worst-oﬀ can beneﬁt only slightly while better-oﬀ people could beneﬁt greatly,allocating to the better-oﬀ is often justiﬁable. 1,30 Some small beneﬁts, such as a few weeks of life, might also be intrinsically insigniﬁcant when compared with large beneﬁts. 8
Saving the most lives is also included in this system because enabling more people to live complete lives is better than enabling fewer. 8,44 In a public health emergency,instrumental value could also be included to enable more people to live complete lives. Lotteries could be used when making choices between roughly equal recipients, and also potentially to ensure that no individual—irrespective of age or prognosis—is seen as beyond saving.
34,80 Thus, the complete lives system is complete in another way: it incorporates each morally relevant simple principle.
When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance,whereas the youngest and oldest people get chances that are attenuated (ﬁgure). 78 It therefore superﬁcially resembles the proposal made by DALY advocates; however, the complete lives system justiﬁes preference to younger people because of priority to the worst-oﬀ rather than instrumental value. Additionally, the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them. Conversely, ALY allocation treats life-years given to elderly or disabled people as objectively less valuable.
Finally, the complete lives system is least vulnerable to corruption. Age can be established quickly and accuratelyfrom identity documents. Prognosis allocation encourages physicians to improve patients’ health, unlike the perverse incentives to sicken patients or misrepresent health thatthe sickest-ﬁrst allocation creates. 58,59
We consider several important objections to the complete lives system.
The complete lives system discriminates against older people. 81,82 Age-based allocation is ageism. 82 Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through diﬀerent life stages rather than being a single age. 8,39 Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. 16 Treating 65-year-olds diﬀerently because of stereotypes or falsehoods would be ageist; treating them diﬀerently because they have already had more life-years is not.
Age, like income, is a “non-medical criterion” inappropriate for allocation of medical resources. 14,83 In contrast to income, a complete life is a health outcome. Long-term survival and life expectancy at birth are key health-care outcome variables. 84 Delaying the age at onset of a disease is desirable. 85,86
The complete lives system is insensitive to international diﬀerences in typical lifespan. Although broad consensus favours adolescents over very young infants, and young adults over the very elderly people, implementation can reasonably diﬀer between, even within, nation-states. 87,88 Some people believe that a complete life is a universal limit founded in natural human capacities, which everyone should accept even without scarcity. 37 By contrast, the complete lives system requires only that citizens see a complete life, however deﬁned, as an important good, an daccept that fairness gives those short of a complete life stronger claims to scarce life-saving resources.
Principles must be ordered lexically: less important principles should come into play only when more important ones are fulﬁlled. 10 Rawls himself agreed that lexical priority was inappropriate when distributing speciﬁc resources in society, though appropriate for ordering the principles of basic social justice that shape the distribution of basic rights, opportunities, and income. 1 As an alternative, balancing priority to the worst-oﬀ against maximising beneﬁts has won wide support in discussions of allocative local justice. 1,8,30 As Amartya Sen argues, justice“does not specify how much more is to be given to the deprived person, but merely that he should receive more”. 89
Accepting the complete lives system for health care as a whole would be premature. We must ﬁrst reduce waste and increase spending. 81,90 The complete lives system explicitly rejects waste and corruption, such as multiple listing for transplantation. Although it may be applicable more generally, the complete lives system has been developed to justly allocate persistently scarce life-saving interventions. 39,80 Hearts for transplant and inﬂuenza vaccines, unlike money, cannot be replaced or diverted to non-health goals; denying a heart to one person makes it available to another. Ultimately, the complete lives system does not create “classes of Untermenschen whose lives and well being are deemed not worth spending money on”, 91 but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.
As well as recognising morally relevant values, an allocation system must be legitimate. Legitimacy requires that people see the allocation system as just and accept actua lallocations as fair. Consequently, allocation systems must be publicly understandable, accessible, and subject topublic discussion and revision. 92 They must also resist corruption, since easy corruptibility undermines the public trust on which legitimacy depends. Some systems, like theUNOS points systems or QALY systems, may fail this test, because they are diﬃ cult to understand, easily corrupted,or closed to public revision. Systems that intentionally conceal their allocative principles to avoid public complaints might also fail the test. 93
Although procedural fairness is necessary for legitimacy, it is unable to ensure the justice of allocation decisions o nits own. 94,95 Although fair procedures are important,substantive, morally relevant values and principles are indispensable for just allocation. 96,97
Ultimately, none of the eight simple principles recognise all morally relevant values, and some recognise irrelevant values. QALY and DALY multiprinciple systems neglect the importance of fair distribution. UNOS points systems attempt to address distributive justice, but recognise morally irrelevant values and are vulnerable to corruption. By contrast, the complete lives system combines four morally relevant principles: youngest-ﬁrst, prognosis,lottery, and saving the most lives. In pandemic situations,it also allocates scarce interventions to people instrumental in realising these four principles. Importantly, it is not an algorithm, but a framework that expresses widely aﬃrmed values: priority to the worst-oﬀ, maximising beneﬁts, and treating people equally. To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo.
“Dr. Mengele” Emanuel is the Primary Author and Point of Contact for the Article.
Department of Bioethics,The Clinical Center, National Institutes of Health, Bethesda,Maryland, USA
(G Persad BS,A Wertheimer PhD,E J Emanuel MD)
Correspondence to: Ezekiel J Emanuel,Department of Bioethics,The Clinical Center, National Institutes of Health, Bethesda,MD 20892-1156, USA firstname.lastname@example.org