Thoughts On a Controversial Essay

My neighbor, who is approaching 75 years of life, asked for my thoughts about oncologist/bioethicist Ezekiel J. Emanuel’s essay in The Atlantic, “Why I Hope to Die at 75.”  Emanuel presents a well-reasoned argument in favor of strictly palliative, noncurative medical care after the age of 75.

He argues that, by the arbitrarily chosen age of 75, he “will have lived a complete life.  [He] will have loved and been loved.  [His] children will be grown and in the midst of their own rich lives. [He] will have seen [his] grandchildren born and beginning their lives. [He] will have pursued [his] life’s projects and made whatever contributions, important or not, [he is] going to make. And hopefully, [he] will not have too many mental and physical limitations. Dying at 75 will not be a tragedy.”

You should read the entire piece for yourself.

He goes into detail about the mental and physical debility that comes with old age and how that decreases our quality of life, places a burden on our progeny (notably, he does not directly mention the burden on society), and leaves a final memory of us as frail and feeble.

He argues that Americans have a “misguided and potentially destructive” desire to “endlessly extend life,” which he defines as a cultural type, the “American immortal.”  The American immortal wants to believe in “compression of morbidity,” which means that debility will be compressed into the very end of our lives and that our golden years will be largely free of debility.  However, despite this cultural expectation, he says, research suggests that increasing age has been associated with increasing–not decreasing–debility.

Finally, at the end of the essay, he reserves the right to change his mind later on and to present a well-reasoned argument in favor of living as long as possible.

It’s certainly something to think seriously about.  Emanuel is a residency- and fellowship-trained physician, as well as a bioethicist, so he has seen the particular cross-sections of society that most other physicians are familiar with.  The non-physician (or non-clinical professional), though, largely interacts with people healthy-enough to show up to his workplace, so unless he goes out of his way, he’ll see a different cross-section entirely.

I did my internal medicine residency mostly at a hospital in which the average age of admitted patients, at the time, was supposedly 76.  Although I took care of some “wellderly” patients–patients who were highly functional in old age–I took care of many more with significantly diminished physical and mental capacities.  Many required caregivers (these were often family members), lived in skilled nursing facilities, or were transferred to skilled nursing facilities after convalescence from the acute conditions that landed them in the hospital.  Many were what some physicians refer to as “frequent flyers”:  they rotated frequently between the skilled nursing facilities and the hospital (and sometimes their own homes).

Surely the states of existence of most such patients were far cries from those of their younger selves.  Were they perceived differently, in a permanent way, by their children and other loved ones?  (Certainly, they are initially perceived differently by most who meet them in old age; it takes effort to imagine the old as they may have been in youth, and such musings may be wrong.)  Had they been of sound mind (some certainly were), would they have agreed with Emanuel’s thesis?  (Some of them told me that old age is painful, while others seemed to like it just fine.)  Did they expect old age to be somehow different from how it turned out?  From watching the plethora of medically inaccurate TV shows and movies, did they expect code blue situations to have a much higher rate of success than they actually do (and to not result in the chronic pain of broken ribs)?  Did they expect science and technology to work miracles, to save them somehow? (Science and technology have never saved anyone from progressive debility and eventual death.)

Pencil Portrait of My Former Clinic Nurse

I decided to upload some of my old pencil drawings.  I put them up on Facebook years ago, but they’re visible only to my friends there, and I figured that others might find them inspiring.

Just before finishing internal medicine residency in June 2012, my continuity clinic nurse for all three years, Pam, asked me to draw something for her.  I decided to draw her portrait, with graphite on Bristol board, freehand while looking at her Facebook profile photo.  I started with her eyes…

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Then, I added her nose and lips (the lighting was different in this photo, so the paper looks blue)…

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Here’s the finished portrait:

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The Priceless Habit

I blogged last month about starting a meditation habit.  Despite knowing about zazen, or zen meditation–my preferred form of meditation–since my college days, I just recently began a regular practice!  Meditation is one of those deceptively simple activities that isn’t easy at all; in fact, its difficulty is part of what makes it so worthwhile.

Since starting my meditation practice, I’ve meditated for 5-15 minutes most days.  For the past few days, I’ve meditated for 15 minutes several hours before bed, and I’ve experienced something I hadn’t for at least the past year:  probable REM sleep (indicated by vivid dreams) right up until I wake in the mornings!  I’ve also felt more calmly alert and attentive during the day (in short, I’ve felt fresh), even though I’ve only gotten about seven hours a night (which, previously, was not enough for me).  I haven’t made any other changes to my lifestyle, so I’m doubtful that anything else could account for the new REM cycles.

I feel that my attention span has broadened considerably.  I’m much better-attuned to the world around me.  Layers of thought and mental impressions, many of them barely conscious, have been lifted, revealing a calm, clear view of things.  Meditation, for me, is about “lifting” the “layers” of thought and consequent feelings that obscure the truth.  I’ve solved harder problems correctly, I’ve made fewer mistakes overall (before, in haste, I would occasionally bump into things and hurt my finger or my toe or my knee), I’ve become more cognizant of and attentive to all important matters, I’ve become more calmly (instead of harriedly) efficient, etc.

The sum of all these and other effects of meditation has been something truly priceless:  a much higher quality of life experience per moment of time.  The overall quality of my life has risen considerably.

I’ve learned that if I want to see the forest and the trees, then I should meditate.  I look forward to continuing and deepening my meditation practice!

P.S.  These are the zazen instructions that work for me.  They work because they stress the importance of non-striving, of not pursuing a goal while meditating, which is critical to getting “behind” your barely conscious thoughts and “lifting” them out of the way.  (Pursuit of a goal, or striving, can itself be a near-unconscious ambience of thought that colors your mind a certain way, with consequent anxieties and behaviors you wouldn’t otherwise engage in.)

P.P.S.  Meditation, for me, is strictly practical.  I ignore the spiritual/religious side of it.  Remember that Buddhism became a religion only after the Buddha died–he did not want to make it a religion, he did not want to be worshipped, and he did not make any claims about a higher power(s).  The religious transformation of his movement came about after he died.