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.)

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