Dr. Ezekiel Emanuel, one of three remarkable, overachieving brothers including Chicago Mayor Rahm and Hollywood super-agent Ari, is a University of Pennsylvania and Wharton School medical professor, ethicist, and public policy guru.
He has made news lately with an article in The Atlantic. “Why I Hope to Die at 75.” It has produced a predictable spate of craziness from Obama haters. Emanuel was prominently involved in the fight for the Affordable Care Act so the article is said to prove they were right all along about death panels.
Also howling are the people Emanuel describes as American Immortals. We all know these inhabitants of cloud-cuckooland who imagine that by eating the paleo diet or exercising ceaselessly, thinking pure thoughts or uploading our consciousness to the Cloud we can live forever.
Sorry. It isn’t going to happen as this reasoned and rational article demonstrates. Emanuel cites the depressing statistics that explode many of the Immortals favorite myths. First, longevity is no longer rising rapidly as it did in the last century due to improved public health, clean drinking water, vaccination against childhood diseases, the advent of antibiotics, improved diet and reduced tobacco use.
Now, life expectancy appears to have plateaued at 76 for men, 81 for women. Since these are averages, many still live longer. The Lake Wobegon Effect means we all think we will be in the half that lives longer than average, but a glance at any obituary page suggests we may as easily wind up in the less than average half.
Even if we do beat the odds, the experience may not be as alluring as advertised in all those soft focus spots for old age palliatives — the erectile dysfunction ads and their female equivalents, those for arthritis, a-fib and so on. In fact, all this pharmaceutical happy talk is one giant fib.
Emanuel reminds us that half of the people 80 and over have functional disabilities (they have trouble sitting, standing, bathing and the like) and a third of those over 85 have Alzheimer’s or other dementia. No rosy scenario there. And all of us can expect to experience not just creaky joints but creaky minds. Memory, mental processing speed, problem solving ability all inexorably decline as we age while distractibility and the inability to focus increase.
Emanuel also cites considerable research showing that creativity, originality and productivity also undergo a slow but steady decline after 40 to 45. Even for highly creative people, their first contribution tends to be around age 24, their best work around 39 and their last signifiant contribution at 62.
All of this we know in our bones or from bitter experience with aged parents and other older relatives, friends and mentors. We grow old in the same way as Hemingway said a man went bankrupt — “gradually, then suddenly.” We like to believe it is something that will happen to everyone else, not to us. Or that a miracle cure or clean living will allow us to beat the rap. This is magical thinking.
Emanuel has provoked ire because he is relentlessly clear-eyed not just about the myths of the American Immortal but about the costs to society of prolonging the agony. For a time it was alleged that morbidity could be compressed, that is we could live longer and remain healthy up to the very end. This, too, proves to be wishful thinking.
In fact, the opposite is the case. As our lives have gotten longer, the period in which we are debilitated has also increased. This is why Emanuel, somewhat hyperbolically, says he hopes to die at 75. The odds for a much reduced quality of life rise fast after that age and the societal costs are gigantic.
Ten percent of Medicare patients account for 70 percent of spending. And which patients might those be? Here’s a clue. Thirty percent of all Medicare dollars are spent in the last year of patients’ lives. And even that vast expenditure doesn’t cover the cost. As a result, a third of all Medicare-age patients are essentially bankrupted by paying for old age care not covered by the program.
The feeble, endlessly doctored, demented old don’t just exact a dollars and cents cost on society. There is also a psychic and emotional toll as Emanuel sees it. The younger generation is compelled to care for them, defer to them, postpone their own maturity and are left not just with grief and debt but with scenes of elongated horror to remember. And due to the huge size of the baby boom generation just now approaching 70, this will amount to a tidal wave of social disruption and distortion for the next 30 years.
For all these reasons, Emanuel proposes to have his own memorial service while he is still alive to celebrate a life joyfully lived. Then, after 75, he intends to dispense with much medical care that passes for normal in our abnormal times. He plans to no longer undergo colonoscopies, cardiac stress tests or to take the annual PSA test. He won’t have a pacemaker or defibrillator implanted, heart valve or bypass surgery or cancer treatment. Though he doesn’t say, presume he would also think twice about hip and knee replacements in his latter years. He plans to settle for palliative care when the life-ending malady comes calling and will insist on a DNR — Do Not Resuscitate — order.
This is not as out there as it may sound. A surprising number of physicians have lately gone on record admitting that when it is their turn they intend to refuse the sort of treatment they are regularly expected to provide for patients. Often they do unto others only because patients or their families insist on last ditch efforts or because they fear being sued for practicing anything less than heroic, bankrupting, extreme end-of-life medicine.
I have seen the demise of my own parents, in-laws and several other old people. Most avoided the most dire scenarios, but the end was still far from pretty. In too many cases it was prolonged by surgeries or other grotesque procedures that had no chance of curing but did manage to make the ends of the patients’ lives worse, not better. I, for one, applaud Emanuel’s sane call for moderation in end-of-lie medical care. I hope I will have the sense and courage he espouses to know when enough is enough, to forgo pointless medical gymnastics and to make as graceful an exit as possible.