Over and Out

I highly recommend a provocative essay by Ezekial Emanuel that appears in the October 2014 issue of the Atlantic. Dr. Emanuel is a prominent academic who has also held important positions in government, including as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. He is also the eldest of the three impressive “Emanuel Brothers” that also includes Rahm (former White House chief of staff and now mayor of Chicago) and Ari (a prominent Hollywood agent). His piece is entitled “Why I Hope to Die at 75.”

OK, so the title is a bit over the top and meant to shock, and it is not even entirely accurate. But the message is really worth thinking about. Emanuel sets out why he wants to avoid the typical American approach to aging and progressive infirmity; he does not want to join the ranks of what he refers to as “American immortals.” Instead, he says that when he hits the admittedly arbitrary age of 75, he will no longer actively seek to prolong his life. No more doctor visits, no more “preventive” measures, no more diagnostic tests, no more interventions. Done. Whatever happens after that, well, so be it.

He is quick and careful to point out that this is not a public policy recommendation (though the on-line comments that accompany the article indicate that a lot of readers are not buying that), but rather his own personal decision. He wants to avoid the decline in physical and mental capacity that comes with aging, and figures his best contributions will be well behind him by then. He specifically rejects the notion that the longer life spans we now “enjoy” come with “compression of morbidity” at the end and instead cites evidence that longer life nearly always comes with a longer period of infirmity or reduction.

On one level, his position resonated with me. I see plenty of behavior that can only be explained by some irrational belief in immortality coupled with Medicare fee-for-service reimbursement unencumbered by any need to demonstrate evidence of efficacy. How else can you explain things like removing basal cell skin cancers in a 90 year old, or doing mammograms in women in their 80s, or worrying about your cholesterol at that age?

On the other hand, he seems way too sure of himself. As Daniel Gilbert pointed out in his book Stumbling on Happiness  we humans are pretty awful at predicting our future emotional state. Things we are convinced would devastate us, don’t. Things we know would make us happy, also don’t. So I am not convinced that the good doctor won’t wake up at age 75 and say, “this isn’t so bad, and I would really like to stick around for a while.” I think the article would have been much more compelling if he were 75 already, and was entitled, “I’m done.”

What do you think?

7 thoughts on “Over and Out

  1. Obviously, Dr. Zeke hasn’t seen anyone dying of colon cancer lately.
    This piece resonated with me with a standing wave akin to Galloping Gertie over the Tacoma Narrows, resulting in a massive implosion from its own ponderous stupidity.

    1. Not sure why you think his essay indicates that he hasn’t seen anyone dying of colon cancer lately. Are you suggesting that screening colonoscopy after age 75 saves lives? No evidence that it does so far as I know…

  2. Ira, one disease which cuts lives far to short is Systemic Lupus Erythematosus. Afflicting women far more than men (10:1 ratio), lupus is an immunological “War On Women.” As all patients do not present the same, the spider sense has to be attuned. As a run up to the October 19 Lupus Walk at Eisenhower Park on October 19, perhaps you could do a post on autoimmune diseases and lupus in particular.

  3. I watched my mom recover from a brain stem stroke that should have taken her life–at one point she was given a choice about whether to continue living on a vent or end it all. At 53 she chose life and now at 71 she is breathing, eating and performing basic life functions on her own. I honestly don’t know if she wishes she would have made a different decision 18 years ago (I doubt it), but I do know that we don’t really know what we’d decide or want until faced with that choice. I work for a health system that supports the practices of several highly skilled surgeons over the age of 70, one of whom is now faced with deciding whether to transplant kidneys in patients over 70. Our nation’s system is broken and personal accountability needs to increase, but I’m uncertain if I can predict the future of healthcare, let alone my own.

    1. I agree completely — “we don’t really know what we’d decide or want until face with that choice.” One additional consequence is that I think we need to be very cautious about interpreting research studies that utilize “quality adjusted life years” as an outcome measure. At their core, these are based on asking people to “discount” their lives based on some imagined disability — something we know people are really bad at doing!

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