58-year-old Ezekiel Emanuel has declared that he hopes to die by age 75. Why should we care? Because he said so in the pages of the The Atlantic, and he’s a man of some influence: a health policy adviser to President Obama, director of the Clinical Bioethics Department of the U. S. National Institutes of Health, and head of the Department of Medical Ethics & Health Policy at the University of Pennsylvania. (He’s also the brother of Rahm Emanuel, current Mayor of Chicago and former Obama Chief of Staff.)
Emanuel begins by opposing the trend to wanting to live longer and to taking steps to ensure a higher quality of life:
Americans seem to be obsessed with exercising, doing mental puzzles, consuming various juice and protein concoctions, sticking to strict diets, and popping vitamins and supplements, all in a valiant effort to cheat death and prolong life as long as possible. This has become so pervasive that it now defines a cultural type: what I call the American immortal. I reject this aspiration. I think this manic desperation to endlessly extend life is misguided and potentially destructive. For many reasons, 75 is a pretty good age to aim to stop.
Emanuel plans to take the opposite tack:
Once I have lived to 75, my approach to my health care will completely change. I won’t actively end my life. But I won’t try to prolong it, either. This means colonoscopies and other cancer-screening tests are out—and before 75. If I were diagnosed with cancer now, at 57, I would probably be treated, unless the prognosis was very poor. But 65 will be my last colonoscopy. No screening for prostate cancer at any age. (When a urologist gave me a PSA test even after I said I wasn’t interested and called me with the results, I hung up before he could tell me. He ordered the test for himself, I told him, not for me.) After 75, if I develop cancer, I will refuse treatment. Similarly, no cardiac stress test. No pacemaker and certainly no implantable defibrillator. No heart-valve replacement or bypass surgery. If I develop emphysema or some similar disease that involves frequent exacerbations that would, normally, land me in the hospital, I will accept treatment to ameliorate the discomfort caused by the feeling of suffocation, but will refuse to be hauled off.
What about simple stuff? Flu shots are out. Certainly if there were to be a flu pandemic, a younger person who has yet to live a complete life ought to get the vaccine or any antiviral drugs. A big challenge is antibiotics for pneumonia or skin and urinary infections. Antibiotics are cheap and largely effective in curing infections. It is really hard for us to say no. Indeed, even people who are sure they don’t want life-extending treatments find it hard to refuse antibiotics. But, as Osler reminds us, unlike the decays associated with chronic conditions, death from these infections is quick and relatively painless. So, no to antibiotics.
Obviously, a do-not-resuscitate order and a complete advance directive indicating no ventilators, dialysis, surgery, antibiotics, or any other medication—nothing except palliative care even if I am conscious but not mentally competent—have been written and recorded. In short, no life-sustaining interventions. I will die when whatever comes first takes me.
It’s clear that on purely personal grounds, Emanuel has every right to adopt such a program and to tell the whole world about it. What makes the article chilling, however, is his rationale — and the extent to which that rationale may eventually be imposed on society as a whole. It comes down to this: after age 75, you’re just not terribly useful anymore.
But as life has gotten longer, has it gotten healthier? Is 70 the new 50? Not quite. It is true that compared with their counterparts 50 years ago, seniors today are less disabled and more mobile. But over recent decades, increases in longevity seem to have been accompanied by increases in disability – not decreases.
Americans may live longer than their parents, but they are likely to be more incapacitated. Does that sound very desirable? Not to me.
Even if we aren’t demented, our mental functioning deteriorates as we grow older. Age-associated declines in mental-processing speed, working and long-term memory, and problem-solving are well established. Conversely, distractibility increases. We cannot focus and stay with a project as well as we could when we were young. As we move slower with age, we also think slower. (The) fact is that by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us. We accommodate our physical and mental limitations. Our expectations shrink. Aware of our diminishing capacities, we choose ever more restricted activities and projects, to ensure we can fulfill them. Indeed, this constriction happens almost imperceptibly. Over time, and without our conscious choice, we transform our lives. We don’t notice that we are aspiring to and doing less and less. And so we remain content, but the canvas is now tiny.Yikes. Should we all abandon hope? Is the “reinvention of aging” an illusion? Is the canvas really all that tiny? What about the explosive growth of experiential traveling, and “back to school” learning for learning’s sake, and bucket lists and all that? What about the “softer” experiences — like more years to enjoy family and grandchildren? Emanuel anticipates this counter-argument…sort of.
Maybe this is too dismissive. There is more to life than youthful passions focused on career and creating. There is posterity: children and grandchildren and great-grandchildren. But having nodded in that direction, he is quick to be dismissive again:
But here, too, living as long as possible has drawbacks we often won’t admit to ourselves. I will leave aside the very real and oppressive financial and caregiving burdens that many, if not most, adults in the so-called sandwich generation are now experiencing, caught between the care of children and parents. Our living too long places real emotional weights on our progeny. We’re getting really close to putting the old folks on the ice floes. And let’s face it, if we really loved our kids and grandkids, we’d actively want to get the hell out of the way:
...parents also cast a big shadow for most children. Whether estranged, disengaged, or deeply loving, they set expectations, render judgments, impose their opinions, interfere, and are generally a looming presence for even adult children. This can be wonderful. It can be annoying. It can be destructive. But it is inescapable as long as the parent is alive. Examples abound in life and literature: Lear, the quintessential Jewish mother, the Tiger Mom. And while children can never fully escape this weight even after a parent dies, there is much less pressure to conform to parental expectations and demands after they are gone. Living parents also occupy the role of head of the family. They make it hard for grown children to become the patriarch or matriarch. When parents routinely live to 95, children must caretake into their own retirement. That doesn’t leave them much time on their own—and it is all old age. When parents live to 75, children have had the joys of a rich relationship with their parents, but also have enough time for their own lives, out of their parents’ shadows.
Emanuel anticipates the firestorm this article will cause — and in particular, the fear that he is trying to lead to some pubic policy conclusions (recall the “death panel” hysteria about Obamacare). He tries to address it by pointing out that he is not calling for radical change — he does want more research into infant mortality and better health for the younger generations, but also calls for more research into Alzheimer’s. And to be fair, too, Emanuel has always been an outspoken opponent of euthanasia. But in the end, he can’t quite hide from the “greater social good” implications of his 75-and-out viewpoint:
The deadline also forces each of us to ask whether our consumption is worth our contribution.
According to this disturbing report on NBCNews.com, “the past decade has seen an astonishing spike in the rate of Asians over 65 choosing to end their lives early, particularly in the region’s economically successful countries.”
The stats are frightening:
In South Korea, for example, suicides in that age group have risen more than fivefold, from 14 per 100,000 in 1990 to 77 per 100,000 in 2009, according to Hallym University’s Institute of Aging.
In Taiwan, seniors took their lives more than twice as often as any other age group, at a rate of 35.8 per 100,000 in 2010, versus 17.6 for the national average.
Suicides among city dwellers in China aged 70 to 74 surged to 33.76 per 100,000 in the mid-2000s, up from 13.39 in the 1990s.
And these numbers are expected to rise.
Even more scary, experts note that government data on elderly suicides is considered to be of poor quality because of many unreported cases. So the numbers could actually be higher.
Why is this happening?
In Asia, experts blame the rapid social and economic changes across the region and scarce mental health services. In some Asian countries a disproportionate number of suicides among elderly has followed financial or health crises, but experts are now looking at the social pressures being placed on the elderly by industrialization and population growth.
And if it’s bad now, the twin forces of greater life expectancy and fewer caregivers will make things worse.
“Now we are enjoying the best moments of this era. We have three to four young adults to support a family with one or two elderly persons,” says Frances Law, a former project director at the Hong Kong Jockey Club Centre for Suicide Research and Prevention, one of the region’s leading institutions in suicide prevention.
“The potential risk is that as life expectancy is getting longer and longer, the dependency ratio is getting much larger. That is, there will be fewer people to support the elderly population in the coming 10 to 20 years.”