Why Ezekiel Emanuel is wrong to ‘hope’ for death at 75

Dr. Ezekiel Emanuel, eminent oncologist, medical sage, policy advisor to the Obama White House, outspoken defender of the Affordable Care Act — has roiled the political and policy communities, both left and right, with an essay in the Atlantic declaring that he hopes to die at age 75. That’s a mere 18 years from now.

Emanuel’s subject is our inability to accept the inevitability of decline and death. He disavows any intention to set forth general principles either for individuals or American society: “I am not saying that those who want to live as long as possible are unethical or wrong,” he writes. “I’m not even trying to convince anyone I’m right.... And I am not advocating 75 as the official statistic of a complete, good life in order to save resources, ration health care, or address public-policy issues arising from the increases in life expectancy.”

Yet he protests too much. Plainly he aimed for his piece to be provocative, in the sense of enlivening a public debate about aging, death and public policy. And of course he’s advocating: “This manic desperation to endlessly extend life is misguided and potentially destructive,” he writes. If he’s not trying to convince his readers that he’s right and the counterarguments are wrong, why publish the piece at all?

Emanuel’s essay is provocative, all right — not because its ideas are thought-provoking, but purely because of Emanuel’s position as a prominent figure in a national debate about healthcare policy. At its heart, it’s profoundly misguided, profoundly vain and profoundly inhumane. It addresses our debate about society’s resources and its treatment of old versus young without shedding new light on the topics. That’s a lost opportunity and a shame, because many scholars and policymakers have been thinking about this question for years.

Any analysis of Emanuel’s essay must start with the narrowness of his personal perspective. His conviction that he will surely have lived a complete existence by 75 reflects the experience of an upper middle-glass gentleman whose life and career paths have been smoothed by a superb education and the environment of family accomplishment. (His brothers are Chicago Mayor Rahm Emanuel and Hollywood talent agent Ari Emanuel.) He’s on the faculty of the University of Pennsylvania, which will presumably support him, if necessary in an emeritus capacity, as long as he wishes.

Today he’s a vigorous 57, without any known chronic or latent diseases. He says he doesn’t intend deliberately to end his life at 75 but rather to cease accepting medical interventions at that point — nothing, that is, except pain relief or other palliatives. No colonoscopies, no cancer screening or treatment, no cardiac tests or surgeries. Not even antibiotics or flu shots. (Though getting a shot might make unnecessary the palliatives he might need if he contracts the flu.)

One question posed by this pledge is whether it’s enforceable. Zeke Emanuel, 57, is committing Zeke Emanuel, 75, to a lifestyle that the latter Zeke may not, in the fullness of time, find acceptable.

Such a reality created some embarrassment for medical ethicist Daniel Callahan, who proposed in 1987, at age 58, setting limits on healthcare for seniors; yet in his late 70s, he underwent an $80,000 treatment for a heart condition. (He said he wasn’t aware of the cost at the time.)

We are very different persons at different stages of our lives; and our own evolving perspectives can make it impossible to bind our own selves to our own resolutions. Today’s Zeke Emanuel is convinced that by 75 he will have lived a life sufficiently fulfilled to shed it at nature’s command; but that Zeke Emanuel may have a different perspective. “By the time I reach 75, I will have lived a complete life,” he declares today. How could he know that, two decades in advance?

Emanuel’s chief target is the conviction of many Americans that they can lead a fulfilled life after 75 — and deserve to do so. Emanuel ascribes this notion to a group he calls “American immortals.” He implies that they’re hopelessly naive and, worse, that they impose insupportable costs on society in their quest to extend their lives.

“The fact is that by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us,” he writes. Those whose lives contradict this fiding are merely “outliers.”

With these words, Emanuel casually dismisses the essential variability of human life. To narrow so drastically the range of contributions to life and society we define as worthy is to overlook the glorious richness of the mature mind.

Giuseppe Verdi wrote two unique masterpieces, “Otello” and “Falstaff,” at 69 and 74 (inspired by collaboration with a youthful librettist, Arrigo Boito). Thomas Pynchon, whose prose crackles with the energy of a 20-year-old, published his monumental “Against the Day” at age 69, and followed up with “Inherent Vice” at age 72 and “Bleeding Edge” at 76. Pynchon’s near-contemporary, Philip Roth, published one of his finest novels, the haunting and harrowing “Nemesis,” at age 77.

In the public-policy sphere, Federal Appeals Judge Richard Posner is still setting down compelling principles of law at 75, and U.S. District Judge Jed Rakoff is fighting ferocious battles for justice from the New York bench at 71. Neither shows any sign of slowing down, and society would be poorer if they did.

The real issues Emanuel’s essay raises are economic. That’s where its implications are broadest, and where it’s the most misguided. By couching his argument for death at 75 in spiritual and emotional terms, Emanuel evades direct confrontation with economics, except briefly — at one point he mentions “the very real and oppressive financial and caregiving burdens” of the “sandwich” generation caring for children and parents simultaneously, and at another proposes that Americans at 75 “ask whether our consumption is worth our contribution.”

But the economic underpinning of Emanuel’s viewpoint is inescapable. If aging didn’t impose costs on society, who would care whether anyone decided to shed or sustain his or her mortal coil at 75? It would be an individual and inconsequential decision unworthy of a major essay in, say, the Atlantic.

Instead, Emanuel’s essay feeds into an enduring conundrum known to ethicists as the “duty to die.” Put briefly, the idea is that elders should step aside for rising generation, freeing up society’s resources to nurture children and allow younger workers to thrive.

In politics, this was expressed most notably in 1984 by then-Colorado Gov. Dick Lamm, who said at a meeting of health lawyers that seniors have got “a duty to die and get out of the way. Let the other society, our kids, build a reasonable life.”

But it lives on today in talk of “generational theft” and “generational warfare.” Usually the context is the cost of programs for retirees such as Medicare and Social Security, which is decried as a drain on the federal government, which consequently spends less on the needs of children.

We’ve addressed this argument before, observing that most government spending on children comes in the form of spending on education by states and localities, which balances the books. More importantly, nothing about spending on seniors prevents American society from spending much more on children or young families: America has more than enough resources to spend all we want on programs for citizens at all stages of life. If there’s an imbalance in spending on seniors versus children, that’s a political choice we’re making, not a fiscal imperative.

As philosopher Christine Overall observes, “even if there are genuine problems of resource scarcity, it ought not be assumed that age rationing is the only method of responding to them, especially when age rationing entails coercive pressures on older people to die.” And is there genuine scarcity? No, she writes, only an assumption that “‘health care’ is a sealed envelope to which no new funds can be added” — not from reducing military spending, or handouts to big corporations, or any other sources.

Bioethicist Arthur Caplan similarly questions the notion that using available medical measures to extend life was unnatural, excessively costly to society, or morally wrong. Addressing Callahan’s argument in 2004, Caplan wrote, “the empirical evidence does not seem to bear out his case that trying to live longer must of necessity either bankrupt society or lead to lives of pain and misery.”

His words would apply equally to Emanuel’s case. Emanuel doesn’t even examine whether living longer will bankrupt society and lead to lives of pain and misery; he appears to accept those notions as givens.

Emanuel’s ruminations on mortality lack the empathy that might tell him that the conditions of aging he describes — “faltering and declining, a state that may not be worse than death but is nonetheless deprived ... feeble, ineffectual, even pathetic” — are not universal, and that even those who suffer them might not want to give up their last years.

Instead, what comes through is Emanuel’s terror of losing even a small measure of capacity. He turns an anecdote about his own 87-year-old father--who describes himself as “living a happy life” and by Emanuel’s account is independent, physically vigorous and mentally and emotionally engaged--into one about a man overstaying his time on Earth because “no one would say he is living a vibrant life.” (It sounds like his father would contradict him.)

“Mortality can be a treacherous subject,” writes the physician Atul Gawande in his latest book, “Being Mortal.” Gawande, whose subject also is the inevitability of decline and death but doesn’t think in terms of artificial deadlines, observes that we lack “a coherent view of how people might live successfully to their very end.” He could be writing about Ezekiel Emanuel.

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