The Atlantic Monthly's Weird Deathwish Article Is an Insult to the Elderly

A middle-aged bioethicist's high-profile rant casts more heat than light.

Photo Credit: Mayovskyy Andrew

In “Why I Hope to Die at 75,” Ezekiel J. Emanuel, MD, once again plays the agent provocateur—or more aptly this time, the ageist provocateur– announcing in the Atlantic cover story (Sept. 17) that he plans to refuse any  “life-prolonging” medical treatment or drugs after his 75th birthday. The article has generated so much attention that the PBS “New Hour’s” Judy Woodruff, conducted an extensive interview with the ever-jocular bioethicist on Oct. 3.

Emanuel insists throughout this lengthy, disjointed and dishonest essay that his position is purely personal—a view which the distinguish oncologist, 57, retains the right to reverse when the time comes. Yet he proceeds with a more expansive ethical appeal, facilely shifting from “I” to “we” within paragraphs, like a sly prosecutor.

A more careful examination of Emanuel’s article, though, exposes that far from stimulating healthy debate on longevity, its muddled logic bares his poor understanding of chronic disease processes and shows that in the end he is more enamored with youth than those he accuses of perversely embracing their vigorous younger selves.

What’s more, GBONews found that Emanuel’s primary scientific source flatly rejects his use of her research.

“The American Immortal”

Emanuel’s principal foe is “the American immortal,” those he derides for fruitlessly fending off their mortality through endless exercise and consumption of protein drinks. A key shaper of Obamacare and former head of the National Institutes of Health’s Office of Bioethics, he fervently denies favoring health care rationing among the old. Also, he adamantly opposes euthanasia. That’s an accusation Sarah Palin and others leveled when they attacked aspects of his work on the Affordable Care Act as establishing “death panels.”

Still, Emanuel contends that Americans have no right to hang on beyond 75, beyond what he perceives as one’s productive years.  Even though he concedes that 75 is an arbitrary choice, he goes on, “The deadline also forces each of us to ask whether our consumption is worth our contribution.”

In his Atlantic essay, the influential Zeke–brother of Chicago Mayor Rahm and Hollywood agent Ari–slips easily from statements of personal preference to general indictments of older Americans, that is, from his ethical “I” to the profligate “we.”

Emanuel, now director of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, asserts, “By the time I reach 75, I will have lived a complete life. I will have loved and been loved. My children will be grown and in the midst of their own rich lives . . . . I will have pursued my life’s projects and made whatever contributions, important or not, I am going to make.”

Later, though, he writes, “The specificity of 75 means we can no longer just continue to ignore them and maintain our easy, socially acceptable agnosticism.” Agnosticism? The word indicts aging Americans for presuming to be neutral toward their obligation to—what?–decline medical treatment, atrophy and whither away like an autumn leaf? Back to “me,” Emanuel pleads that it will be his mission in the coming 18 years to wade through the difficult questions he raises for himself, rather than “trying to hang on to every additional day and forget the psychic pain they bring up, while enduring the physical pain of an elongated dying process.”

But the arduous dying process he describes in this article is not in the range of futile  medical interventions imposed upon so many Americans in their final months of life. For Emanuel, after 75, preventive measures such as “colonoscopies and other cancer-screening tests are out,” as well as pacemakers, bypass surgery and the rest, regardless of his actual prognosis. “What about simple stuff,” he asks? “Flu shots are out.”

The late geriatrics pioneer and Pulitzer Prize-winner Robert N. Butler, MD, founding director of the National Institute of Aging, is surely getting an energetic spin in his rest. For decades Butler countered arguments for health care rationing of the old by Emanuel’s predecessors, especially bioethisist and Setting Limits author Daniel Callahan. Butler argued convincingly that the ethical dilemma of U.S. heath care was not overspending at the end of life, but chronic undertreatment of the old due to pervasive ageism in our health care system.

Scientist to Emanuel: “I Feel Used”

Emanuel contends that advanced age almost always arrives with burdensome decrepitude. He invokes research, which he claims challenges the longstanding concept that modern science will enable us to maximize our well-being and compress decline (morbidity) into the very last of life. He reminds us that most longevity gains in infancy and childhood were achieved early in the 20th century through vaccines, antibiotics and other medical miracle. Then Emanuel confronts the very idea that it has been worthwhile since the 1960s for us to add most of our longevity gains later in life: “Rather than saving more young people, we are stretching out old age.” Exactly how the vampire-like tradeoff he describes is being made, isn’t exactly clear.

Emanuel goes on to justify his argument that age brings relentless descent for most of us by invoking the scientific analysis of respected University of Southern California gerontologist Eileen M. Crimmins. He describes her findings to show that increased human longevity has come not with waning disability, but instead with waxing decline. Others can explore the complexities of Crimmins’ research, but GBONews asked for her response to Emanuel’s citation of her work as a main scientific premise of his essay.

In a brief e-mail Crimmins replied, "I spoke with him once for about a minute. As I said to the ‘fact checker’ from the magazine, I feel used. That was the sum total of my exchange with the lot of them.”

It’s not that Emanuel misstated her findings, in narrowly citing them. But anyone who has known of Crimmins’ work for years would have to doubt that she’d agree with Emanuel’s application of her research to an interpretation of inevitable human decay, not to mention his implication that science has forever been defeated. It seems so odd that this elevated man of science would take analyses of data sets as a resoundingly and hopelessly personal defeat.

This editor couldn’t help but think of Emanuel’s defeatism on reading yesterday’s New York Times report, “Finding Clues in Genes of ‘Exceptional Responders’” by Gina Kolata. Scientists now want to study people who previously helped, even cured, but pharmaceutical that otherwise failed in drug trials to understand better what their resilience can offer the rest of us. Are these responders among the “outliers” Emanuel insists have nothing much to offer?

Fear of Losing Control?

In a critical review of Emanuel’s protest against old age, Harris Meyer, a top editor at Modern Healthcare, further exposes fissures in the good doctor’s arguments. For one thing, Meyer, noting Emanuel’s claim that he does not advocate rationing health care services to elders, mentions that the eminent physician did support “age-based or quality-of-life-based rationing of scarce medical resources” in a 2009 Lancet article.

But more essentially, Meyer observes, “The strange thing about Emanuel’s essay is that he himself believes that getting old, sick and feeble is cause for depression, hopelessness and loss of dignity and control, and he sees no possible help for it. ‘Living too long… renders many of us… faltering and declining, a state that may not be worse than death but is nonetheless deprived… We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.’”

Meyer interviewed Barbara Coombs Lee, president of Compassion & Choices, who observed that Emanuel’s article focuses on his fear of losing dignity and control. She added, “He casts aspersions on other people because they fear losing dignity and control and he would deprive them of taking steps to prevent it.”

Coombs Lee told Meyer, “The fantasy he creates is that if you don’t avail yourself of life-prolonging treatment, your death will come relatively quickly, painlessly and gently. That’s not necessarily true.” Talk to any geriatric physician about whether arbitrary nontreatment of serious health conditions for a patient with, say, Alzheimer’s or Parkinson’s disease would ease the suffering and stress for both patient and family. Not likely for these deteriorating conditions.

Also, Emanuel’s pledge to rely only on “palliative care,” belies is failure to understand that palliative care—not terminal hospice treatment—involves controlling pain and stabilizing symptoms through appropriate application of both comfort care and medical intervention as needed for seriously ill people. The article shows that the man doesn’t grasp the essence of end-of-life care at all, much less have an appreciation of the therapeutic value of well-applied, individualized medical care in advanced years.

Playing Off Young Against Old

Emanuel contends that he does not wish to live beyond his ability to be creative and productive. ”We literally lose our creativity” with age, he insists, confusing brilliant flashes of youthful minds with the insights of mature thinking, such as those defined by the late visionary gerontologist, Gene Cohen, MD, in his book, TheMature Mind: The Positive Power of the Aging Brain (Basic Books, 2005).  Emanuel simply dismisses the many examples elder genius as “outliers.” Such exceptionalism in old age, Emanuel tells us, is beyond the capacity for the “vast, vast” majority of us—as if the vast, unblessed majority equates the age old wish to “live long and prosper,” (thank you, Mr. Spok) with one’s ability to perform mental gymnastics.

Throughout his commentary, Emanuel plays off the interests of the young against those of the old. But to what end? Echoing previous media attacks against the boomer generation for wanting to live forever, he returns repeatedly to his derision of the “American immortal, once a vital figure in his or her profession and community, [who] is happy to cultivate avocational interests, to take up bird watching, bicycle riding, pottery, and the like.” It’s as if slowing down and taking in life is mere self-indulgence, risking one’s own burdensome decay at the potential expense of youth.

Conceding that an elder’s death is usually a “huge loss” for their children, Emanuel believes that for older people, lingering too long, leaving their children and grandchildren “with memories framed not by our vivacity but by our frailty is the ultimate tragedy.”

Emanuel laments, “When parents routinely live to 95, children must caretake into their own retirement.” Well, yes, in the U.S. health care system, that’s deeply troubling—as a public policy choice, though, not as a decision individuals can control in our ethical vacuum.

In our family, my grandmother was not one of the “annoying” or “destructive” Jewish grandmother’s Emanuel conjures up in his sagging image of elderhood. She had eight more wonderful years following implantation of her pacemaker at 85, years treasured by her children, grandchildren and great-grandchildren. Her knees no longer allowed her into her beloved garden, but she was the gentle and very world-wise soul of our family.

Emanuel likely would disregard the likes of my grandmother as exceptional, but not if he understood the desire of the vast, vast majority of people, who understand that death – and all that comes with it – is, yes, hard, but part of our lives. No one wants to embrace pain and suffering. But neither do most really want it all to just go away and leave us to our pleasant recollections of, well, Zeke Emanuel’s notion of what’s “productive.”

He’s the Virtual Peter Pan

Emanuel urges the old to make a graceful exit: “We wish our children to remember us in our prime. Active, vigorous, engaged, animated, astute, enthusiastic, funny, warm, loving.” In doing so, however, he belies his bias. Think about it. The man who so ridicules the 99 percent of “American immortals,” is also the one who wants always to be remembered as the jovial companion to the young. A photo published with his article shows him with two nephews during their climb this summer of Mount Kilimanjaro, just as he says he’d like to be remembered.

Zeke Emanuel, it turns out, is not the “deadly doctor” as Palin and others dubbed him in the Obamacare debate. He never wants to grow up—he’s Uncle Cool. The hale fellow in perpetually well met in his Immortal selfie. Zeke Emanuel wants to be the virtual Peter Pan.

Emanuel’s failure to grasp the essence of long life exposes his underlying ageism. And that may well yield the results he seems to desire, dying at 75. You see, for those who live today in the United States to age 65, the average added life expectancy is to about 82. But according to well regarded and internationally corroborated research by Yale psychologist Becca Levy, PhD, people who hold a negative view of old age earlier in life die on average about 7.5 years earlier than those with a positive view of aging. That’s roughly the difference between 75 and 82. Emanuel may be imposing a self-fulfilling prophesy on himself.

Joking aside, what’s so sad about Emanuel’s public exposure of his dark view of longevity is that it practically defines the ageist undercurrent in so much contemporary thinking in American media and entertainment. It’s the anti-aging reinforcement that Levy’s research reflects, and even more troubling in public policy proposals to cut Social Security and Medicare in the cause of deficit reduction for future generations, as if our grandchildren won’t grow old.

It always amazes me to hear of brilliant people, “ethicists” no less, individuals far more accomplished than I could ever be, who confuse the convolutions of intellectual exercise with any real presence of mind. Reading Zeke Emanuel’s essay, I was reminded of a favorite quote by the 17th century philosopher René Descartes. Here it is in its entirety:

The greatest minds, as they are capable of the highest excellences, are open likewise to the greatest aberrations; and those who travel very slowly may yet make far greater progress, provided they keep always to the straight road, than those who, while they run, forsake it.

–From “Discourse on the Method of Rightly Conducting the Reason, and Seeking Truth in the Sciences”

 

Paul Kleyman is editor of Generations Beat Online (GBONews.org) and an editor at New America Media.

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