emanuelAn interesting essay by Obamacare architect, Dr. Ezekiel Emanuel called Why I Hope to Die at 75 is making the rounds. It is significant for a couple of reasons. First, it provides an insight into how the secular elites are coming to regard life. Secondly, Emanuel had, and continues to have, enormous influence on how health care policy is developed in the United States.

Let me make two points before proceeding.

  • Talk is cheap. Emanuel is currently 57 years old so his statement is very much an academic one. As Samuel Johnson said, the prospect of being hanged concentrates the mind wonderfully. If he still feels that way when he turns 75 then I’ll be happy to show up with the cellophane bag and duct tape and let him deliver on his promise.
  • Emanuel is not directly espousing euthanasia, though it is very easy to see how following his logic could lead there.

Emanuel starts with the observation that Americans strive for immortality.

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.

This is hardly original. A colleague of mine, a British officer, once quipped that “Americans seem to think death is optional.” (This was longer ago than I care to talk about.) Perhaps. If so, there are worse failings to which a nation can succumb. This strikes me as a rather snooty reaction that ignores the fact that Americans are bombarded by carefully crafted messages from the medical community virtually every day on health, diet, etc. These messages are based on hundreds of billions of dollars invested in biomedical research… research conducted and led by doctors, like Emanuel (who worked for the National Institutes of Health). For heaven’s sake, we have a harpy in the White House forcing carrot sticks down the throats of resisting children across the country. We’d have to both deaf and stupid not to react to some of this Niagara Falls of information that washes over us continually.

And for many of us, the impulse to diet and exercise (full disclosure, I started my day a 4:30 am by lifting weights) is driven more by the desire to ensure the years that we live are healthy and pain-free rather than any thought of actually avoiding the inevitable.

What is most striking is the unbridled narcissism. For Emanuel life isn’t life unless it is awesome. While he makes a somewhat valid point about the limitations of physical function made virtually inevitable in aging, he sees the need to work around these limitations as demeaning:

As Crimmins puts it, over the past 50 years, health care hasn’t slowed the aging process so much as it has slowed the dying process. And, as my father demonstrates, the contemporary dying process has been elongated. Death usually results from the complications of chronic illness—heart disease, cancer, emphysema, stroke, Alzheimer’s, diabetes.

So American immortals may live longer than their parents, but they are likely to be more incapacitated. Does that sound very desirable? Not to me

And it isn’t only physical health that Emanuel uses as a screening criteria, he uses “creativity”:

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.

It is not just mental slowing. We literally lose our creativity. About a decade ago, I began working with a prominent health economist who was about to turn 80. Our collaboration was incredibly productive. We published numerous papers that influenced the evolving debates around health-care reform. My colleague is brilliant and continues to be a major contributor, and he celebrated his 90th birthday this year. But he is an outlier—a very rare individual.

American immortals operate on the assumption that they will be precisely such outliers. But the fact is that by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us. …

This, of course, is nothing more that utilitarian bioethics tarted up with a smiley-face:

Key Concepts:

  • According to utilitarianism, an action is right if, and only if it maximises well‐being.
  • >When we assess a person’s well‐being, we are assessing how well or badly that person’s life is going.
  • Utilitarianism entails that it is morally required to kill an innocent person if it promotes overall well‐being.
  • For utilitarians, allowing a person to die or suffer when that could have been avoided is just as bad as directly inflicting suffering or killing.
  • For utilitarians, a couple (or a single reproducer) has a significant moral reason to select the best child, one with the lowest chance of disease and the best prospects for the best life.
  • Because utilitarians have a broad understanding of what makes a life go well, which goes beyond prevention or treatment of disease, they have no objections to genetic enhancement, if it promotes overall well‐being.

While Emanuel has a cute little chart showing the peak productivity of creative people is between 40 and 50 and says the average age of Nobel Prize winners when they made their discovery is 48, what he passes by is fact that the overwhelming majority of people are not uniquely creative and do not win Nobel Prizes. We get up, go about our business, tend to our families, contribute to our communities, all without thought to how really cool and unique our lives are. We want to live, not because we are going to invent the next big thing but because we want to see our kids, our grandkids, grow up. We want to be part of their lives and we want to pass on part of what we are, hopefully the good part, to subsequent generations. We want to live because to we aren’t God, and God owns our lives while we are merely stewards of what has been given us.

Let’s put Emanuel aside for the moment and go to the New York Times, Panel Urges Overhauling Health Care at End of Life:

The panel, which included doctors, nurses, insurers, religious leaders, lawyers and experts on aging, said Medicare and other insurers should create financial incentives for health care providers to have continuing conversations with patients on advance care planning, possibly starting as early as major teenage milestones like getting a driver’s license or going to college.

It called for a “major reorientation and restructuring of Medicare, Medicaid and other health care delivery programs” and the elimination of “perverse financial incentives” that encourage expensive hospital procedures when growing numbers of very sick and very old patients want low-tech services like home health care and pain management.

All this, like Emanuel’s essay, sounds very reasonable and benign. But how will it work in practice, when the physicians being paid to dispense advice believe that if you have some physical limitations and aren’t quite as sharp as you used to be (though not having a Nobel Prize or being highly creative, you were not that sharp to begin with) decides you should just pack it in? Back to Emanuel:

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.

Back in 1984, Colorado Governor Richard Lamm made a notorious statement for the time:

Elderly people who are terminally ill have a ”duty to die and get out of the way” instead of trying to prolong their lives by artificial means, Gov. Richard D. Lamm of Colorado said Tuesday.

People who die without having life artificially extended are similar to ”leaves falling off a tree and forming humus for the other plants to grow up,” the Governor told a meeting of the Colorado Health Lawyers Association at St. Joseph’s Hospital.

”You’ve got a duty to die and get out of the way,” said the 48-year-old Governor. ”Let the other society, our kids, build a reasonable life.”

He was widely lampooned on the left and right. Left wing folk singer Tom Paxton immortalized the advice in “Come and Grow Old With Me in Colorado.” Now we have that exact same policy gracing the pages of Atlantic and being taken as a serious philosophical piece rather than what it is, an effort to strip man of his humanity, reduce his worth to what he can produce, and allow him to live only so long as he doesn’t embarrass others by his presence.