(Ezekiel Emanuel's article from the ATLANTIC,
October 2014 issue.)
To convince me of my errors, they
enumerate the myriad people I know who are over 75 and doing quite well. They
are certain that as I get closer to 75, I will push the desired age back to 80,
then 85, maybe even 90. I am sure of my position. Doubtless, death is a loss.
It deprives us of experiences and milestones, of time spent with our spouse and
children. In short, it deprives us of all the things we value.
But here is a simple truth that many of us seem to resist: living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.
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 seen my grandchildren born and beginning their lives. I will have
pursued my life’s projects and made whatever contributions, important or not, I
am going to make. And hopefully, I will not have too many mental and physical
limitations.
Dying
at 75 will not be a tragedy. Indeed, I plan to have my memorial service before
I die. And I don’t want any crying or wailing, but a warm gathering filled with
fun reminiscences, stories of my awkwardness, and celebrations of a good life.
After I die, my survivors can have their own memorial service if they want—that
is not my business.
Let me
be clear about my wish. I’m neither asking for more time than is likely nor
foreshortening my life. Today I am, as far as my physician and I know, very
healthy, with no chronic illness. I just climbed Kilimanjaro with two of my
nephews. So I am not talking about bargaining with God to live to 75 because I
have a terminal illness. Nor am I talking about waking up one morning 18 years from
now and ending my life through euthanasia or suicide.
Since the 1990s, I have actively
opposed legalizing euthanasia and physician-assisted suicide. People who want
to die in one of these ways tend to suffer not from unremitting pain but from
depression, hopelessness, and fear of losing their dignity and control. The
people they leave behind inevitably feel they have somehow failed. The answer
to these symptoms is not ending a life but getting help. I have long argued
that we should focus on giving all terminally ill people a good, compassionate
death—not euthanasia or assisted suicide for a tiny minority.
I am
talking about how long I want to live and the kind and amount of health care I
will consent to after 75. 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. Americans may live longer than their parents, but they are
likely to be more incapacitated. Does that sound very desirable? Not to me.
What are those reasons? Let’s begin
with demography. We are growing old, and our older years are not of high
quality. Since the mid-19th century, Americans have been living longer. In
1900, the life expectancy of an average American at birth was approximately 47
years. By 1930, it was 59.7; by 1960, 69.7; by 1990, 75.4. Today, a newborn can
expect to live about 79 years.
(On average,
women live longer than men. In the United States, the gap is about five years.
According to the National Vital Statistics Report, life expectancy for American
males born in 2011 is 76.3, and for females it is 81.1.)
In the
early part of the 20th century, life expectancy increased as vaccines,
antibiotics, and better medical care saved more children from premature death
and effectively treated infections. Once cured, people who had been sick
largely returned to their normal, healthy lives without residual disabilities.
Since 1960, however, increases in longevity have been achieved mainly by
extending the lives of people over 60. Rather than saving more young people, we
are stretching out old age.
The
American immortal desperately wants to believe in the “compression of
morbidity.” Developed in 1980 by James F. Fries, now a professor emeritus of
medicine at Stanford, this theory postulates that as we extend our life spans
into the 80s and 90s, we will be living healthier lives—more time before we have
disabilities, and fewer disabilities overall. The claim is that with longer
life, an ever smaller proportion of our lives will be spent in a state of
decline.
It
promises a kind of fountain of youth until the ever-receding time of death. It
is this dream—or fantasy—that drives the American immortal and has fueled
interest and investment in regenerative medicine and replacement organs.
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.
For
instance, using data from the National Health Interview Survey, Eileen
Crimmins, a researcher at the University of Southern California, and a
colleague assessed physical functioning in adults, analyzing whether people
could walk a quarter of a mile; climb 10 stairs; stand or sit for two hours; and
stand up, bend, or kneel without using special equipment.
The
results show that as people age, there is a progressive erosion of physical
functioning. More important, Crimmins found that between 1998 and 2006, the
loss of functional mobility in the elderly increased. In 1998, about 28 percent
of American men 80 and older had a functional limitation; by 2006, that figure
was nearly 42 percent.
And
for women the result was even worse: more than half of women 80 and older had a
functional limitation. Crimmins’s conclusion: There was an “increase in the
life expectancy with disease and a decrease in the years without disease. The
same is true for functioning loss, an increase in expected years unable to
function.”
This was confirmed by a recent
worldwide assessment of “healthy life expectancy” conducted by the Harvard
School of Public Health and the Institute for Health Metrics and Evaluation at
the University of Washington. The researchers included not just physical but
also mental disabilities such as depression and dementia. They found not a
compression of morbidity but in fact an expansion—an “increase in the absolute
number of years lost to disability as life expectancy rises.”
How
can this be? My father illustrates the situation well. About a decade ago, just
shy of his 77th birthday, he began having pain in his abdomen. Like every good
doctor, he kept denying that it was anything important. But after three weeks
with no improvement, he was persuaded to see his physician. He had in fact had
a heart attack, which led to a cardiac catheterization and ultimately a bypass.
Since then, he has not been the same.
Once
the prototype of a hyperactive Emanuel, suddenly his walking, his talking, his
humor got slower. Today he can swim, read the newspaper, needle his kids on the
phone, and still live with my mother in their own house. But everything seems
sluggish.
Although
he didn’t die from the heart attack, no one would say he is living a vibrant
life. When he discussed it with me, my father said, “I have slowed down
tremendously. That is a fact. I no longer make rounds at the hospital or
teach.” Despite this, he also said he was happy.
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.
Take
the example of stroke. The good news is that we have made major strides in
reducing mortality from strokes. Between 2000 and 2010, the number of deaths
from stroke declined by more than 20 percent. The bad news is that many of the
roughly 6.8 million Americans who have survived a stroke suffer from paralysis
or an inability to speak.
And
many of the estimated 13 million more Americans who have survived a “silent”
stroke suffer from more-subtle brain dysfunction such as aberrations in thought
processes, mood regulation, and cognitive functioning. Worse, it is projected
that over the next 15 years there will be a 50 percent increase in the number
of Americans suffering from stroke-induced disabilities. Unfortunately, the
same phenomenon is repeated with many other diseases.
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. The situation
becomes of even greater concern when we confront the most dreadful of all possibilities:
living with dementia and other acquired mental disabilities.
Right
now approximately 5 million Americans over 65 have Alzheimer’s; one in three
Americans 85 and older has Alzheimer’s. And the prospect of that changing in
the next few decades is not good. Numerous recent trials of drugs that were
supposed to stall Alzheimer’s—much less reverse or prevent it—have failed so
miserably that researchers are rethinking the whole disease paradigm that
informed much of the research over the past few decades.
Instead
of predicting a cure in the foreseeable future, many are warning of a tsunami
of dementia—a nearly 300 percent increase in the number of older Americans with
dementia by 2050. Half of people 80 and older with functional limitations. A
third of people 85 and older with Alzheimer’s. That still leaves many, many
elderly people who have escaped physical and mental disability. If we are among
the lucky ones, then why stop at 75? Why not live as long as possible?
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. Einstein famously said, “A
person who has not made his great contribution to science before the age of 30
will never do so.” He was extreme in his assessment. And wrong.
Dean
Keith Simonton, at the University of California at Davis, a luminary among
researchers on age and creativity, synthesized numerous studies to demonstrate
a typical age-creativity curve: creativity rises rapidly as a career commences,
peaks about 20 years into the career, at about age 40 or 45, and then enters a
slow, age-related decline.
There
are some, but not huge, variations among disciplines. Currently, the average
age at which Nobel Prize–winning physicists make their discovery—not get the
prize—is 48. Theoretical chemists and physicists make their major contribution
slightly earlier than empirical researchers do.
Similarly,
poets tend to peak earlier than novelists do. Simonton’s own study of classical
composers shows that the typical composer writes his first major work at age
26, peaks at about age 40 with both his best work and maximum output, and then
declines, writing his last significant musical composition at 52. (All the
composers studied were male.)
This
age-creativity relationship is a statistical association, the product of
averages; individuals vary from this trajectory. Indeed, everyone in a creative
profession thinks they will be, like my collaborator, in the long tail of the
curve. There are late bloomers. As my friends who enumerate them do, we hold on
to them for hope.
It is
true, people can continue to be productive past 75—to write and publish, to
draw, carve, and sculpt, to compose. But there is no getting around the data.
By definition, few of us can be exceptions. Moreover, we need to ask how much
of what “Old Thinkers,” as Harvey C. Lehman called them in his 1953 Age and
Achievement, produce is novel rather than reiterative and repetitive of
previous ideas.
The
age-creativity curve—especially the decline—endures across cultures and
throughout history, suggesting some deep underlying biological determinism
probably related to brain plasticity. We can only speculate about the biology.
The connections between neurons are
subject to an intense process of natural selection. The neural connections that
are most heavily used are reinforced and retained, while those that are rarely,
if ever, used atrophy and disappear over time. Although brain plasticity
persists throughout life, we do not get totally rewired.
As we
age, we forge a very extensive network of connections established through a
lifetime of experiences, thoughts, feelings, actions, and memories. We are
subject to who we have been. It is difficult, if not impossible, to generate
new, creative thoughts, because we don’t develop a new set of neural
connections that can supersede the existing network. It is much more difficult
for older people to learn new languages.
All of
those mental puzzles are an effort to slow the erosion of the neural
connections we have. Once you squeeze the creativity out of the neural networks
established over your initial career, they are not likely to develop strong new
brain connections to generate innovative ideas—except maybe in those Old
Thinkers like my outlier colleague, who happen to be in the minority endowed
with superior plasticity.
Maybe
mental functions—processing, memory, problem-solving—slow at 75. Maybe creating
something novel is very rare after that age. But isn’t this a peculiar
obsession? Isn’t there more to life than being totally physically fit and
continuing to add to one’s creative legacy?
One
university professor told me that as he has aged (he is 70) he has published
less frequently, but he now contributes in other ways. He mentors students,
helping them translate their passions into research projects and advising them
on the balance of career and family. And people in other fields can do the
same: mentor the next generation.
Mentorship
is hugely important. It lets us transmit our collective memory and draw on the
wisdom of elders. It is too often undervalued, dismissed as a way to occupy
seniors who refuse to retire and who keep repeating the same stories. But it
also illuminates a key issue with aging: the constricting of our ambitions and
expectations.
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.
The
American immortal, once a vital figure in his or her profession and community,
is happy to cultivate avocational interests, to take up bird watching, bicycle
riding, pottery, and the like. And then, as walking becomes harder and the pain
of arthritis limits the fingers’ mobility, life comes to center around sitting
in the den reading or listening to books on tape and doing crossword puzzles.
And then …
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 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.
Mentorship
is hugely important. But it also illuminates a key issue with aging: the
constricting of our ambitions and expectations. Unless there has been terrible
abuse, no child wants his or her parents to die. It is a huge loss at any age.
It creates a tremendous, unfillable hole. But 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.
But
there is something even more important than parental shadowing: memories. How
do we want to be remembered by our children and grandchildren? We wish our
children to remember us in our prime. Active, vigorous, engaged, animated,
astute, enthusiastic, funny, warm, loving. Not stooped and sluggish, forgetful
and repetitive, constantly asking “What did she say?” We want to be remembered
as independent, not experienced as burdens.
At age
75 we reach that unique, albeit somewhat arbitrarily chosen, moment when we
have lived a rich and complete life, and have hopefully imparted the right
memories to our children. Living the American immortal’s dream dramatically
increases the chances that we will not get our wish—that memories of vitality
will be crowded out by the agonies of decline.
Of
course, our children won’t admit it. They love us and fear the loss that will
be created by our death. And a loss it will be. A huge loss. They don’t want to
confront our mortality, and they certainly don’t want to wish for our death. But
even if we manage not to become burdens to them, our shadowing them until their
old age is also a loss. And leaving them—and our grandchildren—with memories
framed not by our vivacity but by our frailty is the ultimate tragedy.
Seventy-five.
That is all I want to live. But if I am not going to engage in euthanasia or
suicide, and I won’t, is this all just idle chatter? Don’t I lack the courage
of my convictions? No. My view does have important practical implications. One
is personal and two involve policy.
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. Today, when the doctor recommends a test or
treatment, especially one that will extend our lives, it becomes incumbent upon
us to give a good reason why we don’t want it. The momentum of medicine and
family means we will almost invariably get it.
My
attitude flips this default on its head. I take guidance from what Sir William
Osler wrote in his classic turn-of-the-century medical textbook, The Principles
and Practice of Medicine: “Pneumonia may well be called the friend of the aged.
Taken off by it in an acute, short, not often painful illness, the old man
escapes those ‘cold gradations of decay’ so distressing to himself and to his
friends.”
My Osler-inspired philosophy is this:
At 75 and beyond, I will need a good reason to even visit the doctor and take
any medical test or treatment, no matter how routine and painless. And that
good reason is not “It will prolong your life.” I will stop getting any regular
preventive tests, screenings, or interventions. I will accept only
palliative—not curative—treatments if I am suffering pain or other disability.
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.
As for
the two policy implications, one relates to using life expectancy as a measure
of the quality of health care. Japan has the third-highest life expectancy, at
84.4 years (behind Monaco and Macau), while the United States is a
disappointing No. 42, at 79.5 years. But we should not care about catching up
with—or measure ourselves against—Japan.
Once a
country has a life expectancy past 75 for both men and women, this measure
should be ignored. (The one exception is increasing the life expectancy of some
subgroups, such as black males, who have a life expectancy of just 72.1 years.
That is dreadful, and should be a major focus of attention.)
Instead,
we should look much more carefully at children’s health measures, where the
U.S. lags, and shamefully: in preterm deliveries before 37 weeks (currently one
in eight U.S. births), which are correlated with poor outcomes in vision, with
cerebral palsy, and with various problems related to brain development; in
infant mortality (the U.S. is at 6.17 infant deaths per 1,000 live births, while
Japan is at 2.13 and Norway is at 2.48); and in adolescent mortality (where the
U.S. has an appalling record—at the bottom among high-income countries).
A
second policy implication relates to biomedical research. We need more research
on Alzheimer’s, the growing disabilities of old age, and chronic conditions—not
on prolonging the dying process.
Many
people, especially those sympathetic to the American immortal, will recoil and
reject my view. They will think of every exception, as if these prove that the central
theory is wrong. Like my friends, they will think me crazy, posturing—or worse.
They might condemn me as being against the elderly.
Again,
let me be clear: I am not saying that those who want to live as long as
possible are unethical or wrong. I am certainly not scorning or dismissing
people who want to live on despite their physical and mental limitations. I’m
not even trying to convince anyone I’m right. Indeed, I often advise people in
this age group on how to get the best medical care available in the United
States for their ailments. That is their choice, and I want to support them.
We
avoid constantly thinking about the purpose of our lives and the mark we will
leave. Is making money, chasing the dream, all worth it?
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. What I am trying to do is
delineate my views for a good life and make my friends and others think about
how they want to live as they grow older. I want them to think of an
alternative to succumbing to that slow constriction of activities and
aspirations imperceptibly imposed by aging. Are we to embrace the “American
immortal” or my “75 and no more” view?
I
think the rejection of my view is literally natural. After all, evolution has
inculcated in us a drive to live as long as possible. We are programmed to
struggle to survive. Consequently, most people feel there is something vaguely
wrong with saying 75 and no more. We are eternally optimistic Americans who
chafe at limits, especially limits imposed on our own lives. We are sure we are
exceptional.
I also
think my view conjures up spiritual and existential reasons for people to scorn
and reject it. Many of us have suppressed, actively or passively, thinking
about God, heaven and hell, and whether we return to the worms. We are
agnostics or atheists, or just don’t think about whether there is a God and why
she should care at all about mere mortals.
We
also avoid constantly thinking about the purpose of our lives and the mark we
will leave. Is making money, chasing the dream, all worth it? Indeed, most of
us have found a way to live our lives comfortably without acknowledging, much
less answering, these big questions on a regular basis. We have gotten into a
productive routine that helps us ignore them. And I don’t purport to have the
answers.
But 75
defines a clear point in time: for me, 2032. It removes the fuzziness of trying
to live as long as possible. Its specificity forces us to think about the end
of our lives and engage with the deepest existential questions and ponder what
we want to leave our children and grandchildren, our community, our fellow
Americans, the world. The deadline also forces each of us to ask whether our
consumption is worth our contribution.
As
most of us learned in college during late-night bull sessions, these questions
foster deep anxiety and discomfort. The specificity of 75 means we can no
longer just continue to ignore them and maintain our easy, socially acceptable
agnosticism. For me, 18 more years with which to wade through these questions
is preferable to years of 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.
Seventy-five
years is all I want to live. I want to celebrate my life while I am still in my
prime. My daughters and dear friends will continue to try to convince me that I
am wrong and can live a valuable life much longer. And I retain the right to
change my mind and offer a vigorous and reasoned defense of living as long as
possible. That, after all, would mean still being creative after 75.
(Ezekiel Jonathan "Zeke"
Emanuel - born September 6, 1957- is an American oncologist and bioethicist and
senior fellow at the Center for American Progress. He is the current Vice
Provost for Global Initiatives at the University of Pennsylvania and chair of
the Department of Medical Ethics and Health Policy. Previously, Emanuel served
as the Diane and Robert Levy University Professor at Penn.
He holds a joint appointment at the
University of Pennsylvania School of Medicine and the Wharton School and was
formerly an associate professor at the Harvard Medical School until 1998 when
he joined the National Institutes of Health. He is the author or editor of 10
books, including Brothers Emanuel and Reinventing American Health Care.
An architect of Obamacare and a special
adviser to the director-general of the World Health Organization, he has been
widely cited by the news media in recent days arguing that life in the U.S.
can’t fully return to normal for about 18 months, estimating that’s when a
Chinese coronavirus vaccine could be broadly available.)
