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Quality Of Life Trumps Number Of Years Lived, According To Bioethicist Zeke Emanuel


“We begin this week with these provocative words: “Seventy-five. That’s how long I want to live: 75 years.” That’s how Dr. Zeke Emanuel started off an essay in a recent edition of The Atlantic. He went on to explain why living ‘too long’ can be a loss.

He wrote, ‘it renders many of us, if not disabled then faltering and declining. It transforms how people experience us. And most important, remember us. We are no longer remembered as vibrant and engaged, but as feeble, unaffectionate, even pathetic.'

Well, as you might expect, the article set off a firestorm, from people suggesting that Dr. Emanuel was proposing euthanasia, or at least depriving society of the wisdom that comes after many years. We wanted to close the circle so we invited Dr. Emanuel to respond to some of those critics and explain more fully why he says now he will refuse life-extending treatment once he reaches age 75.”

Dr. Emanuel: I’ve long thought about how long I want to live. And I’ve also been sort of perplexed by the obsession of people to live as long as possible—just on and on. I find it a little surprising that people think just sheer quantity is what matters. Most people, I would think, would say it’s quality, but I wanted to get people to think about what is the quality that they really want. What is the meaning in their life? The idea was to spark that. I’ve noticed two things in the responses. The first is: If I had said 80, instead of 75, it would’ve gotten no attention. 80 feels normalish to people. 75 feels premature, which I find surprising. It’s only five years difference. It’s a little surprising to me that it makes that big a difference, but psychologically it seems to be a very big difference. Second: The responses have sort of fallen into three categories. One group of people, very skeptical, if not downright dismissive of it. “He’s not going to stick to it. I’m going to wait till he’s 75 and he’s going to completely change his mind.” There’s a second group that’s completely supportive of the idea. They tend to be predominantly either health care workers, doctors and nurses who have seen a lot of patients, or people who are caring for functionally or mentally disabled people, family members who now have dementia. They may quibble about the date, but typically they are generally very supportive. Then there’s another group, which is sort of the challenge, the anxious. This thing I really thought provoking to them. They have really suppressed this issue of what’s important in their life. That creates a lot of anxiety and concern.

Lewis: I was very surprised actually by the response. I read your article, you know, once just reading it, and then, obviously, a couple times before doing this interview. And I don’t think you could be clearer about it being your choice, but since you’re a prominent ethicist and a designer of the Affordable Care Act, I mean, the pundits and bloggers read your article and exclaimed death panels. So, the question is, do you advocate any policies that would pace in death or change policies for the elderly in how they access medical treatment? 

Dr. Emanuel: I think it could only be willfully misreading the article if you think there are big policy implications for death panels. It’s quiet clear that this is a personal piece. It opens personally. It’s about my philosophy, my family’s reaction to my philosophy. It’s all about how I’m thinking about it... A lot of people call me for advice (because I’m an oncologist) about cancer or sometimes for other illnesses. And I help many, many people who are over 75, their decision is very different from mine. This isn’t about policy. This is about personal reflection on your own life and what it is you that are living for. That’s the fundamental issue here.

Lewis: Let’s talk a little bit more about the article. You are not planning to kill yourself at 75, which I may remind you is just 18 years away. But you aren’t going to take any steps to prolong your life. How will you approach your health at 75?  

Dr. Emanuel: One thing to emphasize is I’ve been against legalizing euthanasia and assisted-suicide for all of my career. I’ve been very vocal about it, written articles, including a previous article in The Atlantic about it. That’s not the idea here. The idea here is that I’m going to stop taking medical care, where the reason for the medical care (it’s important I’m not stopping all medical care) is going to prolong your life. And that, I think is a very different view. It’s like an intervention, for example, to replace a heart valve because it’s going to prolong your life. That’s not on my agenda.

Lewis: But, something as simple as a flu shot, which you can argue, or other people have argued, could actually help prevent other people from getting the flue.

Dr. Emanuel: We could have deep philosophical argument about the purpose behind the flu short and herd immunity. That may be very valuable discussion in some circles. But, for this purpose, the idea is that there are some vaccines where the purpose is to prolong your life, flu shots being one of them, and there are some vaccines that are really palliative to preventing painful things like the shingles vaccine that prevents shingles from happening. The shingles vaccine is something that I would actually do. And the flu shot, on the other hand, to prevent my dying is something I will stop doing.

Lewis: And the antibiotics will stop?  

Dr. Emanuel: Correct. That seems to be the biggest, most challenging one to people. When I was very active treating patients, withholding antibiotics is very hard for people to do.  

Lewis: To make your case for 75 being a good ending point, you assert that creativity and productivity fades by this age. And you also think older folks should step aside at some point so that the younger generation can become the heads of their families. Let’s talk a little bit about those points. And then why else do you think 75 is really the ideal target?

Dr. Emanuel: Well, I try to look at three or four factors. First is, functional disabilities. When do we begin to have severe limitations on our abilities: climb ten stairs, walk a quarter of a mile. And you see a pretty substantial increase in that, and again, not all the studies mark the same point, but you are seeing a substantial increase. And we’ve seen over the last twenty years an increase in those functional limitations in the population when you are getting over 75. Similarly, there’s a sort of very big increase in Alzheimer’s and other Dementias, such that at 85, you see roughly 33-40 percent of the population having Dementia. Separate from the dementia, there is clear, very reliable data on the slowing of mental processes. We are not as fast. Our short-term memory goes way down and our ability to resolve problems goes down, our distractibility goes way up. I look at that set of data and they aren’t all calibrated to the same age, and you say the chance of being functional, both physically and mentally, 75 is a good time, where you are just before the take-off of big increase in these limitations. And then you look at things like creativity, and again that definitely again, there’s an average, and there’s a distribution. Some people maintain their creativity and their productivity well into their late 70s and 80s. They are the exception. They are clearly outliers... You know, you reach your sort of maximum creativity, productivity in your mid 40s, about 20 years after you start your career. And then you decline, and that decline is pretty reliable. And last, what kind of memories do I want to leave my kids? How do I want them to remember me? That’s very, very important to me. I don’t want them to spend a lot of time with frail dad. Dad not able to get around, constantly asking what he said, and being a burden. And avoiding that is actually quiet valuable to me.

Lewis: You write at the very end that you might just change your mind. Do you feel that way?  

Dr. Emanuel: Let me say two things to that. For those people who know me best, if you think I’m going to somehow flip my view at 75, they are willing to take big bets on it. The second thing is I’m not, I hope I’m not, rigidly dogmatic. I’ve changed my mind on lots of things over my life and career, where I thought I had one opinion, and I’ve looked at this issue, wrestled with it and changed my mind. But this isn’t a view that I’ve come to lightly or immediately. I’ve been talking about this for many decades to my family and kids. So, people who know me don’t think this is out of character or a newfound view. It’s a pretty long thought out, well settled view. And again, lots of people have written me and said, it seems like you don’t have place for kindness, you don’t have place for just a stroll in the garden. You know, I have place for that. One of the things I enjoy most is having dinner parties at my house, and cooking for my friends and having great conversation. If that’s all my life is for, however, that would not be fulfilling to me. And that’s what I’m saying. The point of the piece was to challenge people to be able to articulate for themselves, not just to criticize, “oh, we don’t agree with you, Dr. Emanuel.” It’s a challenge for themselves: what is meaningful for them? And I don’t think it’s simply racking up the number of years. But yet, most of us live like, just living a long time, regardless of what the quality of that life is, is enough.

Dr. Ezekiel Emanuel is the Director of the Clinical Bioethics Department at the U.S. National Institutes of Health. He's also the chair of the Department of Medical Ethics & Health Policy at the University of Pennsylvania.