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09/25/2014

So when do you hope to die?

Perhaps you’ve seen it already:  the ever-more-present Dr. Emanuel has a piece in The Atlantic entitled “Why I hope to die at 75.”  Follow the link and you can read it for free online.

I confess that, upon learning of the title and the author, my mind was flooded with wisecracks.  I publicly repent of those and will repeat none of them here.

I don’t know if the author or his editors wrote the title, but he says that, reminiscent of Holden Caulfield, he means it, he really does. Upon attaining the age of 75, he will most assuredly not change his mind.  And to that end, he intends to curtail cancer screening, eschew treatment for cancer should it be diagnosed, refuse flu shots or antibiotics, and generally take his leave from physicians.  Although one gets the impression that he thinks you should decide likewise, he is adamant that such is not his goal.  Nor will he suggest or advocate for euthanasia or physician-assisted suicide.  He points out that he has consistently opposed those.  And indeed he has.

His real target in this piece is an attitude he calls “the American immortal.”  It is the notion that we can substantially prolong the period of our vigorous life, if not the entire lifespan itself, and compress the decline of old age into a very brief period at the very end.  But the data say otherwise.  Immortality is an unwise goal and the compression of morbidity an illusion; as we age, we our physical and mental capabilities inevitably, and seriously, decline.  We should be ready to pass the torch to the next generations, get out of their way, let them be relieved of the burden of our looming presence, and let them remember us in our glory, not our dotage, the author says.

There’s more than a little wisdom in this.  Immortality is indeed an unwise goal, and we should have realistic expectations for our mortal coil as we age.  From the little reading I’ve done in bioethics, I hear a bit of Daniel Callahan in Dr. Emanuel’s essay.

But there’s also enough internal contradiction in the piece to suggest that he is not taking age 75 (for him, 2032) as a firm cutoff.  He thinks that mental decline necessarily constrains our old age but also that more research on Alzheimer’s is urgently needed (I agree), with the presumed goal to enrich life into one’s late 70s and 80s.  He speaks of his 87-year-old father, whose delay at seeking medical help for what turned out to be a heart attack 10 years ago might have preserved more of his function than he has now.  And, apart from all that, we must not forget that we all age at different rates, and that research has shown that people, including physicians, tend to think when they are health that they would not want life-prolonging care that in fact they do want when confronted with the end of life.  People do change their minds.

And of course, given Dr. Emanuel’s role in health policy and his other writings on, for example, the “complete lives system” for allocating scarce resources, one might well worry that even if Dr. Emanuel is telling us the truth when he says he doesn’t want to force-feed anyone else with his approach to old age, people who can, and quite likely will, take medical decisions out of the hands of us and our physicians will.  That is indeed a problem.  “I’m sorry, Mrs. Fitswhistle, but you are too old to get treated for your condition, even if there’s a good argument that you are physiologically a good candidate for it.”  Cancer doctors like Dr. Emanuel know well that chronologic age by itself does not generally determine whether cancer treatments are effective.  Will the politicians, the bureaucrats, and the bean-counters in hospitals and private insurance companies remember things like that?  We should worry they won’t.  I mean it, I really do.

But the most telling, most poignant feature of the essay in The Atlantic is the affluent American conceit that a life well lived consists in one’s achievements and ongoing capacity to achieve.  We shouldn’t want our kids to remember us old and frail?  My grandfather, in his later years, said of himself and my grandmother, “Jesus said whatever you do the least of these my brethren, you do to me.  Well, we’re the least!”  And then there is this, from Dr. Emanuel’s word processor:

“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 [sic] 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.”

And that brings to mind this, from the pen of the Puritan Jonathan Mitchell, in 1659, in a preface to Thomas Shepard’s book on The Parable of the Ten Virgins: 

“That to make sure of life eternal is the one necessary business that we sons of death have to do in this world, and without which all our time here is worse than lost, every enlightened mind will easily acknowledge; this present life being, by the rule of it, appointed but to this end, to be preparation time, spent in a continual care to make ready, that we might have a good meeting with Him who shall be seen in this air one day.”

And these words from the mouth of Jesus of Nazareth:  “Strive to enter through the narrow door.  For many, I tell you, will seek to enter and will not be able.”

We should hope to live long enough to be ready.

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