Monday, October 06, 2014

Hoping to die at 75 isn't the right approach

Ezekiel Emanuel, a bioethicist (and brother to Rahm Emanuel) has created a bit of a firestorm with an Atlantic article about his desire to stop at 75. The Emanuel brothers seem to share a gift for brashness and controversy, because I am guessing that 90% of the attention that is being given to the article is because of the choice to name a specific age for his end. That's a shame, because there are some genuinely important issues getting lost in the brouhaha.

Emanuel, as a bioethicist, sees health and life and death from a population-level perspective, and makes some excellent points about the way our current so-called health care system just manages to prolong sickness and disability. I think that those points have gotten lost in the furor over the idea that there is an age at which people might want to choose death (in a passive way, as Emanuel opposes euthanasia and doctor-assisted suicide).

Americans are uncomfortable with death as a rule, so like everything unpleasant, we don't think about it and hope to put it off as long as possible. The best thing about this article going viral is that maybe it will start people thinking about not only what kind of life they want to have, but what kind of death they'd like to have.

We don't have a health-care system, we have a death prevention system and an illness-curing system.   Doctors rightly focus on patching us up when we're sick or injured, because that is what they are trained to do.  But if patients go on with the same habits that got them sick and injured in the first place, they may be worse off in the long run for that care, or even get a false sense of security that they can continue to make bad choices because the doctors will fix them with a procedure or a pill.

It makes sense to think, when making medical decisions, about what the likely long-term outcomes will be, given the patient's lifestyle and willingness to make changes. This kind of decision-making should be done at all ages, not just after 75.

I also think Emanuel is too quick to dismiss the role that lifestyle plays. Maybe total "compression of morbidity" is impossible, but lifestyle definitely plays a role in long-term health. I think that he envisioned people like himself when writing the article, health-conscious people with relatively high incomes.  For many Americans, the kind of slow decline that he envisions from old age starts happening a lot younger because they don't look at the ways to prevent disease and disability with lifestyle.  75 may be way too late for them.

The author has a high standard for what he considers a quality life, and though as he acknowledges, some exceptional people live high-achieving, high-quality lives long past 75, he doesn't want to live long after he starts to slow down.  It's a hard-driving male perspective, but he's a man and he has the right to have it.

My grandfather had the kind of quiet life that Emanuel was so quick to dismiss. He was from Italy and he was a shoemaker. He gardened, painted, and spent time with his family. He was active but also overweight. He smoked a pipe sometimes. A cardiologist who didn't know him tried to tell him to have open-heart surgery in his late 70s, and recommended a strict diet and all kinds of changes. Another cardiologist, a friend of the family, said, "Nick, don't do it. Go home and enjoy the rest of your life." He had the ideal death. He had a stroke a couple of weeks before his 90th birthday, and never regained consciousness, dying a few days after. A nurse said, "He's the strongest 70-year-old man I've ever seen."

I don't discount the value of a quiet life, but I am also never going to be the kind of person who wants to put death off as long as possible. I know too well what "as long as possible" looks like, and it isn't pretty. I'd suffer just about anything as long as there was hope to go back to a satisfying, mostly self-sufficient life.  But I would think carefully about any surgery or prescription drug. What is the whole picture? What are the risks? Are the long-term consequences worse than whatever it is I'm trying to address? What kind of lifestyle changes can I make instead? This is the kind of thing we should all be doing, and not just after 75.

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