October 12, 2014

Farewell to All That

In his 1905 farewell speech to the faculty of Johns Hopkins University Medical School, Dr. William Osler commented that the school was wise to hire someone young and energetic in his stead (he was very distinguished—and 55 years old). In passing, he mentioned Anthony Trollope’s satirical novel from 1882, “The Fixed Period,” in which all 67-years olds are to be sent to a special sanctuary, a kind of cross between a high-end resort and a liberal arts college, and given one year to put their affairs in order. At the end of the year, the plan is to chloroform them. The idea was to make sure that everyone quit while he was ahead, without waiting for the decline thought to inevitably accompany aging. Osler’s speech sparked a huge outcry in the media, which inveighed against his alleged endorsement of universal, mandatory euthanasia. Osler, who was well known as a joker and prankster, had endorsed no such thing. His remarks about the “comparative uselessness of men over 40 years of age” and his recommendation for compulsory retirement at age 60 were said tongue-in-cheek.

A similar media frenzy ensued nearly 80 years later when then governor of Colorado, Richard Lamm, was quoted as saying that elderly, terminally ill patients "have a duty to die.” Lamm hastened to assure the public that he didn’t actually mean that seriously ill patients should commit suicide, assisted or otherwise. What he meant, or so he insisted, was that it made no sense from a societal perspective to expend enormous resources on medical care for the dying. His choice of words was unfortunate, as was his failure to acknowledge that another reason for limiting care near the end of life was precisely that it aggressive treatment did little, if any good, not merely that it cost a lot.

Now enter Ezekiel Emanuel, an ethicist, physician, and health policy guru, with his loud proclamation that once he reaches the age of 75, he wants treatments devoted only to his comfort, not to prolonging his life. Emanuel, unlike Trollope and Lamm, is dead serious, as his article in the Atlantic, "Why I Want to Die at 75," attests.

At its core, his argument shares the legitimate concern of his intellectual predecessor, philosopher Daniel Callahan, that failure to accept our inevitable mortality is leading us to make foolish decisions about medical care. As patients we choose, as a society we pay for, and as researchers we pursue treatments that offer a vanishingly small possibility of prolonging life, treatments that come with tremendous physical and emotional suffering and enormous cost. To the extent that Emanuel is arguing that this approach is wrong, I agree with him entirely. To the extent that Emanuel is arguing that we as individuals need to revise our goals of medical care as we age, I agree with him entirely. But to the extent that he is arguing that life is worthless after age 75 and that it would be better to forgo all medical care except that focused on comfort after one's 75th birthday, I think he is fundamentally misguided. 

Of course if Dr. Emanuel wishes to decline medical treatment in the future, that is his prerogative. Contemporary biomedical ethics teaches respect for individual autonomy, which means every individual is free to refuse any (or all) proffered medical treatments. So why should anyone apart from his friends and family, and perhaps his physician, care about the personal decisions that Emanuel makes about his medical care? The reason that people care—and that there has been a strong and negative reaction to Emanuel’s announced plans—is that they rest on various assumptions which, if true, would suggest that everyone else ought to consider the same approach. So it is essential to examine critically Emanuel’s views of what matters in life and his implicit belief that the only possible goals of medical care are either maximization of comfort or prolongation of life.

As a quick way to get a sense of what Ezekiel Emanuel considers important, take a look at PubMed, which lists all published scientific publications. Emanuel published 19 articles in 2013, almost all of them in leading journals including the New England Journal of Medicine, JAMA, and the Lancet. And that doesn’t include all his New York Times op-ed pieces (he is a “contributing opinion writer” for the Times), which arguably are far more influential. Now move on to Emanuel’s bio. He is Chair of the Department of Medical Ethics and Health Policy and Vice Provost for Global Initiatives at the University of Pennsylvania. As to what he does in his spare time, apparently he climbs mountains—the Atlantic article features a photo of him and his two nephews, with whom he recently climbed Mt. Kilimanjaro. Dr. Emanuel (he is also an oncologist) continues, at age 57, to function at a level that many would place somewhere off in the stratosphere.

So Emanuel is something of a superman and he’s concluded that when he stops being able to keep up his current pace, he can’t imagine that life will be worth living. Not that he plans to commit suicide or to ask anyone else to end his life. He will simply forgo all potentially life-prolonging therapy and die at the earliest opportunity. Now here is the first place where Emanuel is sadly misguided. He fails to understand or at least acknowledge the importance of any dimension of life other than what he has thus far experienced—success measured by the publication count and the prestigious positions, the mountains scaled, literally and metaphorically. It’s not just that proclaiming that life must be lived at a fevered pitch or not at all seems to categorize most of the rest of us as not-living-a-worthwhile-life; after all, Emanuel doesn’t claim to be imposing his standards on everyone else. It’s that Emanuel’s relentless desire for a narrowly defined kind of accomplishment gives short shrift to precisely those activities that many cultures deem of greatest value. The Jewish tradition, for example, calls upon every individual to participate in acts of loving kindness (gemilut chasadim) and in efforts to repair the world tikkun olam), however small those efforts.  Every stage of life comes with its challenges and its possibilities and it’s up to us to try to do our best in whatever condition we find ourselves.

But while I feel sad that such a talented and (otherwise) insightful person as Dr. Emanuel fails to see any merit to a life other than the one he is currently leading, that is not my main criticism of his stance. Nor is my main criticism that he is na├»ve if he believes that forgoing life-prolonging therapies such as pacemakers and antibiotics will necessarily shorten his life, when many people live for years without such treatments. Moreover, excluding a treatment from consideration merely because it might lengthen life may well have several presumably unintended consequences: refusing a flu shot (in the hope that you might contract the flu, develop complications, and die, a relatively unlikely outcome) has public health consequences as you may transmit the flu to others who do not share your death wish; and declining a pacemaker (in the hope that a slow heart rate might be lethal) may result in falls, broken bones, and dizzy spells all of which impair your quality of life without killing you. The primary difficulty I have with Emanuel’s perspective is that he completely misses the possibility that someone might have any other goal aside from maximizing comfort, on the one hand, or prolonging life, on the other. My view is that this is in-between position that Emanuel ignores is precisely what most people find themselves endorsing as they age.

We are both mortal and at high risk of experiencing increasing disability in the last couple of years of life (though not, as Emanuel seems to think, starting at age 75). The implication of these realities is that when death appears on the horizon (if, for instance, you develop a fatal illness) or when frailty rears its head (if, for example, you develop one or more impairments in your basic daily activities), it is a signal to reconsider the goals of medical care. Most people, I have suggested elsewhere in this blog as well as in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, choose comfort as their primary goal if death is imminent and choose maintaining their daily functioning, that is maximizing their quality of life, if they are becoming frail. Most people make this switch even though they continue to wish for a longer life; they are simply saying that if the price they have to pay for longer life is pain and suffering (in the first case), or poor quality of life (in the second), they are not interested. Dr. Emanuel, in his black-and-white, all-or-nothing view of the world, fails both to recognize that there is a middle ground where people choose treatments that promote quality of life, and that decisions to forgo treatment are predicated on the need to make trade-offs, not on the wish to die.

I hope that in all the furor over Dr. Emanuel’s article in the Atlantic—and he has certainly triggered a storm of protest—we will be able to get beyond the arrogant implication that only a life of intense and continuous activity is worth living, and accept the more modest reminder that is at the heart of his article: that we are all mortal. And as we approach the end of our lives, we may wish to modify our hopes and expectations in accordance with the reality of our situation and seek medical treatments that correspond to our new goals of care.


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