Wikipedia will tell you that Dr. Ezekiel “Zeke” Emanuel is a 57-year-old bioethicist. This is a person who deals with ethical questions about aging, dying, and appropriate medical care. His education is about as distinguished as it gets: a bachelor’s degree from Amherst; a master’s in biochemistry from Oxford; and two degrees from Harvard, an M.D. and a Ph.D. in political philosophy. His medical career is even more impressive: an internship and residency at Beth Israel Hospital in internal medicine, an associate professorship at Harvard Medical School, the Chief of Bioethics at the Clinical Center of the National Institutes of Health, and a special advisor on health policy to the Director of the Office of Management and Budget. The last position gave him the ear of the president on matters concerning health care reform. For the past three years he has headed the Department of Medical Ethics and Health Policy at the University of Pennsylvania. It seems safe to say that he’s not just any bioethicist but likely the foremost bioethicist in America. His influence is heightened by the near celebrity status he enjoys by being the older brother of Rahm Emanuel, the outspoken and sometimes profane mayor of Chicago, and Ari Emanuel, a talent agent known as a “21st century Hollywood mogul” and “the pre-eminent power player” in Hollywood.
I’ve presented Emanuel’s credentials at length as a glaring contrast to what’s coming next. It was last month that he stunned many members of his profession and, no doubt, millions of older Americans by writing a piece for The Atlantic titled “Why I Hope to Die at 75.” He opposes euthanasia and assisted suicide, so he won’t take direct steps to die at that age. However, he asserts he will reject any medical care from that age forward. If he is resolute, that action will certainly shorten his life. As a man of science, one would expect that he has a rational explanation for this plan, and indeed he does. He says statistics show that 75 is a plateau from which health steadily declines. Before that age we are generally in fair to good health, active, and engaged with life. Afterward our bodies steadily fail—morbidity increases, he would say—and the quality of life begins a steady progression toward death. His plan appears to be data-based and, one might add, courageous and virtuous. Virtuous because he will not burden society with the costs of being propped up by perhaps a decade or more of life-prolonging treatment.
But is it really courageous and virtuous? I’ll get to that question in a minute. First I want to ask, is his announcement ethical? It had better be; otherwise, he has impeached his entire career. I answer this question by imagining that Yolanda, our cleaning lady, has just told us she hopes to die at 75. Of course we’d never ask ourselves whether this confidence is ethical or unethical. Emanuel, on the other hand, is a famous and learned specialist on matters of aging and dying. When he tells the world that 75 is a good age to die, that is a celebrity endorsement. It’s no different from Martha Stewart saying that she favors the home furnishings made by Company ABC. What is the impact of a celebrity endorsement? Persuasion—uncommon persuasion. It’s plausible that millions of older Americans, somewhere in the ballpark of 75 years, have now begun an uncomfortable inner dialogue. Haven’t I had a full life, and aren’t I slowing down? My aches and pains are a nuisance all right, and of course there’s my high cholesterol, hypertension, arthritis, and forgetfulness. I don’t want to be a burden, and I’ve always tried to be honest with myself. Perhaps Dr. Emanuel has shown me what I need to do. These thoughts will undoubtedly be stressful. Most elderly people are just as goal-driven as they were in younger years, but their goals have changed. They may want to see their grandchildren grow to young adulthood at least, if not graduate from college and get married. They may have their 50th wedding anniversary ahead of them, or a long vacation they’ve always meant to take. If they’re still working, they may want to leave enough in the bank to make a surviving spouse more secure. To be sure, we can say that all Emanuel has in mind is to help elderly people think more clearly about their final years, but I don’t think this defense really holds up. After all, there was no need whatever for him to frame his presentation as a momentous decision that he will enact at an arbitrary age. He could still have written about the period of prolonged morbidity that typically begins in the 70’s. But then he could have avoided the personal slant by saying, “It’s up to you to decide when the hardship of old age outweighs the sweetness you find in life.” He could have concluded by observing, “At that point you might reasonably decide to reject further medical care.”
But he didn’t. Instead he chose to take center stage in a national magazine and marshal his medical authority to argue for dying at 75. That isn’t sound ethical counseling; that’s grandstanding. Any doubt of it vanishes when we realize that he won’t be 75 for 18 more years! If he would turn 75 in a few more years, think of the wonders that difference would do for his credibility. But at his present remove from old age, there’s every reason not to take him seriously. He knows very well that the pace of medical progress grows ever faster. He’s certainly familiar with the advances in using gene therapy to treat disease and the clinical trials underway for generating specialized tissue from stem cells. Likewise, he’s aware of how close we are to having drugs that can target specific kinds of cells, the “magic bullets” that have been sought for so long. However, he can’t wait, say, 15 years to become more credible; the medical landscape he describes may by then no longer exist. So now is the time for him to seize the limelight. And therein lies the answer to the earlier question of whether his announcement is courageous and virtuous.
Since the publication of the magazine piece, Emanuel has done well to keep its sensationalism alive. Late last month he was interviewed on the ABC news show “This Week,” and last week he was a guest on “PBS NewsHour,” the much-respected evening news show. I missed the former but saw the latter. He spoke with Judy Woodruff, who gave one of the most inept interviews in my memory. Her approach to Emanuel was “Gee, you’re such an original and surprising person. Why don’t you share your fascinating point of view with everyone?” Too bad that something like the Razzies aren’t awarded for journalistic malpractice. The key moment in the interview was when he declared what would happen when he turned 75. “I’ll no longer seek medical care,” he said. Period. But what did that mean exactly? If he breaks a leg, would he have it set? If an ailment causes pain, would he take pain medication? If he develops a serious infection, would he take antibiotics? Would he accept medication for high cholesterol or high blood pressure? Would he get annual flu shots? If his balance deteriorated, would he consent to using a cane. How about cataract surgery? How about a pacemaker? Woodruff did nothing at all to get him to expand his simple declaration, and he didn’t volunteer anything further. Fortunately, I knew what was in the magazine article. Essentially, he has no problem with accepting treatment for pain, but if he develops any condition that might threaten his life, treatment is out of the question. In fact, even care that might prevent such a condition is verboten. So no to vaccines. No to antibiotics. No to cholesterol or blood pressure medication. No to a pacemaker or defibrillator. I suppose he’d agree to cataract surgery because cataracts won’t kill you, but I’d guess no to a cane. After all, if your balance is poor, you might fall and kill yourself, and it would be wrong to prevent that possibility.
Woodruff had the opportunity to unpack all this for her audience. Without being confrontational, she could have revealed the goofy and arbitrary line Emanuel had drawn. Perhaps his unnecessary personalization of the issue would have also been clear to see. Her viewers might even wonder whether his motive was self-aggrandizement. A pity that this alternative point of view never had a chance to emerge. What’s worse, though, is that she never focused on what Emanuel sees as the arc of a person’s life. He laid it all out in The Atlantic, and it’s the key to everything else he has espoused. Emanuel sees life as being full of growth, creativity, and richness in youth, full of productivity and social meaning in middle age, and then dramatically declining in the eighth decade. At that late point, he sees only reclusiveness and an engagement in quiet hobbies that are almost embarrassing compared with the accomplishments of earlier years. You can read between the lines and feel his scorn for the pastimes of the elderly. The picture grows even darker as he describes the sadness of children and grandchildren as they reflect on what the aged person used to be. Finally, he writes of the shadow this person casts over younger relatives, who can never truly own their lives so long as an older authority figure lives. It’s very grim, but then you realize what Emanuel’s “Hope to die at 75” is really all about: he knows subconsciously that deep depression is coming, and he needs to plan his suicide. The problem is, he is publicly opposed to suicide, assisted and unassisted. He has asserted that suicide is almost always due to depression, and depression should be treated! (How’s that for a twist?!) So his challenge was to come up with a nonsuicide suicide, and sure enough, he found a way to do it. His solution is to combine suicide with Russian roulette; that is, invite death to take him without knowing where the fatal blow will come from. Very clever, and very self-deceptive.
If I were to meet Emanuel by chance, I’d advise him to consult with a competent bioethicist. There’s no need that he do it right away, but certainly within the next 18 years. The competent bioethicist would tell him something like this: People differ sharply in their attitudes toward every aspect of life—sex, money, work, religion, politics and, of course, death. They know that chance plays a huge role in the time and manner of death, but they nevertheless want as much choice as fate will allow. When you try to take suicide off the table, you constrain choice and commit a cruelty. Remember that depression can be rooted in hard facts, like multiple disabilities, intractable pain, degenerative illness and, yes, the loss of a stellar public life. But whatever the cause of the depression, the loss of one’s will to live must be respected.
You may wonder what my personal thoughts on dying are. As it happens, they are very much like those of the “competent bioethicist.” I trace my thoughts back to a man who is conceivably the most brilliant bioethicist who ever lived: Woody Allen. He’s made many profound observations about dying, but the one that stays with me most is: I am not afraid of death. I just don’t want to be there when it happens. Now, many people think he’s referring to his body not being present at death, and that makes for a pretty good joke. But I’m convinced he’s referring to his mind, and this gives the statement a bioethical meaning. I like to tack a thought of my own on to Allen’s. I call it the Marks Corollary to the Allen Observation: If I’m not there and not likely to return, I want it to happen.
The Scratching Post 