“Seventy-five. That’s how long I want to live: 75 years.” So opens a piece in the September 17 issue of the Atlantic written by Ezekiel J. Emanuel. In “Why I Hope to Die at 75,” Emanuel reasons that by age 75 he “will have lived a complete life.” He writes, “I will have loved and been loved … I will have pursued my life’s projects and made whatever contributions, important or not, I am going to make. And hopefully, I will not have too many mental and physical limitations.”
The conversational tone of the 14-page feature, replete with personal anecdotes and photographs, might suggest to the casual reader that the author is simply expressing his personal preference for how and when he would like to see his life end. But Emanuel, head of the Department of Medical Ethics & Health Policy at the University of Pennsylvania, is an influential player in the US health care establishment.
Emanuel is also the director of the Clinical Bioethics Department at the US National Institutes of Health, the group that recently brought us “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” analyzed in some detail by the WSWS. More specifically, Emanuel is a close ally of President Barack Obama, having served as a special adviser of health care reform to the White House, and credited as one of the chief architects of the Affordable Care Act. He is also the brother of Chicago mayor and former Obama Chief of Staff Rahm Emanuel.
Emanuel has called for an outright end to employer-based health care, and in his most recent book predicts approvingly: “By 2025 few private-sector employers will still be providing health insurance,” mainly as a consequence of Obamacare. In an earlier book he proposed, as part of plan to overhaul the health care system, a voucher-like scheme that would scrap Medicare, Medicaid and the State Children’s Health Insurance Program (SCHIP).
So Emanuel does not have the luxury of musing from the sidelines on the meaning of life. He writes with an agenda, and it is a sinister one. He disparages Americans’ obsessive efforts to “cheat death and prolong life as long as possible,” a phenomenon he defines as a “cultural type: what I call the American immortal.” He says that while people are living longer, “our older years are not of high quality.” Simply put, his prescription to do away with this “manic desperation to endlessly extend life” is for the people to forego advanced medical treatment and tests as they age, and to allow death to take its course.
In an effort to champion this “die sooner, but die better” cause, Emanuel advances a set of arguments that are simultaneously spurious and Malthusian. While admitting that seniors today are less disabled and more mobile compared with their counterparts 50 years ago, he notes that, “over recent decades, increases in longevity seem to have been accompanied by increases in disability—not decreases.” He stresses, therefore, that, “health care hasn’t slowed the aging process so much as it has slowed the dying process” (emphasis added). One can only assume that he advocates an acceleration of this “dying process.”
In curiously distasteful fashion, he uses the example of his own father to bolster his argument. The senior Emanuel suffered a heart attack about a decade ago at the age of 76. “Today he can swim, read the newspaper, needle his kids on the phone and still live with my mother in their own home,” Emanuel writes, “But everything seems sluggish. Although he didn’t die from the heart attack, no one would say he is living a vibrant life.” He adds parenthetically, “Despite this, he also said he was happy.” Apparently his father’s life is not sufficiently “vibrant,” and a better course of treatment would have been to forego the bypass surgery that saved his life, which would have undoubtedly resulted in a quick death.
Emanuel notes that as life expectancy increases, so do the number of Americans suffering from disabilities induced by stroke and other medical conditions and diseases. He also warns of a “tsunami of dementia,” with experts predicting “a nearly 300 percent increase in the number of older Americans with dementia by 2050,” and no cure in sight in the foreseeable future. Emanuel evokes the specter of growing hordes of physically and mentally disabled seniors in an effort to alarm his readers to bring them around to his point of view: they would be better off dead.
However, he conveniently avoids a number of pertinent questions. Children of elderly parents are often tasked with providing their care, or negotiating for it in the underfunded and bureaucratized Medicare system. Why not advocate for a huge infusion of cash to provide care for such individuals—whether at home or in a hospital setting—where the needs of patients and their families could be dealt with compassionately? Also, while the US squanders trillions of dollars to bomb and terrorize the world’s population, where are the resources to fund vital medical research to fight cancer, heart disease, Alzheimer’s and other debilitating conditions? Emanuel does not address these issues.
In an article published in the Hastings Center Report in 1996, Emanuel wrote that, “services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.”
Anticipating the reader’s argument that they or their parents might be among the lucky ones who escape dementia or physical disability in old age, Emanuel counters: “Even if we aren’t demented, our mental functioning deteriorates as we grow older,” adding, “It is not just mental slowing. We literally lose our creativity.” He provides a chart showing the typical “age-creativity curve,” according to which “creativity rises rapidly as a career commences,” peaks at about age 40-45, and then enters “a slow, age-related decline,” with the last significant creative contribution shortly after age 60.
So are we to believe that a decline of creativity as one ages is an argument that this life no longer has meaning? And that society has no responsibility to value the lives of its citizens in old age, regardless of their physical or mental state? There is more than a whiff of fascism is such conceptions. Lest the reader protest that we exaggerate, consider the similarity to the views of Dr. Arthur Guett, a high-ranking health official in the Nazi regime, who declared that “the ill-conceived ‘love of thy neighbor’ has to disappear…. It is the supreme duty of the … state to grant life and livelihood only to the healthy and hereditarily sound portion of the population in order to secure … a hereditarily sound and racially pure folk [Volk] for all eternity.”
Emanuel argues as well that parents living too long places “real emotional weights on our progeny” and makes it “hard for grown children to become the patriarch or matriarch.” Emanuel embraces the contempt promoted in ruling circles for society’s senior members, who instead of being cared for and honored for their lifelong contributions are considered a financial drain. “When parents routinely live to 95,” he adds, “children must caretake into their own retirement.” Again, what goes unmentioned is the fact that under the for-profit health care system, and the miserable provision for the vast majority of the population in retirement, the burdens—financial and otherwise—that should fall on society, fall instead on stressed families.
Emanuel finally gets to what he proposes for himself. He says at 75 and beyond, “I will “accept only palliative—not curative—treatments if I am suffering pain or other disability.” His last colonoscopy will be at 65, and he will refuse cancer treatment, bypass and other heart surgeries, as well as antibiotics. And he will have a do-not-resuscitate order and will refuse all life-sustaining interventions.
He claims that he is not trying to convince anyone that he is right, or saying that anyone who chooses otherwise is unethical. He then insists: “And I am not advocating 75 as the official statistic of a complete, good life in order to save resources, ration health care, or address public-policy issues arising from the increases in life expectancy.” Excuse us for rejecting this disingenuous disclaimer, based on Dr. Emanuel’s long record of promoting the “free-market” model of health care delivery.
In the same Hastings Center Report quoted above, Emanuel advises that under conditions where the “free market,” i.e., for-profit health care under capitalism, limits resources, he favors “a two-tiered health system—some citizens will receive only basic services while others will receive both basic and some discretionary health services. Within the discretionary tier, some citizens will receive very few discretionary services, other richer citizens will receive almost all available services, creating a multiple-tiered system.” According to Emanuel’s “Hope to Die at 75” vision, it is the wealthy who would have the “choice” of life-prolonging treatments for themselves and their families, while workers and the poor would be relegated to substandard palliative care in understaffed nursing homes.
Which brings us to the doctor’s conclusion, where he writes after badgering his readers on the correctness of his viewpoint: “I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible.” What cynicism! But it is not surprising, as his argument was never really about him. Rather, the promotion of early death is a particularly sinister component of a campaign aimed at realigning health care in America even more heavily in the interest of the rich.