Will Dr. Emanuel opt for death at 75? Maybe not

Nobody has ever accused the famous Emanuel brothers—Dr. Ezekiel Emanuel of the University of Pennsylvania, Mayor Rahm Emanuel of Chicago or Hollywood agent Ari Emanuel—of humility. And no one who reads Dr. Emanuel’s new essay in the Atlantic Monthly, “Why I Hope to Die at 75: An Argument That Society and Families—and You—Will be Better Off if Nature Takes its Course Swiftly And Promptly,” will accuse him of that trait now.

Emanuel, 57, an oncologist and bioethicist who played a role in crafting the Obamacare legislation, tries to convince readers of the rightness of his own preference to only live to 75 and go out while he’s still making solid professional contributions and his family and friends can remember him as a vigorous and productive person. He wants everyone to consider adopting his view, though he acknowledges that his physician father, now in his late 80s, is still happy despite having slowed down a lot.

But the big unanswered question in the essay is what effective steps the good doctor would have us take to avoid what he regards as the “ultimate tragedy” of living too long and leaving our families with “memories framed not by our vivacity but by our frailty.”

He argues against pursuing medical interventions in old age that could extend our lives, such as the cardiac catheterization and bypass his father underwent after suffering a heart attack at 76. Emanuel does not advocate rationing healthcare services to the elderly in this article, though in a 2009 Lancet article he has supported age-based or quality-of-life-based rationing of scarce medical resources. Instead, he advocates voluntarily eschewing tests and treatments after turning 75 that could potentially prolong life, such as PSA tests, colonoscopies, cardiac stress tests, pacemakers, and even flu shots and antibiotics. “I will accept only palliative—not curative—treatments if I am suffering pain or other disability,” he wrote.

The problem with that is even if Emanuel rejects tests and other medical interventions, he still may enter a period of decline, for example from Alzheimer’s disease, that could carry him without treatment well into his 80s or 90s, notes Barbara Coombs Lee, president of Compassion & Choices, a group which counsels people on end-of-life options and supports physician aid in dying for the terminally ill. “The fantasy he creates is that if you don’t avail yourself of life-prolonging treatment, your death will come relatively quickly, painlessly and gently. That’s not necessarily true.”

What Emanuel rules out are any active measures that aging people with deteriorating quality of life could take to end their lives. He cites his long-standing opposition to physician-assisted suicide, which is legal for terminally ill patients in five states and which nearly was approved by voters two years ago in Massachusetts. People who seek aid in dying, he wrote, “tend to suffer not from unremitting pain but from depression, hopelessness, and fear of losing their dignity and control. ... The answer to these symptoms is not ending a life but getting help.”

Let’s leave aside the substantial evidence from Oregon and Washington that many patients seeking aid in dying under those states’ pioneering Death with Dignity laws do indeed suffer untreatable pain and that they overwhelmingly are not suffering from clinical depression.

The strange thing about Emanuel’s essay is that he himself believes that getting old, sick and feeble is cause for depression, hopelessness, and loss of dignity and control and he sees no possible help for it. “Living too long … renders many of us … faltering and declining, a state that may not be worse than death but is nonetheless deprived … We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.”

Coombs Lee points out Emanuel’s whole article is about his fear of losing dignity and control, but then “he casts aspersions on other people because they fear losing dignity and control and he would deprive them of taking steps to prevent it.”

What will Emanuel do when his time of infirmity arrives? Wisely, he leaves himself some wiggle room: “I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible.”

Follow Harris Meyer on Twitter: @MHHmeyer