Striving for Quality, Not Quantity, of Life

A Conversation With Ezekiel J. Emanuel, MD, PhD

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Ezekiel J. Emanuel, MD, PhD

My main goal for writing the article was to start a conversation about the importance of quality rather than quantity of life, but I’m very comfortable with lots of people not agreeing with my view.

—Ezekiel J. Emanuel, MD, PhD

Advances in science and medicine have led to humans living longer than at any other time in history. According to a new report1 on mortality from the Centers for Disease Control and Prevention’s National Center for Health Statistics, life expectancy in the United States is at an all-time high of 78.8 years, up 0.1 year since 2011. “Good news, America: We’re living longer!” read the opening line in a story in USA Today2 announcing the report’s findings.

But those extra years do not necessarily add up to quality ones. Advances in health care have not so much slowed the aging process as they have the dying process, contends Ezekiel J. Emanuel, MD, PhD, Chair, Medical Ethics & Health Policy at the University of Pennsylvania in Philadelphia, in an essay he penned in the October issue of The Atlantic.3 

Titled “Why I Hope to Die at 75,” the article has set off a firestorm of controversy, including accusations by critics that Dr. Emanuel is advocating health-care rationing, death panels, and even legalized euthanasia for people living beyond 75, none of which is true.

Instead, Dr. Emanuel writes about his personal preference to refrain from taking life-sustaining medical steps once he reaches 75.

While it is doubtless that death is a loss, living too long is also a loss, wrote Dr. Emanuel. “It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death, but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us,” he said.

In the article, Dr. Emanuel cites studies showing the progressive erosion of physical and mental functioning as people age. Rather than experiencing the expectations expressed in the theory of “compression of morbidity”4—which argues that as life spans are extended, people will live longer healthier years, with a shorter proportion of time spent in a state of decline—there has been an expansion of morbidity in which there is an increase in the absolute number of years lost to disability as life expectancy rises, he wrote.

The ASCO Post talked with Dr. Emanuel about his views on aging, the public health-care policies he would like to see changed, and the reaction to his article.

Position Clarified

How did you arrive at 75 as the optimal age to die?

Although the title of my essay is “Why I Hope to Die at 75,” I didn’t pick it—my editors did—and it misrepresents what I was was trying to say in the article. I’m saying that at 75 I’m going to stop taking any life-sustaining medical treatment in which the justification for the medical intervention is that it will prolong my life. That’s my view. I fully expect to be alive at 75, kicking, talking, I hope coherently, and probably reasonably healthy.

How I got to 75 as the number of years I want to live is when you look at the increase in the rates of physical disability and mental deterioration as well as dementia as you age, and you look at the rates of decline in productivity, creativity, and intellectual contribution as you age, 75 looks like the maximum age you are most likely to still be physically fit, mentally sharp, and still able to contribute to society.

Drawing the Line

You are 57 now, and you say that at age 65, you will stop getting screening tests for prostate, colorectal, and other cancers. After 75, you will refuse treatment if you develop cancer or heart disease as well as flu shots and antibiotics for pneumonia. Why?

The only time I had a prostate cancer screening test was when a urologist forced it on me. When he called me with the results, I hung up before he could tell me what they were. I don’t think prostate cancer screenings are a useful public health measure, and getting them leads to more side effects for men than benefits. So that screening is out for me regardless of age.

I will get my last colonoscopy at 65, and it is good for 10 years, which will take me to 75. At that point, I am not doing any more health screenings or treatments that will prolong my life.

The harder medical decision is refusing antibiotics. In my experience in helping people manage their parents’ or grandparents’ health care, making the decision to refuse antibiotics for pneumonia or skin and urinary infections is the hardest one. But as I make clear in my quote from Sir William Osler in his turn-of-the-century medical textbook, The Principles and Practice of Medicine, unlike the decays associated with dementia or other chronic conditions, death from these infections is quick and relatively painless. Antibiotics are effective and often prolong life in people with debilitating diseases like Alzheimer’s, so no to antibiotics.

‘American Immortal’

You coined the term “American immortal,” which you describe as someone bent on furiously exercising, adhering to strict diets, and popping vitamins and supplements in a futile attempt to avoid death. What is wrong with maintaining a healthy lifestyle to potentially ward off infirmities for as long as possible and aiming for a healthier older age?

There is nothing wrong with eating a good diet and exercising regularly. But there is a sort of religious obsession in this country with living as long as possible. People go to extremes to consume various juice and protein concoctions and refuse to eat meat thinking if they deprive themselves today it will add a few years to their life.

Indeed, we know the best way to live a long time is severe caloric restriction. But that is hardly a good life on the way to a long life. The data suggest that those extra years are likely to include some physical and mental limitations and dementia, and that is what I am arguing against.

This religious fervor of prolonging life for as long as possible comes at a cost, including the cost of not living a high-quality life today.

Two Perspectives

In your article, you describe the decline in your father’s health after he suffered a heart attack 10 years ago when he was 77. Bypass surgery saved his life but left him weaker, slowing down both his step and his speech. Still, you quote your father saying he is happy. He has had an extra decade to spend with his family, and you have had an extra decade with your father. Isn’t that a reasonable tradeoff to living a less healthy but longer life?

Part of the reason I included that information in the article was to contrast the parent’s and the son’s view. Part of what I feel is somewhat tragic. We had a long discussion about his decline when I read him this section of the article, and he elaborated his perspective.

My father was a doctor, and he recognizes that he has slowed down tremendously. He is no longer able to make rounds at the hospital or teach, and there is a kind of wistfulness for the life he had before and a bemoaning about his current circumstance. He is very, very constricted in what he is able to do, he shuffles around slowly, and it is hard for him to be the active, completely engaged guy he was. Despite this, he also said he is happy.

From my perspective, he is now a very different kind of person.

It is exactly the issue I was talking about in the article, which is, we end up being satisfied with smaller and smaller elements of life. In evolutionary terms, it is probably natural to want to live as long as possible, but I don’t think it is necessarily the meaningful life we want. Rather, it is a compromised lesser life we get used to because it happens so imperceptibly and without a lot of reflection.

Health-Care Policy Shortcomings

Other than increasing the life expectancy of some subgroups of the population, you say there should be more focus on infant and adolescent mortality and research on Alzheimer’s disease rather than on prolonging life as a measure of quality of health care.  Please talk about the public policy changes you would like to see.

I think once a country reaches an average life expectancy past 75 for both men and women, this measure of quality of health care should be ignored. Clearly, that is not applicable in the case of African American males, who have a life expectancy of just 72.1 years, or in places like Africa or South Asia, where life expectancy is in the low- to mid-60s.

Instead, it seems to me, we need to be devoted to the health of our kids, and there are clear measures in the American health-care system where we are not doing well. I cite three of them.

One is preterm deliveries before 37 weeks (currently one in eight U.S. births), which are correlated with poor outcomes in vision, cerebral palsy, and brain development. The second is infant mortality. We have 6.17 infant deaths per 1,000 live births, while Japan has 2.13; that is a crazy number for us to find tolerable, and we can do much, much better than that. The third measure is in adolescent mortality, where we rank at the bottom among high-income countries. We need to pay much more attention to this problem. These are all terrible and tragic statistics, and we need to do better by our kids.

Another public policy change I would like to see relates to biomedical research in diseases like Alzheimer’s. We haven’t made a lot of advances in that disease, and it is quite clear that it is a major, major health problem.

We also need more research in the growing disabilities of old age and the chronic conditions that come with it—and not on prolonging the dying process.

Reader Reactions

There was an immediate negative reaction to your article, with some accusing you of wanting health-care rationing and death panels. What is your response?

Most of the people talking about death panels and rationing have not read the article. They just read the headline and have no idea what they are talking about. I’ve gotten used to criticism over the years, but it remains extremely frustrating that you can’t be subtle and nuanced in discussing this topic.

As I made clear in several points in the article, I am not talking about ending my life through euthanasia or suicide, and I have never advocated legalizing euthanasia. In fact, I have been consistently against it for all of my career and probably among its most vocal opponents.

Second, I make it quite clear that I’m not suggesting public policy changes regarding health-care coverage for the elderly.

And third, I make it quite clear in the first paragraph that this is a completely personal reflection of what my philosophy of life is. What I am trying to get across is that I want people to think about their lives and what is meaningful and valuable to them.

I am not saying that those who want to live as long as possible are unethical or wrong. I do not scorn people who want to live a longer life despite physical or mental limitations. I’m not even trying to convince anyone that I am right. In fact, as an oncologist, I often advise people in this age group on how to get the best medical care available in the United States for their ailments.

I am talking about how long I want to live and the kind and amount of health care I will consent to after 75.

I would say that the reaction from people who have contacted me directly has been mostly positive. About one-third said they hate the article, and one-third said they found the article thought-provoking, although they were somewhat uncomfortable by its challenge to them to justify what is meaningful in their lives.

And one-third of the people were completely supportive, agreeing with my assessment. Interestingly, of that number, about half are physicians, nurses, and other medical professionals, who were overwhelmingly supportive. Then about half of those supportive people said they are caring for a family member with a severe physical limitation or dementia, and while they may not agree exactly with 75 as the upper age limit, they certainly agreed with me that the physical and mental deterioration of their loved one was crowding out their memories of the once healthier, vibrant person.

My main goal for writing the article was to start a conversation about the importance of quality rather than quantity of life, but I’m very comfortable with lots of people not agreeing with my view. ■

Disclosure: Dr. Emanuel reported no potential conflicts of interest.

References

1. Xu J, Kochanek KD, Murphy SL, et al: Mortality in the United States, 2012. NCHS Data Brief. October 2014. Available at cdc.gov/nchs/data/databriefs/db168.htm. Accessed October 28, 2014.

2. Copeland L: Life expectancy in the USA hits a record high. USA Today, October 9, 2014. Available at www.usatoday.com. Accessed October 28, 2014.

3. Emanuel EJ: Why I hope to die at 75. Atlantic, October 2014. Available at www.theatlantic.com. Accessed October 28, 2014.

4. Fries JF: Aging, natural death, and the compression of morbidity. N Engl J Med 303:130-135, 1980.

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