Blog | Tuesday, November 11, 2014

Over and out


I highly recommend a provocative essay by Ezekial Emanuel that appears in the October 2014 issue of the Atlantic. Dr. Emanuel is a prominent academic who has also held important positions in government, including as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. He is also the eldest of the three impressive “Emanuel Brothers” that also includes Rahm (former White House chief of staff and now mayor of Chicago) and Ari (a prominent Hollywood agent). His piece is entitled “Why I Hope to Die at 75.”

OK, so the title is a bit over the top and meant to shock, and it is not even entirely accurate. But the message is really worth thinking about. Emanuel sets out why he wants to avoid the typical American approach to aging and progressive infirmity; he does not want to join the ranks of what he refers to as “American immortals.” Instead, he says that when he hits the admittedly arbitrary age of 75, he will no longer actively seek to prolong his life. No more doctor visits, no more “preventive” measures, no more diagnostic tests, no more interventions. Done. Whatever happens after that, well, so be it.

He is quick and careful to point out that this is not a public policy recommendation (though the on-line comments that accompany the article indicate that a lot of readers are not buying that), but rather his own personal decision. He wants to avoid the decline in physical and mental capacity that comes with aging, and figures his best contributions will be well behind him by then. He specifically rejects the notion that the longer life spans we now “enjoy” come with “compression of morbidity” at the end and instead cites evidence that longer life nearly always comes with a longer period of infirmity or reduction.

On one level, his position resonated with me. I see plenty of behavior that can only be explained by some irrational belief in immortality coupled with Medicare fee-for-service reimbursement unencumbered by any need to demonstrate evidence of efficacy. How else can you explain things like removing basal cell skin cancers in a 90 year old, or doing mammograms in women in their 80s, or worrying about your cholesterol at that age?

On the other hand, he seems way too sure of himself. As Daniel Gilbert pointed out in his book Stumbling on Happiness we humans are pretty awful at predicting our future emotional state. Things we are convinced would devastate us, don’t. Things we know would make us happy, also don’t. So I am not convinced that the good doctor won’t wake up at age 75 and say, “This isn’t so bad, and I would really like to stick around for a while.” I think the article would have been much more compelling if he were 75 already, and was entitled, “I’m done.”

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.