An Open Letter to Ezekiel Emanuel on Life and Death

In the October issue of The Atlantic, physician and medical ethicist Ezekiel (Zeke) Emanuel, brother of Rahm Emanuel (former official in the Clinton White House, then Congressman, then Chief of Staff for President Barack Obama, now Mayor of Chicago) published an article why he thinks we should all forgo advanced age and die at 75. As a 69-year-old moving toward 75, my response to that article is this blog post requesting a stay of execution from our newly appointed Czar of American longevity.

An Open Letter to Ezekiel Emmanuel.

Dear Ezekiel Emmanuel:

Please forgive me for taking so long to comment on your article in The Atlantic arguing that we should declare our lives to have reached their productive limit at age 75 and therefore gracefully exit this world before we move into an inexorable decline. Your article – “Why I Hope to Die at 75″ –– appeared in The Atlantic in October and here it is December and I have not joined the 3000 plus people who commented on it earlier. First, I confess, I did not read it until almost a month ago, and then, I had to stew in some juices before figuring out how to reply. You make many good points in your article. Americans do indeed consider themselves to be “immortals,” do prolong death rather than extend life when they push for futile treatments or agree when their physicians who too often recommend them (if they were not so enthusiastically recommended, would so many American patients so heartily sacrifice themselves on the altar of science?) But does the solution to the out of control medicine lie in declaring that 75 should be the age of exit?  See, for example, Shannon Brownlee’s Overtreated.

In your article, you carefully explain why you have picked 75 as the human sell by date. You argue that, for most of us, “creativity, originality, and productivity are pretty much gone” by the time we reach our 75^th birthdays. Assuming that we all aspire to win the Nobel Prize, you point out that “the average age at which Nobel Prize–winning physicists make their discovery is 48.” Should we doubt the decline in our productivity, you kindly provide us with a chart of the productivity of “people with high creative potential” meant to convince us that the average meritocrat makes his (or her?) first contribution at between the age of 20 and 30. Their best contributions occur at 40 and their last at 60. Which makes one wonder why you’ve chosen age 75 and not 65 as the age of exit. (You’re 58, were you trying to cheat and give yourself an extra17 years?) Along with not much needed reminders of the decline of both body and mind that awaits us, you warn that after the age of 75, “the old joys have to be actively conjured up.” You do mention the argument that us old codgers have some accumulated wisdom to pass on and mentorship to provide, but none of that is for you (and thus shouldn’t be for us). “Mentorship is hugely important,” you reluctantly admit. “But it also illuminates a key issue with aging: the constricting of our ambitions and expectations.” The Emanuel boys are nothing if not competitive and helping others move ahead and standing aside so younger folks can occupy our seats is clearly, for you, not in the same league as being Number One yourself.  (Readers might like to know, just parenthetically, how you replied when, for a New York Times article,  you were asked to comment about Brother Rahm’s forray into Wall Street after he left the Clinton White House. In that article The Times reported that brother Rahm parleyed his Clinton White House connections into a job in the financial services sector, where with no prior experience, he managed to make more than $18 million in just two years.  Apparently, you saw no ethical problems with the Beltway’s corrupt revolving door practices.  In fact, you commented that,”“He had a number in his head to make enough for the family.”  That’s a pretty high number Zeke.  $18 mil??

In the articulation of your argument, you of course acknowledge that there are children to consider. They don’t want their parents to die earlier deaths than necessary. But, you counter, “We wish our children to remember us in our prime. Active, vigorous, engaged, animated, astute, enthusiastic, funny, warm, loving. Not stooped and sluggish, forgetful and repetitive, constantly asking “What did she say?” We want to be remembered as independent, not experienced as burdens.”

The idea that helping vulnerable loved ones could actually be a benefit not a burden has apparently never occurred to you. You’re even worse than those Japanese elders who would rather be cared for by a robot than by a gaijin or foreigner. In a medical version of better dead than red, you apparently prefer death to vulnerability.   ( I think here of the English aristocrats who refused to feed those suffering during the Irish famine because they might, God forbid, become dependent on food – see Cecil Woodham Smith, The Great Hunger).

It’s obvious that you think of yourself as more than a medical ethicist but as a medical prophet. And who can blame you? Our society has led many to believe that physicians have some special knowledge – and thus right to guidance and jurisdiction – about life and death issues. In so doing, we confuse an understanding of pathophysiological processes with a philosophy of life. Too many people believe that MDs are qualified to do more than declare a death to have occurred but to suggest how lives should be lived – or when and how they should be ended. As you put it, “to delineate… views for a good life.” Is it an accident that the photo accompanying your article shows you reclining in your office with your feet up and your hands cradling a mug that unabashedly proclaims you to be “THE BOSS.”

Well, since you have declared yourself to be THE BOSS, the Czar of American longevity, I hearby beg you to consider granting me an exemption from a death sentence at 75, which would give me just six more years to live.

Let me delineate my reasons for wanting to live as long as I can so that I can continue to aspire, contribute and be involved in critical and meaningful and activities relationships (which, will involve  a definition of aspiration, achievement, contribution, and relationship that is very different from your’s. )

Don’t worry, Zeke, I have hammered into my children and husband’s head that I do not want any of the medical measures, tests, and treatments which you, in your only piece of sage advice, suggest we old foggies forego.   As you consider my petition for an exemption, I don’t dispute the idea that we should all – at no matter what age – reject unnecessary treatment. What I do dispute is the idea that creativity has stopped once one reaches sixty. Particularly if you have a more expansive definition of creativity than you seem to have.  Aging people may actually be as or more creative as they get older. I know that my accumulated life experience, reading, thinking, knowledge, and relationships makes me look at people, politics, policies, and social and individual dilemmas through a lens that refracts with much more clarity, complexity, and nuance than one through which I viewed the world when I was young. As a child of the Sixties, I used to believe I could change the world, just like that. Now, I am delighted when I can change the thinking or ideas of just one person. I have more humor, less arrogance (hey Zeke, you’re only 58, so you have eleven years – if you give yourself a reprieve that is, to catch up with me). Maybe my brain is so crowded that it takes longer to sort through the data. But that overcrowding produces a far richer tableau than I could have ever painted at 20,30 or 40.

In fact, I would not go back to any of those ages if you paid me. What I would do, if I had a magic time machine, is revisit my earlier writings with my 69- year -old brain and redo them in light of what I have learned in the ensuing years. The tragedy of aging is not just that “old joys have to be conjured up” but that we can’t go back and redefine those “joys” in ways that may actually enrich our experience of them. I’ve often thought of writing a book called Between Delusion and Dementia: The Thirty Best Years of Your Life (age 55 -85). I think the title is brilliant. I’ve just never been able to come up with what would go between the covers.

As for the idea that we should make a hasty exit because we will be a burden on others – gosh Zeke, that is just so….well 21^st century, Silicon Valley, hipster, and well just plain ignorant. Anyone who looks carefully at the dilemmas of people taking care of their parents or aging loved ones quickly notices that the overwhelming burden of care does not stem from the activities of caregiving – which, of course, can be burdensome. Those who care for the ill, aging and vulnerable experience preventable suffering because no one will help them do the job. (See Carole Levine’s work on this).  Our society won’t offer them respite, won’t provide them with financial help, and won’t provide the kind of professional level help and non-professional assistance (visiting nurses, home health aides, medical equipment) they so desperately need. In fact, as the literature amply documents, those who care for the ill, aging and vulnerable (mostly women) are actually penalized for so doing by job loss, as well as loss of community and friends. (This literature is so vast I can’t begin to Google it all for you).

Another burden that adult children bear stems from the very individualism you so eloquently champion and which leads to their parents’ inability to accept help.  Talk to almost anyone in their fifties and sixties who is caring for an aging parent and what drives them nuts is that fact that their parents adamantly refuse to get help in the home.  Lacking any concept of interdependence, they are terrified – as you are – of losing their overly valued independence. I want an exemption from death at 75 so I can continue fighting for decent benefits for those who care for their loved ones and again against radical definitions of individualism.  Believe me, as your article illustrates,  that struggle will take longer than the six years allotted to me by your longevity program.

I also want my exemption so that my kids can have the opportunity to care for me as I cared for them. Unlike you, I want to give my kids the experience of paying forward – or paying back. Why shouldn’t the young take care of the old? Why shouldn’t they see me “ stooped and sluggish, forgetful and repetitive, constantly asking ‘What did she say?’” Is filial love about only seeing us when we are the so-called best and the brightest? Do kids develop and grow only by watching their type A, overachieving parents continually compete, produce, and get ahead? If you believe that, I shudder to think about conversations at your dining room table, or what your kids have turned into. I don’t want my kids to care for a breathing corpse. If I don’t recognize them, can’t feed myself, and have no agency what so ever, I want out. I don’t want to be like my mother-in-law who sat in a chair and stared at a wall for five years to the tune of $60 grand a year. Unlike you, I fully intend to be the third generation in my family to check out.  I plan to be the third generation of women in my family who – like my grandmother and mother did  (at age 86 and 94 respectively)– stops eating and drinking when they’ve had enough.

But I do not want to deny my children the amazing opportunity to provide care for someone who spent years – decades – caring for them. I watched both my girls take care of both of their grandmothers and one grandfather when they were in their teens, and I can tell you that it was both heart warming for me and heart – and brain –developing for them. It’s bad enough that so many upper class kids today wait until they are in their thirties or forties to have children and thus fail to understand what it means to be truly responsible for another human being until they are much older. It’s bad enough that people like Sheryl Sandberg,  want them to spend so much time “leaning in” that women working for Apple or Facebook are actually encouraged to freeze their eggs so they can avoid the sell by date problem of reproduction. Now you want us to help them avoid the important life lessons of caring for the elderly by making sure there are no elderly for them to care for. All this is enough to make you think that Sarah Palin was actually right when she warned that Washington bureaucrats were creating death panels that would determine who was worthy of “medical care.” Of course, you aren’t arguing for death panels where bureaucrats decide who should live and die. What you want is almost worse. As proof of  good citizenship, as well as social, and family responsibility you want people to voluntarily line up  in the self- check- out lane.

I don’t know if you will grant me an extension or exemption. What I really want to know is whether you will have the guts to practice what you preach and pull the plug on yourself in another 17 years. I wonder, if you reach 75 and can still write opeds touting the virtues of voucher based health insurance, or some other unworkable scheme to deal with the nation’s healthcare mess,  will you still decide to check out yourself? After all, in your Atlantic piece you reserve the right to change your mind at 75 and keep on trucking. (This reminds me of the guy who initiates a suicide pact with a woman and, after she pulls the trigger, he decides it was all a bad idea in the first place).

My conclusion? All of this ranting about facing reality isn’t really about puncturing the myths of American immortalism. It’s about perpetuating yet another version of the American idea of success – extending it, as you do, to the end of life. As you rail against “American immortals” what you actually delineate is not a version of the good life or death, but what aging means to “American competitives,” people who cannot conceive of a life lived without races to win, mountains to climb, prizes to covet, money to be made, achievements to catalogue, and more unworkable policies to propose. I just hope as I get older, I continue to have the wisdom to use a different metric to assess how my last days should be lived, what images I leave my children, and what counts as a good life. It’s not too late for you to do the same Zeke. They say that if you meditate on something for only eight weeks, it can change how your brain works. If I were you, I’d start today.