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A doctor and medical ethicist argues life after 75 is not worth living

Ezekiel Emanuel questions “whether our consumption is worth our contribution” in old age.

August 21, 2019
Ezekiel Emmanuel
Ezekiel EmmanuelJustin Muir

In October 2014, Ezekiel Emanuel published an essay in the Atlantic called “Why I Hope to Die at 75.” Because Emanuel is a medical doctor and chair of the University of Pennsylvania’s department of medical ethics and health policy, as well as a chief architect of Obamacare, the article stirred enormous controversy.

Emanuel vowed to refuse not only heroic medical interventions once he turned 75, but also antibiotics and vaccinations. His argument: older Americans live too long in a diminished state, raising the question of, as he put it, “whether our consumption is worth our contribution.”

Emanuel was born into a combative clan. One brother, Rahm, recently completed two terms as the controversial mayor of Chicago; another brother, Ari, is a high-profile Hollywood agent. But even given his DNA, Emanuel’s death wish was a provocative argument from a medical ethicist and health-care expert.

Emanuel, now 62, talked with me about the social implications of longevity research and why he isn’t a fan of extending life spans. I was particularly curious to get his reaction to several promising new anti-aging drugs.

Q: It’s five years since you published the essay. Any second thoughts as you near the deadline?

A: Not really! [Laughing]

Q: You announced that you wouldn’t take any measures to prolong your life after 75. Isn’t that an extreme position?

A: First of all, it’s not an extreme position. I’m not going to die at 75. I’m not committing suicide. I’m not asking for euthanasia. I’m going to stop taking medications with the sole justification that the medication or intervention is to prolong my life.

Q. But it’s called “Why I hope to die …”

"The world will exist fine if you happen to die. Great people, maybe even people greater than you, like Newton and Shakespeare and Euler—they died."

A. As you probably know better than everyone else, it’s editors that choose titles and not authors.

I often get, from the people who want to dismiss me, “You know, my Aunt Nellie, she was clear as a bell at 94, and blah-blah-blah …” But as I said in the article, there are outliers. There are not that many people who continue to be active and engaged and actually creative past 75. It’s a very small number.

Q: You suggest that one effect of our obsession with longevity is that it diverts attention from the health and well-being of children.

A: Lots of presidents and lots of politicians say, “Children are our most valuable resource.” But we as a country don’t behave like that. We don’t invest in children the way we invest in adults, especially older adults. One of the statistics I like to point out is if you look at the federal budget, $7 goes to people over 65 for every dollar for people under 18.

Q: The buzzword in longevity research is “health span”living a maximum life with a minimal amount of disability or ill health. Isn’t that a worthwhile goal?

A: If you ask anyone, “All right, design out the life you want,” I think people initially say, “Oh, I want to keep going as fast as I can, and then just fall off a cliff.” And then they reconsider: “Well, maybe I don’t want to die of a heart attack or a stroke in the middle of the night. I want to say goodbye to my family. So I want some gentle decline, but a very short amount of time. You know, months, not years.”

It makes perfect sense. I’m no different. I would like to maintain my vigor, my intellectual capacity, my productivity, all the way through to the end. But I think we also need to be realistic—that’s not the way most of us are going to live.

Q: Does that mean you’re skeptical about the health-span idea?

A: In the early 1980s, we had a theory that as we live longer, we’re going to stay in better health. You know, at 70, we’re going to be like our parents were when they were 50. Well, if you look at the data, maybe not. We’re having more disabilities. We have people with more problems. And even more important, for most people, is the biological decline in cognitive function. If you look at really smart people, there aren’t that many writing brand-new books after 75, and really developing new areas where they are leading thinkers. They tend to be re-tilling familiar areas that they’ve worked on for a long time.

Q: What’s wrong with simply enjoying an extended life?

A: These people who live a vigorous life to 70, 80, 90 years of age—when I look at what those people “do,” almost all of it is what I classify as play. It’s not meaningful work. They’re riding motorcycles; they’re hiking. Which can all have value—don’t get me wrong. But if it’s the main thing in your life? Ummm, that’s not probably a meaningful life.

Q: Are the anti-aging drugs in development just a bid for immortality by the back door?

A: Certainly. You listen to these people and their lingo is not “We’re just trying to get rid of problems.” Right? It’s “We want to live longer.” I notice that almost all of these things—not all of them, but many of them—are based out in California, because God forbid the world should continue to exist and I’m not part of it!

The world will exist fine if you happen to die. Great people, maybe even people greater than you, like Newton and Shakespeare and Euler—they died. And guess what? The world’s still there.

Q: What message do you think it sends when iconic innovators in Silicon Valleypeople like Peter Thiel and Larry Ellisonare clearly fascinated by life extension and …

A: No, no—they’re fascinated by their life extension! This idea that they’re fascinated with life extension [in general]? Naw, they’re fascinated by their life extension. They find it hard to even contemplate the idea that they are going to die and the world is going to be fine without them.

Q: You have described the “American immortal”people interested in life extension and immortality.

A: There is this view that longevity, living forever—and if not forever, 250 or 1,000 years—is really what we ought to be aiming at. And once you’ve got cultural leaders, or opinion leaders, saying this, people glom onto it. And it feeds into a whole situation of “Yes, dying is a bad thing.”

I do fear death. But I think I fear being sort of decrepit and falling apart more.

Q: Is it really a problem if one of these drugs like metformin shows a modest life-extending effect?

A: I think it would be, especially if what ends up happening is it adds a few years of life. Then the question is: What are the downsides of that? There may be a cognitive downside, maybe a little more mental confusion.

It’s very funny—every time I talk to people, it’s like, “Oh, yeah, definitely quality of life over quantity of life.” But when push comes to shove, it’s really quantity of life. “I might be a little more confused, but I’ll take that extra year!”

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