How long should we live? At BBC Future’s recent World-Changing Ideas summit in New York, Ezekiel J Emanuel argued that we focus too much on racking up years, and it’s time for a new attitude to death…
Death – along with sex – is one of our two great taboos. So it came as some surprise when Ezekiel Emanuel took to the stage in New York. Here, at 57 and in full health, he is already planning the date of his death – at 75. “My brother called me on my birthday and said, ’Is it 17 or 18 more years that I have to put up with you?’” he told BBC Future’s World Changing Ideas Summit in New York. “I think by 75 you’ve lived through the full arc of life… You’ve worked hard as an adolescent, you’ve made a career and had a family. That seems like a great life to me, so why run the risk of dementia, drooling, and being a burden to your family?”
The statement is all the more surprising, considering that Emanuel is an oncologist and the director of the Clinical Bioethics Department at the USNational Institutes of Health. He surely knows more than most about the potential of modern medicine. Yet he says it is important that we all consider the nature of our deaths, as hard as that may be. Is there an ideal time to die, and should we choose to end our lives at that point? Emanuel has been talking about the question for much of his adult life. “My kids have been hearing it since they were in diapers,” he told the conference delegates. But his views gained national attention when he explored them in an article for The Atlantic magazine last month. As he wrote:
“Doubtless, death is a loss. It deprives us of experiences and milestones, of time spent with our spouse and children. In short, it deprives us of all the things we value. But here is a simple truth that many of us seem to resist: living too long is also a loss. 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. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.”
Emanuel’s point has, of course, been made many times before. Both the desire for immortality – and the pain this can bring – have long haunted humanity. Greek mythology tells the story of the goddess Eos, who begs Zeus to grant her lover Tithonus eternal life. But there is a catch: although he lives forever, Tithonus still ages like the rest of us, and descends into senility. Eos is eventually so disgusted with her lover that she locks him in a separate chamber, from which he can be heard begging for death. One of the more recent figures to share this view was the writer Martin Amis, who caused controversy when he said he would welcome “euthanasia booths” on the street, to allow anyone to end their life when the indignities of old age became too much to bear.
But something about Emanuel’s views strike a nerve. Perhaps it was the fact that we heard this from a doctor – someone we expect to give us hope and protect us from the Grim Reaper. While we may have put aside superstitions and belief in the afterlife, we gain comfort from the idea that medicine can – and should – extend our lives for as long as possible. The crucial point, according to Emanuel, is that although many therapies might prolong the years we live, they don’t necessarily preserve a functioning, active life: more people live with disability and chronic illness than ever before. As an example, he says that 20 per cent more people survive stroke now than in the past – even though they are often seriously disabled as a result. “On one hand, it’s a triumph; on the other hand – maybe not.”
It’s important to note that, unlike Amis, Emanuel is not suggesting that people should take deliberate action to accelerate death; rather, once he reaches 75 he will simply refuse medical care – such as chemotherapy, a pacemaker or statins– that could prolong his life. “It’s about not being driven by the medical establishment to take every medicine,” he says. Even antibiotics will be off the cards, he says. Even so, his point of view seems hard to reconcile with the fact that Emanuel has long opposed legalised euthanasia for the terminally ill. But it’s important to note this is a personal choice; he certainly isn’t suggesting that it should impact policies for health care. Changing the law to allow assisted suicide creates many more legal and moral issues that are far more difficult to resolve and could be abused, he says.
One issue that Emanuel readily acknowledges is that everyone will age differently. As one member of the audience pointed out, her father, in his 80s, plays saxophone in the morning, then runs a mile and plays tennis with his friends later in the day. “Almost everyone’s initial response to my article was to list the 27 people they know who are over 75,” says Emanuel. “And there are things you can do if you want to live a vigorous, engaged, intellectually vibrant life: exercise is important; continue to have a large social sphere, and keep working – because it forces you to have social interactions and do a routinised thing of having a plan, and getting things done. Yes, those things might boost you chances of being an outlier – but remember, we can’t all be outliers.”
Another audience member – an epidemiologist – points out that over 70s often show up as being the happiest members of a society, with the fewest mental health issues. “But people accommodate to their restricted circumstances and lower their expectations – is that really the way we want to achieve happiness?” he responded. He says he already has experience of this. “I Skype with my daughters and they say I’m more distractible… Do I notice that, no? But do they notice it? Yes.” And the thought of happily sliding into senility while becoming a burden to his family just doesn’t appeal to his own view of people should age.
Ultimately, he admits the specific limit, of 75 years, is somewhat arbitrary – but his point is that it makes you start to consider where your life is heading; the ultimate memento mori. “I’m challenging people to think about their personal philosophy,” he says; he’s certainly not suggesting that others follow him. “I think one of the problems, if you don’t set a date, is that you don’t confront the big question, and you don’t perceive you decline,” he says. “I want to shift to focus to saying ‘you’ve got 75 years, what are you going to make of it?’”