In a powerful essay for the Atlantic, Ezekiel Emanuel, head of the Department of Medical Ethics and Health Policy at Pennsylvania University, says that he hopes to die at age 75. He's 57 now, and he's not contemplating suicide or any kind of physician-assisted death, but after he turns 75, he will refuse all life-extending interventions — including antibiotics to fight infections. We spoke on Friday, and a lightly edited transcript of our conversation follows.
Ezra Klein: You hold two positions here that seem to be in tension with each other. On the one hand, you want to die at age 75. On the other hand, you are loudly and publicly opposed to euthanasia. Why, if you think it is a good and valuable choice to die early, shouldn't you have the legal right to make that happen?
Ezekiel Emanuel: If you look at people who want euthanasia it's not who we think it is. It's not people writhing in pain. It's not people who can't breathe because of emphysema. It's people who are depressed and hopeless and don't see meaning in life. I don't think the right answer to that question is, "let's give them some pills to knock them off." They need meaning back in their life. They need therapy or medication. Euthanasia, I think the research shows, is much more like suicide than it is like a medical treatment.
My piece about wanting to die at 75 is really about what gives your life meaning, and the need to really think about that. Someone e-mailed me and said, well, my father is having a great time telling stories to his grandchildren about growing up in New York City. And that's fantastic! But I remember my grandfather and what I remember most about him is his vigor and love of life. I remember his huge right hand, his reaching into a hot oven to pull out bagels, his running around with us. It would be horrible if my memories of my grandfather were just him shuffling around and telling us memories of his childhood in Chicago. And, similarly, what I want to leave my kids and my grandkids is a very certain kind of memory of me as vigorous, fun, someone they can travel with and horse around with.
EK: Let me push on this for a moment though. You say you'll reject any life-extending medical intervention after age 75. And you take that pretty far. You won't even accept antibiotics. But you might still get dementia and undergo a slow decline. You may still get cancer and waste away. So if the point is to control how you're remembered, shouldn't you be able to end your life at a time of your choosing?
EE: In the families I've seen where that has occurred, the circumstances of the death itself become the overwhelming memory. Either it's dad committed suicide or we helped dad die. It washes out everything else. Even when it comes to terminating care — and being an oncologist I've spoken to many families about this — they are all worried that they're killing their father. And you have to reassure them that they're not killing him, that this is nature taking it's course. You don't want how you died to become the narrative of your life.
EK: One of the things your article lays out in detail is that we have prolonged life but we have not prolonged health. That seems like a terrible indictment of our medical advances.
EE: There's this idea that as we grow older we'll be healthier. I call it the rectangularization of life. You go on as healthy as you've always been and then at the end you just fall off a cliff and die of a heart attack or stroke or something. But over the last 30 years the data has said the opposite. As we add years of life we're adding more years of life with disabilities. We are saving more people who have strokes. That's a triumph. But the consequence is people are living after strokes and they typically have disabilities - they have speech problems or cognitive problems. There's a tradeoff. We have extended the dying process.
Partly, this reflects good news. If you take the whole 20th century early on we expanded lifespan because we eliminated childhood diseases. Once you saved a child from whooping cough they lived a perfectly normal life. But beginning in the 1960s, we had done most of what we could do. There's a bit further to go — I point out in the article that infant mortality is way too high in America — but we're not going to get very much life extension out of saving kids. The life extension we're getting is prolonging people over 65, and that means prolonging the lives of people with disabilities.
One of the reasons I'm against using life expectancy and birth as a metric of how a lifespan performs is we don't ask how many years are really good years for people? More is not always better. More years with Alzheimer's is not necessarily better.
EK: Do you believe in anything after death?
EE: I'm Jewish. I go to synagogue often, I keep kosher in two houses, but I'm an atheist. I think we return to the worms. By the way, though, I think people who believe in god should be perfectly fine with my view. You just get to heaven a little faster.
EK: This piece gives your family an unusual level of clarity about what you do and don't want done after you turn 75. You didn't just write up an advance directive. You published it in a national magazine. But a lot of people don't have this conversation with their family or their doctors. In politics, when we got anywhere near this discussion, we got "death panels."
EE: This is a hard conversation to have. I spent 30 years of my career devoted to end-of-life care. A lot of that was developing a new kind of advanced care directive called the medical-care directive to help with that. If I've done nothing else but stimulate families to talk about this I think it's an important public service. I think most Americans want to have this conversation but they're afraid of it, they're worried that having the conversation will communicate something awful.
That said, when I started out in the 1980s, and I said in Harvard Medical School I wanted to work on end-of-life care, the dean of students basically said to me, "that's a career ender." He was wrong and I was right. And in America, we're doing a much better job. When I started out in cancer, 60 or 70 percent of the people who died from cancer died in the hospital. Now it's under 25 percent who die in the hospital. We do a much better job with hospice and other things here. It's not as if the country hasn't progressed. It has progressed.