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Exploring the value of longevity with bioethicist Ezekiel Emanuel

baby hand in old hand - big

In a popular article in the Atlantic published this past fall, Ezekiel Emanuel, MD, bioethicist and prominent federal policy adviser, made a controversial case against longevity. Just before the recent holidays, the USC Annenberg School for Communication & Journalism sponsored a webinar during which Emanuel explained and elaborated on his message. It's not that he "hopes to die at 75," as the title chosen by the Atlantic suggested, but he wants a life at 75 focused on living, not on living longer.

Emanuel essentially argues for quality of life over quantity of years, and he claims that American society is becoming obsessed by the latter. I listened in on his December talk, which began with an ad from the AARP that glorifies "going on forever" - a value he says is reflected in both the medical system and our contemporary culture.

He directed his scientific criticism against the idea of the "compression of morbidity" - the belief that with enough medical advances, disabilities will go away and people will live in good health until, more or less suddenly, they die. He calls this the "rectangularization" of life: falling off a cliff instead of rolling down a gradual decline. The idea is immensely popular and money-making, but while some research claims to prove it, far more proves the opposite. There is, in fact, an expansion of morbidity as people live longer, an elongated and more gradual decline with more disabilities and less and less creativity.

Given this, Emanuel's hope and recommendation is two-fold: that people will consider what makes their life meaningful and spend their energy cultivating that, and that medical resources will be redirected from prolonging life to improving its quality at the outset - by reducing the country's exceptionally high rate of premature births, for example.

American life expectancy is at an all-time high at nearly 80 years, but are octogenarians living meaningfully? Last month in the New York Times, David Brooks argued against Emanuel's earlier piece by saying that the "happiest people" are ages 82-85; in the webinar, Emanuel says this misses the point. It's much easier to measure happiness than meaningfulness, yet the latter is the real aim of life (and, furthermore, Brooks didn't account for the perspectives of those in nursing homes, assisted living, or suffering from dementia). Emanuel talked of patients who say cancer was "the best thing that happened to me" because it made them focus on what was meaningful in their life. The end of life is important to think about, as it helps us see what we want from life now.

"Contorting life around living as long as possible seems to me to be counter-productive," he said. "What we should be focusing our life on is what's meaningful, how we enrich other people and contribute to our families and society."

Optimizing medical and social resources is a large part of Emanuel's argument (and one that has attracted criticism, linking it to the idea that the elderly have a "duty to die" to make way for the youth). Emanuel mentioned the enormous burden that expanded morbidity puts on unpaid caretakers, overwhelmingly female, and he advocates that medicine instead focus on enabling people to live a healthy life in the medium term. In the U.S, one in eight babies is born pre-term, which is highly correlated with decreased cognitive and physical function, a "lifetime issue". The U.S. also has the highest rate of adolescent mortality in all developed countries; Emanuel said "we are failing our youth… Rather than compete with Japan on longevity, we ought to be competing at trying to get down to their level of infant mortality."

Emanuel suggested that physicians - and nurses - be specifically trained to spend time with patients planning for end-of-life care, as well as be reimbursed for this activity: "Those are the worst, hardest conversations - emotionally draining, inconclusive."  No one is born knowing how to talk about the end of life, he said, but there are many good curricula to help providers do so.

Previously: Tick tock goes the clock – is aging the biggest illness of all?Americans are living longer, but are we healthier in our golden years? and Researchers aim to extend how long – and how well – we live
Photo by Tim Bouwer

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