COMMENTARY

Dr Emanuel's Death Wish Harms Rather Than Helps

John Mandrola

Disclosures

September 23, 2014

The thing about being a physician writer is that you have a responsibility to be self-aware. Like it or not, as a doctor, people will listen to you. You can do a lot of good, but you can also cause harm. Indeed, the challenge in writing in the public forum is the same as practicing medicine: balancing benefit with harm.

In writing the controversial essay,[1] "Why I Hope to Die at 75," I believe Dr Ezekiel Emanuel worsened the current crisis in end-of-life care in the US. His words caused harm; they empowered those who oppose common sense and humanity in the way we treat the elderly. Emanuel is no ordinary doctor or writer. He is an influential health-policy leader. His words matter—a lot. It was a bad idea to write the essay in the manner he did.

There are many barriers to improving the nonsensical inhumane way American patients and doctors approach death. Perhaps the biggest of these is the fear that policy makers equate the value of life, and hence, how much we should spend on one's healthcare, with productivity. This is the "death-panel" fear, and Dr Emanuel, of all people, should understand its power. When he writes that having "an [age 75] deadline forces each of us to ask whether our consumption is worth our contribution," Dr Emanuel creates fear.

It's like Drs Joseph Mercola and Mehmet Oz . Most of what these guys avow is really good—exercise, sleep, nutritious food, and the like. But you can negate your message with just a couple of transgressions. Eighteen of 20 things you say can make perfect sense. But the two nutty ones ruin the entire message. And worse, the mistakes give fodder to your opposition.

The dilemma with Dr Emanuel's piece and his positions on US healthcare is that he makes important points, many of which I agree with. He is against euthanasia and physician-assisted suicide. He argues that appropriate end-of-life care, with its attention to relief of symptoms, renders these slippery-slope policies unnecessary. That's spot on. He emphasizes that prolonging death is not the same as extending life. Recent gains in lifespan, he points out, have come by extending the period of illness at end of life. Living longer is not the same as living better. Yes, of course. Emanuel also highlights the dreadfulness of living with cognitive decline—an increasingly relevant problem these days. The risk of technologies that support organ function is that human beings can end up in diapers, imprisoned in nursing homes, poisoned by loneliness. Is that living? Does anyone want that?

Emanuel has also called US healthcare "spectacularly wasteful." Exactly. Wasteful medical care may be the major problem in US healthcare. He says once he reaches 75, preventive medicine, such as colonoscopy, prostate cancer screening, and regular check-ups, are out. This, too, is reasonable—as there is little to no evidence that screening procedures improve outcomes in the elderly.

But then, like Mercola and Oz, he ruins good arguments with hubris and nonsense.

First, Emanuel tells us (at age 57) he won't take antibiotics after age 75. Why? Because Sir William Osler once said death from infection was quick and relatively painless. He would also refuse heart surgery, even a pacemaker. To say you would allow a simple scratch on a leg to fester into a gangrenous infection is nutty. Also, it is not uncommon for an otherwise-healthy older person to develop a sudden loss of conduction of electrical impulses in the heart. It might be just a fleck of calcium in the wrong place. Decades of normal life could be restored with a 30-minute pacemaker implant. To say you would refuse a simple surgery 18 years from now strains credibility. It scares people.

Second, his profound vanity about aging overwhelms his reasonable arguments about overtreating the elderly. He doesn't want to get old because his creativity may decrease. He supports this thesis by noting that Nobel Prize winners accomplish their major findings in middle age. He hates the idea of his family remembering him as an old forgetful man. And, most egregiously, Emanuel posits that old parents should pass on earlier because their presence "casts a big shadow" on their children. Really? His family must be different from mine, and maybe yours.

Third, he gets the compression-of-morbidity concept wrong. In the 1980s, Dr Richard Fries, a Stanford professor of medicine, introduced the theory that the period of time from the onset of illness and disability to death could be reduced. Biology may program a finite lifespan of human cells, Fries argued, but it is possible to compress the time we are sick or disabled. Dr Emanuel called compression of morbidity a "quintessentially American idea," one that told us exactly what we wanted to believe. He likened it to fantasy.

But that's not how I understand it. In 1998, Fries and colleagues published this 1741-patient-study,[2] which found compression of morbidity turned largely on patient choices. Smoking, body weight, and exercise patterns in midlife and late adulthood were strong predictors of subsequent disability. So . . . living a healthy life with a short period of disability before death isn't an American idea or magic; it's largely a result of choices. The fact that most Americans aren't enjoying compression of morbidity doesn't make the theory incorrect. Rather, it underscores the importance of making healthy choices before birthdays accumulate.

In being critical of Emanuel's essay, I don't mean to suggest he should have to think one way or the other. People are free and equal to choose their own medical treatments. I once watched a healthy man die over the course of a week because he refused a pacemaker. It was difficult to witness, but I wasn't conflicted; it was his choice to live or die.

The problem with Dr Emanuel's essay is illustrated in this email I received from an intelligent thoughtful American:

I   think Emanuel is sick, and he is emblematic of the kind of thinking that characterizes the progressive movement. This article sounds like the story outline for one of those dystopian sci-fi movies. And there is no doubt in my mind that with his personal belief that anyone over 65 ought not have preventive screening, or flu shots, or anything that might keep him healthy beyond age 75, is the underpinning of the [Independent Payment Advisory Board] IPAB and part of the DNA of Obamacare.

The tone and content of this email aligns with many of the 1000-plus comments after the essay. I don't harbor these same views, but many people do.

Our current default in treating the elderly is an American tragedy. It's devoid of truth and candor; it's inhumane and it's wasteful. It must get better. Solving the problem of death denial, infusing care back into the healthcare of the elderly, and cutting wasteful spending won't come from inflaming the opposition or fomenting fear.

Self-awareness is a useful trait for any writer; it's especially so when you (and your policies) are in a position to help or harm millions of people.

I wished someone, an editor, an advisor, had stepped in and called time out on that essay. As therapies go, it was a harmful one. It made our work harder.

JMM

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