Should we hope to live to very ripe old ages?

I say yes.  A number of you have been asking me for comments on this now-famous Atlantic piece by Ezekiel Emanuel.  You should read his whole argument, but here is one bit:

…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.

Ezekiel basically wishes not to live beyond age 75.  Not that he will do himself in, but he regards that as a limit past which it is probably not desirable to go.  Just to be clear, I don’t read Emanuel as wishing to impose or even “nudge” this view on others, he is stating a personal vision.  Still, it strikes me as a somewhat strange approach to understanding the value of a life or estimating when that value ends.  The value of an individual life is to be sure somewhat ineffable, but for that same reason it is difficult for a life to lose so much of its value.

It is easy for me to see how a person could be a valuable role model for others past the age of seventy-five.  I expect Ezekiel in particular to fulfill this function superbly.  I still think frequently of the late Marvin Becker, the Princeton (later UM) Renaissance historian, who for me was an important role model at the age of seventy-seven.  Marvin often used to say “Oh, to be seventy again!”  He had more than his share of aches and pains, but he was always a comfort and joy to his wife Betty, and most likely to his children and grandchildren as well.

Or visit the list of words in Emanuel’s paragraph, cited above.  Many people are “disabled” to begin with, and many other lives are “deprived” to begin with, for one thing most of the lives in the world’s poorer countries.   But they are still, on the whole, extremely valuable lives.  I don’t just mean that external parties should respect the rights and lives of those persons, but rather internally and individually those lives are of great value.

To pick another word from that paragraph, “creativity” is overrated and most of us do not have it in the first place.  And if one does have it, perhaps its passing is in some ways a liberation rather than a personal tragedy.

I would rather be remembered as “that really old guy who hung on forever because he loved life so much” than as vibrant.  At some points I felt this piece needed a…marginal revolution.

And to sound petty for a moment, I don’t want to pass away during the opening moments of a Carlsen-Caruana match, or before an NBA season has finished (well, it depends on the season), or before the final volumes of Knausgaard are translated into English.  And this is a never-ending supply.  The world is a fascinating place and I fully expect to appreciate it at the age of eighty, albeit with some faculties less sharp.  What if the Fermi Paradox is resolved, or a good theory of quantum gravity developed?  What else might be worth waiting for?

I cannot help but feel that Emanuel is overrating some key aspects of what are supposed to be making his current life valuable, and thus undervaluing his future life past age seventy-five.  (See David Henderson too on that point.)

It was Dan Quisenberry who once said: “The future is much like the present, only longer.”

More to the point, and coming from the marginalist camp, there is Art Buchwald, who noted: “Whether it’s the best of times or the worst of times, it’s the only time we’ve got.”


Why are we expected to take ethical advice from, of all people, one of the Emanuel Brothers? Hasn't anybody watched "Entourage?"

Emanuel seems very concerned about how he is remembered. This is a vice of the rich and famous. The rest of us are known only to our family and friends, and will be remembered (when we are remembered at all) as whole people.

If someone knows you only by the disability that you suffered in the last few years of life, then it matters little how they remember you.

The original article seems designed to be "interesting", rather than "true", but still contains enough truth to require a response. (Some people refer to this as "trolling", or, to be kind, "starting a discussion"). That pretty much sums up how I will remember Ezekiel.

I always thought that envy was a weakness of the less than rich against the rich.

The first two comments on this thread show envy and ad hominem attacks to be the province of the right.

Who would have ever guessed.

So if I find Emanuel interesting but self-absorbed, then I get grouped in with the "right". You would appreciate the humor in that if you knew me. (Suffice it to say that I am far to the left of both Emanuel Brothers.)

I disagree that it is only "envy" that makes one favor income redistribution, for example. Piketty has made excellent arguments that do not rely on class warfare. Personally, I rarely resent anyone for being rich, but I do occasionally resent the honors and accolades that we pile on people just for being famous.

Even liberals (like me) are free to hold some people in high regard for earning their wealth (or fame) on their own. But we are still free to disagree. In this case, it was not me who said that how you are remembered was "most important", it was Emanuel.

Here’s another interesting subtext to “Why I Hope to Die at 75” in The Atlantic by bioethicist Ezekiel Emanuel, a leading architect of Obamacare and brother of the mayor of Chicago and the Hollywood superagent portrayed by Jeremy Piven on Entourage:

Many of the leading candidates for the Democratic Party’s 2016 presidential nomination would be by the conclusion of a second term in the White House well into what Ezekiel Emanuel tells us are their Better-Off-Dead years.

For example, on January 19, 2025, outgoing two-term President Hillary Clinton would be 77 years old. President Joe Biden would be 82. And President Jerry Brown would be 86.

In contrast, to pick completely at random an example of a younger Democratic leader with both foreign and domestic experience, President Rahm Emanuel would only be a still vibrant 65 after his two triumphant terms in the White House.

"I always thought that envy was a weakness of the less than rich against the rich."

How funny! That's exactly what Polus, the dumb sophist, said to Socrates!

(That's over 2400 years old; you need to get out more.)

One subtext of Emanuel's article is how he wishes his father, the old terrorist, would hurry and drop dead. But his father doesn't seem to be in any hurry ...

The weakness of the argument is highlighted when applied to other contexts. "Other people over 75 would be better off dead" is one inescapable conclusion of his argument. Another is that disabled people, or people whose lives just suck for whatever reason, would probably be better off dead, too.

Ultimately, the only reasonable way to interpret his argument is "life that is somewhat less than optimal is worse than no life at all", which is a very life-devaluing argument--and a dangerous one to be informing government policy.

Papa Emanuel, the old member of the Irgun terrorist organization, is a loose cannon. His staying alive and talking poses a continued threat to the fabulous careers of his sons. Back in 2008, when Obama appointed his son Rahm White House chief of staff, Benjamin Emanuel crowed:

“Obviously he will influence the president to be pro-Israel,” he was quoted as saying. “Why wouldn’t he be? What is he, an Arab? He’s not going to clean the floors of the White House.”

It's only natural for his son to wish him dead.

Seems like it is only stating the obvious, that the life of the old and feeble has relatively low value. Why must people like you lie about it?

"Seems like it is only stating the obvious, that the life of the old and feeble has relatively low value."

I'm not sure that's what he said, and talking honestly about the relative value of different people's lives is something most folks are awfully uncomfortable with a government policy architect doing. Showing my nerd roots, the Star Trek episode "The Conscience of the King" was all about this very point. Kodos would be a good nickname for Ezekiel.

"Why must people like you lie about it?"

That one's easy. We want to signal we care about the elderly. The entire existence of Medicare is due to this.

Then why are older people happier?

I don't think that is "obvious" at all, Benny.

I believe that any life that can help to teach sensitivity and compassion in this (ever more dreadful?) culture is very much a worthy life.

And yes, I've singlehandedly changed adult diapers, for years. I miss it, too.
And I'm an attorney.

Boy is that going make for an awkward Thanksgiving at the Emanuel household...

Remind me never to write an article in a national publication stating I wish my dad had just died instead of becoming a disappointing shell of a man not really worth having around despite his express wishes. 'Cause he can't do surgical rounds anymore.

Does Emanuel also think the handicapped would be better off dead? Or regular people who aren't as vibrant as his dad used to be and could never have expired to surgical rounds?

The funny thing is that I understand the basic argument that maybe if you want extraordinary end-of-life care, maybe you should have to write the checks yourself and not expect the government to do so. Emanuel may have set that cause back by decades with this moral tarpit.


Ugh. Should have been "aspired."

Apparently I'm no longer as vibrant as I once was. Off to the Soylent Green plant...

Also, considering the thence in marriage age and childbearing, our grandchildren might be just 5 by the time we are 80 and if we manage to keep relatively fit, we could provide a few years of massive savings to our kids as baby sister (OK, that's in south Europe, it might not apply in the US)

thence->trend... silly autocorrect and impossibility of editing comments....

=) not to mention, 'baby sister' and yes, applicable to the US.

My aunt recently died at 85. Until the year before, she'd been occupied full time as a free babysitter for her two daughters who both worked. The cost to my cousins of hiring a decade's worth of work from a college educated, ultra-reliable nanny/governess would probably have approached a half million dollars.

75 is ridiculously silly. Genetics obviously play a big role, but in general if one refrains from smoking, exercises and avoids eating like crap, having top notch physical and mental faculties at 75 is quite likely. Carl Icahns still mounting litigious hostile corporate takeovers at 78. An elderly Swede just bench pressed 90 kilos on his 90th birthday, which is more than the median 20 year old at my gym does. An 80 year old just climbed amount Everest.

We'll probably be treated to long Atlantic articles by Ezekiel Emanuel on his 75th, 80th, 85th and 90th birthdays on how's he decided to add 5 years to his 75-and-out idea.

But, obviously, the Emanuels are genetically superior to the average human. Indeed, the three biological Emanuel brothers (Rahm the mayor of Chicago, Ari the Hollywood superagent, and Ezekiel the celebrity bioethicist) have an adopted sister who, despite all that fine Emanuel nurture, is, according to Ezekiel, a dud.

Bernie Ecclestone is 84 and he's still sharp as fuck. Though he often pretends not to be when it suits him (in court).

Ronald Coase co-wrote a pretty good book a couple years ago.

You guys are way too optimistic... being 75 will suck for more than 80% of people...

Sure. But the Emanuels will likely still be going strong. In 2034, Rahm will get 26 aldermen to vote to incorporate his new residence in the lower-gravity Elysium luxury satellite as legally part of the city of Chicago for purposes of his running for re-election.

Are you going to beat this horse all the way to the end of the thread? Your an enigma Steve, you tend to start with an insightful thought provoking comment, and then like andrew', although far les so, some sort of OCPD kicks in an you just can't quit, and soon your answering your own threads.To be fair though, unlike andrew' you do create allot of orignal content. Don't take it personally, when i first came here you pushed me out of some very deeply established positions, so i'm always interested in what your saying, if not vehemently opposed most of the time.

First off, you are one of these guys who doesn't get the joke that this is Zeke Emanuel. Steve gets the joke. It isn't really a serious discussion.

But your valuable contribution is?....

Hmmm. At age 50 male life expectancy is about 80. For a doctor like Emanuel that could easily be 90 and a pleasant sudden massive heart attack.

Dispute this, puts. Dispute anything I say any time.

Nothing? That is what I thought. I invalidated his whole article with 5 seconds of Google. There is nothing anyone can say. GFY.

1. I believe you meant "putz" but I'm not certain. And..
2. (this is not in reply to Andrew') One is bound to die before an NBA season is over, because NBA seasons are endless.


A long suffering Laker fan.

@Moreno, I doubt it, based on my anecdotal experience of knowing many old people. But even if so:

1) Is a 20% chance not worth a try?

2) How much does life have to "suck" before death is preferable? A serious attempt to answer that is needed.

In America, there is this bias to hook people up to machines and "keep them alive." EE may have seen a lot of that as a doctor, and perhaps is signalling, from way out, that he doesn't want extraordinary measures taken to keep him alive.

Lots of people seem to want to explain how he really meant something sensible.

Relative to 30, sure. But relative to dead? Revealed preference suggests otherwise.

Inspired by SS, I Googled this guy's name and came up with this?! (is this the same guy, how can it possibly be if he advocates no euthanasia!?) Talk about cognitive dissonance!

And TC says: "And to sound petty for a moment, I don’t want to pass away during the opening moments of a Carlsen-Caruana match..." - that's not petty! LOL the first mention of Caruana in this blog methinks.

Since I was a child, I've thought that if I were ever to learn I had a terminal disease, I would sacrifice my life (or face the death penalty, if I was not killed in the process) killing someone who really deserved it. At the time, I was thinking of Mafia kingpins. Now, I have other targets in mind . . .

Well don't keep us hanging, who are your other targets? Does this post have anything to do with this thread? Or is this another one of your "I've discovered cold fusion" posts? lol

Doctor: "I'm sorry to tell you this, but you have terminal rabies. You only have three days to live."

Patient [Looking thoughtful]: "May I have pen and paper, please?"

Doctor: "Why, of course. Your last will and testament?"

Patient: "A list of people to bite."

I hope all the trolls in here never get my list if wh can bite me.

"Mafia kingpins" - that's quaint.

And sexist.

Why does our society repeatedly overlook Mafia queenpins?

Can we check back with this guy at 74 and 3/4 and see if he's changed his tune?

Well if he has alzheimer, we will not remember what he said anyway...

If he doesn't, neither will we.

As he notes, only 1/3 have Alzheimers by 85. A 33% chance of something bad happening 10 years later is not a great argument for wearing a WW1 German army helmet during thunderstorms at 75.

That's not the kind of logic that produces mandatory seat belt laws and has eliminated asbestos as pipe insulation.

Coffee protects against dementia and Alzheimer's Disease. This is a big risk reduction -- about 2/3 reduction in risk for 3 to 5 cups daily.'s_disease/file/d912f5100f5d1ec4be.pdf

But there's even more good news . . .

Coffee protects against cirrhosis of the liver. Again, this is not a small effect -- risk reduced by more than half for one cup daily, more than 80% for three cups.

The doctors I've seen discussing it have said basically that it is incorrect to interpret it as him wanting to be dead at 75, but rather that he is expressing a strong wish not to have any life-prolonging measures taken when he is that old. They say this, for example in light of dealing with elderly cancer patients considering chemo, or quadruple amputees due to diabetes, i.e., real cases they've dealt with where there may not be a quantitative measure of quality of life but it's clear that quality has degraded significantly.

The article is titled "Why I Hope to Die at 75" and starts with the words "Seventy-five. That's how long I want to live: 75 years." The closing paragraph begins "Seventy-five years is all I want to live."

Is there any ambiguity here? I don't think so. The position you mention is very reasonable, but it is not the position he took.

He us so earnest we almost want to believe he means what he says, but he doesn't. Giving him the benefit of the doubt is to not work with his words but to try to find the basic concept.

And it is my understanding medicine is already marginal. People who go into a procedure who assume a small payoff already often opt out.

If he didn't mean it, he shouldn't have written and published an article that clearly said it. Given that he did write and publish the article, he should be held accountable for the words he actually said. If we don't have that as a starting point, then discussion and debate become meaningless.

It's possible that his plan was just to say an outrageous thing to get attention--this article got far more publicity than a boring discussion of how much end of life care is appropriate. But if so, he shouldn't just get away with that. He should have to defend this position or retract it and say he didn't really mean it.

What is the problem with him wanting to die at 75? Sounds quite reasonable...

Ezekiel Emanuel is regularly afforded ample space to express his thoughts fully in leading magazines. For example, there was his 2013 memoir in Vanity Fair "Growing Up Emanuel."

There's mention of their mother's membership in the C.O.R.E. civil rights organization in America, but less talk about their father's membership in the Irgun paramilitary / terrorist organization in Israel.

And then there is this scene:

"We understood we belonged to a minority that had suffered in the past and was still subject to discrimination and exclusion. However, change was coming fast. Jews were quickly becoming accepted into the white majority, and our parents taught us that nothing that really mattered was beyond our reach and we had little to fear as we moved through the world. We were safe in this assumption except, ironically enough, when Rahm was “black.”

"Rahm and Ari had my mother’s skin coloring. Both brothers needed just a few days in the sun to turn the color of café au lait. By the end of the summer the two of them were almost chestnut brown. With curly black hair and a broad, flat nose, Rahm could easily pass for an African-American. ...

"Exceptions arose when some stranger decided to call Rahm and Ari “n******” and demand that we get off the beach."

Well, maybe.

@Steve, this crap is totally off topic. Can you at least keep it to one thread?

Yeah, he should have.

He doesn't want to die at 75.

Remember dan1111, in a Straussian world, nothing is quite as it seems.

Also, he never got into the practicalities of effectively dying at 75. You need a lawyer and a will that states you don't want life-prolonging measures.

The thing is that someone sitting there will with a lawyer can rarely understand what to put in an advance directive. Usually those patients don't understand their specific prognosis, the care options they will have and what the chances of those options working to prolong life and improve its quality are. All that crap requires a conversation with a doctor, which is uncomfortable for both the patient and doc. The result is that advance directives drawn up by lawyers are usually crap and don't really provide much guidance on the specific situations a patient will end up facing if/when they become incapacitated.

1) I would be surprised if even Emanuel himself holds the same view at age 74.9999--despite his protestations on this point.

2) It is interesting that this argument is coming from someone who has been highly visible in the debate about universal healthcare, specifically on questions about rationing end-of-life care. He may not be advocating anything here, but surely this can't be read in isolation from his previous work. He may not wish to nudge others, but such views on when life is valuable would surely inform any proposals about end-of-life care. And he must at least want to nudge public opinion about old age and medical care--otherwise why write the article?

3) There simply isn't serious thinking about the value of life, or any real attempt to weigh the costs of aging against the benefits of living, in the article. The entire argument amounts to "Some bad stuff happens in old age. QED"

4) Even taking just the positive things that can happen after 75 that he mentions in his article, one could make a compelling case that he was wrong. He repeatedly states great benefits of living to old age, then follows up with rebuttals that are actually less weighty than the original argument. For example, "children don't want their parents to die...but it is hard for children to care for aging parents".

5) Making a decision to treat medical care decisions differently once you get older is perfectly reasonable. A lot of end-of-life medical care goes into the very end, when life genuinely is miserable. And aggressively treating some diseases, like certain types of cancer, may extend life while drastically lowering quality of life. There are reasonable points to be made here, but it is very different from saying "I want to die at 75" without knowing one's health at that age.

2. It is super annoying to be finger-wagged at for stating the obvious that this isn't just some guy and his personal private wishes.

He even touches on policy, and his disclaimer is only that he is not advocating 75 as a magic number for healthcare policy. Great, I'm sure relieved that he isn't advocating literally pulling the plug on anyone who has made one too many trips around the sun.

We have to try to have the discussion as if it were just a random guy and his personal wishes not playing death panel theater. I don't think it is possible though Cowen gives it the old college try.

5. Age is just a number. It is not really correct to not base the decision on values (including health, etc.). Having a discussion is not about having the discussion.

Emanuel says his value is based on creativity, an odd self-congratulatory standard, but hey, to each their own, as long as it is 75.

Emanuels and Sunstein need to hire me for their PR.

I take no pleasure in this, but 75 is crazy. Literally. It is suicidal. He could be very fit until 90. But who knows. The point he tried to make, or should have, he didn't make it. He should read MR where we have asked if we gave you $300k at 75 to use for healthcare or anything else, what would you choose?

Why is his idea better or worse than "letting people die in the streets!!!" w. ith benefits?

Cause this is not a policy proposal. End-of-life care issues are more cultural than Medicare. It's about doctors not wanting to talk to people about dying, about patients not understanding their situations and options, and about families not asking their loved ones what they want.

Speaking of marginalism, life extension doesn't come without a cost. My deceased grandfather had a double hip replacement a few years before he passed away. My living grandfather is 91 years old. His comfortable existence costs several nurses, thousands of dollars in medications, regular blood transfusions and the occasional operation. Do the marginal benefits of living an extra year to age 92 out-weight the marginal costs? Of course it depends on whose paying. Like Emanuel's father, my grandfather is happy, but he only requires the slightest marginal happiness to out weight his near zero private costs of medicare (and to the extent that there are costs to living, the marginal benefits of deferred consumption are at this point asymptotic). 92 is much older than 75, but I think you can get to there by backward induction. My father isn't even 60 and has monthly (insurance covered) bills in the thousands for a drug whose only meta-analysis concluded the QALYs weren't worth it.

I don't mean to sound heartless. I just want to put myself in Emanuel's health-policy shoes, which I think naturally requires thinking about social costs and benefits. Those measurements may be difficult to make but they are necessary. The personal edge to Emanuel's essay thus avoids the more challenging quetof inter-personal comparisons. Perhaps this is because health policy is a great contemporary example of where open and honest analysis leads to *persecution,* first due to the intrinsic repugnance evoked by utilitarian calculations and second due to health spending's role in signalling care. So while Emmanuel writes,

"I am not advocating 75 as the official statistic of a complete, good life in order to save resources, ration health care, or address public-policy issues arising from the increases in life expectancy."

...the MR reader in me bets this is the prototypical Straussian denial. Or as Henderson said, "I don't believe him". Spending on old-age healthcare is only going to continue increasing in line with demographics and as better but low margin medicines come online. In lieu of a policy solution "lowering the status of being aged" might be the next best option.

As Sarah Palin said, un-Straussianishly about the health care finance program Ezekiel Emanuel helped push through: "death panels."

There's a basic logic to it.

American lifespans haven't really gone up that fast, but in a lot of other countries, such as Britain, they've been skyrocketing.

Seriously, you bring down this site with your moronic statements; the latest: "such as Britain, they've been skyrocketing?"

Your racist bullshit is enough, but you can't seem to look up simple facts.

Here's the table on p. 240 of British cabinet Minister David Willetts's 2010 book "The Pinch" of average male life expectancy at the age of 65 in the UK (in other words, in 1950, 65-year-old British men were expected to live to 77.0):

1950: 12.0
1960: 12.2 (+0.2 v. decade earlier)
1970: 12.8 (+0.6)
1980: 14.0 (+1.2)
1990: 15.8 (+1.8)
2000: 18.2 (+2.4)
2010: 21.7 (+3.5) [projected from growth from 18.2 in 2000 to 21.0 in 2008]

So, for every four days you live, you only get three days closer to death? What better excuse for procrastinating?

Now, that's pretty weird. Instead of diminishing marginal returns, we (or at least Brits) are currently enjoying increasing marginal returns. Well, I'm not complaining.

The changes in U.S. longevity are bigger than you may realize. For example, 25% of sixty-year-old U.S. men in 1960 died before reaching seventy (in 1970), compared with 16% in 1990.

Right, you can see it with Supreme Court Justices, who used to keel over pretty regularly with heart attacks or maybe lung cancer before they slowed down too much mentally. Now lifetime tenure of office is a real worry in terms of senility.

This is a very important issue, and it is inescapable when healthcare resources are limited (whether privately or government funded). Emanuel is known for making serious contributions to this debate, but this particular article doesn't further the debate at all. It evades any actual cost-benefit analysis.

That said, QALYs are crap. The way they decide "a year of life with disability X is worth half as much as a healthy year of life" is utterly bogus.

Right, and as with Sumner and climate change, otherwise wise commentators accept the tricks.

(Sumner just accepts the strawman that most if us who doubt the alarmists are marching to the beat of to "science deniers")

At the same time we have beltway conservatives telling us not to talk about death panels we have Paul Krugman saying with no irony that we really are discussing death panels. Arbitrary multipliers in qaly calcs is one way to put lipstick on the pig.

This is what the world needs a Cowen piece on, BTW.

I don't think this is about a cost-benefit analysis. The truth is that if people actually understand their prognosis and their treatment and palliative care options (b/c someone like a doctor who isn't a coward explains it to them), they often choose to forgo some of the most invasive and expensive treatments, which can increase quality of care and their satisfaction. Savings can be an indirect result, but that's just because that happens to align with people getting the care they actually want at end-of-life.

If individuals are paying for their own care, there is no formal cost-benefit analysis needed. Patients can simply decide what care is worth it to them, ideally based on an informed choice, as you say. This is true whether they are paying for treatments directly, or indirectly by deciding what insurance plan to get.

However, if someone else is subsidizing the care, that someone else has to decide what to cover, and a cost-benefit analysis is necessary. But this boils down to calculating the monetary value of life, which is deeply problematic. Quality-Adjusted Life Years highlight this problem. The most common method is that patients are asked to rate their state of health on a scale--say, 0 to 100--and if they answer 50 then a year of life at that level of health is considered half as valuable as a year at perfect health. But the patient didn't actually say that; nor is it likely that patients can objectively value their own life in that manner (just look at Emanuel's take on the value of his life after 75. Will he feel the same at age 74?) There is also the basic problem of putting a price on a year of healthy life, a completely arbitrary decision.

This is the stuff that I wish people were talking about instead of "death panels".

We have social insurance and that isn't changing. But that also isn't why doctors don't want to have these conversations. It's uncomfortable to talk about dying.

I'm not sure how true this is in practice. From "How Doctors Die" that we all read a few years ago:

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and was admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support. This was Jack's worst nightmare. When I arrived at the hospital and took over Jack's care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn't died as he'd hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack's wishes had been spelled out explicitly, and he'd left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill.


Most of the other comments seem to be based on who wrote the essay rather than the content of the essay.

Not exactly. As with Cass Sunstein, some people we have to fight through who wrote a piece to provide them with what they actually meant to say, partly hoping in vain they will get the next one better.

Point if info, You realize if this were anyone else writing it would not have been published, and certainly would get zero retweets.

Jacklegs, not you Anon, you are welcome to your aesthetic opinion, I address the peanut gallery. This is what at least half of my comments do.

The other halg are responding to "no, I really believe it!" Then after the troll has made me think about it I add the additional thoughts. Sue me.

Critical point: The value isn't decided by who pays, the incentives are.

That's how they design the incentives.

Oh no it ain't.

Sure it is. Most value for the insurer.

I don;t think you understand health care.

Incentives aren't so much designed as sneezed out of a giant nose.

To paraphrase Douglas Adams.

But you do sound heartless. Unless you've looked your grandfather in the eye and told him that the marginal value of the remaining years of his life are not valuable enough to compensate for the costs of caring for him...

And if you want some committee to do it instead -- you're a coward and a hypocrite as well....

I would never say that, but that's just more evidence for Robin Hanson's "we spend too much to signal we care" model. If a new pill came out that was a million dollars and gave him six more months, he'd take it if it had a zero deductible, and we'd all fight for him if he was denied the treatment, but is that the best way to organize society as a whole? In the counterfactual where the pill wasn't invented he dies peacefully a bit earlier having lived a full life. The issue is the way in which new medical innovations make what use to be a fate of nature an consequence of intentional choices subject to budget constraints. It's the intentionality that makes peoples stomachs churn, even holding all other outcomes constant.

Wouldn't it be wonderful if we had a system where people paid for their own medical bills so their choices would not need to be subjected to a society-wide cost-benefit analysis?

Christ on a stick

Have any of you has *any* science in college? (Shake your heads "no")

I'm 45, and do you think I'll be worried about my health care plan when I'm 75 in the year 2045?

The Cowen view is that it will be somewhat different than Obama Care today... 20 fuck'in 45, guys!

Yeah, I has science in college.

Tyler spotted the keywords deprived and disabled. It's really interesting to conclude that life is not worth living when people has lived with those disabilities since day zero. This is an extreme case of loss-aversion..........I'm afraid of losing 50% of my investment portfolio value, I prefer not to play.

Isn't death a 100% loss in this analogy?

Depends on your religious views.

That is exactly why I added "in this analogy". Everything changes if you believe in any kind of existence after death. But I think we are basically ignoring that for the purposes of this debate--Emanuel's argument seems purely based on what happens in this life, and it is being discussed on those terms.

Bequeathment also happens after death.

The death would be a 100% portfolio loss is the dead missed a lot life.

If religious views are left out of discussion, you won't miss life since dead means the end of consciousness. Death is no loss, it's just the nothingness........don't know a better word.

Loss-aversion, at least Wiki entry, it's about the tendency to prefer avoiding losses to acquiring gains. That's being more worried about being the idiot that forgets where the keys are and loss of productivity ( Mon dieu! ) compared to a nice sunset, chocolate, or a hug from someone you love.

Do you have to be conscious of a loss for it to be a loss? I say no.

There's a whole bunch of stuff you won't experience if you die. You really missed out on that stuff, even if you don't know about it.

Emanuel's interests are in health policy, and he was on the [obviously bullshit] "death panel" train. He realizes that people think of that background whenever they see his name, so he smartly made this article about his personal desires.

Saying he doesn't want to live past 75 accomplishes exactly what he wants: to make people start thinking about aging and end-of-life care generally. I have know idea whether he really wants to die at 75, but the implied idea of rationing care for people at 75 is so ridiculous that it makes us start to talk about alternative, more rational ways for the health system and our culture to approach this issue. It is a way for him to spark a dialogue that might start to rehabilitate this topic--it's been kryptonite for four years. Doing it this way, he brings so much more attention to the issue than he would have publishing an article in the Journal of Geriatric Obscurity.

There is an interesting contrast here between the level of generosity with which you approach Emanuel's argument and the "death panel" argument.

Both are outrageous and indefensible but highlight serious underlying points. Couldn't you just as easily turn it around and say the death panel claim was a great way to "spark a dialogue" and "bring...more attention to the issue" of healthcare allocation in a government-funded system, while Emanuel's argument is "obviously [poopy]"? I see no reason other than partisan predisposition to prefer one over the other.

Personally, I think arguments that are crap should be treated as such, from either side. The way to talk about a serious underlying issue is to talk about that issue, not make stuff up to get people's attention.

I guess it is okay for people who share his goals to assume his argument is disingenuous.

It's not you're fault.

That is correct, because I am actually giving Emanuel more latitude than you are.

No you're not. You're just bitching about him b/c you disagree with what he said.

Well the death panel was a reaction and a lie about a specific piece of pending legislation, clearly intended to undermine whole bill. I do think this is different. I'm not saying you shouldn't call this 75 thing bs, because it probably is. But we are doing exactly what Emanuel wanted by talking about all this stuff.

Were "death panel" claims lies, exaggerations, or predictions about future consequences? One would have to go through all of the different statements one by one to decide.

But I admit you have a point that a direct lie like "X is in the bill" when X was not in the bill is different in kind that what Emanuel is doing here (even if he is being disingenuous). At least some of the death panel statements fall into this category.

Incidentally, I doubt that Emanuel would look over this comment section and think "now this is what I wanted people talking about"!

We were already talking about it. Just not in the retarded way we are today.

LOL. And I only say that if it really happened.

No you weren't. Not on here.

Death panels and money is all his convoluted mumbo jumbo is about. Otherwise it is even dumber. Refusing to address the issue head on is why he sounds like a fool.

He obviously can't talk about it head on, so he has to take alternative approaches. May be disingenuous, but he is winning. All I agree on is that people should be talking about this. Few others can accomplish that, so yeah I'm fine with this.

Yeah, my wife told me to go fuck myself and I said, "well, I have to give you a lot of credit for at least starting the conversation."

"Winning" would be moving the debate in his direction. If you start a discussion that damages your side because of the ham-handed way in which you decided to frame the issue, you have not won.

To go back to our parallel, Sarah Palin didn't "win" by getting people to talk about death panels. She harmed the conservative side of the debate by distilling serious arguments into an over-the-top, misleading claim that was easily dismissable. That's my take, anyway. Or, maybe that is too optimistic about human nature, and actually the silly talking point did more political good than harm. But in either case, I don't see how Emanuel is winning. No one is going to rally around the cause of dying at 75.

I'd say she absolutely did win. And I'd say Emanuel is winning because there are a lot people having rational discussions about the end of life issues because of it.

but the implied idea of rationing care for people at 75 is so ridiculous

Why is it "so ridiculous?"

I'm wondering this, too. Any sane medical system rations care: it has a point where it says "yeah, procedure X could save your life, but the cost/likelihood is too small, sorry. (You're free to raise the funds elsewhere, though.)"

Emanuel likely set back this conversation by decades with his ill-considered, poorly-thought-out death plan.

Yeah, I'd rather not pay for the general public's care in their 80s. If you save up for it, or can convince your family or employer to pay? More power to you. If it is prohibitively expensive and gap insurance is unfeasible, than we probably shouldn't pay for it with Medicare either. If it's just normal expensive and insurance could work, then we can let people make their own darn decisions about the costs and benefits.

The only reason that "our culture" needs to have a discussion about this because we've made our end-of-life decisions everyone else's business by forcing other people to pay for them.

I think this op-ed says more about Ezekiel Emmanuel -- or more specifically about many people in the power elite -- than it does about aging.

Their identity is bound up in professional success in a hugely competitive environment that values power and influence, being the 'smartest guy in the room', being hyper-capable, being active and telegenic. To be forgetful, a little unsteady, maybe even a little dribbly, no longer important is enormously disturbing because it messes with a huge part of the sense of self.

Saner folks are actually reasonably happy to keep on muddling through with their loved ones. Of course, people sensibly worry about the ravages of extreme dementia and disorientation or being in horrible unrelenting untreatable pain. Of course, they would prefer to be able to get around more easily or still play a mean game of poker or whatever. But they're actually pretty OK with 'not vibrant' or even 'feeble'...

good point.

one view of aging is that, as a person loses some of his/her previous faculties, there is something to be said for the resulting humility. it's this idea that being alive and being forced by nature to relinquish some or all of your powers is an important stage to pass through, that there is some psychological growth in this, in some sense. maybe, at the end, one gains a new and interesting perspective on the meaning of life which one could not have had before.

of course, it's easier to state that view than to actually experience it, and I think I understand why some would prefer not to experience it at all.

For me, this is the crux of it. Even as an infirm geriatric, I imagine I will continue to enjoy the passing show too much to want to let it slip from my grasp:

And to sound petty for a moment, I don’t want to pass away during the opening moments of a Carlsen-Caruana match, or before an NBA season has finished (well, it depends on the season), or before the final volumes of Knausgaard are translated into English. And this is a never-ending supply. The world is a fascinating place and I fully expect to appreciate it at the age of eighty, albeit with some faculties less sharp. What if the Fermi Paradox is resolved, or a good theory of quantum gravity developed? What else might be worth waiting for?

Yeah, people who go on about how more than n years of life would be unendurably boring are like people who boast about not watching television.

Directly related: Go rent "Zardoz." You'll be glad you did.

Beautifully put. This is your greatest post.

From the post:

"To pick another word from that paragraph, “creativity” is overrated and most of us do not have it in the first place. And if one does have it, perhaps its passing is in some ways a liberation rather than a personal tragedy."

I'm really curious about the second sentence in particular - in what way is it a liberation?

It's noteworthy that many leading public intellectuals, men like Robert Reich, Leon Kass, and Ezekiel Emanuel, from the left, right, and center, all advocate reduced spending on life extension. This position is also heavily promoted by the editorial board of the New York Times.

Observe that research has shown that Ashkenazi Jews disproportionately possess genes conferring extreme longevity.

The Jerusalem Post: "According to British census data, Jews live an average of five to six years longer than their gentile counterparts, and there may be nearly three times as many Jewish centenarians as in the general U.K. population."

Could it be that some of these men oppose radical measures to extend life expectancy because they know that in all likelihood they will naturally live much longer than average?

"Instead, we should look much more carefully at children’s health measures, where the U.S. lags, and shamefully: in preterm deliveries before 37 weeks (currently one in eight U.S. births), which are correlated with poor outcomes in vision, with cerebral palsy, and with various problems related to brain development"

Wait...isn't the ability for pre-term infants to survive an example of us blowing everybody else away?

You guys can make these comments too, but you aren't.

I am surprised such an avid Robin Hanson fan would suggest the resolution of the Fermi Paradox is likely to be worth sticking around for....

I'm 33. I don't really expect us to observationally prove any quantum theory of gravity in my life - and probably my children's lives.

CERN may be awesome, but it's not able to measure Planck scale effects. To prove any theoretical work, you'll need to design, fund, build, and successfully run a larger, more powerful particle accelerator... maybe two. At least we know that's possible. Technologically, the measurement instrumentation at the Planck scale is going to have to make some pretty gigantic leaps forward as well. It's not the kind of thing we're going to magically discover in the years after any of us turn 75. Maybe 175... Maybe.

This is the real Great Stagnation. Sad, but true. Oh we'll always have theories - String theory, M Theory, Loop Quantum Gravity, etc. But evidence? We have a long long long way to go. I find myself depressed about it sometimes.

"What else might be worth waiting for?"

All my life I've wanted to live in the distant future. A thousand years from now, a million years, a billion, assuming we're still around somewhere. I want so badly to see what we come up with, our tech, our culture, our political systems, our games, our discoveries, our art and architecture, the extent of our colonization of other worlds, what we look like... or how we've destroyed it all. But I'm optimistic and I tend to think humans will do well for a very long time, on this planet and others, with periods of struggle, of course.

One of my favorite questions to ask people is this: if you could be born in any year, which year would it be? It doesn't have to be a year that has already happened. It can be the year 500,000 BCE, it can be 1994, it can be the year 5,257,142. Everyone always chooses a year that has already happened, which makes sense, I guess... you know what you are getting. I always choose the year 3,000.

You know what is super ironic?

The fact that progressives have FOR DECADES used the emotional arguement that not paying for healthcare for the elderly was morally equivalent to pushing grandma off a cliff to argue for greater government control of health care.

And what happens the instant they put in place their society-wide "universal" health care system? They start arguing that it's too expensive for society to pay for grandma's health care.

So what was the point of all those years of arguing that we HAD to have universal health care so that old people wouldn't have to die because they couldn't afford treatment? Was the whole point of that just PURELY for the sake of concentrating power over life and death in the hands of the state? Because right now it certainly looks that way.

Next thing, they will be arguing that it's too expensive for society to care for pre-term babies, or Down Syndrome kids or childhood leukemia treatments. Where's the cost-benefit analysis to society as a whole huh?

Oh for the days when you only died because you couldn't afford treatment and not because a cost-benefit analsys showed that your life was no longer beneficial to the collective.

Just because it's an underrepresented perspective here, I plan to die around 50 and have already quit my job to live off my savings. (I'm 37.) To me a life where you're not disabled or deprived is just barely worth living -- you still get aging pains, stress, and guilt over being one of the lucky ones. Take away the economic freedom and good health, and the life of a coal miner, beggar, or conscript is way past the point of not being worth living. The fact that people in these situations continue to struggle to survive and even have children who will be fated to their same lot is a testament to a massive survival bias created by natural selection.

Even if you are happy at 75 you should be constantly aware that your survival depends on the suffering of others who labor in Alaskan drilling rigs and hospitals to support you. Government should be incentivizing these people to die peacefully.

Ezekiel Emmanuel has a huge amount of his professional identity tied up in the question of whether end of life care is worth the cost, and he advocates a position just short of putting arsenic in the birthday cake. For all I know, he might be willing to die at 75 just so that he could write "I was right!" on his tombstone.

That's the Chicago way.

Only 14% of Americans said their ideal lifespan was less than 78. But even fewer (8%) said over 101.

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”The value of an individual life is to be sure somewhat ineffable, but for that same reason it is difficult for a life to lose so much of its value.“

It always bothers me when people talk about "the value of life". At what rate of exchange do you value life and does it apply equally across the cultural spectrum?

I think all Emmanuel is saying is that life is indeed precious because it is all we have. You make out of it what you can until you are no longer able. At that point I think that to only “be remembered as ‘that really old guy who hung on forever because he loved life so much’” is mere sentimentality as has little regard for what it takes these days to “hang on”.

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