Opinion | Would You Refuse All Medical Interventions After Age 75?
In an article in The Atlantic from 2014, noted bioethicist and oncologist Ezekiel Emanuel, MD, PhD, wrote that he will refuse all medical interventions including antibiotics and vaccinations after age 75. The logic of his position is likely out of concern over a loss of autonomy and dignity associated with aging. Dying younger is intended to preserve one’s legacy to be remembered as vital and not decrepit.
Emanuel is now 65. Interest exists in the durability of his 2014 claim. Recently, Helen Rumbelow of The Times of London asked Emanuel if he wanted a quick illness to decide his fate because it would take bravery to withstand a long treatment or take his own life. To this query Emanuel replied, “Well, I think it’s bravery to say no to interventions where the majority of people would say yes.” Words like bravery seem to appeal to both Rumbelow and Emanuel, but perhaps bravery is less about personal character and more about how we describe the actions of people bad at math. Nevertheless, Emanuel may not be wrong that America might be a bad place to grow old. Let’s explore these ideas.
To unpack Emanuel’s claim, it is fair to start with the likely origin of what might be special about age 75. Why pick this age over all other ages? According to the CDC, U.S. life expectancy peaked (78.9 years) in 2014 and subsequently decreased significantly for 3 consecutive years, reaching 78.6 years in 2017. In 2020, the number fell further to 77.28, and just over 76 in 2021. COVID-19 and drug overdoses are the biggest reasons for the decline. Life expectancy represents the average age of death of a population starting at a particular point in time. However, average age at time of death is a number that warrants further explanation. It is possible to have an average age of death that represents a smaller portion of an entire population. If, for example, infant and childhood mortality is high, that might skew the average death age down. If a person survives infancy and childhood, they may live a long life. Emanuel selected 75 so I imagine he had something close to current U.S. life expectancy as his target.
Some very interesting things related to life and death can be found when one examines the Actuarial Life Tables from the U.S. Social Security Administration. In the current Period Life Table from 2019 and listed in the 2022 Trustee Report, the average age of death at time of birth for a man is 76.22 and the probability of dying at birth is 0.006081, or 0.6%. Mortality drops down every year after birth until about age 10 when the number is an impressively small 0.0097%. After age 10, the chance of dying in each subsequent year goes up. The table also lists life expectancy in remaining years. At birth, life expectancy is 76.22 years but at age 10, life expectancy for a man is 76.81. Surviving birth means you are over that first hurdle of a threat to your life. Let’s jump ahead to 74, one year before Emanuel is ready to let nature take its course. At age 74, your chance of dying in that year is 3.1% and you can expect to live another 11.95 years. At age 65, the chance of dying is about 1%, and on average you can expect to live another 18 years. The point here is that although we study life expectancy from birth, life expectancy from higher ages is also important.
At birth, a male child may expect to live to age 76 but at age 75, instead of turning to dust, a man can expect to live to age 86. If he makes it to 86, he can expect to live to 91. If he makes it to 91, he may live to 94. The age where a person has an approximately 50% chance of dying in that year is 108. Why we live longer has a lot to do with the social determinants of health and access to the best medical care. People who die before age 75 are usually the victims of trauma or a variety of illnesses or just bad luck. The population of survivors beyond age 75 are a smaller, but more resilient, group. It is very likely that Emanuel is in the best position to live years after age 75, and in reasonably good health. What we know is that life is a survival of the fittest curve and the longer one lives, the longer one lives.
To be fair to Emanuel, what likely concerns him is the loss of life of a certain quality. His fear of irrelevance and infirmity likely exceeds his fear of death. This fear is logical, particularly for accomplished individuals where youthful vigor is advantaged. Our society is youth-oriented, and we don’t seem to hold advanced age with much reverence or respect. Apart from the curious acts by some younger people to dye their dark hair gray as some sort of display of maturity, most of what we do is to hide signs of advanced age by darkening our hair and injecting ourselves with Botox and filler. We celebrate 40 under 40, and we hand out lifetime achievement awards to people who are still alive. Small wonder Emanuel might fear the threat of irrelevance and frailty. For powerful and influential people like Emanuel who had the ear of the President, the threat of being sidelined might be just too much.
Transitions are hard but, in my opinion, avoiding them by dying is not necessarily an act of bravery. Emanuel opposes medically-assisted suicide and emphasizes in The Atlantic piece that isn’t what he’s picturing for himself at 75; however, the push for “medical” assisted dying — couched as the relief of suffering because of irremediable pain — continues to be advanced in other circles. In some versions, medical assistance in dying might create worrying incentives for some to die because society failed to provide them support and cast them off. For many, dying starts when they have nothing to look forward to. A good society can help many people live past 75. In terminal illness, the prolongation of life by a series of painful and seemingly ineffective medical treatments perhaps strikes as pointless those most used to powerful personal agency. As an oncologist, Emanuel no doubt confronted these scenarios with his patients who received yet another round of chemo, to no avail.
For many, a long life is now possible, but what to do with all that extra time shatters the myth of graceful retirement. As Nietzsche points out, “He, who has a why to live for, can bear almost any how.” As we advance in age, Emanuel’s struggle is increasingly clear: Now what?
Joel Zivot, MD, is an associate professor of anesthesiology/critical care at Emory University School of Medicine in Atlanta, and a senior fellow in the Emory Center for Ethics.
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