An Open Letter to Ezekiel Emanuel on Life and Death

Ezekiel Emanuel

In the October issue of The Atlantic, physician and medical ethicist Ezekiel (Zeke) Emanuel, brother of Rahm Emanuel (former official in the Clinton White House, then Congressman, then Chief of Staff for President Barack Obama, now Mayor of Chicago) published an article why he thinks we should all forgo advanced age and die at 75. As a 69-year-old moving toward 75, my response to that article is this blog post requesting a stay of execution from our newly appointed Czar of American longevity.

An Open Letter to Ezekiel Emmanuel.

Dear Ezekiel Emmanuel:

Please forgive me for taking so long to comment on your article in The Atlantic arguing that we should declare our lives to have reached their productive limit at age 75 and therefore gracefully exit this world before we move into an inexorable decline. Your article – “Why I Hope to Die at 75″ –– appeared in The Atlantic in October and here it is December and I have not joined the 3000 plus people who commented on it earlier. First, I confess, I did not read it until almost a month ago, and then, I had to stew in some juices before figuring out how to reply. You make many good points in your article. Americans do indeed consider themselves to be “immortals,” do prolong death rather than extend life when they push for futile treatments or agree when their physicians who too often recommend them (if they were not so enthusiastically recommended, would so many American patients so heartily sacrifice themselves on the altar of science?) But does the solution to the out of control medicine lie in declaring that 75 should be the age of exit?  See, for example, Shannon Brownlee’s Overtreated.

In your article, you carefully explain why you have picked 75 as the human sell by date.You argue that, for most of us, “creativity, originality, and productivity are pretty much gone” by the time we reach our 75th birthdays. Assuming that we all aspire to win the Nobel Prize, you point out that “the average age at which Nobel Prize–winning physicists make their discovery is 48.” Should we doubt the decline in our productivity, you kindly provide us with a chart of the productivity of “people with high creative potential” meant to convince us that the average meritocrat makes his (or her?) first contribution at between the age of 20 and 30. Their best contributions occur at 40 and their last at 60. Which makes one wonder why you’ve chosen age 75 and not 65 as the age of exit. (You’re 58, were you trying to cheat and give yourself an extra17 years?) Along with not much needed reminders of the decline of both body and mind that awaits us, you warn that after the age of 75, “the old joys have to be actively conjured up.” You do mention the argument that us old codgers have some accumulated wisdom to pass on and mentorship to provide, but none of that is for you (and thus shouldn’t be for us). “Mentorship is hugely important,” you reluctantly admit. “But it also illuminates a key issue with aging: the constricting of our ambitions and expectations.” The Emanuel boys are nothing if not competitive and helping others move ahead and standing aside so younger folks can occupy our seats is clearly, for you, not in the same league as being Number One yourself.  (Readers might like to know, just parenthetically, how you replied when, for a New York Times article,  you were asked to comment about Brother Rahm’s forray into Wall Street after he left the Clinton White House. In that article The Times reported that brother Rahm parleyed his Clinton White House connections into a job in the financial services sector, where with no prior experience, he managed to make more than $18 million in just two years.  Apparently, you saw no ethical problems with the Beltway’s corrupt revolving door practices.  In fact, you commented that,”“He had a number in his head to make enough for the family.”  That’s a pretty high number Zeke.  $18 mil??

In the articulation of your argument, you of course acknowledge that there are children to consider. They don’t want their parents to die earlier deaths than necessary. But, you counter, “We wish our children to remember us in our prime. Active, vigorous, engaged, animated, astute, enthusiastic, funny, warm, loving. Not stooped and sluggish, forgetful and repetitive, constantly asking “What did she say?” We want to be remembered as independent, not experienced as burdens.”

The idea that helping vulnerable loved ones could actually be a benefit not a burden has apparently never occurred to you. You’re even worse than those Japanese elders who would rather be cared for by a robot than by a gaijin or foreigner. In a medical version of better dead than red, you apparently prefer death to vulnerability.   ( I think here of the English aristocrats who refused to feed those suffering during the Irish famine because they might, God forbid, become dependent on food – see Cecil Woodham Smith, The Great Hunger).

It’s obvious that you think of yourself as more than a medical ethicist but as a medical prophet. And who can blame you? Our society has led many to believe that physicians have some special knowledge – and thus right to guidance and jurisdiction – about life and death issues. In so doing, we confuse an understanding of pathophysiological processes with a philosophy of life. Too many people believe that MDs are qualified to do more than declare a death to have occurred but to suggest how lives should be lived – or when and how they should be ended. As you put it, “to delineate… views for a good life.” Is it an accident that the photo accompanying your article shows you reclining in your office with your feet up and your hands cradling a mug that unabashedly proclaims you to be “THE BOSS.”

Well, since you have declared yourself to be THE BOSS, the Czar of American longevity, I hearby beg you to consider granting me an exemption from a death sentence at 75, which would give me just six more years to live.

Let me delineate my reasons for wanting to live as long as I can so that I can continue to aspire, contribute and be involved in critical and meaningful and activities relationships (which, will involve  a definition of aspiration, achievement, contribution, and relationship that is very different from your’s. )

Don’t worry, Zeke, I have hammered into my children and husband’s head that I do not want any of the medical measures, tests, and treatments which you, in your only piece of sage advice, suggest we old foggies forego.   As you consider my petition for an exemption, I don’t dispute the idea that we should all – at no matter what age – reject unnecessary treatment. What I do dispute is the idea that creativity has stopped once one reaches sixty. Particularly if you have a more expansive definition of creativity than you seem to have.  Aging people may actually be as or more creative as they get older. I know that my accumulated life experience, reading, thinking, knowledge, and relationships makes me look at people, politics, policies, and social and individual dilemmas through a lens that refracts with much more clarity, complexity, and nuance than one through which I viewed the world when I was young. As a child of the Sixties, I used to believe I could change the world, just like that. Now, I am delighted when I can change the thinking or ideas of just one person. I have more humor, less arrogance (hey Zeke, you’re only 58, so you have eleven years – if you give yourself a reprieve that is, to catch up with me). Maybe my brain is so crowded that it takes longer to sort through the data. But that overcrowding produces a far richer tableau than I could have ever painted at 20,30 or 40.

In fact, I would not go back to any of those ages if you paid me. What I would do, if I had a magic time machine, is revisit my earlier writings with my 69- year -old brain and redo them in light of what I have learned in the ensuing years. The tragedy of aging is not just that “old joys have to be conjured up” but that we can’t go back and redefine those “joys” in ways that may actually enrich our experience of them. I’ve often thought of writing a book called Between Delusion and Dementia: The Thirty Best Years of Your Life (age 55 -85). I think the title is brilliant. I’ve just never been able to come up with what would go between the covers.

As for the idea that we should make a hasty exit because we will be a burden on others – gosh Zeke, that is just so….well 21st century, Silicon Valley, hipster, and well just plain ignorant. Anyone who looks carefully at the dilemmas of people taking care of their parents or aging loved ones quickly notices that the overwhelming burden of care does not stem from the activities of caregiving – which, of course, can be burdensome. Those who care for the ill, aging and vulnerable experience preventable suffering because no one will help them do the job. (See Carole Levine’s work on this).  Our society won’t offer them respite, won’t provide them with financial help, and won’t provide the kind of professional level help and non-professional assistance (visiting nurses, home health aides, medical equipment) they so desperately need. In fact, as the literature amply documents, those who care for the ill, aging and vulnerable (mostly women) are actually penalized for so doing by job loss, as well as loss of community and friends. (This literature is so vast I can’t begin to Google it all for you).

Another burden that adult children bear stems from the very individualism you so eloquently champion and which leads to their parents’ inability to accept help.  Talk to almost anyone in their fifties and sixties who is caring for an aging parent and what drives them nuts is that fact that their parents adamantly refuse to get help in the home.  Lacking any concept of interdependence, they are terrified – as you are – of losing their overly valued independence. I want an exemption from death at 75 so I can continue fighting for decent benefits for those who care for their loved ones and again against radical definitions of individualism.  Believe me, as your article illustrates,  that struggle will take longer than the six years allotted to me by your longevity program.

I also want my exemption so that my kids can have the opportunity to care for me as I cared for them. Unlike you, I want to give my kids the experience of paying forward – or paying back. Why shouldn’t the young take care of the old? Why shouldn’t they see me “ stooped and sluggish, forgetful and repetitive, constantly asking ‘What did she say?’” Is filial love about only seeing us when we are the so-called best and the brightest? Do kids develop and grow only by watching their type A, overachieving parents continually compete, produce, and get ahead? If you believe that, I shudder to think about conversations at your dining room table, or what your kids have turned into. I don’t want my kids to care for a breathing corpse. If I don’t recognize them, can’t feed myself, and have no agency what so ever, I want out. I don’t want to be like my mother-in-law who sat in a chair and stared at a wall for five years to the tune of $60 grand a year. Unlike you, I fully intend to be the third generation in my family to check out.  I plan to be the third generation of women in my family who – like my grandmother and mother did  (at age 86 and 94 respectively)– stops eating and drinking when they’ve had enough.

But I do not want to deny my children the amazing opportunity to provide care for someone who spent years – decades – caring for them. I watched both my girls take care of both of their grandmothers and one grandfather when they were in their teens, and I can tell you that it was both heart warming for me and heart – and brain –developing for them. It’s bad enough that so many upper class kids today wait until they are in their thirties or forties to have children and thus fail to understand what it means to be truly responsible for another human being until they are much older. It’s bad enough that people like Sheryl Sandberg,  want them to spend so much time “leaning in” that women working for Apple or Facebook are actually encouraged to freeze their eggs so they can avoid the sell by date problem of reproduction. Now you want us to help them avoid the important life lessons of caring for the elderly by making sure there are no elderly for them to care for. All this is enough to make you think that Sarah Palin was actually right when she warned that Washington bureaucrats were creating death panels that would determine who was worthy of “medical care.” Of course, you aren’t arguing for death panels where bureaucrats decide who should live and die. What you want is almost worse. As proof of  good citizenship, as well as social, and family responsibility you want people to voluntarily line up  in the self- check- out lane.

I don’t know if you will grant me an extension or exemption. What I really want to know is whether you will have the guts to practice what you preach and pull the plug on yourself in another 17 years. I wonder, if you reach 75 and can still write opeds touting the virtues of voucher based health insurance, or some other unworkable scheme to deal with the nation’s healthcare mess,  will you still decide to check out yourself? After all, in your Atlantic piece you reserve the right to change your mind at 75 and keep on trucking. (This reminds me of the guy who initiates a suicide pact with a woman and, after she pulls the trigger, he decides it was all a bad idea in the first place).

My conclusion? All of this ranting about facing reality isn’t really about puncturing the myths of American immortalism. It’s about perpetuating yet another version of the American idea of success – extending it, as you do, to the end of life. As you rail against “American immortals” what you actually delineate is not a version of the good life or death, but what aging means to “American competitives,” people who cannot conceive of a life lived without races to win, mountains to climb, prizes to covet, money to be made, achievements to catalogue, and more unworkable policies to propose. I just hope as I get older, I continue to have the wisdom to use a different metric to assess how my last days should be lived, what images I leave my children, and what counts as a good life. It’s not too late for you to do the same Zeke. They say that if you meditate on something for only eight weeks, it can change how your brain works. If I were you, I’d start today.

Suzanne Gordon is an award-winning journalist and author/editor of 18 books. She has written for The New York Times, Los Angeles Times, Philadelphia Inquirer, Washington Post and a long list of other publications. 

49 replies »

  1. I’ve just read some of the posts from 2014 which was seven years ago and can’t believe how phony, pseudo intellectual
    bores alway dominate whatever conversation is occurring, turning it into a continual opinionated discourse on economic, lust for money and the worship of things. Shut the hell up! Ms. Gordon’s enjoyable article concerns this matter that concerns our souls and spiritual values. The problem with our world, in general, is the disrespect for all living beings and the worship of money and things. Those from 2014 were not living through a pandemic where people have been forced to re-evaluate the value of life. I’ve observed the behavior of human beings in the covid test tube. I’ve seen reprehensible behavior on the part of some and great beauty on the part of others. I wonder how much care Emanuel has taken to preserve his pathetic, dried up life during this time? Thank you, Ms. Gordon, for a good article which was not about MONEY and the ECONOMY; instead it was about the human spirit as it relates to life. Life is a precious gift not to be denigrated by neglect of the body or the mind but to be nutured as long as a being can function whatever his/her age. I love life too much to wither and die because of a prescribed age to begin letting ourselves ‘go’.

  2. Thank you for your well thought out and rational essay addressing what I think is a Hitlerish approach to a specific group of human beings of a certain age and in this case not a religious group. I have recently attained membership in that group and can’t begin to express how repulsive I find this particular so-called doctor’s psychopathic rantings and terror of losing his value as a living being by possibly having to reliquish his ‘superman’ status and step aside for the younger generation, in that he will have to give up the all knowing omnicience he arrogantly thrusts in our faces if we happen to read his ‘Kampf’. Unfortunately he has equally demented followers in the medical field which I recently had the misfortune to encounter. A particular doctor suggested the intentional forgoing of preventive care and if I “bleed”, I should see her and she would be glad to finish euthanizing. me since I “have to die from something”. I will make sure anyone I can contact having to do with the medical associations as well as legal experts will be hearing about this from me. As for this Emanuel creature 1. He is extremely dangerous 2. He should be removed from the elderly Biden’s committee of greedy cronies and finally since he doesn’t want longevity he can drop dead as soon as possible.

  3. What a joke. You want to control how people heal themselves because they are spending “your money?” I spit on you.

  4. I spit on Ezekiel Nazi Emanuel. This low life scum liar. And he wants to ration his Omurdercare by having us all die in line waiting to his scummy crummy substandard care. I am glad I am not related to this puke. I have greatly enjoyed my Grandparents over 75. And to think this murderer scum wanted them to die at 75, well, you know what Ezekiel – I’m pretty sure if I came to relieve you of your problem living after 75 you would cower like the sick little afraid person you are. Scum.

  5. “My bet is that a lot of what is accepted as current economic orthodoxy at the roots of capitalism including such tenets as Schumpter’s creative destruction idea are either seriously challenged or thrown out entirely in the next 50 years too.”

    All economic theories are products of historical moments of their time.

    Economists who believe that rules of economics are as immutable as laws of physics are deluded.

    Keynes recognized that and came up with the General Theory of Employment, which was essentially a sequel to Economic Consequences of Peace.

    The macro idiots who parrot him would probably have made him blush with embarrassment.

    Back on the theme: the role of the state in providing employment will increase in the next 15 years. USA will change from regulated capitalism to state capitalism. HC will be the primary driver of jobs.

    The end point? I think we all secretly know the answer.

  6. Today’s “Morning Edition” on NPR:

    Sandra Lopez said that before her oncologist told her about hospice care, she frequently called 911 to request an ambulance to take her to the hospital, where she would be admitted and spend days at a time. That happened “dozens and dozens of times,” in a year, Lopez said.

    At around $210 a day, Lopez’s hospice care cost Medicaid tens of thousands of dollars — probably less than her revolving-door trips to the hospital (with all their multinight stays), but still a lot of money.


  7. Based on my limited experience, doctors often recommend against surgeries on the oldest and frailest patients. (not to save money, but out of fear that the patient may not survive the surgery.)

    In general, keeping the oldest patients out of the hospital will not impact our medical care costs very much. If hospitals have fewer older patients in the ICU’s, then they will just raise the rates on younger patients. For 30 years we have driven down hospital days of care, only to see costs go up because of upcoding and other hospital maneuvers.

    One last note:

    The CLAAS program for LTC was a failure because iit was structured like private insurance. People would have had to sign up and pay premiums.
    The solution of course will be social insurance, i.e, taxes. Germany set up a payroll tax of about 1.5% for LTC and their program is working fine so far.

  8. Interesting links, MG. Those Australia and China examples illustrate well the main challenge facing most of the modern world — how best to care for an aging population as they become a bigger drain on revenue and sweeten the pie less and less as they age. This is a huge problem for all countries, also dramatically underscored by Japan. I read last week that in Japan adult diapers are now outselling baby diapers. One of the first parts of PPACA to prove unworkable, immediately out of the gate, was Ted Kennedy’s CLASS Act (Community Living Assistance Services and Supports Act), modeled after Social Security to be self-funded over time by funds from the working population paying to assist the non-working aging group. This continues to be an unmet challenge. Policy makers tend to delay correctives until problems reach crisis level.

    Musing about the way out in a comments thread here at THCB is an interesting exercise, but the challenges are far greater than most people are willing to face. It’s easy to outline problems but tough to overcome the cultural and political obstacles to solutions.

    I know of a small group of Nigerians a few years ago who withdrew from a multi-cultural church to form their own congregation, not because of theological or discrimination issues, but because they wanted their children in America to grow up with a cultural appreciation of elder care like what they had in Nigeria. These adults from another place considered their children a the most important component of their old age — and they realized that if they didn’t intervene early, that generation would grow up like everybody else in America, in denial about the problems facing old people.

    It’s no accident that the CLASS Act failed. It was torpedoed by an amendment to the legislation that said it had to be actuarially feasible, which of course it was not. Social safety nets are never feasible for those who think of all problems in economic terms, believing sincerely that all problems can be resolved — social, medical, educational, criminal, political — if we can just adjust the economic challenges exactly right. It springs from Libertarian or Austrian purists who see life through an economic lens, always believing that an invisible hand in the marketplace will rectify all problems. It’s also no accident that the senator who put that amendment into ACA was a Republican who left his seat in the Senate for a position at Goldman Sachs.

    Which leads us to the challenge of our day — wealth inequality and the large and growing gap between rich and poor. By writing that I just alienated a big chunk of readers, but I said it anyway. Thomas Piketty stirred up a shitstorm but the core of his thesis refuses to die. We are looking at the gates of Hell and I hope you and your generation will discover a way to keep them closed. I like the Robin Hood Tax but that’s just me dreaming out loud.

    I’m signing off here, MG. Thanks for your comments. Perhaps we will cross paths elsewhere some time.

  9. Yes. The authority and professionalism of the doctor is important, but I don’t think a lot of expensive time needs to be invested. Nearly everything that’s important can be made available using well-done resources — written, video, etc. Experienced nurses, PAs or even non-medical types (chaplains? lay ministers?) can guide patients and families through the learning process. Hospice outfits do it all the time, and doctors are rarely involved. Executing an advance directive is nothing more than going down a checklist. The tough part is getting patients families to come to terms with the choices and decisions being made.

    The most common mistake is waiting until the Angel of Death is clearly in sight. End-of-life choices should be made calmly, under no duress, while we are all still in good health. This calls for a cultural shift, which is the aim of Emanuel’s article and Gawande’s book. I would be more impressed with Ms. Gordon’s writing if she joined forces with those of us pushing for these attitudinal changes.

    You mentioned palliative care. I have started to use that term instead of hospice because the H-word triggers too many ill-informed negative responses. Part of the reason is that in many places there is virtually no meaningful regulatory oversight of hospice companies. I guess because it’s not yet part of the vernacular for most non-medical people, most of whom equate it with a death sentence, the “six months” survival expectation is confused with six weeks. What they don’t know is that sometimes people fail to die, get better and must be de-certified!

  10. Moving back to a country where Americans are increasingly going to work (not because they want to but they have to) until they either drop dead and/or physically/mentally unable to hold employment.

    Question is at what scale does it take place and how much of the social safety net is eroded or scaled back.

  11. Thanks John. Personally I think there is going to be a massive generational struggle between my generation (latter end of Gen X/Gen Y) vs Boomers in the 2020s as the bills become due for retirement and the tab is so considerable that it crowds out real portions of discretionary spending all levels of govt & Gen X/Gen Y are struggling to somehow pay their bills/debt while saying for retirement & paying other expense.

    This US isn’t the only country facing this issue. Almost OECD country that has enacted a comprehensive retirement system including healthcare is struggling. Take a look these stark numbers facing Australia’s retirement system which just came out:


    China has the exact opposite problem and even the latest numbers (take them for what you will in terms of accuracy – I don’t and even the limited numbers of data that were valid including electric generation and shipping numbers are increasing dubious) show they aren’t spending enough yet on unemployment benefits and healthcare.


    Xiaolu Wang and Yixiao Zhou, authors of the academic paper “Deepening Reform for China’s Long-term Growth and Development,” contend that it will be difficult for China to jump from middle-income to high-income status — a key requirement for a truly global power and that it will require a real increase in these two areas in terms of additional gov’t funding to meet Western high-income status standards..

    It is going to be a huge challenge for every country to face how to fund retirement for their increasing elderly populations and one no human civilization has ever faced. Pretty stark conversation that does have a lot of difficult and challenging elements to it especially from a Western perspective that places so much value on individual life at least in a general perspective.

    Gas excise tax couldn’t be counter-cyclical though because of the long-term necessity and consistent funding streams needed for the bonds to underwrite long-term capital expenditure projects. We should implement surge pricing in tolls and people/trucks be charged for the actual mileage they use but these raises some legit privacy and equality concerns. Also a non-starter in U.S. political discussion too.

  12. The point is that there isn’t . Even if there is a technological revolution that somehow massively improves worker productivity on par with what IT did in the late 80s through the 90s, it will almost certainly require a completely new policy and tax framework to deal with the issues of less full time employment. Arguably already there and there is no signs either party is remotely thinking along these lines. Both just are stuffing the pockets of there respective bidders and protecting their economic interests.

    My bet is that a lot of what is accepted as current economic orthodoxy at the roots of capitalism including such tenets as Schumpter’s creative destruction idea are either seriously challenged or thrown out entirely in the next 50 years too.

    The biggest issue I see is in regards to energy. Everything I have seen on shale depletion well rates (best case they deplete 85% in 3 years) shows that it is a stop-gap and not something that is going to propel the US ahead forward to decades to come. It buys us a little more time and space which we should be taking full advantage of but we aren’t. Obama has accomplished a few things including increasing CAFE standards (his most enduring energy legacy in terms of its impact) but otherwise has been seriously blunted.

    Things are reorienting to the East and their historical center during the course of human civilization. Question I have is how willingly is the US going to let this transition happen and to what extent are they going to be able to both influence events and find common ground through more peaceful economic means.

  13. “Living well is a good plan, but readers are encouraged to get a copy of Gawande’s “Being Mortal” and think about the meaning of dying well.”

    I agree John. Gawande did a good job on this subject. However, one of the key points he made relates to the importance of trying to draw the patient out about his or her hopes, goals and fears for the time remaining and to tailor treatment to address as many of those objectives and fears as possible.

    To do that, though, requires some time and effort which professionals need to be paid for. This is where I think Sarah Palin’s death panel crap does a real disservice to both patients and the medical system generally. Often, this is not a five or ten or fifteen minute conversation. Treatment options need to be explained as well as the quality of life implications of each and patients and families need to communicate their values and what’s most important to them. Paying doctors, palliative care specialists, social workers, etc. to have those conversations is money well spent, in my opinion, regardless of what patients and families ultimately decide to do.

  14. Emanuel said in unmistakable language he didn’t want to die, only that at 75 he would be ready. Important difference. This is from one of his opening paragraphs:

    I just climbed Kilimanjaro with two of my nephews. So I am not talking about bargaining with God to live to 75 because I have a terminal illness. Nor am I talking about waking up one morning 18 years from now and ending my life through euthanasia or suicide. Since the 1990s, I have actively opposed legalizing euthanasia and physician-assisted suicide. People who want to die in one of these ways tend to suffer not from unremitting pain but from depression, hopelessness, and fear of losing their dignity and control. The people they leave behind inevitably feel they have somehow failed. The answer to these symptoms is not ending a life but getting help. I have long argued that we should focus on giving all terminally ill people a good, compassionate death—not euthanasia or assisted suicide for a tiny minority.

    Living well is a good plan, but readers are encouraged to get a copy of Gawande’s “Being Mortal” and think about the meaning of dying well.

  15. “But does the solution to the out of control medicine lie in declaring that 75 should be the age of exit?”

    Republicans seem to think so – or at least for those not able to pay their high deductibles or premiums.

    “I have hammered into my children and husband’s head that I do not want any of the medical measures, tests, and treatments which you, in your only piece of sage advice, suggest we old foggies forego.”

    Seems like agreement to me.

    “Nor am I talking about waking up one morning 18 years from now and ending my life through euthanasia or suicide.”

    So where is the controversy in Mr. Emmanuel’s article?

    Ms. Gordon misses the wisdom in a tongue in cheek article. Lost for something this week to fill the pages with Ms. Gordon?

  16. A vastly complex topic, but still this is an important exchange. Let me offer two observations:

    1. Dr Emmanuel lives in a social circle where nearly everyone has enough money and pensions to retire in their sixties or even sooner.
    However, there are millions of Americans who must work until age 70 for financial reasons — who have no pension, moderate savings, or who have made poor spending decisions over the years.
    This group deserves a little more time retired.

    2. For all of human history until very recently, medicine struggled to reduce early deaths among the young. (this is still true in Africa.)
    The energies of this life saving impulse has turned toward preserving the elderly in the advanced nations.
    This is totally understandable. But there some unexpected problems when the elderly can live a very long time. We hesitate to even speak of these problems in public, so as not to sound heartless. But the unpleasant truth is that for some American families, death of the elders would be a relief.

  17. One part of Emanuel’s article I agree with is to stop getting preventive screening tests such as colonoscopies, PSA tests, mammograms, etc. after age 75. Indeed, when I recently asked my primary care doctor when I can stop getting colonoscopies, his answer was after age 75. I plan to stop them at that time.

    Treatment for serious conditions like cancer and heart disease probably should depend on the prognosis and quality of life related issues. The whole aspect of care at or near the end of life that bothers me the most is that, for the most part, patients are spending other people’s money, mainly taxpayers’ money. If they’re spending their own money, I don’t care what choices they make. When they’re spending mine, I do.

  18. MG: I see no way out of this quagmire.

    Not unless there is double digit growth from an unexpected economic boom.

    As long as we have to pay no more than interest on the debt that should be ok, right?

  19. @MG, I don’t know the details, but I heard an interview just a day or two ago with whoever was the guy in charge of getting Detroit out of bankruptcy. The road ahead will be rough, but the legal challenges have apparently all been resolved. Part of his remarks mentioned exactly that — the public employee pensions. He said they had voted to accept lower amounts as part of a final settlement, but he didn’t go into the details.

    My guess is that they were promised more than they could ever hope to see and after somebody ‘splaned the facts to them, they began to face reality, deciding that something was better than nothing at all. I’m just guessing, of course, but the final settlement probably swapped money for health care. The arithmetic would have been easier to grasp. But as I said, that’s just a guess. As for California, I have no idea.

  20. Interesting reflections, MG. I wish more people had that degree of clear thinking, especially those in your cohort. Your generation will either iron out the wrinkles or face the consequences. Most old farts like me are hung up with “get the government out of my life but don’t touch my Medicare or Social Security.”

    One bright spot, since you mentioned actuarial considerations, is related to Dr. Emanuel’s main point — mortality lightens the baby boom load before you and your peers join the ranks of the non-productive. Hopefully by then the ratio of working to non-working people will improve.

    A Social Security trust fund remains a smart idea. Part of the current retirement challenge is what to do about public employee plans that promised more than can be delivered — to people who opted out of Social Security with the expectation of something better. (Politicians are bad to promise more than can be delivered.) A trust fund will be a hedge against a similar population in your generation whose best laid employee funded arrangements turn out to be Devil’s bargains of the same kind.

    Employer-funded pensions are essentially obsolete. A few companies may retain them, but will still be obliged to feed employee-paid plans as well, either by better wages or matching 401(k) or similar arrangements. The jury is still out whether people will have the discipline to steward their plans properly, but I expect their vision will get better as the years go by.

    Your mention of the gasoline tax reminds me how more rational a counter-cyclical tax would be — shrinking as the retail price of gas goes up, but increasing when the price plummets, as it is now doing. Imagine how much less painful a gas tax would be added to today’s prices, even if it were twice or three times what it was a few years ago, and we would still be paying less at the pumps.

    Thanks for putting this end-of-life discussion into a larger context. Too much compartmentalized thinking tries to disconnect this discussion from challenges way bigger than the medical costs.

  21. Have you been following closely enough what has occurred with the Detroit public employees and their retiree healthcare costs?

    I haven’t and have wondered if it would serve as a ‘canary in the coal mine’ or if it was so highly politicized and unique that not a lot of parallels could be drawn from it.

    I wanted to see what other towns including Vallejo in CA have done in regards to public employee health benefits.

  22. Yes it is from an actuarial standpoint and a ROI standpoint. Someone my age (under 40), it expected to get <2% annual ROI on their SSI payroll deductions from their employer/individual over the course of their lifetime. Horrendous investment and not even what I would get from dividend yield on U.S. and European blue chip stocks. Basically there is no way that I will even see it keep up with CPI over time.

    Problem is that transitioning to a private-based account system for SSI is almost untenable because of the huge largely upfront transition costs. Costs of administration for the program would also greatly increase too and I am certain that if the law was written it would be way too favorable to Wall Street given both parties enthrallment to large finance. One of the largest great bastions of wealth for Wall Street to rip off in the U.S. and West in general.

    I greatly favor modifying the current SSI program which is still possible but requires some very difficult political compromises including adjusting the COLA formula for current retirees.

    Medicare/Medicaid are much tougher nuts to crack and I don't know how we are going to realistically address them but local & state gov't aren't going to have that luxury. Very few have remotely adequately funded for public employee health retirement costs and they are in much worse shape than public pension retirement solvency levels.

    Tax dollar waste and spending in the US military is unparalleled (US military-related budget is really $1T+ and quite possibly larger given who is black book operations and off the official records) and if the nonsense/saga that has been going on with the US DOD audit process occurred in any other US gov't agency the GOP would be having hearings every week. Instead, since it is really a massive job programs for both parties there is little public focus on it.

    As for infrastructure, it is already here. Kind of quietly the Obama administration has done a lot of work & laid groundwork for this in the future. With no appetite to raise the federal gasoline excise tax and the amount of miles driven by autos peaking in '07 with real doubts about it increasing in the near future, the US Highway Trust Fund has real solvency issues both short-term and long-term.

    Private-public infrastructure deals can work but a lot of it depends upon very savvy contracts with clawback provisions being struck & having real teeth.

  23. Bastiat once said: The state is that great fiction by which everyone tries to live at the expense of everyone else.

    Everyone. I mean everyone! Each and every person!

  24. ” I noticed years ago when I started work with old people that old women outnumber men about six to one.”

    Which is great if you’re an old man.

  25. “Your left/right oversimplification is a false equivalency”

    Actually it’s spot on, even if I may say so myself.

    Everyone thinks their little parch of tax-payer funded security is morally deserved, and a right.

    The right and left are not similar in this regard, but identical.

    When it comes to me I am an individual and when it comes to you we are a society.

    History has replayed this time and again. No body has managed to convince me why America would be any different.

  26. What we should do is change from engaging in risky behavior (drugs, sex, alcohol, rock’nroll, red meat, fatty foods, fast cars, fast women,etc.) at the teen-early 20s age to late 60s. That way you can have lots of fun and there’s planned obsolescence. No more worries about taking care of grandpa in his dotage, he’s flamed out.

  27. “People who think they can pick and choose which parts of the Constitution they need to follow are “woefully ignorant.”

    Talk about woeful ignorance. Conflationists who think the Constitution cannot be amended and updated shouldn’t have the word “lawyer” in their screen name.

  28. I know it escapes your slippery slope / non sequitur mind, but calling for the repeal of the 2nd Amendment is NOT automatically the same as calling for the banning of firearms.

  29. Those of us clinging to the idea that basic health care is a right, not a commodity, will always lose in a democracy. Notice I said “basic health care” not cosmetic or other expensive variants. Your left/right oversimplification is a false equivalency.

    Basic health care has different meanings for different people. It’s like drinking water. A municipal supply of potable water, free of contaminants, is not the same as the installation of a super-deluxe filtration system in every home and apartment.

    Peddle your death panels arguments to someone else. I’m not buying. Besides, Ms. Gordon’s screed is more an exercise in rhetoric than reason. Let’s not be led astray by the intoxicating effect of her ninety-proof prose.

  30. Zeke should read Benjamin Franklin. Franklin says “Don’t put off for tomorrow what you can do today.”

    Maybe Zeke should realize that things change so perhaps for Zeke 75 is the right time for him today, but he shouldn’t be the one singing such a tune. He is too intermingled with death panels and a lot of legislation that doesn’t work and is scary to a lot of intelligent people that have minds of their own.

  31. To those that wish to ban the second amendment: It is an idea, but one has to think ahead. Guns are a part of our present civilization where protection is just one reason for their existence. What would happen if guns were banned? Does that stop illegal ownership? Of course not so a law against guns is just another law to be broken. Furthermore, there is no evidence that banning guns would improve society unless one is cherry picking the evidence.

    If guns suddenly disappeared don’t you think knives would start killing more people? Make knives disappear and people will use chopsticks. There is no end. The focus of ones concerns should be on where and why so much violence exists in our society.

  32. John, you nicely demonstrate why America’s healthcare and fiscal woes can and will never be solved democratically.

    Every sector/ citizen/ interest group says it’s the other that is more deserving of a haircut, and to some extent, everyone has a point, but everyone misses the point.

    Medicare vouchers instill the same demagoguery as death panels. It’s either Paul Ryan who is throwing granny off the cliff or Obama’s death panels.

    It’s a case of “me and my government is more important than you and your government.”

    The left and right are identical in this regard.

  33. Surely you’re not suggesting that excessive (presumably “least productive/completely unproductive”) spending is a “retirement benefit” for seniors. This comment seems to be sniffing around the notion of curbing or privatizing social security and/or Medicare benefits to offset (that’s the new favorite budgeting buzzword, I hear) infrastructure spending.

    It’s bad enough that the pharmaceutical-medical-industrial complex gets as many tax and policy breaks as it does, without coupling that hemorrhage with federal spending. This is a political challenge, of course. But let’s not open the political argument without first taking a look at other places where taxes are wasted.

  34. Emanuel’s general point stands that as a society the US invests the lion’s share of its domestic spending especially at the federal level on its least productive/completely unproductive. This is a recipe for disaster and where we are headed but it happens because the elderly/near-elderly vote in huge numbers that is much more representative than their actual % of the population. Even more pronounced in primaries and elections not in Nov (in elections this year people aged 60 and older were estimated to cast 37% of all ballots yet only make up 20% of the population, when you get to 55 and older was 48% and 27% respectively).

    Any politician who remotely threatens to change federal retirement benefits for this demographic will get annihilated. Complete non-starter politically.

    As draconian as that may sound, it is a harsh truth and the US federal budget on infrastructure isn’t even % of what it was from a GDP perspective in the 50s/60s. Not even investing enough to maintain the current levels of infrastructure let alone fundamentally upgrading and preparing the transition away from gasoline-propelled cars. It is a key reason why when the annual American Society of Civil Engineers report comes out, it seems to get worse with each passing year.

  35. On-staff ER physicians open-carried at all times including when treating patients in a U.S. hospital?

    What a load of cr@p. If that is remotely true, tell me what supposed hospital this was.

    Even Temple in Philly which treats the most gun shot victims in the city has a strict ‘no gun/weapon’ policy in the ER for anyone except law officers.

  36. I guess none of you guys have ever actually worked at a hospital where people are treated for gunshot wounds, stabbings, rapes, etc.

    I’ve staffed ED’s where EVERY single physician carried a gun at all times. And many of them had used same to thwart criminals, ON PREMISES. Our director of nursing was abducted, beaten, and raped. Doctors had their cars stolen and broken into in their physician parking lot. Gang violence that spilled into our ER waiting area was common and frequent. But keep thinking that the police will protect you from bad/stupid/drug addicted people everywhere and at all times.

    People who think they can pick and choose which parts of the Constitution they need to follow are “woefully ignorant.”

  37. Quite a polemic there — smacks of overkill (if you’ll excuse the expression).
    Shorter Emanuel is that dying well is as important as living well, and it’s okay for responsible people to do both, thank you very much, And after Dr. Gawande’s latest, Being Mortal, dying is a subject finally getting attention after years of denial.

    This seems to be a modern problem. Prior to the discovery of germs and vaccines dying was an everyday event, beginning with childhood. Discussions like this would be unimaginable. So lighten up, please. And besides, as a woman, Ms. Gordon, you get bonus years for having been born female. I noticed years ago when I started work with old people that old women outnumber men about six to one.

  38. It isn’t so much but the belief that the 2nd right should triumph almost all other rights including property rights and the very focused effort at the state level to make this a reality.

    Anyone who thinks that they gun rights are more important than private property rights to the success of American democracy and capitalism is woefully ignorant.

    Also anything who thinks they need to have a gun on their person at all times when they leave their house either has real paranoia/mental issues or a very warped sense of their personal dabger level.

  39. “Seriously, do you not see the paranoia his piece has instigated?”

    Not really. This was a relatively minor story with no legs. And, he was really saying, IIRC, he’d be foregoing medical care by age 75, not that he wanted to die precisely then. I don’t recall him writing that he’d be killing himself, just that he’d be moving on to the Vik Khanna School of Spartan Wellness.

    But, then, media fueled “paranoia” is just business as usual. EVERYTHING is The End of Civilization As We Know It.

    I have rather long experience as a next of kin caregiver, first with my late daughter (cancer), then picking up where that left off in 1998 with my parents, both of whom eventually languished in LTC for years, my dad addled with dementia.


    He died at 92, my mom in 2011 just shy of 90.

    I certainly don’t want that.

  40. I missed the bit where Emanuel said others should follow his example. He doesn’t wish to spend his last breath somewhere between a nursing home, ICU and a CAT scanner. He is not denying others the right to do so.

    Seriously, do you not see the paranoia his piece has instigated?

    When I hear “death panels” I sort of tune off. It’s the healthcare version of Godwin’s Law.

  41. There’s no such thing as too much emphasis of the first amendment!

    The second amendment, well that’s a whole different matter.

  42. “it’s worth emphasizing that Emanuel has a right to opine”

    I guess I missed the part where she advocated that he be silenced.

  43. Wow!

    The (exaggerated and often vitriolic) response to Emanuel’s piece will be an interesting analysis for future anthropologists for the odd paranoia that afflicts citizens of this country about the last few days of their lives.

    Death panels is cheap talk.

    For now, it’s worth emphasizing that Emanuel has a right to opine, and a right to die when he chooses. Of course, one has a right to lose sleep over his opinions.

    He wishes to exit with grace. In some civilization in a parallel universe that would be considered laudable.

  44. “As you rail against “American immortals” what you actually delineate is not a version of the good life or death, but what aging means to “American competitives,” people who cannot conceive of a life lived without races to win, mountains to climb, prizes to covet, money to be made, achievements to catalogue, and more unworkable policies to propose. I just hope as I get older, I continue to have the wisdom to use a different metric to assess how my last days should be lived, what images I leave my children, and what counts as a good life.”

    Ding, ding, ding, we have a winner.

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