My father was lucky. At 79, he placed his first shot almost at the pin of a par 3 hole on his hometown golf course. He walked up to make his putt and died suddenly of a heart attack. For many of us, though, death will come from a disease process that lasts months or years. Our bodies and minds will deteriorate from age and sickness and will change profoundly when death is near. We will have decisions to make. We should have information about what may happen and about our choices. But these are difficult conversations.
Ezekiel Emanuel, an oncologist and bioethicist, has an essay in The Atlantic about his preferences concerning what he wants to do when he is aged and facing death. The essay is brave and constructive. It’s brave because Emanuel and others who want to encourage end of life discussions have been falsely accused of promoting euthanasia — Emanuel has been a notable opponent of euthanasia and assisted suicide — and this article elicited more of the same. It’s constructive because Emanuel writes informally, candidly, and personally in a way that may help make it possible for the rest of us to reflect on our choices in the light of our values.
Emanuel says that he hopes to die at 75. Focusing his essay on a specific age was, unfortunately, poor writing. Emanuel doesn’t care about the age. What he wants to say is that there will be a time when his mental and physical powers will have deteriorated to the point where the value of his additional life would not justify the treatments that would extend it. He’s emphatically not going to kill himself. But he will begin to forgo treatments that might extend his life. He’s not arguing for a policy that would require others to make similar end of life choices. He’s giving the reasons for his plans. You can take them or leave them.
Expressing a hope for death is mildly shocking, particularly when the writer is healthy and appears ebulliently happy. But in my experience many elderly people speak this way.
– How’s your hip today, mom?
– Not so good. I had to take an extra Tramadol.
<Pause.>
– Ah. Then I’m not sure another glass of pinot is such a good idea…
– And your point would be?
My mother is no fool. By her lights, it’s rational to disregard certain risks to enjoy life while it’s still here. Similarly, there may be a point in the care for a disease where treatment will mostly get you more suffering. My beloved aunt and physician uncle died of cancer in their 90s. In their final illnesses, they took only palliative care. I will never forget the grace they showed in these choices and I am deeply proud of our family for supporting them.
Not accepting death can be, as Emanuel points out, a kind of insanity. Brilliant people fall prey to it. Susan Sontag
was surprised when the doctors in Seattle came in to tell her the bone-marrow transplant had failed and her leukemia was back. She screamed out, “But this means I’m going to die!” [Her son David Reiff writes that] I will never forget that scream, or think of it without wanting to cry out myself. And yet, even that terrible morning, in a pristine room at the University of Washington Medical Center, with its incongruously beautiful view of Lake Union and Mount Rainier in the background, I remember being surprised by her surprise. I suppose I shouldn’t have been. There are those who can reconcile themselves to death and those who can’t.
To measure the cost of denial I urge you to read Reiff’s memoir of his mother’s ghastly death.
Emanuel’s end of life plans are tied, naturally, to how he values his life. Here he and I diverge. He seems to evaluate his life meritocratically. For example, he presents data on the ages at which world historical figures made their final contributions. When disability accumulates to the point where he can’t excel, apparently life is not worth living.
A life so focused on the success of projects seems barren to me. Just being with family and friends is a good life. Just being in the inner and outer world has value.
Two things fill the mind with ever new and increasing admiration and awe, the more often and steadily we reflect upon them: the starry heavens above me and the moral law within me.
For an atheist, the continuing relevance of the great religious sages is that they point to deeper ways of valuing life that are open to the able as well as the disabled. Most of us cannot excel, that’s built into the definition of the idea. In a more just world, we would all have access to a good life that would be worth living even if we can’t or can no longer contribute.
There are many TIE posts on end of life decision making.
