Two quasi-celebrity physicians have recently stirred a great deal of discussion on the subject of aging and the medical treatment that accompanies it.
Dr. Ezekiel Emmanuel, an oncologist and bio-ethicist, writes that after age 75 life is hardly worth living, and so he’d rather just skip it, thank you. (“Why I Hope to Die at 75,” Atlantic Monthly, October, 2014)
The surgeon and prolific writer, Atul Gawande, focuses on the medical care typically received by the aged or critically ill. In his view, it’s fundamentally misguided; it seeks to “ensure health and survival” when its aim should be to “enable well-being.” He proposes a number of changes in the conduct of assisted living facilities and nursing homes and in the way physicians think and act. Without such change—and luck—being old or infirm is apt to include unnecessary suffering.
Emmanuel and Gawande are extremely accomplished and admirable. These two works have merit (Gawande’s a lot, Emmanuel’s just a smidgen). But in my view, they are chockablock with questionable notions and omissions.
Emmanuel begins with: “living too long” leaves us “faltering and declining…[and] deprived.” If by “too long” he means continuing to breathe until one is fully senescent, it’s hard to disagree with him. But he seems to think “too long” will start the day after he turns 75. He’ll require Depends, a ventilator, and a feeding tube before he’s finished the leftover birthday cake. Even if his breakdown is not sudden, it will happen before long, unless—here he loses me—unless he refuses all post-75 medical tests and medical treatment other than palliative care. I suppose his intends to get his life over and done before he can become seriously infirm or senile, but it’s not clear. (He’s on record in this essay and elsewhere as being opposed to assisted suicide and euthanasia, and he believes that view is not inconsistent with refusing prophylactic and curative medical care after 75. Perhaps he just lacks the courage of his convictions.)
Faltering, declining, and deprivation are a part of old age, of course, but they don’t usually occur all at the same time and in force, do they? Like Sandburg’s fog, they slip in “on little cat feet,” little by little, giving us time to get used to stiffening joints and ever-thicker eyeglasses.
I’m editing this on the Amtrak to New York City where I have two doctor appointments; one to follow up on ear surgery that may save some of my hearing and one for help with a urinary problem. Also, my back hurts. But I don’t see this day’s events and what they foreshadow as a reason to wish I had died when I was 75. I find it more taxing to ski and snowshoe now than I did a few years ago. So what? I still enjoy it.
And another thing. I couldn’t ski or snowshoe at all when I was younger and more fit. There was no snow where I lived, and I couldn’t afford to travel to where it was, and anyway, I was usually too busy. Of course, if I had lived in snow country when I was young, my performance would have been superior to what it is now by every measure except pleasure derived.
On the other hand, on the five or six days a week when I work out now, I notice some ways in which I’m stronger than when I was young. My old-man routine includes, for example, three sets of 60 pushups. In college, I struggled to do one set of twenty.
Then there is the matter of what happens to the mind. To Emmanuel, by 75, “creativity, originality, and productivity are pretty much gone for the vast, vast majority of us.” “Vast, vast” overstates the case in my view, but even if you accept it, that doesn’t sound like much of a reason to hope to die at 75. Admittedly, it’s one of a number of unfortunate developments that are part of aging, and, in Emmanuel’s view, it’s the combination that leads him to his bleak hope.
But what about this: many people have little creativity, originality, and productivity at any age. Most just get up and go to work—mind a store, take care of the kids, lay bricks, sell real estate. For them being creative and original is pretty much overshadowed by doing a reasonably good job and making it to payday.
And even if at age 40, one was the equal of Rubens, Mozart, and Dostoevsky combined, I should think life as an old person could still be worth living even with the diminution of genius.
Anyway, the notion is too broad. Not everyone is less creative, original, and productive after 75. I’m sure not. I’ve not yet received a National Book Award for my essays and newspaper column, but sometimes my work has merit; almost always far more than anything I wrote when I was younger. In fact, I could not have written then the way I do now; my whole life has been preparation for my present calling. I may be unusual in this way, but I’m not unique.
Emmanuel doesn’t consider such a way of being. He sees life as conforming to a pattern that starts with a career choice at the end of adolescence or thereabouts, industrious pursuit of it until retirement, with a peak of achievement in early middle age. He cites average ages when Nobel prizes are earned (emphasis mine) as evidence. No doubt some people live lives that are structured in such a way, but many do not. My guess is that most people just find a job (if they can), set the alarm clock, and get on with it. Or, as in my case, look high and low for a way to earn a living that suited my talents and likes and that also transcended merely earning a living. Emmanuel seems unaware of these other ways of being, common as they are.
At the beginning and end of his essay, Emmanuel refers to a “complete” life. More on that below.
Gawande’s subject is the shortcoming of American medical practice and institutions in meeting the needs of the “frail,” i.e., the very ill or old. His picture of the trials of people in these circumstances is a familiar one. Many, perhaps most, adults have had a brush with deciding whether to approve treatment of a loved one with yet another procedure that might do more harm than good. And surely everyone knows what a horror nursing homes usually are. (To me, assisted living isn’t much better.) Gawande describes all this clearly and makes a case for changing institutional care of the old as well as for altering the very purpose of their medical care.
Most of his book focusses on end-of-life treatment, but the first two chapters are about the part of life that precedes critical illness and/or extreme old age. Regrettably, he treats this period as a mere preliminary. In my view, it doesn’t just precede old age, it more or less forms it. In fact, early life is inseparable and fully present in the lives of the gravely ill and extremely aged. Neither Gawande or Emmanuel consider that how you experience senescence and dying depends a great deal on who you have become at the time when they occur.
It’s common these days to believe that remarkable fitness can be made to continue into the senior years. All you need do is buy this book, hire that trainer, believe, and work at it. (You’d think that even the most gullible would know that the amount of exercise you can tolerate and how much fitness you can achieve is governed not just by wanting and doing but by what you bring to the effort. A handful of people can train for marathons by running 130 miles a week. Most people, no matter how motivated, break down under the stress of many fewer miles than that. Variation in tolerance of physical stress, i.e., training, exists at every stage of life.)
Similarly, cyberspace bulges with ads for programs designed to keep the brain functioning like young Einstein’s. If Emmanuel’s essay keeps getting attention, these ads may soon feature the promise of staying “creative, original, and productive.” Though I am past 75 myself, my brain still works well enough to tell me to be skeptical of these schemes.
I watched my mother work the crossword daily even as her conversation came to be dominated by perseveration and her memory failed. Of course, she didn’t attempt the Sunday New York Times or the The Sunday Times of London puzzles. Maybe if she had, she’d have been clearer of mind when she died at 92.
I don’t do puzzles myself, nor have I bought any books or tried any of the exercises that purport to preserve memory. Anyway, if there’s anything to their questionable claim that mental gymnastics really do keep you sharp, I’ve already got it covered. I’m forced to go geeky over my malfunctioning computer and IT problems about as often as I urinate. (Urination is more fun.)
This commercial promise of extending youthful physical and mental fitness into old age is not what I’m talking about when I say Gawande and Emmanuel should have paid more attention to the junior years.
Emmanuel describes retirement as a time of unavoidable and unwelcome decline. One day you quit going to the office or the job site and you turn your attention to avocations. But it turns out that shuffleboard and dog races and any pursuit of mere pleasure loses its allure before long. You stagger and wobble into an increasingly sedentary life and a broken hip and other physical failings, and pretty soon your memory starts to fail, and then—whoa—it’s all over. As the years pile up, even the most progressive assisted-living centers and nursing homes cannot give people whose lives follow such a pattern much reason to get out of bed in the morning.
A corollary belief (my word—it’s usually thought of as a fact) is that when people reach senior status they become subject to “constricting of ambition and expectations.” No doubt that’s often the case. But it’s not a law of nature, and it is to some extent preventable.
As I approach 77, my life is nothing at all like that. Since I was a teenager I’ve had a notion—a vague impression actually—of how I wanted this part of my life to be. It was to be full of reading and writing and music and exercise and sex and making another attempt—this time energetically—to gain some facility with Latin and Greek. Except for the last, it’s the life I actually have. At no point in my life have I been so ambitious, so full of expectation.
Emmanuel’s hope to die when he’s 75 grows out of one word—”complete.” “By the time I reach 75, I will have lived a complete life….I will have pursued my life’s projects and made whatever contributions, important or not, I’m going to make.” I find this astonishingly muddle-headed; a restricted and crabbed notion that’s sure to make the time following completion empty and pointless.
Neither Gawande nor Emmanuel address two common ways (not mutually exclusive) to make aging less challenging—even agreeable.
One is to have work about which you are so passionate that you pursue it until you drop.
The other is to have religious belief that endows life with transcendent meaning, no matter the circumstances of the moment.
Gawande has almost nothing to say about the salutary effect of living in such ways; Emmanuel even less, though he implies that he regrets the omission.
“Many of us have suppressed, actively or passively, thinking about God, heaven and hell, and whether we return to the worms. We are agnostics or atheists, or just don’t think about whether there is a God and why she should care at all about mere mortals. We also avoid constantly thinking about the purpose of our lives and the mark we will leave. Is making money, chasing the dream, all worth it? Indeed, most of us have found a way to live our lives comfortably without acknowledging, much less answering, these big questions on a regular basis. We have gotten into a productive routine that helps us ignore them. And I don’t purport to have the answers.”
At least he could have explored some possibilities.