Realistic, courageous aging

Dr. Emanuel climbed Kilimanjaro at 57. (I climbed the peak at 55, so there.) Photo grabbed from the article discussed here.

Ezekiel J. Emanuel is an Emanuel -- that is, like his even less appealing brother the mayor of Chicago, he's a bit of a twit, attracting our attention by intentionally stimulating outrage and projecting a know-it-all self-assurance.

But if you can get through the annoying tone of his Atlantic feature article, Why I Hope to Die at 75, there's a lot to ponder here.

Very briefly, Emanuel describes our culture as having succumbed to a pervasive medical and cultural quest for an illusory and false promise of pseudo-immortality.

Since 1960, however, increases in longevity have been achieved mainly by extending the lives of people over 60. Rather than saving more young people, we are stretching out old age.

The American immortal [Emanual's snark label for our conventional aging aspiration] desperately wants to believe in the “compression of morbidity.” Developed in 1980 by James F. Fries, now a professor emeritus of medicine at Stanford, this theory postulates that as we extend our life spans into the 80s and 90s, we will be living healthier lives—more time before we have disabilities, and fewer disabilities overall. ...

Compression of morbidity is a quintessentially American idea. It tells us exactly what we want to believe: that we will live longer lives and then abruptly die with hardly any aches, pains, or physical deterioration—the morbidity traditionally associated with growing old. It promises a kind of fountain of youth until the ever-receding time of death. It is this dream—or fantasy—that drives the American immortal and has fueled interest and investment in regenerative medicine and replacement organs.

He maintains that if we had the courage to look around us, we'd understand that as a society we may be living more years, but would also question whether a medically assisted old age consisting of multiple heart by-passes and poisonous cancer treatments was always worth the extension of a diminished life. The statistical evidence he presents about the declines we can expect after age 75 is persuasive, as is his understanding that almost every one of us wants to cling to the fantasy that we will be the lucky statistical outlier to whom decline does not come. Sure, there are people who live to great old age in comfortable good health and die "good" (quick, painless) deaths. But that will not be most of us. The cultural imperative that we believe in the norm of such a passing reminds me of the belief I've encountered in some communities that if you got cancer, you must have failed somehow, have entertained "bad thoughts."

I found the article particularly interesting on the social consequences of extended longevity in the United States.

Our living too long places real emotional weights on our progeny. ... When parents routinely live to 95, children must caretake into their own retirement. That doesn’t leave them much time on their own—and it is all old age. When parents live to 75, children have had the joys of a rich relationship with their parents, but also have enough time for their own lives, out of their parents’ shadows.

I am extremely aware of this occurring around me because it is one of the experiences I did not share with many of my age peers. Because my parents waited until very late in life to bring me into the world, for good or ill I passed the milestone into "the older generation" with their decease by age 50.

If demographic trends (which Emanuel doesn't cite) continue, the chance to be "the older generation" while we are still close to our primes will become more and more a class-based phenomenon in the future. Educated and professional women in developed societies marry later and have children later than their less privileged age-mates, so their tenure in the "sandwich" role, caring for both the very young and the very old, is likely to be shorter. People who have their kids young at the peak of their fertility (the human norm from which our society is varying) will bear the brunt of longer, more decrepit aging of their parents. Since they are also the most likely to be economically challenged, the prospect is scary for them and their kids.

I sympathize with Emanuel's prescription for elders who choose his way; he'll forego significant, life-extending medical interventions.

At 75 and beyond, I will need a good reason to even visit the doctor and take any medical test or treatment, no matter how routine and painless. And that good reason is not “It will prolong your life.” I will stop getting any regular preventive tests, screenings, or interventions. I will accept only palliative—not curative—treatments if I am suffering pain or other disability.

As it happens, both my parents more or less died this way, not exactly by choice, but because that is how they thought aging proceeded. Your parts wore out; there wasn't much that medicine could do about this inevitable decline; you stumbled on, gradually diminished; eventually you died at home. They made it to 87 and 90 respectively. As far as I could tell, they didn't welcome death, but they imagined no other way and did not resent their fates, though they mostly maintained a will to live to the end.

Despite finding him annoying, I applaud Emanuel for trying to get us to think more realistically about aging. Most of us will be lucky enough to get old. We can do this with more or less realism and courage. I want more.