Friday, November 14, 2014

Ezekiel's Flawed Ethics - the Die at 75 Plan

Ezekiel Emanuel wrote an article for the Atlantic on "Why I Hope to Die at 75 - An argument that society and families—and you—will be better off if nature takes its course swiftly and promptly."  As an Oncologist and Ethicist, he says he speaks for himself but implies not so subtlety that it may be best to avoid the consequences of aging and declining health (which probably really begins around age 25).  For himself he would not want any medical tests or therapeutics after age 75.  He argues that the productive years of life are over, that accomplishments should be complete, and that prolonging aging and its consequences is something he wishes to avoid.

Recently, I gave a talk called "Your Life Your Choices" to a couple of life-care communities where the average age was near 80 and most were still in independent living.  Many had lost their spouses and most, by definition, had some degree of declining health.  Sounds depressing doesn't it?  Yet these folks were active - in their faith groups, with their grandchildren, swimming, singing, playing and performing in bands or quartets, line dancing, playing tennis (a few), golf, and enjoying each others company.  There was keen recognition and understanding about end-of-life issues.  Many had POLST forms saying they would never want CPR, but they would accept removing an appendix, taking an antibiotic, and even a new knee or hip. 

I showed these groups a video of CPR, and talked for about 90 minutes about having "the conversation" with loved ones, designating a durable power of attorney for health care, etc. It seems that Emanuel wants to shock us into accepting that we need to face up to the declining years and make plans so I discussed Emanuel's proposal in these groups.  None of them felt they should have died 5 years ago!

Emanuel states that his family disagrees with his wishes.  I hope he can find someone to follow them and respect his autonomy.  But what if he comes in with an infected hangnail with an ascending infection threatening his life with septicemia.  At age 74 take an antibiotic, but decline at 75?

So I think I get his over-exaggerated point that we need to think carefully about prolonging the dying process when we are at an end.  But, with due respect, I think his ethics are flawed.  He is discounting the delight of being old and still functional.  Yes, we won't win a Nobel Prize.  But how about the joy of attending a grandchild's concert, going up to the lake cabin once more with the family, traveling together to Alaska, singing old favorites, volunteering at the food bank or library, or going to the opera.  Ezekiel, there is no age cutoff for enjoying family, friends, and the pleasures of life.  Even though you say you don't support "death with dignity", you are basically proposing that for yourself when you would even decline taking an antibiotic after age 75.

As we die, we leave a legacy for those we leave behind.  Ethical wills, sharing our values, showing love, and supporting our loved ones - yes, even as our spouses age.  There's nothing wrong with a cane, a walker, or a wheelchair - enjoyable life can still be there for many of us.  There can be growth in our spiritual life and new-found loves even as we experience loss.  The old saying "getting old isn't for sissies" rings true because aging does have its trials.  Personally I think rekindling an old forgotten friendship is more important, and perhaps as satisfying, compared to your climb of Mt. Kilimanjaro.

At age 76, as I write this, I think your ethical view of aging is at best cloudy and seems based on fear of loss rather than autonomy.  Yes, there are problems of cost, resources, and "getting out of the way" for the next generation.  But with my new corneas, I can drive safely again.  I love playing tennis doubles with my 80 year old friends twice a week.  Should I have resigned to go blind at 75?  At your healthy age of 58 Ezekiel, you seem to have a peculiar disconnect with those aging and declining in health.  So please re-write your article at age 74!

Friday, November 7, 2014

Voluntary Stopping Eating and Drinking (VSED)

Just today I attended the Washington State End of Life Coalition annual meeting where there is always a lot of sharing of stories.  Phyllis Shacter from Bellingham gave a very moving account of her husband's onset of Alzheimer's and how he ultimately decided the path of VSED while he was still mentally competent.  Here's a link to her TEDxBellington Talk:

I don't know if you've seen the French movie, "Amour", which is a beautiful but sad story about an aging French couple with deteriorating health.  Their path of dying was unsupported and tragic.  Please see this link ( for more discussion about the movie and VSED.

Monday, November 3, 2014

Brittany Maynard's Way of Dying

Brittany Maynard has passed from this life.  This brave but unfortunate 29 year old woman with incurable progressive brain cancer drew public attention by choosing to go public with her choice about end of life care.

"Brittany suffered increasingly frequent and longer seizures, severe head and neck pain, and stroke-like symptoms," according to a statement Sunday night from Sean Crowley, spokesman for Compassion & Choices, a national nonprofit working to expand end-of-life options.  "As symptoms grew more severe, she chose to abbreviate the dying process by taking the aid-in-dying medication she had received months ago. This choice is authorized under the Oregon Death With Dignity Act. She died as she intended — peacefully in her bedroom, in the arms of her loved ones," the statement said.

Her decision to post a video and promote dialogue is stimulating an important conversation.  Brittany did not want to die and felt that the term suicide did not ring true in her case.  She did not want to suffer. As the end approached she wanted to be able to die on her own terms.  In the comments to this article, many supported Brittany but a few felt that dying should not be by "assisted suicide".  Indeed, with good palliative and hospice care, "death with dignity" is relatively rare even in the states where it is legal - Oregon, Washington, Vermont, and Montana.  About 1 in 500 deaths are by self ingestion of prescribed lethal drugs.

The fears of the "slippery slope" leading to wider use or abuse have not materialized, but these fears are not unfounded.  I'm a little surprised that Oregon does not keep track of the "tourists" who come to their state for "death with dignity".  It's important to be transparent here.  Some critics fear the "culture of death" to such an extent that they oppose the POLST form and continue to promote the irrational fear of government sponsored "Death Panels".

To me the positive aspects of a case like Brittany's are not only the battle over "death with dignity".  Rather, it's a flash point to get us talking about the inevitable fact that we are all going to die.  In this conversation, we need to talk about our values, hopes, and fears.  Most importantly we need to appoint a person as our Durable Power of Attorney for Health Care, because there's a 50% chance we will be too sick to participate in the discussion about our wishes when we are near life's end.

Thank you and God bless, Brittany.  You are in a better place now.  And you have left behind a legacy that we all need to have choices and have the important conversation about end of life wishes.

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