David R. Henderson  

Zeke Emmanuel on Optimal Life Expectancy

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Private Policy

Like Arnold Kling, I found some of the information in Ezekiel Emanuel's article on aging troubling. But also, like health policy analyst Greg Scandlen, I found Ezekiel Emanuel troubling. I first saw reference to his article in a Tyler Cowen post and read the whole thing through. It shifted my prior. Shortly after I turned 40, I needed to get glasses for the first time and the experience made me so aware of my mortality that when I went back to Lenscrafters an hour later to pick them up, I had to work hard to restrain my tears in front of the woman putting them on me. In my men's group that evening, I "went against" that feeling by saying that I wanted to live to age 100. That has been my line--and my belief--ever since.

Until Saturday, when I read Emanuel's article.

For the first day after reading the Emanuel article, I did what I often do with a new idea that seems somewhat plausible but contradicts an old idea: I tried it on. I told my wife about the article and said that maybe I wouldn't want to live past 80. (Notice that I had already adjusted the age in Emanuel's article: with only 11 years and 2 months to go before I turn 75, the 75 number just seemed too low.) She asked me how old Emanuel is. "57," I replied. "How can he know at age 57 how he'll feel at age 75?" she asked. I had to grant her point.

So here's how I've integrated his thinking into mine. There might be certain things that will happen to me that will make me want to end it early. But is that really new thinking? I've always said that if I get Alzheimer's, I'll try to figure out, before it's too late, how to take my own life. So, now that I've had a few days to kick the tires of Emanuel's idea, I don't really think it has shifted my thinking much at all.

Now to one of Greg Scandlen's points. Scandlen puts his finger accurately, based on what I've seen of Emanuel in the past, on Emanuel's attitude. The way I would sum it up is "Sometimes wrong; never in doubt." The man (Emanuel) really does seem to think he knows how everyone should live.

It seems clear, for example, that Emanuel would like his father to die:

My father illustrates the situation well. About a decade ago, just shy of his 77th birthday, he began having pain in his abdomen. Like every good doctor, he kept denying that it was anything important. But after three weeks with no improvement, he was persuaded to see his physician. He had in fact had a heart attack, which led to a cardiac catheterization and ultimately a bypass. Since then, he has not been the same. Once the prototype of a hyperactive Emanuel, suddenly his walking, his talking, his humor got slower. Today he can swim, read the newspaper, needle his kids on the phone, and still live with my mother in their own house. But everything seems sluggish. Although he didn't die from the heart attack, no one would say he is living a vibrant life. When he discussed it with me, my father said, "I have slowed down tremendously. That is a fact. I no longer make rounds at the hospital or teach." Despite this, he also said he was happy.

OMG! Can "no longer make rounds at the hospital or teach." As Marisa Tomei says at the end of one of my favorite movies, My Cousin Vinny, "What a _______ nightmare!"

What might you expect the next paragraph to be? Maybe that, well, OK, different strokes (no pun intended) for different folks? No. Instead, Emanuel just goes back to his theme that when our physical faculties falter a lot, we should welcome death. I would like to know whether his 87-year-old (approximately) father, who is happy, would welcome death. Or whether he would have welcomed it age 77.

What I learned from Emanuel's article is what a narrow view of the good life he has.

Health Care Policy

Now, this wouldn't matter much if Emanuel were a random guy saying that he doesn't want certain kinds of medical tests after age 75. But he's not. Remember that he was one of the architects of ObamaCare. With his attitude about the importance of people over age 75, can we seriously think that he wouldn't want to cut off certain health care services for people over age 75?

Emanuel says he's not advocating any particular health policy based on his views:

Again, let me be clear: I am not saying that those who want to live as long as possible are unethical or wrong. I am certainly not scorning or dismissing people who want to live on despite their physical and mental limitations. I'm not even trying to convince anyone I'm right. Indeed, I often advise people in this age group on how to get the best medical care available in the United States for their ailments. That is their choice, and I want to support them.

And I am not advocating 75 as the official statistic of a complete, good life in order to save resources, ration health care, or address public-policy issues arising from the increases in life expectancy.


"Let me be clear." Hmmm. Where have we heard that before? Basically, I just don't believe him.

Now, if it's just a matter of not having Medicare pay for health care services for people over age 75, but still allowing people to pay for them, then I'm on board, as I've written before. But Emanuel has never come across as someone who simply wants to persuade people; he has always come across as a life arranger. So don't be surprised if he advocates that certain health care services not be available to people over age 75 even if they want to pay out of their own pockets or get Medigap insurance that would pay.


Comments and Sharing






COMMENTS (33 to date)
RPLong writes:

Whether Emanuel truly wants to live no longer than age 75 is an empirical question. We should be able to observe his revealed time-preferences and determine for sure whether even he himself believes what he's written. My suspicion is no.

When I read the article, I couldn't help but think of Dostoevsky's The Idiot. (No, I'm not making a joke about the title of the book.) I'm tempted to send him a copy, as it appears he has much to learn from it.

JKB writes:

It is important to keep in mind that individuals over 65 are prohibited, by law, from purchasing private health insurance. Yes, there are gap insurance policies but those won't work. To ensure some reasonable coverage post-75, a person would need to carry health insurance right through age 65-75, which by law they are not permitted to do.

Becky Hargrove writes:

Another way this could backfire on today's healthcare: his article was a prior shifter in that anyone with relatively low income approaching retirement age and concerned about health issues may want to take social security as soon as possible, rather than waiting with hopes of securing more substantial monthly means for a longer life.

S.C. Schwarz writes:

Articles like this are not the random musings of a random individual. This is a trial balloon. This is the elite liberal establishment beginning to get us ready for restricting medical care for the elderly.

David R. Henderson writes:

@RP Long,
When I read the article, I couldn't help but think of Dostoevsky's The Idiot.
I admit that I’ve never read it. Are you willing to say, briefly, how it connects?
Yes, there are gap insurance policies but those won't work.
I think they would work. They are for gaps. This would be a gap.
Articles like this are not the random musings of a random individual. This is a trial balloon.
Definitely not random. And definitely not just an individual. I put a probability greater than 0.5 on your being right.

Daublin writes:

Above all, I don't want people in Washington making these decisions. Not for the bulk of people.

I don't think this is a trivial statement, and I can see the other side of it. Making medical decisions is hard, and it's very tempting to think there is a right answer that can be just recommended by the experts. There's also a form of pressure between loved ones that might lead to an over-expediture on care.

However, I don't think the experts are likely to be very good at it, on this kind of question. It's going to be people like Emanuel, who are 57 and yet opining that 87-year olds who self-report as happy are in fact deeply miserable under the surface.

RPLong writes:

Prof. Henderson -

Part of the book deals with coming to terms with death and mortality. One rather interesting idea in the book is the way we perceive time changes depending on how close we are to the moment of death.

If you knew you only had 2 weeks to live, you might be inclined to think that the 2 weeks will pass all too quickly. But one of the characters in the book puts forth that if you know when you'll die, then time spent waiting for the inevitable will become an eternity of dreadful anticipation. The character is a terminally ill man, but he (the character) gives the example of a prisoner sentenced to death.

I have read accounts of people who attempted suicide, but survived. They often describe the moment they jump off the bridge and realize what a mistake they've made, and they start to wish they could take it all back and survive. Imagine what an eternity that moment must be for them. This seems to be roughly consistent with what Dostoevsky suggests in The Idiot.

There are many possible conclusions to draw from all this, but I think Emanuel is greatly undervaluing the worth of the twilight years. If Dostoevsky is right, then the 99th year is much more than merely "the 35th year, but with health problems."

JKB writes:

Gap? It would be a chasm. That would mean that the cost of gap insurance would be very high, even from 65-75. Many would not purchase it and it would be unavailable for original purchase after 70 or so. Thus the poor would be left to die, which the rich and connected either paid out of pocket or were given exemption.

Does anyone think they would put down an old Senator or ex-President at 75?


That also raises incentives. If the government is going to put me down or leave me to die at 75, I've no incentive to eat right, exercise or whatever the latest government edict is. Live hard for tomorrow we die. And if I'm not infirm at 75, why not take up arms against the government, at least take out some of the exceptions. Lots of bad incentives.

Dan S writes:

I think there is one respect in which I agree with Emanuel. There was once a time when most people would get to a certain age, and then their heart would give out and they would die. Think Vito Corleone in The Godfather. Death is never good, but there was a certain dignity and quickness to it. Nowadays we keep coming up with new ways to prop up our aging bodies. Medical innovation is great but it can't fill in all the cracks, and eventually your body will decay and decay until all the medicine in the world can't keep it going. So we stretch out the suffering, and hardly anybody dies of old age anymore without spending years in severe discomfort and pain, and their mind addled.

Sometimes I do wonder if the old way was better.

Daniel Shapiro writes:

Nice post, David. FYI, I have a discussion of some of Emanuel's work in my book Is the Welfare State Justified?

Bostonian writes:

How can David Henderson support a hard cut-off from Medicare for people over 75? If Medicare is cut off on your 76th birthday, the government is effectively saying your life is worthless at age 76, which contradicts the rest of Henderson's essay.

A more reasonable way to ration Medicare is to balance the cost of treatment against the expected gain in life expectancy. The older someone is, the less Medicare will pay for, but there will be no hard cut-off.

Edogg writes:

So many aggravating things to pick apart from the article...

Aside from everybody's fears about what this portends, all of Emmanuel's supposedly modest policy recommendations seem wrongheaded to me.

He advocates ignoring life expectancy past 75 when comparing countries, but surely he knows that life expectancy is affected by mortality before age 75.

"A second policy implication relates to biomedical research. We need more research on Alzheimer’s, the growing disabilities of old age, and chronic conditions—not on prolonging the dying process." First, I have no confidence that there is a clean distinction between life extension research and morbidity reducing research. Second, why not just argue for a larger budget for the NIH? Isn't the NIH about 1 percent of the federal budget? He should just flatly recommend a cut to the NIH budget if he wants to be against life extension research, instead of pitting life extension against other medical research.

"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." This seems really perfunctory given the entirety of the rest of his argument.

Daniel Klein writes:

I read the Atlantic piece by Emannuel. He does not seem to have much of a sense of the eternal. And I write as a Humean. (On the eternal in Adam Smith, see TMS pp. 130-134.)

He also doesn't seem to have much of a general sense of duty. So, after age 75 one's creativity and originality are far less than they used to be. And, yes, duty might, under certain circumstances, call on you to end your life. But normally -- I think of my father -- one's duty would not be served by offing oneself. Even my Grandmother, with extreme Alzheimer's, by making it to 95, was able to give my toddler daughter, who was named after her, a knowledge of the sweet beloved soul of that sacred family person.

Really no sign of such attitudes in Emmanuel's piece.

Hazel Meade writes:

Is this the same Ezikiel Emmanuel who was an architect of the ACA?

Does anyone else find it slightly creepy that this guy is writing an op-ed arguing that people should not want to live past 75?

I never bought into the "death panels" stupidity, but if I had, I would be looking on this as validation of that fear.

Todd Kreider writes:

After reading the article, it reminded me of The Great Stagnation--- very provocative, not well thought out, and blind to what is currently happening in technology.

What do economists and policy makers make of top longevity researchers who have claimed for the past few years that serious health pills will likely be on the market by around 2020?

No one knows exactly what the health pills will do, but they are expected to extend healthspan between 7 and 25 years. So if Emannuel takes the pill in 2020 at age 62, it would be as if he would reach his desired death year of 75 in 2033 with the body and mind of what he would have had at around 65 to 68. But what health pill or rejuvenation therapy will be like at 2033?

Before economists and healthcare policy makers can discuss the elephant in the room, they need to know that there is an elephant in the room

The character is a terminally ill man, but he (the character) gives the example of a prisoner sentenced to death.
Which Dostoievsky experienced himself, right up to almost being put in front of a firing squad.
ColoComment writes:

Anyone here old enough to remember Dick Lamm? When he suggested something similar (somewhat mischaracterized as the elderly having a "duty to die"), it was pretty much the end of his political career. To this day, I don't doubt that it's the first thing* remembered by anyone who has any recollection whatsoever of the Lamm name.

http://www.nytimes.com/1984/03/29/us/gov-lamm-asserts-elderly-if-very-ill-have-duty-to-die.html

* the second thing is that he led the opposition to public financing of the 1976 Olympic Games in Colorado, without which Denver had to withdraw from hosting the Games after winning it.

Steve Brecher writes:

JKB, I'm not sure what you mean by,

"It is important to keep in mind that individuals over 65 are prohibited, by law, from purchasing private health insurance."
I'm over 65 and have private health insurance. I had purchased insurance from the issuer prior to age 65; do I escape the prohibition due to a grandfather clause?

Rob writes:

@RP Long

I have read accounts of people who attempted suicide, but survived. They often describe the moment they jump off the bridge and realize what a mistake they've made, and they start to wish they could take it all back and survive. Imagine what an eternity that moment must be for them.

I find that unrealistic. I planned suicide three times and aborted every time, not (primarily) out of a desire to live, but (mostly) out of visceral aversion to imminent death, and the dying process with the means at my disposal.

There is this weird idea that suicide is a mistake and suiciders realize this immediately and are oh-so-glad to survive. This is often used as a justification why euthanasia and the sale of the best methods should be banned, and what a gift life is, yadda yadda.

The truth is, the subjective value of life is highly contingent on personality, genetics, context, and so on. It is not at all universally equivalent for everyone, nor can it be cheaply designed to become that way.

I still don't like living. I also still don't like (the process and awareness of) dying. I am merely 35 years old, yet I already would rather be dead, modulo externalities.

On the other hand, I can easily imagine a life-lover to value life deeply still at age 85+ with strong physical disabilities. Governments should not get to decide who lives and dies, and when. Only the individual owners of those lives shoud decide this. (That said, you can't expect people to pay arbitrary healthcare costs for other people against their will either)

Mark V Anderson writes:

I was really impressed by this article. I am a little surprised by all the cynical comments. It is true that it wasn't the policy prescriptions that impressed me; it was the personal point of view.

I really like the idea of dialing back the preventative care when I get older. I don't know if 75 is the right age, but certainly at some advanced age. It is certainly true that almost inevitably ones quality of life decreases dramatically sometime in ones 70's or 80's. I am close to the age of Emanuel ( I am 58), and I have been thinking about the increased medical care I will need in the coming years. Why torture myself with all the recommended doctor visits and procedures if it is to prolong a lower quality of life? Maybe I will change my mind when I am in my 70's, but right now his points make very good sense to me.

Hugh writes:

Setting an arbitrary age limit (75) seems an unhelpful approach. It would make more sense to write down a list of minimal functionalities that you require to make it worthwhile going on living.

You should write the list in your late fifties or early sixties, and set the bar really low. Your list is not a think-piece or blog post, but a hard, personal and family commitment.

You might fall below your standards at 65 or 95, there's no way of telling, but assuming that 75 is right for everyone is not helpful at all.

john hare writes:

At 57, my attitude (can't remember where I read the phrase)is that I want to live forever or die trying. I once met a man 45 years old that was trudging through and ready to go, and the next very day a 77 year old that was vibrantly alive that I had to really move to stay up with. Health and life is extremely individual.

I want to make my own choices as long as I have the mental capacity to do so. At the same time, I don't see why other people should be required to fund extreme care for me even if I really really want it late in the game. A million dollars of other peoples' money to keep me alive for an extra couple of years could easily be the funds needed to keep ten 30 something people quite healthy. My resources, my choice, your resources, yours.

RPLong writes:

Rob,

Two things:

First, I can only speak to the things I have read. If your experience is different, that is fair enough. But I'm not writing about an impression I have, I'm writing about what I read from others. So perhaps your disagreement is with them.

Second, maybe my perspective is odd, but in my book having a greater aversion to death than to life is the same thing as wanting to live.

I, for one, am glad you took the time to write your comment. it offered a unique and valuable insight into your experiences. I'm sure that wasn't the first time that happened, nor will it be the last. Thank you!

Andrew' writes:

When David Henderson is to the snark of me, that should give people pause. It won't.

The support for the article seems to be mood affiliation with the nugget of truth.

But his support for this nugget is awful. Every paragraph is either wrong, misleading, or just irrelevant.

He brings up PhD physicists. Can there be a worse, less representative sample? Oh, it's just about his personal views, oh, is he a Nobel-track string theorist? No? Oh, does that illustration have any bearing on anything? Nope.

Rob writes:

RPLong,

Second, maybe my perspective is odd, but in my book having a greater aversion to death than to life is the same thing as wanting to live.

To clarify, there is a very real distinction. I have no aversion to being dead. I only have an aversion to the process and awareness of dying. I also have a (milder) aversion to the process and awareness of living.

In other words, I can't/won't complete a suicide, but I would be better off if I unexpectedly died in my sleep.

A final point are externalities, I think the rest of the world is slightly better off because I exist than I am worse off.

LT Phillips writes:

Excellent post, as I had many of the same concerns about Emanuel's essay. Are we really expected to believe that if Emanuel contracted pneumonia at age 76 he wouldn't welcome a regimen of antibiotics? Emanuel is a true believer. He knows what's good for everyone, and never doubts the wisdom of his policy prescriptions. The perfect social engineer. The perfect Obama administration apparatchik.

Seth writes:

A great tie-in with Caplan's post, "Social Desirability Bias and Abortion".

Talk is cheap.

Emmanuel touches on something, but never follow it to its logical conclusion:

Americans seem to be obsessed with exercising, doing mental puzzles, consuming various juice and protein concoctions, sticking to strict diets, and popping vitamins and supplements, all in a valiant effort to cheat death and prolong life as long as possible. This has become so pervasive that it now defines a cultural type: what I call the American immortal.

The research Caplan points to shows that when faced with having a baby with Down's Syndrome, a super majority abort, which is the opposite of how many say they would abort if they were in that situation, but are not.

Emmanuel provides stats to substantiate his personal preference of not living past 75, but neglects to explore why so many people (perhaps super majority, I don't know) -- when they are faced with dealing with the reduced faculties that Emmanuel points out choose to keep on living.

Perhaps the way you value your life at 85 is different than what you think you can imagine it to be at 57.

Mark Bahner writes:

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LD Bottorff writes:

I think Professor Henderson's analysis of Dr. Emanuel's piece is spot-on. Good, thoughtful points.

Mark Bahner writes:

Hi Rob,

You write:

I planned suicide three times and aborted every time, not (primarily) out of a desire to live, but (mostly) out of visceral aversion to imminent death, and the dying process with the means at my disposal.
I still don't like living. I also still don't like (the process and awareness of) dying. I am merely 35 years old, yet I already would rather be dead, modulo externalities.

...I hope you've seen someone about that. Several someones, if the first someones didn't help. I'll offer a personal anecdote: I had some medical problems (advice to everyone: if you use a CPAP machine, make sure the humidifier stays clean!). The thing is, the physical changes in my body also caused some kind of chemical change in my brain. My attitude became much darker.

The whole episode made me a great believer that changes in brain chemistry can really change outlooks. I hope you'll find someone/something somewhere such that you'll know longer think, "I still don't like living."

Best wishes,
Mark

Rob writes:

Thank you for your kind words, Mark. And good health to you.

ThomasH writes:

I'm having trouble even understanding the conspiracy that some people thinks lies behind this article.

Even leaving aside the idea that there is a "Liberal" "elite" cabal that can plan "trial balloons" like this, I thought the problem with Medicare was supposed to be that it was too "generous" in order to be costly in order to require more taxes, in order to punish the "makers" and or cause a deficit explosion-hyperinflation so the terrified population will embrace Fascism, (oops) Socialism.

Now we learn that the problem is that the plan is for Medicare not to cover people after some arbitrary age to reduce cost. Can we at least have a qui bono analysis of this new angle?

Better still, maybe Henderson and many of the commentators should remember Freud's possibly apocryphal application of Occam's razor: "Sometimes a cigar is just a cigar."

ColoComment writes:

To clarify the matter re: declining to enroll in Medicare.

You can defer enrolling in Medicare if you are covered by an employer's plan (with restrictions). You can enroll in Medicare even if you also have private insurance.

However, if you simply want to opt out of Medicare (perhaps you want to pay cash from your pocket for your healthcare), then that will make you ineligible for Social Security. Even if your "full age" Social Security benefit starts at >66 years, you must still enroll in Medicare at 65 to retain your SS eligibility. You may delay your Medicare enrollment, but if you then enroll later than age 65, you'll pay a penalty.

http://www.huffingtonpost.com/2012/02/07/dick-armey-medicare-lawsuit-social-security_n_1260051.html

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