The Conversation

Responses and reverberations

MATTERS OF LIFE AND DEATH

In October, Ezekiel J. Emanuel explained “Why I Hope to Die at 75.” The article sparked a vociferous response, including nearly 4,000 comments online. Some readers defended Emanuel’s stance, but plenty protested his decision to cease most medical treatment when he turns 75. These readers cited the post-75 accomplishments of Benjamin Franklin, Gandhi, Ronald Reagan, Nelson Mandela, and others. On Conan O’Brien’s late-night talk show, the octogenarian Larry King issued a satirical response. “I’m ticked!” he said. “This stupid argument comes up every 200 years. This means this is my 10th time addressing it.”

I hope The Atlantic will ask Dr. Emanuel to write a new version of his article when he is, say, 74 years old. He might have a quite different take on the subject. I hope so.

Hugh Van Dusen
Yorktown, N.Y.

Dr. Emanuel’s penultimate sentence says it all: “I retain the right to change my mind.” I await his “vigorous and reasoned defense” of living past 75 in The Atlantic’s October 2032 issue.

John Frank
Ann Arbor, Mich.

I’m 75. Vital signs are good. Still working productively. Swim, row, and hike. Future looks promising. So I’ve decided to hang on for the 18 years it will take Emanuel to reach 75 and see if he still hopes to die.

Mark Dowie
Point Reyes Station, Calif.

All of the points Dr. Emanuel makes confirm what I’ve thought for some time, although my optimal age is 80, an age I’ve had in mind since my 20s. He expresses well that this idea is not his expectation for public policy nor a choice that everyone should agree to.

The best reason for moving on/out is to give the next generation a chance! We Baby Boomers have already commanded the cultural stage ad nauseam. There’s no need to endlessly oppress those behind us with our slow parade of dying.

John Barnowski
Colchester, Conn.

We octogenarians—despite an onslaught of medical issues requiring frequent appointments, tests, and treatments; and tests for suspected problems; and all sorts of treatments to manage the aforesaid—have grown more understanding of our fellow elderly, more grateful for the love and companionship of our mates, more intent on remaining deeply involved in the lives of each and every family member, and more determined to set an example for our children and grandchildren of how to age in such a way that we don’t leave our loved ones with a dread of incapacity, a horror of diminished vitality.

I understand that we cannot anticipate what will befall us, that we may not be able to fulfill this goal, but having this positive philosophy brings a certain peace of mind.

Arlene Pollack
Yarmouth Port, Mass.

If Dr. Emanuel hopes to die at 75 rather than live at less than the peak of his mental and physical powers, that is his prerogative, although other people might reject such elitism, especially if they never had remarkable mental or physical powers at all.

If Dr. Emanuel hopes to die at 75 because he thinks this would benefit his children, that is his prerogative, although other people might doubt that children selfish enough to welcome this parental sacrifice deserve it. Moreover, Dr. Emanuel’s suggestion that it would be good for “each of us to ask whether our consumption is worth our contribution” will hardly attract those who think that even the unproductive have an unalienable right to life, liberty, and the pursuit of happiness.

If Dr. Emanuel were obscure, his views would be no cause for alarm. Because he is the director of the Clinical Bioethics Department at the National Institutes of Health, he is a danger to old people. For example, his insistence that we don’t need more research on “prolonging the dying process” endangers people who value their lives even if they have an illness that will eventually kill them.

Felicia Nimue Ackerman
Professor of Philosophy Brown University Providence, R.I.

The logical flaw in Emanuel’s article is that he essentially defines life—or a life worth still living—using but two metrics: creativity and productivity. Even if one accepts that these attributes decline greatly by 75, why are these the only (or at least the main) barometers for judging life? After all, the example of Emanuel’s own father undermines his thesis: his father, though in his late 80s and declining, still proclaims that he is happy.

William Choslovsky
Chicago, Ill.

I heartily agree with Dr. Emanuel’s intent. As a fellow physician, I feel awash in the decrepitude of patients who desire just one more medical procedure to extend their bionic existence. No one discusses the ethics of therapeutic intervention, simply the mechanics of medication, surgery, hospitalization. I had hoped that the rise in palliative-care services would help channel elderly, chronically ill patients to a more natural death. As a society, we cannot support this current trend toward eternal existence, either financially or emotionally.

Mary Kemen, M.D.
Cedar Rapids, Iowa

I read this article for the first time on the eve of my 74th birthday and for the second time a week later, on Rosh Hashanah (the Jewish new year), after reading the prayer concerning “who shall live and who shall die” in the next year.

If Dr. Emanuel is saying that we all have to die sometime, and that we should not allow medical professionals, drug and equipment manufacturers, or nursing-home directors to subject us to useless tests, procedures, and pain and suffering when the inevitable is at hand, whatever our age, then I agree.

If, however, Dr. Emanuel is saying that there is no sense in leading a life in which one is not able to climb Mount Kilimanjaro, gain great applause at professional meetings, direct the behavior of one’s family members and friends, and implant memories in loved ones of an energetic, risk-taking guy so that children and grandchildren, students and friends can hope to emulate one’s nonempathetic ways, then I couldn’t disagree more.

We may not be entitled to immortality, but we are entitled to maturity and, if we are fortunate, old age. We should not earn Dr. Emanuel’s disrespect just because we have lived beyond 75. Who is to define what is a life worth living? Certainly not the middle-aged Dr. Emanuel. He can see little pleasure in helping future generations mature, in continuous learning, in days spent enjoying the company of others when we are not at the head of the table. He ignores the blessings of performing everyday tasks and attending routine events and basking in the joy of memories. He gives little value to happiness gained from kindness, generosity, shared wisdom, unselfish love, a walk with a cane in a beautiful garden, and a lifelong search to discover who we are and what our role is in the continuum of life in our community and on Earth.

Caroline M. Simon
Loubressac, France

Where Emanuel veers off-course, I think, is in his conviction that the capacity to be productive is what makes life worth living. He bemoans the sad decline, from authoring papers to taking up hobbies until, eventually, “life comes to center around sitting in the den reading or listening to books on tape and doing crossword puzzles.”

This goes, I know, against the Emanuel family DNA, but there is no sin in slowing down. There is satisfaction in completing the crossword. You don’t always have to bike past the roses on your way up the mountain. In high gear.

Where Emanuel makes a powerful point is in condemning the “manic desperation to endlessly extend life.” Medical choices should not be dictated by a patient’s age, but they should be informed by it. Extreme treatments to save or even minimally extend the life of a young mother are not necessarily appropriate for an 80-year-old grandmother. Physicians fail their patients by automatically defaulting to treatment.

Here I break from Emanuel. He opposes euthanasia and physician-assisted suicide, but this position does not give adequate weight to the dignity with which we would like to live and die.

Why must a terminally ill cancer patient suffer an agonizing decline when there is a more merciful alternative? Why, and this is a harder question, must an Alzheimer’s patient be condemned to slowly lose mental and physical capacities? Facing that terrible situation, I would prefer the choice not to be remembered, in Emanuel’s words, as “feeble, ineffectual, even pathetic.”

Ruth Marcus
Excerpt from a Washington Post column

I applaud the ethic described in Dr. Emanuel’s article. His ethic mirrors that of my mother—a mentally and physically healthy woman who at age 70 wheeled a suitcase containing sleeping pills, vodka, and plastic baggies into a hotel room to die. My mother killed herself at age 70 for many of the reasons Dr. Emanuel cites. But she also did it for one reason he denies. She feared losing dignity and control. Dr. Emanuel, on the other hand, maintains an inconsistent stance against legalized death with dignity.

He opposes euthanasia or physician-assisted suicide because “people who want to die in one of these ways tend to suffer … from depression, hopelessness, and fear of losing their dignity and control.” The “answer to these symptoms,” he claims, “is not ending life but getting help.” Yet his one-sided description of aging past 75 (“progressive erosion of physical functioning,” “incapacitation,” and the “most dreadful of all possibilities … mental disabilities”) highlights his own fears. Dr. Emanuel, too, aches for control—why else cling to the ethic he espouses, in which he combats aging by taking control of his health-care choices? Dr. Emanuel closes his eyes to his inconsistency. But his arguments make a most compelling case for death with dignity, at any age.

Christine W. Hartmann, Ph.D.
Boston University School of Public Health Bedford, Mass.

If large dividends are to be reaped should a number of us agree to forgo life-extending procedures beyond a defined age, then why not create incentives to do so? We have long agreed that ages to receive Social Security are malleable, and we also agree that the payments to which we are entitled can be adjusted—and they have been. Nor is Medicare wholly writ. Its structure has also been periodically adjusted.

Why not reward people for not draining both programs? Can we provide a full suite of medical services essentially for free up to age 76? Beginning at that age, the program obligations would be ameliorating pain, setting broken limbs, and stitching lacerations. But not much more. As for Social Security: provide full benefits at age 62. Some actuary can figure out that it’s truly a better deal to, instead of doing valve replacements, chemotherapy, etc., etc., give Dr. Emanuel the full payments early—because he will not be around to access them for nearly as long as the people who choose not to opt in.

Thomas Joyce
Pittsburgh, Pa.

This article took me back 50 years to a conversation with my then-85-year-old grandmother. She was living in a senior citizens’ apartment building, and one of her friends was having a 100th-birthday party. I remember saying to my grandma, “Who would want to live to be 100?” Without a pause she replied, “Someone 99!”

Barry Van Kirk
Chattanooga, Tenn.

I don't often get mad at a magazine article, but Ezekial Emanuel has managed to do it. Gosh, here is a man who by the age of 57 has managed to become an oncologist, a bioethicist, vice provost of a major university, and the author or editor of no less than 10 books, and who has just climbed Mount Kilimanjaro. Nothing anyone else couldn't do, of course, but he has elected to give it all up if there is a hint he can't continue at full blast after he reaches 75.

When we're growing up, most of us don't contribute much to the world and often don't even have a clear idea of what we are doing. Why then should we go on? If we are disabled physically or mentally, congenitally or at an early age, why should we go on? Because there is life, there is nothing else, anywhere, and there are no rules about its quality.

I have never been any of the things Emanuel is. I did once write a book, but no one ever considered publishing it. I climbed a few mountains, mostly when very young. I worked a long time at just one pretty dull, ordinary job. I have had health issues that now, age 89, have definitely slowed the pace and reduced the quality of my life. But why should I have picked 75 as the age to die, or at least to stop trying to live? I have had deeply satisfying and enjoyable accomplishments and experiences in the past 14 years that I feel were enhanced and enriched by the wisdom and experience gained from what went before.

Tom Bourne
Woodstock, Vt.

It seems sadly obvious that Dr. Emanuel’s desire to leave his children and grandchildren with memories of his vitality is the genuine dream of the American immortal. To actually believe that one can shape the memories of our progeny with a possibly truncated life is sheer hubris. It’s an unattainable aspiration. Just this morning, I recalled the way my now-deceased father would give us big hugs and “whisker burns” when he came home from work. In spite of the terrible illness he endured at the end of his life, I did not need to actively conjure up this memory. And although my dad’s final years were largely spent in the hospital, they are not the most prominent memories that I have of him. The invaluable moments and lessons that were imparted during those difficult, declining years, I wouldn’t trade for the world. No matter when or how we die, we do not get to pick and choose the memories that will be kept and recalled by our loved ones.

Margaret Connolly
Niles, Ill.

Ezekiel J. Emanuel replies:

I have succeeded—at least in part. I have inspired people to begin to think and discuss and debate how to age, how to face the last chapter in their lives, and what they take to constitute a meaningful life for themselves.

As these many letters demonstrate, the responses to my view fall into three distinct categories. There are the skeptics—people who question the integrity and depth of my convictions or who outright dismiss my ideas. Many people, like Hugh Van Dusen, John Frank, and Mark Dowie, doubt I will follow through or think I just can’t know what I will want at 75. Just let me say, people who know me better are willing to take a large wager with these skeptics.

A second group, represented by Mary Kemen and John Barnowski, agrees with me even if it might quibble with the age I picked—which I acknowledged in the article was somewhat arbitrary. Interestingly, these supporters usually fall into two subgroups: those in the health-care professions, who have seen many, many older incapacitated or demented individuals continually kept alive; and caregivers of older people who are functionally restricted or mentally disabled, who know this pain firsthand.

Then there’s the third group, the troubled. They tend to describe my article as “thought-provoking.” They are challenged by it. They object to my view of a meaningful life. As Caroline M. Simon says, “Who is to define what is a life worth living?” Who else but each of us individually for ourselves? My goal was to challenge these people to not live the habitual life, to not avoid the “big questions” about the ultimate worth of our lives. We carefully construct our lives, filling them to overwhelming with activities in order to assiduously avoid such spiritual and existential questions, I think at our peril.

INSIDE THE PRISON EXPERIENCE

In October’s “How Gangs Took Over Prisons,” Graeme Wood reported from Pelican Bay, a prison in California.

In his exploration of California’s Pelican Bay prison, Graeme Wood comes about as close to absolute power as one can get in the U.S. But instead of elucidating that power for his readers, he succumbs to it, letting an economics theorist and the prison’s staff tell him where to look and what to see. Wood is so taken by what he hears about gangs and their frightening folkways that he misses the horror in front of his face: the prison’s unchecked control over thousands of lives. His acquiescence to the powers that be would be embarrassing in any piece of prison journalism, but in an article about Pelican Bay, it seems absurd.

This is a prison widely known for a two-month hunger strike over solitary confinement in 2013, not to mention years of litigation over the same. Yet Wood tours the solitary unit at the prison with hardly a word about why the strikers starved themselves or why the lawyers went to court. He looks in the eyes of prisoners sent to solitary at the whim of the guards and says nothing about this punishment’s cruelty, how it can cause or exacerbate mental illness, or how its damage can be permanent.

Prisoners’ attorneys and family members don’t get the kind of access that Pelican Bay granted Wood. Most often, they don’t get past the visiting room. Wood had a tremendous opportunity here. Who knows what he might have seen if he’d opened his eyes.

David Fathi
Director, National Prison Project, American Civil Liberties Union
Washington, D.C.

I am a former prisoner—I was held captive in Iran from 2009–2011—and a survivor of solitary confinement. In my experience as a reporter who writes about prisons, it is surprisingly rare that I come across people outside of the prison system who justify long-term solitary confinement. Even within the world of prison administrators many are against it …

[Wood] gives a different impression of the practice. He visits Pelican Bay State Prison, which probably has more people in solitary confinement for longer periods than any other prison in the world. He goes to the Security Housing Unit, or SHU, where people are kept in solitary confinement or, as he gently puts it, are “living without cell mates.” When he enters, he says it’s “like entering a sacred space” where the silence is “sepulchral.” The hallways “radiate” and the prisoners are celled in the “branches of [a] snowflake.” Beautiful.

It’s difficult to understand why Wood does not find it worth mentioning that the cells in those snowflakes are each 7 x 11 feet and windowless. Men literally spend decades in those cells, alone … Wood tells us categorically that everyone there is a hard-core gang member. This is what the California Department of Corrections consistently claims, but if Wood did a little digging, he would find that … people get locked away in the SHU based on all kinds of flimsy evidence that doesn’t involve violence …

Keep in mind that the UN considers solitary confinement for anything more than 15 days to be torture or cruel and inhumane treatment. University of California–Santa Cruz psychology professor Craig Haney did a review of psychological literature and found that there hasn’t been a single study of involuntary solitary confinement that didn’t show negative psychiatric symptoms after 10 days …

Wood, on the other hand, makes the experience of living in one of those cells sound transcendental. It is as if everyone is “on one of those interstellar journeys that last multiple human lifetimes.”

It’s hard to know where that impression came from because … there is no indication that he attempted to conduct a single serious interview with a prisoner.

Shane Bauer
Excerpt from a Mother Jones article

Wood provides a colorful account of the contraband prisoners smuggle into their cells … but there is no mention in his piece about the role that prison staff play in assisting with that smuggling, even though there are plenty of stories … chronicling this phenomenon. Given Wood’s limited sources, this omission shouldn’t come as a surprise. No one would expect the warden at Pelican Bay or his spokesman to highlight or even mention the ways in which corrections officers aid and abet in the dissemination of contraband. But the truth is that officials at Pelican Bay are partly responsible for the contraband that flows into the facility. They know it. And the reader should, too.

Andrew Cohen
Excerpt from a TheAtlantic.com article

Graeme Wood replies:

Many of the pious responses to my article about the economics of prison gangs reveal considerable ignorance of journalism, social science, and the distinction between these activities and the authors’ own advocacy.

My article was not about whether Pelican Bay is a human-rights disaster, but rather about David Skarbek’s rational-choice approach to gang activity and whether it finds expression on Pelican Bay’s yards. None of the responses here contains substantive critique of the piece or of Skarbek’s work. (Andrew Cohen’s comes closest, and asks a question I put directly to California prison officials, without receiving a satisfactory answer.)

Shane Bauer’s response is typical in demanding that the story be about his own crusade: a denunciation of California prisons, and of Pelican Bay (and its notorious SHU) in particular. Neither Skarbek nor I took any moral position about California prisons or the well-documented psychological effects of long-term solitary confinement. This doesn’t mean we have no moral positions, only that we recognize that moral outrage is a tiresome posture for journalists and social scientists alike, and moral conclusions are best drawn by readers rather than forced on them.

My article described the SHU as the most extreme form of inmate restraint allowable under U.S. civil-rights norms, and I wrote that to go any further we’d have to beat or summarily execute inmates. I described the silent hallways of Pelican Bay’s long-term solitary unit, with its tomb-like confinement of inmates, as resembling the interstellar hibernation of science fiction, with human bodies put on ice for thousands of years.

Bauer calls this description of the SHU “beautiful” and “transcendental.” I submit that his notion of transcendent beauty needs revision. I wish Bauer a long and successful career as a human-rights advocate, if only because he would evidently be the worst architect or interior decorator the world has ever known. As for his baffling fixation on my description of the SHU as being “snowflake-shaped”: I know Bauer works in San Francisco, but like me he has wintry Minnesota roots and, having been to the SHU himself, should know that my description of its shape, like my description of its interior, is exactly right.

Finally, his complaint that I failed to include inmate voices is disingenuous. There are inmates who are garrulous on the topic of their confinement. (“Are you coming for the Todd Show?,” I was asked by prison officials, referring to the media-savvy efforts of Todd Ashker to organize a hunger strike protesting torturous conditions in Pelican Bay.) But are prisoners willing to talk about the economics of gang activity—a subject whose airing would do nothing to improve their living conditions or win their freedom from the SHU, and could indeed keep them locked up there for years? The alleged gang leaders of Pelican Bay deny their leadership roles, and in some cases deny the existence of the gangs. If they do wish to speak about the subject of my article, rather than the subject of Shane Bauer’s article in Mother Jones, I urge them to contact me.

What's In a Name? Everything.

In the July/August issue, Benjamin M. Friedman reviewed Gregory Clark's The Son Also Rises: Surnames and the History of Social Mobility.

Benjamin M. Friedman notes that Gregory Clark uses as a measure of status in Japan "Japanese whose names suggest that they are descendants of Meiji-era nobility or samurai." What either Friedman or Clark (or both) apparently do not know is that (1) the samurai and most of the nobility were abolished in the Meiji era, so these are pre-Meiji titles, and that (2) non-samurai were not permitted to have official surnames until an early Meiji edict of 13 February 1875 demanded that they adopt them. In the subsequent scramble of approximately 90 percent of Japanese to adopt surnames, many naturally chose the names of their local lords, so the bearer of a very distinguished name today would seem to have statistically a 10 percent chance or less of being an actual descendant of the high-status family that originally bore that name.

Steven G. Silverberg
Goshogawara, Aomori-ken, Japan

Benjamin M. Friedman replies:

I thank Steven G. Silverberg for his useful clarification. On his first point, Gregory Clark's book relates how the new Meiji government abolished the samurai's privileges and "merged the kuge, the ancient court nobility of Kyoto, with the daimyo, the feudal lords, into an expanded aristocratic class"—the kazoku—which it then further expanded "by adding persons who had made distinguished contributions to the nation." Clark goes on to indicate that the kazoku was not formally abolished until the new constitution in 1947. His account of these events is interesting and informative. On Silverberg's second point, Clark is clearly aware of the potential problem: "Most commoners acquired surnames only after 1868, when the government required all families to adopt surnames to aid military conscription, taxation, and postal delivery. Many previously high-status surnames were adopted by commoners." But with the Family Registration Law of 1898, "surnames in Japan had become strictly hereditary, with little possibility that the rare surnames of the elite were being adopted by less distinguished families." The problem therefore arises because of name adoptions during 1868–98. Clark's empirical strategy in this part of his research was to base his calculations on surnames that were both traditional for these elite groups and also rare: "To narrow the list to surnames that were more closely associated with kazoku and samurai families, only rarer surnames from the list were employed in measuring mobility. Rarer surnames were defined as those now held by fewer than ten people per million (1,270 or fewer people)." As with nearly all of Clark's procedures reported in his book, this one is surely not foolproof. As I put it in what I wrote, he doesn't—because he can't—know who is really descended from whom. (To refer to one of his other groups, Clark identified American Jews from familiar surnames such as Cohen, Goldberg, Katz, and the like; but as Clark himself notes, not every American named Cohen is Jewish or of Jewish descent.) In the end, whether there are enough exceptions to this way of identifying people to invalidate his conclusions, either for his work with the Japanese data or for any of the many other cases he examines, is a matter that only further, even more detailed, research can resolve.

TWEET OF THE MONTH

My guess is Zeke Emanuel will change his mind about no medical care after 75 when he has grandkids.

—  @jonathanalter

CORRECTION

“The Adultery Arms Race,” by Michelle Cottle (November), incorrectly stated that the TigerText and CoverMe apps market themselves as tools for cheaters and jealous spouses. Rather, they market themselves as secure-communication apps.