The Plague-Ground – When is a good time to die?

Remember that guy who said years ago he wanted to die at 75 because he was 75? And that we should all think about doing the same at 75 because, as he wrote in The Atlantic in 2014, “… doubtless, death is a loss…but living too long is also a loss.”

His name is Ezekiel J. Emanuel. He’s not a flake. He’s an oncologist, a bioethicist, and a vice provost of the University of Pennsylvania. He is the author or editor of 10 books. Emanuel also comes from a take-no-prisoners family: one brother is Rahm, who was President Obama’s Chief of Staff during his first term, and then Mayor of Chicago; the other, Ari, is a Hollywood agent who owns the Ultimate Fighting Championship.

But on Monday, at age 63, his six-year old article on why we should die at 75 came roaring back to haunt him. Joe Biden announced that Emanuel is one of 12 distinguished scientists to serve on his COVID-19 Advisory Board.

The Trumpers went nuts because next Friday Joe Biden turns 78.

This news took me back to Emanuel’s original article with its call to let nature take its course swiftly and promptly. But now that I am no longer 10 years from reaching 75, as I was when he wrote it, but four years, my interest gets more personal with every passing…..minute.

My big problem is that nature rarely takes its course “swiftly and promptly.” Heart attack and stroke, sure. But those thousand other shocks our flesh is heir to?

“Once I have lived to 75,” wrote Emanuel, my approach to my health care will completely change. I won’t actively end my life. But I won’t try to prolong it, either. Today, when the doctor recommends a test or treatment, especially one that will extend our lives, it becomes incumbent upon us to give a good reason why we don’t want it. The momentum of medicine and family means we will almost invariably get it.”

“My attitude flips this default on its head. I take guidance from what Sir William Osler wrote in his classic turn-of-the-century medical textbook, The Principles and Practice of Medicine: “Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those ‘cold gradations of decay’ so distressing to himself and to his friends.”

But what if you have the bad luck not to get pneumonia at the end, and get bone cancer instead?

Emanuel vaguely suggests ‘palliative care.’ Definitely not assisted-death.

“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.”

Here, Emanuel is just plain wrong.

I know this because Ottawa publishes annual statistics on medically-assisted death since it became legal in 2016. Last year 5,613 Canadians received physician-assisted death, representing 2% of all the deaths in Canada, and a 26.1% increase over the number of deaths in 2018.

This is much more than in U.S. states where patients must be at the end of life and only self-administration is permitted, and much less than the 4.6% in Benelux countries where eligibility is based on suffering rather than proximity to death.

Far and away the most frequent underlying medical condition in these 5,613 deaths is cancer.

Sixty seven per cent.

This is followed by about 10% for each of respiratory (like COPD), neurological (like ALS), and cardiovascular disease (like congestive heart failure) and kidney failure.

So last night I walked into the next room and asked my wife, the physician-assisted death doctor who had just finished virtually assessing a candidate for MAiD (Medical Assistance in Death), what she thought:

“Fear of losing control and dignity is different from depression and hopelessness,” she said.

“One of the symptoms of depression is hopelessness. Depression may contain hopelessness, but hopelessness doesn’t necessarily contain depression. Anecdotally, either experienced pain or anticipated pain, like a stage 4 cancer diagnosis, may propel someone to ask for assistance to die, or at least to know it’s there when the pain does become unremitting.”

“On the other hand, dying with dignity and controlling the end of your life with dignity, is a basic human value that everyone should honour. Not being able to control your bodily functions, to lack mastery of your basic living activities, like walking, dressing, toilet and eating, this is dependency which can quickly become an indignity.”

“In the spring when COVID hit, many dependent patients were also isolated in hospital or long-term residences. They were alone, missing their families and terribly isolated. That may have propelled more of these patients to apply for MAiD. Then summer came. Lockdowns were lifted. These patients could see their families, get outside, sit in the sun. MAiD requests went down. Some who had planned their deaths delayed them.”

“What I’ve learned doing MAiD is that people, even those in endless excruciating pain, don’t want to die. They will do just about anything to live.”

Maybe Dr. Emanuel should talk with Dr. Marmoreo who is 78.