Renowned health adviser Ezekiel Emanuel astonished America when he wrote that he wouldn’t even want antibiotics after his cut off of 75 years of age. He talks Helen Rumbelow of The Times through his reasoning.
Towards the end of my conversation with Ezekiel Emanuel he says, “I better go, they’re going to shoot me otherwise.” He means his colleagues who are waiting for his next meeting. Emanuel trained as an oncologist and now has a role as a senior medical adviser in the United States; he was an architect of Obamacare and has repeatedly worked in the White House for presidents Obama and Biden, most lately on Covid policy.
But in the context of our chat his wording adds a tang of menace. “Zeke”, as he is known, is influential in many ways, but his work that starts the most arguments is an essay entitled “Why I want to die at 75”. It’s not just that he hopes “to die before I get old”, in the immortal lines of the Who. Rather Emanuel pledges that at 75 he will stop trying to cheat death. He will act as if the history of medicine since the 19th century never existed, seeking no cure for any of age’s encroaching ailments. No chemotherapy, certainly, but neither antibiotics, operations, statins, stents, screening, tests or vaccines. Avoid contact with doctors, in other words. He would like to be carried off the old-fashioned way, by nature’s mercifully swift brutality, rather than endure the decade of medically extended multiple illnesses that, on average, awaits us in the final furlong.
“Doubtless, death is a loss,” Emanuel wrote in that essay, which went viral in the US. “But here is a simple truth that many of us seem to resist: living too long is also a loss. It renders many of us if not disabled then faltering and declining, a state that may not be worse than death but is nonetheless deprived . . . We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.”
Zeke with his brothers, Rahm and Ari Emanuel
The essay goes on to enumerate the burdens the typical over-75s place on the world, and how lonely and tired the growing tribe of ninetysomethings are as their lives become constricted to a single chair. Emanuel’s solution to the problem of dying is not desperate denial, as it is for so many Californian tech bros in search of immortality. Nor is it the legalised euthanasia that is gradually spreading across the western world and that Emanuel actively opposes. Instead he promises to pioneer a third way, a radical, retro survival of the fittest. Some people write “living wills” to curb resuscitation efforts when already very frail. This takes that to a new extreme. He first set it forth at the relatively sprightly age of 57. When I read it I wondered: all very well to say this when you have a long lease left but will his resolve to reject medical care falter, like his grip strength, when his 75th birthday draws closer? Will he find himself thinking, maybe a sneaky little Covid booster won’t hurt?
Now Emanuel is 65, with ten short years before the great doctor goes pre-medical. I have a lot of questions. His brothers do too. Emanuel says they call him up on his birthday and ask, “How many more years is it again that I have to put up with you?”
Let’s divert a moment to talk about brothers. Emanuel belongs to what must be one of the most successful sibling groups this side of the Bee Gees. The three brothers grew up in an apartment in Chicago with a paediatrician father. They shared a bedroom and a fierce, close rivalry. Rahm Emanuel is the middle brother, said to be the inspiration for Josh in The West Wing. Rahm would go on to become White House chief of staff for Barack Obama and later mayor of Chicago. The youngest brother, Ari, is the multimillionaire chief executive of Endeavor, one of the most powerful Hollywood agencies, and also appears in parody form as the basis for the super-agent in the TV series Entourage. Ari is close to Elon Musk — a photo of Musk shows him being hosed down by Ari on a superyacht this summer.
His brothers, Emanuel says, think him “crazy”. His son-in-law (Emanuel has three daughters with his ex-wife) even threatens to violate his wishes. When Zeke gets to 75, he says he will attack his father-in-law with vaccine syringes while he sleeps. I speak to Emanuel in a gap in his busy day as chair of the department of medical ethics at the University of Pennsylvania. I can sense his appetite for argument. His mother told her children they always had to “prepare for dinner”, by which she did not mean lay the table but be armed for evidence-based debate.
Emanuel speaks fast and tough, his wiry frame almost springing out of his chair. It’s not long before he invites me to spar: “I’m happy to challenge your criteria [for end of life] as you are happy to challenge my criteria. Absolutely. Let’s discuss it.” So I tell him, I’d rather see how old age pans out and then be offered an exit if I really felt I couldn’t go on. Something a bit like the novelist Martin Amis (now 73) proposed when he talked half-seriously of euthanasia booths, where you would be greeted with a “martini and a medal”. Emanuel hates this. He argues euthanasia is riddled with moral and practical problems, and anyway, even where it is legalised it is only considered by a tiny minority.
“If you think you’re going to legalise euthanasia, and it’s going to solve end of life care, you are deluded,” he tells me with the force of a putdown at a dinner with Ari and Rahm.
He says we focus too much on the acute months before death and not on the long years of degradation. While modern medicine has increased lifespan dramatically, it has barely increased healthspan. A study by the Office of National Statistics is typical. It showed that if you were alive in England aged 65 in 2018, you have on average 20 years left to live. But the second decade would be consumed by chronic “illness or disability”. Aged 75, in other words, is where the suffering begins.
And it’s not just me who is deluded, says Emanuel. Every time he talks about his plan almost everyone’s first reaction is to say 75 is too young and to cite super-agers they know. These range from their 90-year-old surfing granny to current president Joe Biden (80), or Anthony Fauci, chief medical adviser to the president (82), or indeed the oldest practising doctor, the 100-year-old Howard Tucker, who began working as a neurologist in Ohio in 1947 and still treats patients now. We secretly believe we will be these outliers. “We can’t all be outliers.”
I wonder if he wants a quick illness to decide his end as it would take bravery to either withstand a long medical treatment or take his own life. “Well, I think it’s bravery to say no to interventions where the majority of people would say yes.” When I ask him the illness he fears most, he doesn’t hesitate: dementia. “There’s no doubt about it.” And after 75 the rates go “boom”, he says. Even if we are not demented we lose self-sufficiency. “Living too long places real emotional weights on our progeny,” he wrote in his essay, even though they “won’t admit it”.
When his mother, aged 89, hears him say that, does she feel she needs to shuffle off a little quicker? “No!” he cries. His father, who died aged 92, said, “‘I don’t agree with you’. OK, Dad, fine. In our family you don’t have to agree, you just have to have a considered opinion. Look, I don’t want 100 per cent of people to agree with me, I’m not idiotic. I want people to have a considered view of the impact their progressive disabilities — physical, mental and emotional — will have on the people around them.”
He is scornful of the new breed of (mostly male) “immortals” putting so much energy into the dream of living forever. An Ipsos survey in November found that only a third of Britons want to live to 100. More men than women wanted to live that long.
“You see this in the tech gurus who are investing in longevity [he cites Sergey Brin and Larry Page, the Google founders who have made investments in labs working to extend life]. These people think the world will collapse if they’re not here. It won’t collapse . . . They tend to be men. I think many men haven’t figured out what their life’s about. They get on to the conventional treadmill and they haven’t thought through, ‘do I really wanna be an investment banker? What’s the social utility here? Is it a meaningful life?’ Part of wanting to live to 100 is to get more time to make that contribution. But by the end it’s too late.”
He wants to be clear-eyed about when his own “consumption” exceeds his “contribution”. Here he edges closer to what ethicists call the “duty to die” argument, the harsh utilitarian idea that the non-useful need to sling their hook. For someone as energetic and ambitious as him, passivity is clearly terrifying. I say that perhaps “contribution” isn’t a good metric. There is value in the simple pleasures of old age. A large study by the esteemed psychologist Daniel Kahneman (now aged 88) in 2010 found that while happiness and enjoyment tailed off in one’s seventies, “emotional wellbeing” peaked at 82. Emanuel isn’t convinced. He says people instinctively want to work to “leave the world better”, whether it’s as simple as being fit enough to manage a garden.
This is, he insists, not a policy but a personal choice, informed by close study of the aged. William Osler, a doctor and Oxford professor, wrote in 1892 that pneumonia was the “natural end of the old man”, which is where the nickname “old man’s friend” for pneumonia was born (Osler died aged 70 in the Spanish flu epidemic). Emanuel would similarly rather go quickly, at home. So has anything changed now the time draws closer? He says his brother Ari has changed.
“My youngest brother was, ‘I want to live as long as possible.’ He is a health nut. You’ve probably seen some of his pictures with Elon Musk. But he has recently said, ‘I’m not trying to live as long as possible. I’m trying to make sure that as long as I live, I’m functioning and there’s no disabilities.’ And that’s my philosophy. He won’t say, ‘Oh, Zeke, you got it right.’ He’ll say, ‘I want to be healthy. I want to be cognitively intact, I want to be able to walk around.’ For me, when I can’t do those things, I don’t want to be in that situation.”
Second, his father’s quick death in 2019 gave him a positive template. With Emanuel’s help, his father had zero treatment after his cancer diagnosis other than pain relief.
“He said, ‘It’s over, I’ve had it.’ He was quite clear. He died in ten days. We lay down in bed together and he caressed my hand in the way he had done when I was a little kid.”
So nothing has changed for him? “I wouldn’t say nothing,” he replies. His partner disagrees with his plan, and “she would like me to consider preventative measures like a flu vaccine”.
“A lot will depend on whether I really am a rare outlier at 75, and I’m not deceiving myself. That will be the biggest challenge . . . We are in discussions.”
He thinks he will likely stick to plan A. I say in that case I wish him a swift pneumonia. “Yeah, well at least one where someone doesn’t jab me with antibiotics before I can refuse — that’s what I’m afraid of.” And then we say a cheerful goodbye.