Saturday, September 27, 2014

Medicare, Dr. Mengele, and You

So, the multimillionaire architect of Obamacare went on a luxury trek up Mount Kilimanjaro recently with two of his trust-fund nephews. I am guessing that much to his dismay, he got a bit winded moving through all those exotic ecosystems. His 57-year-old body, so buff, so pampered, must have protested with a few creaks and groans. His middle-aged elite lungs probably gave out a few embarrassing wheezes. His technocratic brain, deprived of oxygen at the freezing summit, sent him a Eureka moment message:

If Ezekiel Emanuel, M.D. can't live forever in a young body, then neither should you. If Ezekiel Emanuel's attack of male menopause freaked him out, then you should freak out too. If Ezekiel Emanuel fears a decline, then the rest of the aging population should just quietly disappear, even before they get sick or senile.

 Ezekiel Emanuel has decided that if he can't function like a rich jerk forever, he would just as soon die before he reaches 75. Therefore, nobody else should live past 75 either. Once you stop being entertaining or remunerative, you should just check the hell out.

Ezekiel Emanuel seems to hate old people, believing that they are eyesores and albatrosses around the necks of High Society. This is a Democrat, mind you: a highly influential member of Obama's inner circle of health policy advisers. And you thought Republicans were terrifying fascists? It just goes to show how severely right-wing, nihilist, cruel and cynical this country's ruling class has become. The culling of the herd is nigh. The time has come for Exceptional America to go all nomadic, leaving the old folks behind, so that only the fittest may survive.

The Manifesto of Death to Grandma was published in The Atlantic, which hilariously included an oversize photo of a goofily grinning Emanuel to accompany his Social Darwinism screed. The subliminal message of the photo is that the passive-aggressive dying experience will be fun for the entire family. Don't go away by suicide, assisted or otherwise: just go away. Play a game of Russian Roulette by daring to skip the colonoscopy and the mammogram... and simply fade away through attrition. Your heirs will thank you. The plutocrats of Wall Street will definitely thank you.

Let Natural Selection take its course.... especially if you're dependent on Medicare and Social Security for your continued survival. Let a benevolent smirking rich guy like Zeke be your guide:


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. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.
Full disclosure: I am a physically disabled person, yet somehow I do not feel as deprived as Emanuel thinks I should. Until I read his article, I'd had no idea that my being in a wheelchair has robbed me of my creativity, and even worse, that my continued existence in a less-than-perfect body will rob my children of any pleasant memories of me for the rest of their lives. My living will stipulates only the physical and mental conditions for ending extraordinary intervention, not an arbitrary age for doing so. Moreover, since I still have quite a ways to go before my own date with Diamond Jubilee Destiny, does that mean I'm still safe, despite my "faltering" state?

 But I digress. Let Dr. Death explain further by projecting his own will on everybody:
  By the time I reach 75, I will have lived a complete life. I will have loved and been loved. My children will be grown and in the midst of their own rich lives. I will have seen my grandchildren born and beginning their lives. I will have pursued my life’s projects and made whatever contributions, important or not, I am going to make. And hopefully, I will not have too many mental and physical limitations. Dying at 75 will not be a tragedy. Indeed, I plan to have my memorial service before I die. And I don’t want any crying or wailing, but a warm gathering filled with fun reminiscences, stories of my awkwardness, and celebrations of a good life. After I die, my survivors can have their own memorial service if they want—that is not my business.
It's all about Ezekiel Emanuel. If he can't hear the smarmy accolades at his own funeral, then why even have one? (Speaking of limitations, he already has a major one, one that he was probably born with: a congenital absence of the empathy trait. He is, after all, the brother of Rahm "Mayor One Percent" Emanuel.)
I am talking about how long I want to live and the kind and amount of health care I will consent to after 75. 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.
I reject this aspiration. I think this manic desperation to endlessly extend life is misguided and potentially destructive. For many reasons, 75 is a pretty good age to aim to stop.
I think oxygen deprivation at the summit of Kilimanjaro must have either permanently impaired Emanuel's brain function, or his death-wish may even represent a form of late onset manic-depressive psychosis affecting mainly elites. According to his logic, Ruth Bader Ginsburg should never have been (successfully) treated for her pancreatic cancer. If Hillary Clinton is elected president, she should forgo physical exams midway through her first term, lest Chelsea suffer needlessly in the event that a health problem in Mom is discovered and treated. Albert Einstein should have skipped his annual check-ups, because once he discovered the Theory of Relativity, he was surplus flesh. Ditto for E.M. Forster, who stopped writing 60 years before his death at 91. How pathetic is that? And forget Harper Lee: her artificial leg is a complete and utter waste of Medicare dollars, given that she was a one-hit wonder: Ezekiel doesn't think it'd be a sin to kill that bird.

He finally cuts to the chase after cherry-picking through data that purports to show that while Americans live longer, they live longer most miserably. This is  also all about his Dad, who simply refused to die in the best shape of his life:
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.
Then Daddy must be demented, or at least getting close. As Ezekiel hypomanically continues:
Even if we aren’t demented, our mental functioning deteriorates as we grow older. Age-associated declines in mental-processing speed, working and long-term memory, and problem-solving are well established. Conversely, distractibility increases. We cannot focus and stay with a project as well as we could when we were young. As we move slower with age, we also think slower.
It is not just mental slowing. We literally lose our creativity. About a decade ago, I began working with a prominent health economist who was about to turn 80. Our collaboration was incredibly productive. We published numerous papers that influenced the evolving debates around health-care reform. My colleague is brilliant and continues to be a major contributor, and he celebrated his 90th birthday this year. But he is an outlier—a very rare individual.
I don't know about that. Everywhere you look, there are amazingly brilliant octogenarians and nonagenarians who still dare to function at the peak of their abilities. Several of them contribute to this blog. (see 91-year-old Pearl's scathing remarks in my comments section.) And there is a New York Times commenter named Larry Eisenberg who can produce a limerick on any topic in the space of a few minutes. He is 94. Creative older people are "outliers" only in Emanuel's closed, elitist mind.

Here's a section sure to strike dread into the heart of every gerontologist:
At 75 and beyond, I will need a good reason to even visit the doctor and take any medical test or treatment, no matter how routine and painless. And that good reason is not “It will prolong your life.” I will stop getting any regular preventive tests, screenings, or interventions. I will accept only palliative—not curative—treatments if I am suffering pain or other disability.
How much you want to bet that Zekey-Boy will be screaming for extraordinary measures at the age of 98, ripping the oxygen-mask off the 75-year-old down the hall just to get a last sucking selfish mouthful of life?

He finally gets to the real reason (besides his gerontophobic disgust at looking at Daddy) for his faux-altruism: America is in decline. For a civilized country, our mortality rates are nothing to brag about. Despite being the richest country (the most billionaires on the planet) we rank only 40th in life expectancy. This is not so much because of biology, but because of our cruel social policies and continuing high poverty rate. The plutocrats of Wall Street and the political hacks like Emanuel who serve them want their Grand Bargain of safety net cuts. They don't want even the smallest portion of the wealth that they've managed to siphon off for themselves to trickle back down to medical care for the old, disabled and indigent.

The Bowles-Simpson Catfood Commission went down in ignominy. The debt and deficit are no longer popular campaign themes. So what is an oligarch to do? For starters,  Doc Zeke has come to their rescue with his cheery article, keeping the macabre herd-culling conversation alive. 

What Emanuel has indulged himself in is just more poor-shaming and psychological elder abuse, albeit couched in the most liberal, caring, and sensible terms. Please don't take him to mean that he espouses the easy Ernest Hemingway suicide route out, because Emanuel (says he) is absolutely against that, along with euthanasia. He protests (too much, methinks) that he is no Dr. Kevorkian!  But do skip the flu shot voluntarily this year, old people. Your grandchildren and the Medicare trust fund will be ever so grateful.

Did I mention that Dr. Zeke is director of the Bioethics Department of the budget-slashed National Institutes of Health? And they said that irony is dead.

     “The rich were dull and they drank too much, or they played too much backgammon. They were dull and they were repetitious. He remembered poor Scott Fitzgerald and his romantic awe of them and how he had started a story once that began, ‘The very rich are different from you and me.’ And how some one had said to Scott, Yes, they have more money. But that was not humorous to Scott. He thought they were a special glamorous race and when he found they weren't it wrecked him as much as any other thing that wrecked him.” -- Ernest Hemingway, from the original version of "The Snows of Kilimanjaro".


25 comments:

Kat said...

TTThis was Anthony Trollope's only foray into science fiction. It is described as dystopian. I guess it is not for Ezekial.
http://en.wikipedia.org/wiki/The_Fixed_Period

I have this to say to people such as Emanuel: You don't have to commit all your thoughts to print. Although I have problems with the cult of longevity that exists in our society (more the province of the well to do) I really, really have a problem with these sort of arguments. What they are saying is unless you are free of disabilities you are not fully human. I can only imagine what is like to read these "brave" pieces if you have some sort of disability. Do people with disabilities read them and think "this is telling me I should just die". I think this is the way I would take it.

Anonymous said...

I tried to wrap my 91 year old brain around Ezekial's ravings but when you mentioned Rahm is his brother, a light bulb went on. The parental genes of this family (who support Israel in all its killing frenzy of young children who never get a chance of living to 75) explains the deficiencies of their children. The fact that he would publicly expose his possibly oxygen deprived brain of such inhuman tendencies proves he is socially demented. I would hate to be his patient when medical decisions are made. He is the poster boy for the hidden thoughts of the ultra high percenters who allow much younger people than 75 die off for lack of proper medical care or poor living conditions.
Whenever I wonder why I am still around perhaps it is because I get a chance to denounce such uncompassionate people. I wonder what his father thinks about his ravings. I would feel better if I thought he was unique but unfortunately he is exposing the kind of twisted thoughts so many others in his class harbor.I am surprised that all his statements were allowed to go public and whether this is his true personality or something that snapped in his middle-old age. But remembering some of the behavior and comments by brother Rahm nothing surprises me.

Anonymous said...

Again it is I Pearl who wrote the above as I pressed the wrong button. I guess I should be sent to the gas chambers.

voice-in-wilderness said...

Dr. Zeke was just playing with people's minds. It is obvious to me in reading his article that doesn't have the least intention of giving up at 75 or any age -- and he admits as much at the end.

But he did get lots and lots of media attention, which was no doubt his goal!

Karen Garcia said...

Yes, he he waits till the very end to announce that he "reserves the right to change his mind"-- ergo, if you the reader were in any way offended by his morbid frivolity, your umbrage is totally on you. He is akin to the NYT critic who passive-aggressively called Shonda Rhimes the antithesis of the "angry black woman" by repeating racial stereotypes throughout her article... and then acted shocked that readers did not recognize she was simply being "arch and provocative".

James F Traynor said...

Eh! The guy's a shit. Why bother?

Zee said...

@3Karen—

Thank you so much for giving voice to every angry sentiment that I felt as I read through Emmanuel's Atlantic article, and thanks, too, to Kat and Pearl for further socking it to the a-hole!

Sadly, though, I fear that there are many other Zeke Emmanuels out there, some of who publicly voice his same sentiments, and many others who don't. People ready to (figuratively speaking) put other people on ice floes and push them out into the Arctic fog to die who are (in someone's opinion) so disabled or so aged that they are not now—or are no longer—useful contributors to society and hence, are unfit to further burden society with their medical expenses.

Emmanuel blithely talks about the tests and procedures that he will voluntarily forego beyond the age of 75 because, in his opinion, his best years will be behind him and he'll be ready to die. But you can bet that in the back of his mind—and in the minds of like thinkers—he's probably ready to make that decision for everybody once in a position of sufficient power to do so.

Emmanuel may claim to be against forced euthanasia for the aged and disabled, but is he against withholding the same potentially life-prolonging tests and procedures from others that he will “voluntarily” withhold from himself beyond a certain age?

That's not the same as consciously killing someone, after all—or so Emmanuel and others of his ilk will tell themselves. It's simply a "sound, well-thought-out and fairly implemented socioeconomic policy instituted for the good of all"—or so he will tell us as he sentences some of us to death by the withholding of certain tests and procedures because we're too old or too disabled (in his opinion) to benefit from them.

Already we see attempts by some in the medical establishment to tell us that, for example, “prostate-specific antigen” (PSA) tests for older men are no good because they cause more concerns (false positives for prostate cancer for some, resulting in “costly” additional tests and procedures) than they resolve, and that annual breast x-rays for women similarly cause more problems (Read: “create more costs”) than they resolve on the way to saving some women's lives.

So we should all forego these inexpensive tests and the valuable—maybe life-saving—information that they provide for some, because the results may cause some temporary confusion and expense for others among us?

Boo hoo. As a scientist, I've always believed that more information is better than less, but some physicians and policy-makers would deliberately deny us information because it might put us into a temporary quandry and needlessly burden society with a few additional costs on the way to saving a few lives.

I believe that a single-payer health care system is the way that the United States has to go in order to rein in health-care costs and provide an adequate safety net for every American citizen. But we need to be very careful how much power we cede to the government regarding what is and isn't covered by national insurance for all of us, and regarding the circumstances under which coverage for care can/will be denied for some of us, as will inevitably be the case.

But I do know that I don't want Zeke Emmanuel in charge of those things for me.

Zee said...

@James--

You're right.

Zeke Emmanuel's a turd.

But he's an influential turd, which you and I are not.

When and if this country moves toward a single-payer healthcare system--or, God forbid, toward a National Healthcare System à la the United Kingdom--you can bet that TPTB will be listening to Zeke or his intellectual inheritors, not you or me.

And then, God help old farts like me, and even older farts like you.

See you on the ice floes, in the dense Arctic fog.

Zee said...

@Kat-

Interesting that more than 100 years ago, a Victorian fiction writer would envision a "dystopian" world ( The Fixed Period ) in which individuals would be required to "die off" at age 67 for the convenience of society.

Not so far removed from what we are witnessing today, is it, &agrave la; Herr Dr. (Mengele) Emmanuel?

We have tried to persuade ourselves that the idea of “eugenics” is pass√©, but that's really not the case now, is it?

It's actually neither old nor new, but just something that won't go away no matter how much we wish it to. We will always have a sick contingent in our society who seems to think that it's a good idea.

The old should die by age 75, and the disabled should die by age...?

Be careful to whom you grant power...

Pearl 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. It is Ezekial's description of his father who has certainly earned the right to
take it easy and enjoy his family and not be made to feel guilty for being alive by his narcissistic son..

It is interesting that a wife is never mentioned (oh yes, he is divorced - smart lady) and there is really no actual mention of how we are supposed to get rid of anyone who has the nerve
to live beyond 75. Probably by cutting them off from any health care coverage which will happen soon enough with Obamacare. If he wants to end it all it is his choice but to make anyone feel guilty who is over 75 and not as lively as before, but has the
capacity to enjoy life as he talks only of success and usefulness of the market place means he does not understand the human condition and involvement in other areas of living.
I agree however, that keeping people alive at a certain point with more advanced surgeries, new treatments at great expense can bankrupt the medical
system and serve no purpose if great suffering is involved. I also strongly feel that those of us who are facing a painful
future, should have the choice of when to peacefully end our lives when there is no hope for improvement.
I wonder what the reaction to his article from the public is.
Also another interesting item, he has a sister who suffers from cerebral palsy and I wonder how he views her life.
Also,he may regret not learning the results of his prostate cancer test.

Denis Neville said...

We should be more afraid of Zeke than all the fake terror threats that bombard us on a regular basis.

"Genocide requires well-educated professionals. They are necessary for its technology, its organization, and its rationale." - Robert Jay Lifton and Eric Markusen, The Genocidal Mentality

Dr. Ezekiel Emanuel, Obama’s top medical advisor, has called for denying treatment to senior citizens outright: “Unlike allocation by sex or race, allocation by age is not invidious discrimination. . . . Treating 65 year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.”

http://online.wsj.com/articles/SB10001424052970203706604574374463280098676

Zeke likes data and statistics to advance his arguments. Neil Postman called this using science to make democracy rational:

"Two opposing world-views - the technological and the traditional - co-existed in uneasy tension. The technological was the stronger, of course, but the traditional was there - still functional, still exerting influence, still too much alive to ignore.... two distinct thought-worlds. ... With the rise of Technopoly, one of those thought-worlds disappears. Technopoly eliminates alternatives to itself in precisely the way Aldous Huxley outlined in Brave New World. It does not make them illegal. It does not make them immoral. It does not even make them unpopular. It makes them invisible and therefore irrelevant. And it does so by redefining what we mean by religion, by art, by family, by politics, by history, by truth, by privacy, by intelligence, so that our definitions fit its new requirements. Technopoly, in other words, is totalitarian technocracy.... the submission of all forms of cultural life to the sovereignty of technique and technology." - Neil Postman, Technopoly: The Surrender of Culture to Technology

Alfred Hoche and Rudolf Binding, Release and Destruction of Lives Not Worth Living, argued for “allowable killing” of the physically unfit. “The right to live,” they claimed, “must be earned and justified not dogmatically assumed.” Their ideas provided the justification for the German Third Reich’s euthanasia programs that were responsible for the death of millions of innocent people.

At the Nuremberg trials, chief American counsel Robert H. Jackson viewed the progression of German euthanasia this way:

“A freedom-loving people will find in the records of the war crimes trials instruction as to the roads which lead to such a regime and the subtle first steps that must be avoided. . . .To begin with, it involved only the incurably sick, insane and mentally deficient patients of the institution. . . .But “euthanasia” taught the art of killing and accustomed those who directed and those who administered the death injections to the taking of human life. . . .Once any scruples and inhibitions about killing were overcome and the custom was established, there followed naturally indifference as to what lives were taken…. If one is convinced that a person should be put out of the way because, from no fault of his own, he has ceased to be a social asset, it is not hard to satisfy the conscience that those who are willful enemies of the prevailing social order have no better right to exist.”

Republican House and Senate + Obama “Grand Bargain” = duty to die for those over 75?

Elizabeth Adams said...

I really appreciate the wonderful comments to Karen's post and the offending article. This guy is a classic example of Delusional Dominance Disorder (should be in the DSM IV, but HT to Carolyn Gage).

It makes me angry to think about how much of our language has been co-opted and redefined. What is work? Who defines purpose? Who determines value in our everyday lives? Who defines life? It goes on and on.

I do get irritated by people who determine what would be best for everyone else based on their own personal experiences. These people seem to have very little ability to empathize. They are pathetically clueless.

Jay - Ottawa said...

“Science and technology are indeed admirable and if they fulfill their promises can do much for man. But they can never solve his deepest problems. On the contrary, without the intuition and freedom that enable man to return to the root of his being, science can only precipitate him still further into the centrifugal flight that flings him, in all his uncomprehending isolation, into the darkness of outer space without purpose and without objective.” – Thomas Merton

But let’s not be too hard on Dr Zeke. His ideas about bitter ends aren’t so new, really, although they have been expressed with more delicacy and tentativeness and obliquity in polite discourse. Sometimes, a death wish laid upon another person can be perfectly acceptable, indeed welcome by all parties.

By way of example, it was dear Ben’s birthday last Friday, so after his temple’s Shabbat services friends gathered around to wish him the best.

At one point Irv, a friend of many years, stepped forward to say loudly before everyone, “Benji, may you live to be 99 and ¾ years!”

Benjamin thanked Irving but couldn’t help but ask the obvious question: “99 and ¾ years? Irving, why didn’t you just say ‘May you live to be a 100’ ”?

To which Irv replied, “Oh, Benji, because I’ve heard the last three months are terrible.”

Meredith, NYC said...

I am mixing this up with a NYT op ed
Too Young to Die, Too Old to Worry
By JASON KARLAWISH....SEPT. 20, .... a professor who seemed to say lets take up smoking and drinking again after age 75 and stop bothering about medications and tests--or something like that. Is this just a coincidence?

I can never forget z. emmanuel on cspan a few years ago, telling an audience at the commonwealth club that we could never have universal health care b/c the US is just too big geographically. When the rw lack all arguments, they look at the map and think that one up. All those EU countries are so much smaller, you see.

But, he told the audience, don't worry, I'm sure everyone here will be ok, and have access to care, no matter what.
Then I was dismayed to see the NYT selected him as a guru for expert opinion on ACA?

ste-vo said...

Did you all read the "Art of Lena Dunham" in the current issue of The Atlantic? Who gives a flying you know what about her and Zeke.

pawheels said...

You remind me of the current people who want to privatize education and prisons: if someone cannot meet some arbitrary expectations or goals they should be sidelined or worse, not assisted in some way. If you saw the hunger games movie, I think you took it too seriously.
By the way, I am 56,have dementia With Lewe bodies, and thank God for each day I get. It was hard to type this, but I felt the need to tell you what a disturbed person you are.

Jay - Ottawa said...

Part I

After commenting on Sardonicky earlier, I went over to “The Atlantic” magazine (no paywalls) to read the entire article by Dr Ezekiel Emanuel. I can’t disassociate Zeke from Rahm, his brother, the Mayor of Chicago, but I don’t think he’s in a class with Mengele or the snipers, like Sarah Palin, who railed against the ACA –– for the wrong reasons –– because of its so-called “death panels” set up to snuff out grannies.

The maligned “death panels” sprang from a provision in the ACA (Section 1233, HR 3200) for doctors providing counseling about living wills and end-of-life care options. The time medical personnel spent on those subjects with patients would be reimbursable. Anybody here got a problem with that?

Dr. Zeke expands on end-of-life issues in the “Atlantic” article while steering clear of abstractions. He serves as his own guinea pig to make his points more vividly. He’s not on an ego trip and he’s not forcing others to do as he advises. He’s putting forth a personal view as an informed and, yes, caring clinician with considerable experience in the field. With a tone I find sensitive and self-deprecating –– yes, and a bit light at times –– he argues against keeping old people more or less alive, but miserably alive, by pulling out all the stops of the available medical technology .

Like all writers who seek attention, he employs attention-getting gimmicks and exaggerations with effect. (There are over 3,500 comments/reactions following his article.) The number 75 is one such device, the head-turning number he entertains presently for his own life. He resolves, for the moment, to forgo all life saving measures once he reaches 75 years old. Whether a flu shot or a colonoscopy, after 75 he’ll skip it.

It is best at this point to read why from the source himself in the “Atlantic.” I find him persuasive, probably because I too have worked in the business, have some medical problems, and have refused at least one heavy-duty fix that would supposedly keep me ticking away into more golden years.

Jay - Ottawa said...

Part 2

Dr Zeke says that after he turns 75 he will accept fate’s final blow without resistance, whether it be cancer or heart disease or whatever. If he says anywhere that we should end aggressive care for the disabled before 75, I missed it. I also missed any comment about reducing the overall budget for health care. Money putatively wasted on hopeless end-of-life cures he would shift to research and care for the young and into special afflictions like Alzheimers. He argues strongly for comfort care for those who choose his road to the next big thing. And he stands against physician-assisted suicide.

Forget the arbitrary 75 number for a moment. And the personal connections of Dr Emmanuel. And his making himself the MacGuffin of his piece in the “Atlantic.” The fact is, an enormous amount of medical resources –– time, talent, technology, space and money –– is spent on remedies of dubious merit for people in late life.

Just as there is a military-industrial complex hungry for your money, there is a medical-industrial-nursing home complex that also wants your money for yet another test, or a fancy pacer, or third try at a stent, or a triple bypass, or bag of chemo, or a $600+ per day confinement, willy nilly, in a nursing home in lieu of homecare.
http://www.nytimes.com/2014/09/26/nyregion/family-fights-health-care-system-for-simple-request-to-die-at-home.html?emc=edit_th_20140926&nl=todaysheadlines&nlid=48171052&_r=0

It’s not just immature children who are likely to demand more than their share. Sometimes seniors, especially an old doctor, are in a position to exact more than their share from the medical system. Dr Zeke resolves not to do that and explains why.

He is an example to someone like me, who does happen to be over 75. The available money (finite) for healthcare, instead of being poured into the last few years of life, might better be spent elsewhere on younger populations, especially poor populations early in life.

Dr Zeke, with attention to both economics and humane values, is not saying the money saved on seniors should go into the pockets of the rich. He just asks that we think hard about shifting it to where it will do the most good for the most people for a longer time.

Pearl said...

Jay: I completely understand your level headed analysis of Zeke's comments in his article. However, when he makes a dramatic issue revolving around turning 75 as the starting point for the end, it becomes threatening if not physically at least emotionally to older people who are worried enough about their health problems and the ability to cover the costs or becoming a burden to others.
I also fault him for supporting Obamacare and not addressing the real reasons for lack of national health care in the U.S. He could have used his obviously intelligent mind to fight for decency in the health care system and not let his personal decisions which he overly emphasizes and calls attention to his more eccentric side be foremost.
You, I and others can read somewhat between the lines of his discourse, but it is too inflammatory and threatening in the wrong way for the average citizen and might encourage elderly citizens to make decisions that may be unfortunate by making them feel guilty which may lead to unwise health decisions where the possibility of improvement of their quality of life might be overlooked or not taken into consideration.
Yes, new discoveries for prolonging life are amazing but then they lead to many problems within the health care system as well as making choices either way as to whether or not to try new technologies and who will receive them and will be left out.
I was just about 75 when I had my triple by pass operation and am now living at 91 and hopefully of some use to others although I would never want to have to suffer eventually without the choice of having it mercifully ended at a certain point. But how can I ask my doctor to do this and even a carefully written will of care at the end does not cover all eventualities. This is another issue worth looking into.
So it is a slippery slope and as Karen emphasized it makes those who are disabled feel less wanted in society and guilty of requiring care they cannot personally afford.
Also more preventive approaches to medical care would eliminate the need for many patients becoming disabled through no fault of their own as well as education for healthy life styles with help for proper nutrition and living conditions to those who are financially strapped.
I might also want to add that due to the university plans in some Canadian universities for survivors of its staff members as in my case, my ability to live comfortably with proper assistance is due to my receiving my husband's old age pension as a survivor. However, that will begin to disappear as financial concerns will not keep the tenure system going in universities, so I consider myself fortunate. Also my husband cut back his salary in order to have the difference saved for our retirement years. But many others are not so fortunate.
Do not feel that you should allow money for your health care be shifted over to the younger generations, Jay. You have earned your way to being supported as long as you wish medically and the younger generations will also have to earn their way. You obviously have done many great and good things in your working life, and family and friends who are fortunate to know you (even via computer) cherish the comments and analysis of your wisdom of your senior years. I appreciate your taking the time to explain your reactions to Zeke's article. Much food for thought.

Jay - Ottawa said...

@Pearl
Thanks for your kind and measured approach. Like you, I deplore the ACA’s double down on the failed private health insurance system and Emmanuel’s hand in it with his crafting of Obamacare. As you know, I’m long on record in support of single payer along the lines described by PNHP.

I agree with just about every one of the several points you make to improve the system. But if you elaborate upon each of them for an article in a publication like The Atlantic, the editors will never publish it. The word must be conveyed to the general public in other ways.

With apologies to Abe Lincoln, you can get across a few points to all of the people sometimes, and you can sometimes get across all of the points to some of the people, but you can’t get across all of the points to all of the people all of the time. The healthcare system in the US is complex, and so are the corrections. The US will never embrace anything so revolutionary as single payer; we can only work towards incremental understanding and improvements over time.

When someone like Dr Emmanuel makes a sound case on a very significant issue, even if he does it in a personalized and quirky way, I’ll cut him some slack, just so the big message gets across. “75” as a cutoff for everyone is absurd and unjust. He knows that. But it sure is catchy and the kind of gimmick editors fall back on to snag readers.

The issue Emmanuel is sneaking in is the overuse of technology, medicine and other resources to keep seniors reaching for immortality. Such efforts serve the health e$tabli$hment more than the seniors. I believe it a moral responsibility to raise the issue, as Emmanuel did, and then a moral responsibility to live by it with one’s own body, as he says he will at least try.

He is wildly wrong, of course, to suggest seniors skip a flu shot; it’s both effective and cheap and has few serious side effects. My getting the shot not only protects me, it protects you. Not the same thing, though, for chemotherapy when you’re 85.

Emmanuel is right to say that the engagement of high end, complex and costly technology is morally questionable if the outcome is likely to keep someone alive, just barely, after they reach “a certain age.” What age? That depends on every individual case. Honest medical professionals and responsible laypeople will consider the overall health of the person, the trauma caused by the procedure, its lasting effect, and the capacity of one’s family support system. For A, the cutoff age may be 70; for B, 75; for C, 80, maybe. We should really, really begin to hesitate when stuck with such a decision for someone in the 80s. Surely, for each of us, at some age point, aggressive care will become utterly absurd and profoundly unethical.

I won’t regale you with cases I witnessed where families insisted that everything be done to keep a lost cause alive. Irresponsible chiefs found it preferable to let the epinephrine drip, the morphine infuse and the ventilator huff. Death sat heavy on the patient like an incubus and eventually overpowered the whole damn machinery. The outcomes are so often tragic and wasteful. And oh the bills for the family –– or society. Even if such care were free, someone, at some point, must say, Enough!

Bonnie said...

Delightful to see your article in Truthout, Karen! Hope you reach a wide, wide audience - with ALL of your blogs.

Valerie Long Tweedie said...

I read the article in the Atlantic. It did sound like the author had an agenda to promote and he was certainly smug and clearly well off financially so one can expect he will have great health care for the rest of his life, whether or not Medicare or Obama Care pays for it. I didn't like the part where he talked about people losing productivity and creativity as they age. I think as people age, their priorities change and they are not as driven by making a name for themselves or success as they are by relationships. I don't see anything wrong with that and in fact, see that as a wiser more socially productive way to live our lives.

On the other hand, my dad died a drawn out death of Alzheimer's that cost Medicare a small fortune. I really question whether he should have had the surgeries he had which prolonged his life but certainly didn't add to the quality of it. The doctors didn't want to say "no" and my mom wouldn't say "no." I really don't think it was a dignified end for a man so defined by his intelligence and I think had the surgeries not been paid for by Medicare, they wouldn't have happened . . and that might have been for the best.

If I have the Alzheimer's gene and if I get Alzheimer's, I have told my husband and daughter that I do not want my life extended and to let nature take its course. Personally, after watching my dad die in this way, I might wish for euthanasia.

While most of us who are alert and haven't abused our bodies with too much physical work, smoking, drugs or alcohol, barring a disease, we should be fine into our eighties. But I look at my brother who worked hard, lived on a diet of junk food and smoked his entire life and I wonder at the quality of life he will have at seventy five. He already seems worn out at fifty. Will he become one of those people whose broken down body will continue to be propped up? Is that the best thing for him or for society in general?

I think these are really difficult issues to grapple with. We are going to have to ration health care and it doesn't make sense to spend astronomical amounts in the last month or two of a person's life. Yet, if it were my child or my husband, I know I would want every last minute with them, even if it were sitting beside a hospital bed holding their hands.


Denis Neville said...

Health is a fundamental human right, one that is inextricably connected to our well-being in society.

It is very expensive to give mediocre medical care to poor people in a rich country.

Being concerned with the health and well-being of the poor or otherwise marginalized, of the frail or the elderly, of those bent under the weight of serious illness, Paul Farmer asks,

“What if most of our aches and pains and many of our serious ailments come largely from those outside forces and abstractions? What if we want to prevent disease or complications of it by altering our risk of poor outcomes (not just death, but predictable or unforeseen complications of the chronic conditions and growing infirmity that most of us will one day endure)? What if we acknowledge that we live not only in bodies but in families, homes (mostly), neighborhoods, and cities? What if our lives outside of the clinic or hospital are often difficult and even, for some people and at some times, almost unendurable? What if our clinical diagnoses are not our chief complaints?”

“When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the same cause that wears out
Our bodies and our clothes.
The pain in our shoulder comes
You say, from the damp; and this is also the reason
For the stain on the wall of our flat.
So tell us then:
Where does the damp come from?

Too much work and too little food
Make us weak and scrawny.
Your prescription says:
Put on more weight.
You might as well tell a fish
Go climb a tree.”
- Bertolt Brecht, “A Worker's Speech To A Doctor”

“Increased efficiency and lower costs, though important, are not the alpha and the omega of health care improvement, and still less of improvement in health itself… If only we could develop the right community-based and equitable delivery platforms in advance, we could spare our patients a lot of suffering, and ourselves a lot of headaches and acrimony.”

Jay - Ottawa said...

Whether in silks or in rags, after a life of good health or chronic illness, eventually we shall all have to face our mortality. That is the final phase under discussion, no matter what good fortune or bad, just or unjust, preceded it.

The uncharted zone between late life and death is a minefield. Each of us moves through it with uncertainty. There is no map. Going for a certain medical fix may be appropriate for one senior, but a terrible decision for another. It's hard to prepare, but we can at least try to prepare by listening to the reports from those up ahead.

As was noted at the very top, beginning with Karen’s blog, we have reason to suspect the motives of movers and shakers like Dr Emanuel who engineered the ACA. Is he one of many now planting seeds in the American mind so that ageism and neglect will be more acceptable down the road? Perhaps.

At the same time, understand that Emanuel has not been the only expert cautioning us about prolonging life too long with our magical technology, to the detriment of patients, their families and society. In my experience, such events are not infrequent. Ethicists, clinicians and families themselves –– sometimes too late –– tell us what happens when no one dares to say ‘no’ to the next treatment brought forth, then the next, and the next....

The ancients told a story about a man who had tricked the gods into owing him a favor. He would be allowed one wish. He wished to never die. The gods smiled, and he just got older, and older, and older….

Zee said...

@Jay--

All of your points are well-taken.

At some point, we will all—unless we have the good fortune to die suddenly and unexpectedly—be confronted with the question as to when it is time to let go of life. Or, if we are not of sound mind, our families or designated healthcare representatives will have to make that decision for us.

The key point to me, at least, is that we—or our designated representatives—are allowed to make the choice, not the state, unless the cost of the treatment is extraoridinary or it's experimental.

I understand that it is much better now, but once upon a time, Britain's National Health Service used to routinely deny dialysis to patients beyond the age of 50 or so, because the NHS decided in its infinite wisdom that beyond that age, we all had become a bit “crumbly” and were no longer good candidates for said treatment.

“'As resources are constrained in the United States, we are going to see more and more physicians convincing themselves that older patients are not suitable candidates for this or that procedure,' Tuft's Dr. Schwartz told Health Affairs Quarterly. He quoted a doctor in Great Britain, where health rationing is widespread, as saying: `'No one over 55 or 60 is a suitable candidate (for kidney dialysis) because everybody at that age is a bit crumbly.'”

http://community.seattletimes.nwsource.com/archive/?date=19900108&slug=1049792

At almost age 64 I certainly have my aches and pains, but I'm feeling far from “crumbly” and ready to cash in my chips. So the NHS can respectfully go to hell.

But I worry that no matter how carefully we plan the circumstances under which we finally decide to refuse further care, we just might be ignored by our doctor(s) in the end.

My then-93(?)-year-old mother-in-law had granted Mrs. Zee written, durable Power of Attorney for all of her matters, both financial and medical, including a Do-Not-Resusitate instruction in extremis. However, when we were called to her (nominal) death bed, the attending emergency room physician asked her if she wanted extraordinary measures taken to preserve her life.

Mrs. Zee's mother was clearly not in her right mind, and Mrs. Zee should have been the one to answer the question, which would have definitely been “no.” Still, mother-in-law gasped “yes” to the physician's question, and that answer overrode all the legal paperwork that was in place to preempt just such a response.

So extraordinary measures were taking to preserve mother-in-law's life anyway, only for her to pass peacefully from the world a few weeks later in her nursing home. I wonder what were the extra two or three weeks cost the taxpayer, especially as “mom” never really recovered enough consciousness after her near-death experience to appreciate it?

Bottom line? I guess you can't win for losin' when it comes to end-of-life decisions. No matter how carefully one plans, someone else will make those final decisions for you. Whether you like it or not.