It is amazing how many doctors seem not to have the fuzziest conception of the purpose of medicine. Ezekiel Emanuel who is trained in internal medicine and oncology but who has concentrated on public policy has written an article in the Atlantic that seems to display almost total ignorance of what medicine is about. The piece has received a lot of attention, but nothing about it that I have seen has pointed out its obvious medical naïveté.
Dr Emanuel observes how the body and mind inevitably degrade after 75, though the individual variation is so great that 75 is an entirely arbitrary age. Accordingly, he expresses the wish that his life stop at 75 though he is unwilling to end it himself. He further notes that creativity is an early casualty of age. He goes on to talk about Einstein and Nobel Prize winners who do their important work before they are 50. But so what? Great creativity is bestowed on only a tiny fraction of people. What’s wrong with just having a few beers, watching a football game with your grandchildren, and going to the movies? All of which are doable after 75. But Dr Emanuel will have none of it. Here’s his medical plan after 75. Does his plan suddenly change when he goes from age 74 and 364 days to 75 ?
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.
This means colonoscopies and other cancer-screening tests are out—and before 75. If I were diagnosed with cancer now, at 57, I would probably be treated, unless the prognosis was very poor. But 65 will be my last colonoscopy. No screening for prostate cancer at any age. (When a urologist gave me a PSA test even after I said I wasn’t interested and called me with the results, I hung up before he could tell me. He ordered the test for himself, I told him, not for me.) After 75, if I develop cancer, I will refuse treatment. Similarly, no cardiac stress test. No pacemaker and certainly no implantable defibrillator. No heart-valve replacement or bypass surgery. If I develop emphysema or some similar disease that involves frequent exacerbations that would, normally, land me in the hospital, I will accept treatment to ameliorate the discomfort caused by the feeling of suffocation, but will refuse to be hauled off.
What about simple stuff? Flu shots are out. Certainly if there were to be a flu pandemic, a younger person who has yet to live a complete life ought to get the vaccine or any antiviral drugs. A big challenge is antibiotics for pneumonia or skin and urinary infections. Antibiotics are cheap and largely effective in curing infections. It is really hard for us to say no. Indeed, even people who are sure they don’t want life-extending treatments find it hard to refuse antibiotics. But….unlike the decays associated with chronic conditions, death from these infections is quick and relatively painless. So, no to antibiotics.
Obviously, a do-not-resuscitate order and a complete advance directive indicating no ventilators, dialysis, surgery, antibiotics, or any other medication—nothing except palliative care even if I am conscious but not mentally competent—have been written and recorded. In short, no life-sustaining interventions. I will die when whatever comes first takes me.
Dr Emanuel seems to think the approach described above unique, but rather it’s standard practice for any intelligent and up-to-date general internist. Dr Emanuel has been so deep in writing rules for medical practice that he seems to have lost touch with how it’s done. He can’t see the forest because of the clauses. Let’s go through some of the issues Dr Emanuel raises. But first the purpose of medicine: To prevent premature death and relieve pain and suffering. Thus much of what he says is covered by the first of these two goals. It’s impossible to prevent premature death in a 75 year old.
Why such a big deal about no prostate cancer screening when current good practice no longer recommends it at any age? He won’t get preventative tests after 75. I can’t think of any preventative tests recommended for people over 75 other than blood pressure measurement which you can do yourself. He’s going to have a do not resuscitate order. I’m not sure at what age he intends it to be instituted.
My DNR dates back to when I was 32. When I’d tell my students about it they’d invariably say, “But what if it worked?” “That’s what worries me,” I’d reply. “Can you guarantee that I’d be as good as I was before the collapse?” Of course they couldn’t which is why I likely now have the world’s record for the longest continuous DNR in medical history.
Dr Emanuel won’t get a colonoscopy after 65. I assume he means if colonoscopy before that age is normal. Well, that’s just good medical practice not a startling confession. He’s against geriatric antibiotic therapy. So if the day he turns 75 he gets a boil on the back of his hand he wont smear a bit of triple antibiotic ointment on it? It’s cheap and over the counter. And it works. What about the herpes zoster vaccine? The disease (shingles) is typically not life threatening, but it’s very painful. The vaccine reduces the recipient’s likelihood of contracting the disease by about 50 to 65%. It’s cost effective. Dr Emanuel can get the drug before he’s 75, but the protective effect of the vaccine is about 7 years, though no one is yet sure. If a second vaccination is subsequently recommended will he forgo it rather than reduce his chance of getting a painful non-lethal disease?
The second purpose of medicine is to relieve pain and suffering. Dr Emanuel seems to be OK with that. So where’s the sirloin? He wrote a long article saying he adheres to the purpose of his profession. What’s remarkable is that anyone was surprised by it. Dr Emanuel seems very likely to make to 75 and well beyond. If he has a good primary care doctor he wont have to show him the Atlantic article.
As for life after 75 consider the three examples below. If you weren’t creative at 30, you won’t be at 80.
Tutto nel mondo é burla Giuseppe Verdi, Falstaff, age 80.