Seventy-five.
That’s how long I want to live: 75 years.
This preference drives my daughters crazy. It drives my brothers crazy. My loving friends think I am crazy. They think that I can’t mean what I say; that I haven’t thought clearly about this, because there is so much in the world to see and do. To convince me of my errors, they enumerate the myriad people I know who are over 75 and doing quite well. They are certain that as I get closer to 75, I will push the desired age back to 80, then 85, maybe even 90.
I am sure of my position. Doubtless, death is a loss. It deprives us of experiences and milestones, of time spent with our spouse and children. In short, it deprives us of all the things we value.
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.
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.
Let me be clear about my wish. I’m neither asking for more time than is likely nor foreshortening my life. Today I am, as far as my physician and I know, very healthy, with no chronic illness. I just climbed Kilimanjaro with two of my nephews. So I am not talking about bargaining with God to live to 75 because I have a terminal illness. Nor am I talking about waking up one morning 18 years from now and ending my life through euthanasia or suicide. Since the 1990s, I have actively opposed legalizing euthanasia and physician-assisted suicide.
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.
Americans may live longer than their parents, but they are likely to be more incapacitated. Does that sound very desirable? Not to me. What are those reasons? Let’s begin with demography. We are growing old, and our older years are not of high quality. Since the mid-19th century, Americans have been living longer. In 1900, the life expectancy of an average American at birth was approximately 47 years. Today, a newborn can expect to live about 79 years.
In the early part of the 20th century, life expectancy increased as vaccines, antibiotics and better medical care saved more children from premature death and effectively treated infections. Since 1960, however, increases in longevity have been achieved mainly by extending the lives of people over 60. Rather than saving more young people, we are stretching out old age.
The American immortal desperately wants to believe in the “compression of morbidity.” Developed in 1980 by James F. Fries, this theory postulates that as we extend our life spans into the 80s and 90s, we will be living healthier lives — more time before we have disabilities and fewer disabilities overall. The claim is that with longer life, an ever-smaller proportion of our lives will be spent in a state of decline.
Compression of morbidity is quintessentially an American idea. It tells us exactly what we want to believe: that we will live longer lives and then abruptly die with hardly any aches, pains or physical deterioration. It promises a kind of fountain of youth until the ever-receding time of death.
But as life has gotten longer, has it gotten healthier? Is 70 the new 50?
Not quite. It is true that compared with their counterparts 50 years ago, seniors today are less disabled and more mobile. But over recent decades, increases in longevity seem to have been accompanied by increases in disability — not decreases. For instance, using data from the National Health Interview Survey, Eileen Crimmins, a researcher at the University of Southern California, and a colleague assessed physical functioning in adults, analyzing whether people could walk a quarter of a mile; climb 10 stairs; stand or sit for two hours; and stand up, bend or kneel without using special equipment. The results show that as people age, there is a progressive erosion of physical functioning. More important, Crimmins found that between 1998 and 2006, the loss of functional mobility in the elderly increased. Her conclusion: There was an “increase in the life expectancy with disease and a decrease in the years without disease.” As she puts it, over the past 50 years, the contemporary dying process has been elongated.
Does that sound very desirable? Not to me.
The situation becomes of even greater concern when we confront the most dreadful of all possibilities: living with dementia and other acquired mental disabilities. Right now approximately 5 million Americans over 65 have Alzheimer’s; 1 in 3 Americans 85 and older has Alzheimer’s. And the prospect of that changing in the next few decades is not good. Instead of predicting a cure in the foreseeable future, many are warning of a tsunami of dementia — a nearly 300 percent increase in the number of older Americans with dementia by 2050.
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.
American immortals operate on the assumption that they will be precisely such outliers. But the fact is that by 75, creativity, originality and productivity are pretty much gone for the vast, vast majority of us.
This age-creativity relationship is a statistical association, the product of averages; individuals vary from this trajectory. Indeed, everyone in a creative profession thinks they will be, like my collaborator, in the long tail of the curve. There are late bloomers. As my friends who enumerate them do, we hold on to them for hope. But there is no getting around the data. By definition, few of us can be exceptions.
We can only speculate about the biology. The connections between neurons are subject to an intense process of natural selection. All of those mental puzzles are an effort to slow the erosion of the neural connections we have. Once you squeeze the creativity out of the neural networks established over your initial career, they are not likely to develop strong new brain connections to generate innovative ideas — except maybe in those Old Thinkers like my outlier colleague who happen to be in the minority endowed with superior plasticity.
Maybe this is too dismissive. There is more to life than youthful passions focused on career and creating. There is posterity: children and grandchildren and great-grandchildren.
But here, too, living as long as possible has drawbacks we often won’t admit to ourselves. I will leave aside the very real and oppressive financial and caregiving burdens that many, if not most, adults in the so-called sandwich generation are now experiencing, caught between the care of children and parents. Our living too long places real emotional weights on our progeny.
Living parents also occupy the role of head of the family. They make it hard for grown children to become the patriarch or matriarch.
But there is something even more important than parental shadowing: memories. How do we want to be remembered by our children and grandchildren? We wish our children to remember us in our prime. Active, vigorous, engaged, animated, astute, enthusiastic, funny, warm, loving. Not stooped and sluggish, forgetful and repetitive, constantly asking, “What did she say?” We want to be remembered as independent, not experienced as burdens.
Of course, our children won’t admit it. They love us and fear the loss that will be created by our death. And a loss it will be. A huge loss. They don’t want to confront our mortality, and they certainly don’t want to wish for our death. But even if we manage not to become burdens to them, our shadowing them until their old age is also a loss.
Seventy-five. That is all I want to live. But if I am not going to engage in euthanasia or suicide, and I won’t, is this all just idle chatter? Don’t I lack the courage of my convictions?
No. My view does have important practical implications. One is personal and two involve policy.
Once I have lived to 75, 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.
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.”
My Osler-inspired philosophy is this: 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.”
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 — have been written and recorded. In short, no life-sustaining interventions. I will die when whatever comes first takes me.
As for the two policy implications, one relates to using life expectancy as a measure of the quality of health care. Japan has the third-highest life expectancy, at 84.4 years, while the United States is a disappointing No. 42, at 79.5 years. But we should not care about catching up. Once a country has a life expectancy past 75 for both men and women, this measure should be ignored. (The one exception is increasing the life expectancy of some subgroups, such as black males, who have a life expectancy of just 72.1 years. That is dreadful, and should be a major focus of attention.) Instead, we should look much more carefully at children’s health measures, where the U.S. lags, and shamefully.
A second policy implication relates to biomedical research. We need more research on Alzheimer’s, the growing disabilities of old age and chronic conditions — not on prolonging the dying process.
Many people, especially those sympathetic to the American immortal, will recoil and reject my view. They will think of every exception, as if these prove that the central theory is wrong. Like my friends, they will think me crazy, posturing — or worse. They might condemn me as being against the elderly.
Again, let me be clear: I am not saying that those who want to live as long as possible are unethical or wrong. I am certainly not scorning or dismissing people who want to live on despite their physical and mental limitations. I’m not even trying to convince anyone I’m right. Indeed, I often advise people in this age group on how to get the best medical care available in the United States for their ailments. That is their choice, and I want to support them.
And I am not advocating 75 as the official statistic of a complete, good life in order to save resources, ration health care or address public-policy issues arising from the increases in life expectancy. What I am trying to do is delineate my views for a good life and make my friends and others think about how they want to live as they grow older. I want them to think of an alternative to succumbing to that slow constriction of activities and aspirations imperceptibly imposed by aging.
I think the rejection of my view is literally natural. After all, evolution has inculcated in us a drive to live as long as possible. We are programmed to struggle to survive. Consequently, most people feel there is something vaguely wrong with saying 75 and no more. We are eternally optimistic Americans who chafe at limits, especially limits imposed on our own lives. We are sure we are exceptional.
I also think my view conjures up spiritual and existential reasons for people to scorn and reject it. Many of us have suppressed, actively or passively, thinking about God, heaven and hell, and whether we return to the worms. We are agnostics or atheists, or just don’t think about whether there is a God and why she should care at all about mere mortals. We also avoid constantly thinking about the purpose of our lives and the mark we will leave. Indeed, most of us have found a way to live our lives comfortably without acknowledging, much less answering, these big questions on a regular basis. And I don’t purport to have the answers.
But 75 defines a clear point in time: for me, 2032. It removes the fuzziness of trying to live as long as possible. Its specificity forces us to think about the end of our lives and engage with the deepest existential questions and ponder what we want to leave our children and grandchildren, our community, our fellow Americans, the world. The deadline also forces each of us to ask whether our consumption is worth our contribution. As many of us learned in college during late-night bull sessions, these questions foster deep anxiety and discomfort. The specificity of 75 means we can no longer just continue to ignore them and maintain our easy, socially acceptable agnosticism.
Seventy-five years is all I want to live. I want to celebrate my life while I am still in my prime. My daughters and dear friends will continue to try to convince me that I am wrong and can live a valuable life much longer. And I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible. That, after all, would mean still being creative after 75.
This essay was excerpted from a longer piece originally published by The Atlantic.
Ezekiel Emanuel is director of the Clinical Bioethics Department at the U.S. National Institutes of Health and heads the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Reach him at MEHPchair@upenn.edu.
