“Why I Hope to Die at 75” is the title of Dr. Ezekiel Emanuel’s 2014 Atlantic essay on whether “our consumption is worth our contribution” after a certain point in life. In it, he argues for “quality” versus “quantity” of life. President-elect Joe Biden announced a coronavirus taskforce’s formation, tapping Emanuel as one of the board members. (It is an odd turn of events that Emanuel be selected for this by a man in his late 70s.) Emanuel is the chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.
Emanuel should not help shape the national response to a pandemic that disproportionately affects the elderly and vulnerable. Will their contribution be weighed against their consumption of resources (a question particularly pressing regarding the distribution of a vaccine)?
Unfortunately, the answer to that seems to be yes.
COVID-19 notoriously has hit older Americans the hardest, with one June estimate saying as many as 40 percent—or possibly more—of COVID-19 deaths at that point were linked to nursing homes. And the Centers for Disease Control and Prevention has put the risk of death from COVID-19 for those aged 75-84 as 220x higher than 18-29-year-olds (for those aged 50-64 it is 30x higher, and for those 65-74 it is 90x higher). When putting together a team to address the pandemic, which particularly hurts older people and those rendered more vulnerable by disabilities and various health conditions, someone like Emanuel is an alarming choice, someone who once wrote:
Doubtless, death is a loss. . . . 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.
He adds that though Americans today may live longer than their parents did, “they are likely to be more incapacitated. . . . The situation becomes of even greater concern when we confront the most dreadful of all possibilities: living with dementia and other acquired mental disabilities.”
While Emanuel may be referring to the ailments that accompany old age in his essay, the argument he makes could just as easily be extended to those of any age with physical or mental disabilities. This utilitarian perspective reduces people to how they measure up by some definition of productivity. But an individual’s value is far more than just what they are capable of doing or producing (or have the potential to produce).
In his essay, Emanuel noted that he was “not advocating 75 as the official statistic of a complete, good life to save resources, ration health care, or address public-policy issues arising from the increases in life expectancy.” That disclaimer, however, is not reassuring given Emanuel’s recent work.
Emanuel co-wrote a piece in the journal “Science” this past September on the most ethical way to globally distribute a coronavirus vaccine. The Fair Priority Model, he and his fellow ethicists proposed prioritizes first and foremost the prevention of “premature death” (i.e., a death that “prevents someone’s exercising their skills or realizing their goals later in life”), as premature deaths are worse than deaths later in life, they note. Their explanation evokes Animal Farm: “[this approach] regards all deaths as important but earlier deaths as particularly important.” Essentially, despite the fact that the elderly are at an exponentially higher risk of death than the young, they should not be a priority in vaccine distribution because their lives are not of equal value.
This stands in stark contrast to frameworks such as the one put forward by the National Academy of Science, which includes among its first-tier priorities (along with frontline workers in the health industry, food supply, schools, etc.) “Those at greatest risk of severe illness and death, and their caregivers (e.g., adults aged ≥65 years; others at elevated risk of serious COVID-19 and complications; frontline long-term care providers and health care workers providing direct care to patients with high-risk conditions)”. This appears to be in line with how the Department of Health and Human Services plans to distribute the vaccine. Emanuel and his co-authors dismiss such an approach that focuses on the elderly and healthcare workers, saying that while it “seems to prioritize protecting those judged most likely to die and preventing health system collapse,” it is an “empirical question whether this prioritization optimally reduces death.”
This should make anyone with elderly or medically vulnerable loved ones nervous. Emanuel seems ready to weigh the value of their lives and find them lacking, the “quality” of their human experience making them less worthy of protection than the young and healthy. Biden’s choice of Emanuel for the coronavirus taskforce bodes ill not just for how his administration would respond to the pandemic but also to approach health policy more broadly. Who will be deemed worthy of care?