Dr. Ezekiel Emanuel is an oncologist, Vice Provost for Global Initiatives at the University of Pennsylvania and chair of the Department of Medical Ethics and Health Policy, an architect of Obamacare, and has recently been appointed to President Biden’s US Covid-19 taskforce to help develop a plan for attacking the pandemic and allocating the vaccine. Dr. Emanuel has written extensively on fair and equitable strategies for vaccine distribution. His co-authored articles in the New England Journal of Medicine [1] and JAMA [2] display well thought-out and reasonable approaches to allocating scarce resources utilizing conventional ethical values.

However, in 2014, Dr. Emanuel published an essay in The Atlantic entitled “Why I Hope to Die at 75” [3], a title that he states he did not choose. He is an avowed opponent of euthanasia and physician-assisted suicide, arguing that more counseling and support would alleviate the need for both. [4] His essay is not framed as a policy statement but as his personal philosophy regarding what he believes would be the best outcome for himself and potentially for others given the state of medicine, the unrealistic expectations most people have for good health as they age, and the myriad of shortcomings that he thinks excessively prolonging life yields. To be clear, he is not arguing for hastening death but for foregoing preventive actions and interventions that will prolong life after reaching the age of 75 the age from which statistically, a person’s creativity and productivity diminish, and reliance on others and societal resources increase. He feels that prolonged life after this point is likely to be unfulfilling and possibly counterproductive. Dr. Emanuel reaffirmed his position in an August 2019 interview by Stephan S. Hall in the MIT Technology Review.

I have no intention of analyzing his personal reasons for desiring a death at the age of 75. It seems clear from the essay that were he to know that he would remain healthy and vibrant he might welcome staying healthy into old age. But given the statistics for expected vitality past 75, he feels that taking proactive steps to prolong life for its own sake is not something he would choose to do. His thesis is summed up at the beginning of the article:

“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.”

And towards the end of the article Dr. Emanuel concludes,

“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… What about simple stuff? Flu shots are out… no to antibiotics…”

To be clear, halacha requires unabated medical care for healthy people, regardless of age, both preventative and therapeutic. The idea of deliberately avoiding benign screening tests, routine doctor’s visits and prudent healthcare (including flu vaccinations and taking antibiotics) transgresses the Biblical obligation to guard one’s health. [5] Of course, there is flexibility with testing that is not likely to provide meaningful health benefits; such tests would not be required. Nevertheless, there is an obligation to protect one’s health to the extent reasonably achievable.

Nevertheless, it is worthwhile to examine Dr. Emanuel’s argument for self-imposed limiting of one’s longevity if life will lose its value as his underlying question is contemplated by many people. On the surface, Dr. Emanuel’s conclusion follows from its premise. He carefully documents that most people 80 and older have significant physical limitations, decreased mental acuity, and have passed their peak of productivity. He argues that life expectancy has significantly increased but healthy functional life has decreased over the past few decades with significant increase in dementia. Survival from stroke has increased but leaves many severely impaired.

“Half of people 80 and older with functional limitations. A third of people 85 and older with Alzheimer’s. That still leaves many, many elderly people who have escaped physical and mental disability. If we are among the lucky ones, then why stop at 75? Why not live as long as possible?

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. . .

We accommodate our physical and mental limitations. Our expectations shrink. Aware of our diminishing capacities, we choose ever more restricted activities and projects, to ensure we can fulfill them. Indeed, this constriction happens almost imperceptibly. Over time, and without our conscious choice, we transform our lives. We don’t notice that we are aspiring to and doing less and less. And so we remain content, but the canvas is now tiny. The American immortal, once a vital figure in his or her profession and community, is happy to cultivate avocational interests, to take up bird watching, bicycle riding, pottery, and the like. And then, as walking becomes harder and the pain of arthritis limits the fingers’ mobility, life comes to center around sitting in the den reading or listening to books on tape and doing crossword puzzles. And then …”

So what is the traditional Jewish approach to Dr. Emanuel’s thesis? His approach is based on an analysis of what he supposes to be a meaningful life. He argues that prolonging life just for the sake of having a longer life, at the expense of a consequential life, is not something to be desired. Whereas the loss of meaning in life may lead to a desire for death, Jewish law reflects a sensitive framework in how to treat such individuals.

Most halachic discussions on this topic involve terminally ill patients who are suffering severe pain, not healthy people attempting to prevent further debilitation. Rabbi Moshe Feinstein and Rabbi Shlomo Zalman Aurbach clearly rule that a terminal patient in intractable pain whose pain cannot be relieved and who cannot be cured may decline further treatment intended only for prolongation of life. Both authorities allow for a degree of autonomy.

Rabbi Feinstein explains that if the terminally ill suffering patient is incompetent, the default presumption would be not to treat, and that one should in fact not treat such a patient unless the family knows the patient’s wishes to be otherwise. [6]

But considerations of self-assessed value of life do not only apply to terminally ill patients. Rabbi Aurbach adds nuance to the discussion by ruling that a very sick patient may refuse treatment that might save their life but will leave them paralyzed even if successful, explaining that autonomy is retained by the patient to choose a shortened life over an extended life “when life is bad and bitter,” permitting the patient to refuse life-prolonging therapy or surgery in certain circumstances. Rabbi Aurbach raises the reality that there are situations in which death is preferable to life. Rabbi Aurbach stresses that it is worthwhile to try to convince the patient that prolongation of life is worthwhile. Nevertheless, the final decision is left to the patient.

Such rulings may be understandable for terminally and very sick patients, but what of healthy people who do not wish to live any longer? There is a cryptic Talmudic story in Sota 46b which describes the town of Luz, where no one ever died. “Rather the elderly [in this city,] when their minds become weary [of life and they wish to die,] go outside the [city] wall and die.” [7] But this passage, known as Aggadata, is very difficult to fully understand and limited practical lessons can be derived from it.

But is does raise the key question of what would motivate an inhabitant of Luz to decide that it is time to die? Why not extend life forever? Were they motivated by the same concerns of Dr. Emanuel?

To understand problem with Dr. Emanuel’s approach, we must consider why someone who is not sick would want to die. As I wrote in a Johns Hopkins University Press journal [8]:

There is a long tradition in Judaism to pray for salvation in times of suffering, including serious illness. Yet despite the strong belief that there is always hope, we also find instances in the Bible and Talmud of great men praying to die or praying for others to die. Several Biblical and post-Biblical characters prayed that their lives or the lives of others be shortened for a variety of reasons, some seemingly motivated by physical pain and some seemingly motivated by emotional pain. [9] However, the two motivations are manifestations of one overarching concept: the desire for death arises when physical or emotional pain becomes unacceptable or inexplicable. .

Almost all of these righteous people prayed for death not because of physical pain but because of existential pain, better described as suffering.

There is a key difference between pain and suffering that helps to explain why some patients with terrible pain desire to continue treatment and prolong their lives while others desire a swift death. Pain may be understood as “physical” suffering or distress due to illness, injury, or other painful physical or emotional stimulus. On the other hand, suffering is the perception of pain. That is, suffering may be defined as the state of undergoing pain or distress, whether physical or mental.

The problem with Dr. Emanuel’s essay is not his questioning the value of a life without meaning, but his subsequent analysis.  His evaluation of “old age” is based on the perception that meaningful and satisfying life is tied to physical health, vitality, and creativity. From a Jewish perspective, a meaningful life involves serving Hashem and fulfilling His wishes in this world. Our ability to fulfill Hashem’s desires does not depend on our youth and vigor but on our achieving our potential at each stage of our lives. While Pirkei Avos clearly states that learning Torah during youth is far more effective and easier to retain than in old age, it does not imply that learning in old age is less valuable. It is the recognition that we are doing the will of Hashem at the level that we are able is what makes life meaningful. Mitzvos performed by the elderly are no less precious than those performed by the young.

In Dr. Emanuel’s world, the yardstick by which a life well-lived is measured lacks a spiritual component. While Rabbi Aurbach recognizes that some physical conditions may be more undesirable than death, this is only so if the one suffering the pain finds no meaning in it. He encourages a third party to convince the suffering patient that their pain needs not necessarily lead to suffering. Again from my article:

Why empower friends and family to encourage the patient to persevere? Because it may require a third party’s encouragement to provide inspiration and free such suffering patients from their emotional prison, giving them confidence in the value and integrity of their painful experiences. Nevertheless, if the suffering individual cannot find solace and meaning, the individual retains the right to refuse life prolongation, as continued life has no value or merit if the person cannot find redemption in the painful experience. This concept is poignantly illustrated by a story in the beginning of the first tractate of the Talmud (Berachot 5B): “Rabbi Chiya bar Abba fell ill and Rabbi Yochanon went to visit him. When Rabbi Chiya bar Abba stated that he did not welcome his suffering, Rabbi Yochanon said to him: “Give me your hand” and he healed him. Rabbi Yochanon once fell ill and Rabbi Chanina went in to visit him. When Rabbi Yochanon stated that he did not welcome his suffering, Rabbi Chanina said to him: Give me your hand. He gave him his hand and he healed him. Why could Rabbi Yochanon not cure himself? They replied: The prisoner cannot free himself from [his own] prison (that is, a patient cannot cure himself)!” Thus, suffering terminally ill patients are granted the autonomy to decline life-prolonging therapy while they are simultaneously being encouraged to accept that living in pain is preferable to death.

While most of the Talmudic sources and modern responsa deal with ill patients, the concept applies equally to those who are healthy but have lost touch with the meaning of their lives. The Jewish response to Dr. Emanuel is to recognize the validity of his clinical observations, but also recognize that his conclusions are not valid when the true meaning of life is viewed through the lens of Torah. We all wish for a “good life.” The challenge is to recognize what a “good life” looks like.

[1] New England Journal of Medicine, 382:21, nejm.org May 21, 2020

[2] JAMA. 2020;324(16):1601-1602. doi:10.1001/jama.2020.18513

[3]Why I Hope to Die at 75, The Atlantic, October 2014.

[4]Dr. Emanuel writes, “I have actively opposed legalizing euthanasia and physician-assisted suicide. People who want to die in one of these ways tend to suffer not from unremitting pain but from depression, hopelessness, and fear of losing their dignity and control.” 

Nevertheless, there have been prominent scientists proposing strictly utilitarian approaches to medical ethics. Dr. Fred Rosner and Rabbi J. David Bleich in Jewish Bioethics (pp. 268-269) highlight two Nobel laureates, Dr. James Watson and Dr. Francis Crick, co-discoverers of the double helix structure of DNA, who independently proposed utilitarian ethical resolutions for challenges at the beginning and end of life, respectively:

“Babies born with severe congenital abnormalities or suffering from serious mental retardation are bound to be a burden to their parents, their siblings and society. What can be done? …. Let us redefine birth. Birth shall no longer be regarded as taking place at the moment of parturition but occurring seventy hours after emergence of the infant from the birth canal. Since the baby is not yet born, in the event it is found to be physically or mentally defective it could be destroyed with impunity up to the moment of ‘birth.’ This proposal was made in all earnestness by Dr. James Watson.”

Looking at ethical dilemmas at the end of life, Dr. Rosner and Rabbi Bleich write,

“Who is to decide at which stage of physical or mental deterioration life is no longer worthwhile? … It is entirely conceivable that eventually the concept of death will be broadened to include a person who consumes more of society’s resources than he produces… England’s eminent biologist and Nobel Prize laureate, Dr. Francis Crick, has already advanced beyond this point in advocating compulsory death for all at the age of eighty as part of a ‘new ethical system based on modern science.’”

[5]See my article, “Maintaining Compassion for the Suffering Terminal Patient While Preserving Life an Orthodox Jewish approach,” in Perspectives in Biology and Medicine, volume 60, number 2 (spring 2017): 233–246:

Judaism approaches health from the perspective that humans function merely as stewards of their bodies, with true ownership rights retained by G-d (Benjamin Freedman 1999). Like curators assigned the task of protecting delicate buildings, individuals are charged with guarding their bodies from preventable decay, destruction, and other imminent threats to their future, while mandated to use their bodies in a constructive way. This mandate obligates individuals to guard both their bodies and their lives by utilizing a “prudent man” standard. While difficult, it is necessary to find a balance between being overly cautious and being reckless.

[6]Nevertheless, Rabbi Feinstein is careful to emphasize that it is absolutely forbidden to do anything or to provide any drug that will shorten the patient’s life for even a moment.

[7]ArtScroll Translation. For a discussion of deciding to end life, see Rabbi Alfred Cohen, “Living With Pain Whose Body?” Journal of Halacha & Contemporary Society, Fall 1996. The Mesivta edition of the Talmud asks, if leaving Luz led to immediate death, the elderly would not be permitted to leave since suicide is forbidden. The Mesivta offers two answers from Achronim: 1) Leaving Luz meant re-entering teva/the natural world where illness and death exist and the elderly would then get sick and die like anyone else. 2) Leaving Luz is comparable to the Rema’s ruling (Shulchan Aruch, Yoreh Deah 339:1) where it is permissible to merely remove “an obstacle to death,” like stopping a nearby woodcutter’s chopping that somehow keeps a person alive. But either way, Luz is a supernatural place (where inhabitants lived for hundreds of years, if not “forever”) and is not illustrative of “normal” healthy people.

[8] I discuss the issues presented in this essay at length in the article in entitled “Maintaining Compassion for the Suffering Terminal Patient While Preserving Life an Orthodox Jewish approach,” in Perspectives in Biology and Medicine, volume 60, number 2 (spring 2017): 233–246. The article can be accessed on my website at              https://www.jewishmedicalethics.com/uploads/4/6/4/0/46409757/maintaining_compassion_for_suffering_upload.pdf

[9] Biblical figures include Moses, Elijah, and Jonah (Exodus 32:32, Numbers 11:14–15, Kings I 19:4, and Jonah 4:1–9). Talmudic figures include Rabbi Yehuda Ha’Nasi (Kesubos 104A), Rabbi Yochanan and Choni Ha’Magel (Ta’anis 23A). These cases are discussed in greater detail in the article referenced above.

Daniel Eisenberg, MD, is a Jewish Medical Ethicist, who serves as a radiologist at Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine.

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