Why I Think Dr. Ezekiel Emanuel Is Wrong About Aging

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Jimmie C. Holland, MD

I have a deep sense of gratitude to have lived so long and in such good health, and I feel that life has been good and still is. It is with that sense of gratitude and knowledge that I hope when Dr. Emanuel reaches the age of 75, he changes his position and raises his limit. I think he will find the reality of older age is not what he fears.

—Jimmie C. Holland, MD

The image of aging that Ezekiel Emanuel, MD, PhD, expresses in his essay, “Why I Hope to Die at 75,” in the October issue of The Atlantic,1 is bleak indeed and one that has contributed mightily to the negative views of aging imbedded in our society. But I refute his description of growing older as years spent in declining physical and mental health with no redeeming value. At the age of 86, I have been treating older patients with cancer for over 35 years at Memorial Sloan Kettering Cancer Center, helping them cope with the challenges of having a serious disease, and have witnessed firsthand the important contributions they continue to make to their families, loved ones, and society.

Virtues, Character Strengths, and Aging

Besides my clinical experience, there is also much social science research confirming that while, no doubt, there are challenges to face as we age, they are not as bad as you think. In our book, Lighter As We Go: Virtues, Character Strengths, and Aging,2 my coauthor, Mindy Greenstein, PhD, and I cite large population-based studies by economists and psychologists asking adults between the ages of 18 and 88, and from different countries, to rate their sense of well-being on a scale of 0 to 10. [Editor’s note: See “A New Book Explores an Old Subject: Aging,” in the September 1, 2014, issue of The ASCO Post.] When they looked at the data by age, the researchers found that the pattern of well-being throughout the lifespan resembles a “U” shape.

These “U-Bend” studies show that the older we get, the greater our sense of well-being becomes. For example, although self-reported well-being starts relatively high for people in their early 20s, it starts to decline in the 30s and 40s, and reaches the bottom of the U curve in the 50s. However, rather than continuing to go down, well-being begins going up in the 60s and continues upward into the 80s.

If Dr. Emanuel looked more closely at older age, rather than dreading it, he might find that along with the negatives, there are many positives to look forward to. The physical limitations he cites (decreased ability to walk a quarter of a mile, climb 10 stairs, or stand without special equipment) present only a part of the picture. As we age, we are better able to appreciate the gift of life itself and the wisdom gained over many years—and to use that knowledge to maintain our quality of life.

Keepers of Meaning

While Dr. Emanuel acknowledges the importance of mentorship, a vital role that the elderly can and do play, he devalues it nonetheless as a “constriction of our ambitions and expectations.” Maybe our professional ambitions don’t constrict with age, as Dr. Emanuel fears, but instead evolve into new—and more selfless—ambitions. Mentoring younger colleagues is at least as important as producing papers or making rounds with residents, and makes just as much of a contribution to medicine and the care of patients.

As you get older, you begin to realize how you have incorporated into your life the values you have taken from your parents and the lessons you have learned from mentors. At this stage of life, you are what George Vaillant, MD [Professor of Psychiatry at Harvard Medical School and the Department of Psychiatry at Brigham and Women’s Hospital], refers to as a “keeper of meaning,” with the all-important job of passing these values on to the next generation. No one can do that except the people who have experienced those values and lessons, so I think the elders become particular experts at what is important from the past to carry on into the future.

Living in the Present

As we age we are also better able to be flexible in our thinking, to compromise, and to navigate social conflict, all of which were found in research to be highest in people in the 60-to-90 age range. It was no accident that Nelson Mandela, after spending his youth as the leader of the African National Congress’s armed wing and being imprisoned for 27 years, was able in his 70s to bring about unity in post-apartheid South Africa. But personal growth in older age is not limited to the extraordinary people of the world. Character development happens to the rest of us, too. We all have to deal with the vagaries of life—illness, betrayal, crises of faith—and we all mature over time.

This interaction of continuity and development over the years is vital to our sense of ourselves as whole human beings who lead meaningful lives. As one member in our Aging and Illness group at Memorial Sloan Kettering told us, “I came out of my shell at 70.”

Laura Carstensen, PhD [Founding Director of the Stanford Center on Longevity], suggests that as we age and have a lot less time ahead of us than behind us, we learn to live in the present moment, focus on the bigger picture, and better prioritize and appreciate our lives and our relationships with other people. As a result, we gather and develop our character strengths through years of coping with life’s negatives and appreciating life’s positives, learning to enjoy the good parts and making the best of the bad ones.

Quality vs Quantity of Life

One thing many of us do agree with Dr. Emanuel about is the importance of not trading quality of life for quantity. He is exactly right to question the assumptions of the “American immortals” he describes and their “manic desperation to endlessly extend life.” The notion that additional years are always better can lead to destructive ­expectations.

We know that medical care at any age can be a tradeoff between longer life and better life, and it is reasonable to think about when we should be willing to make that trade and when we should not. That decision is very individual and depends on each person’s goals. That is why empathic end-of-life counseling can sometimes vastly improve our quality of life, and why we should do more to help incorporate it into medical care. But many factors should go into these decisions, age being only one of them.

In our support group, many members are very comfortable with their own mortality and enjoy the experience of living in the now that results from it. The relative closeness of death allows us—more easily than when we were younger—to enjoy the simple pleasures of each day. There are many ways to enjoy a continued quality of life and many ways to contribute to it, no matter what our age.

Meaningful Life at Every Age

Like Dr. Emanuel’s children, I hope he lives—and lives well—long past the age of 75. He will become wiser as he ages and we need that kind of wisdom, which as Cicero once noted, helps counter some of the hot-blooded decisions of the young.

I don’t want to sound like a Pollyanna and say that everything about aging is wonderful, but it is not as bad as people think, and that’s important to remember. Each stage of life has meaning and can be satisfying.

I have a deep sense of gratitude to have lived so long and in such good health, and I feel that life has been good and still is. It is with that sense of gratitude and knowledge that I hope when Dr. Emanuel reaches the age of 75, he changes his position and raises his limit. I think he will find the reality of older age is not what he fears. ■

Disclosure: Dr. Holland reported no potential conflicts of interest.


1. Emanuel EJ: Why I hope to die at 75. Atlantic, October 2014. Available at Accessed October 28, 2014.

2. Greenstein M, Holland J: Lighter as We Go: Virtues, Character Strengths, and Aging. New York, Oxford University Press, 2014.

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