Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt ‐ Wow, you guys are such a great audience. I wish all my freshman seminars acted the same way. Thank you for being here tonight for a very special occasion. This is an opportunity to celebrate the Department of Philosophy and the impact that an alumni can have on the department. Now many of you know that CSU has a distinctive tradition in philosophy in terms of the breadth of the areas of our faculty study and also having pioneered areas such as environmental and animal ethics. Today we're brought together by one of the more distinguished alumni of the Philosophy Department, Bruce Bodaken. Bruce has recently retired as president and chairman and CEO of the health insurance non‐profit Blue Shield of California. His long and successful career was groundbreaking in many ways, especially for his advocacy for universal healthcare in California, more than eight years before President Obama signed the Affordable Care Act. Through Bruce's generous support, the faculty in the Department of Philosophy have established the Bodaken Philosophy Symposium. Following tonight's inaugural event, the department plans to bring an annual series of lectures and workshops to the department. These will provide educational opportunities for both undergraduate and graduate students. As it becomes an annual event, the symposium will enhance the visibility of philosophy on the CSU campus and strengthen the reputation of the department and its faculty both nationally and internationally. So tonight I want to thank the faculty and the Department of Philosophy, especially Moty Goren, Ken Shockley and Phil Kafaro, who have been on the committee that has organized this and John Ditea, the chair of the department. I'd like to thank Mike LaPlante, who's the Associate Vice‐President for Development who helped us connect with Bruce and also the CLA development team and communications teams led by Tanya Mallick‐Carson and Beth Edder. Most of all, thanks Bruce. Alumni like Bruce are very, very special. He has said to me on many occasions that his training and philosophy was central to his successful career, that his background in philosophy distinguished him from his peers with business degrees and uniquely prepared him to be a leader and an innovator and now he is giving back to ensure that future generations have a similar opportunity to explore ideas and develop the skills that will help them in their future lives and careers as well. Please join me in welcoming Bruce Bodaken.

‐ Well, thank you very much. Welcome to everyone. You're in for a treat. I couldn't be happier that we're starting the lecture series here and the ongoing series and workshops I very much hope will expand both the reputation and the nature of the direction of the philosophy faculty. Philosophy here, as was said, changed my life. And it went on, even though I didn't know I was gonna have a business career, I ended up doing that and it was incredibly beneficial to have learned both social and political philosophy, but certainly ethics and an understanding of humane leadership. So I credit that to a very good extent to Colorado State University's philosophy department, many, many years ago. With that I also couldn't be more pleased to introduce our speaker. Dr. Ezekiel J. Emanuel is the Vice Provost for Global Initiatives, the Diane S. Levy and Robert M. Levy University Professor and Chair of the Department of Medical Ethics and Healthy policy at the University of Pennsylvania. That's a mouthful, see. I won't read the many accomplishments and publications. I will mention one thing I looked up in Wikipedia or I was told this, that Zeke is the most cited bioethicist in the nation, I'm sorry, in the world, which tells you how much he's published and how much he's regarded. I will just say Page 1 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt this that during his days in the administration as health policy advisor to the White House in both crafting and then promoting its passage through congress, the Affordable Care Act. I was at Blue Shield at that time and as was mentioned we took universal healthcare very seriously and I got the distinct pleasure of both meeting Zeke and working a bit with him in that process. There was no one brighter, more practical or more impactful in both the creation and the passage of that bill. I thank Zeke for that and I know count him as friend and I can't be more pleased you're kicking off this series. Thanks, Zeke.

‐ Sorry. Well, it's a great honor to be here and I want to thank you all for showing up and I want to thank Bruce for endowing this lectureship and having me come and give the inaugural lectureship. It really is a tremendous honor to be here. This is my first time in Fort Collins and it seems like an amazing place and as the philosophy faculty will tell you already, I've been trying to angle to figure out how I can come back and do some hiking. I don't have that many years to go, so it's really urgent. So, yes, 75. Uh‐oh. Hold on. Okay, now far from here I came up with the idea of talking about the American immortal. You guys in Colorado know something about this. These are the people who think they're never gonna die, who are outside all the time, who are trying the latest gamish to try to live longer, whether it's some pill or some other crazy idea. I happen to be related to one of those people, but I think there's a very high concentration in a few cities in Colorado of these people and I happen to meet them on occasion. But there is a version of the American immortal who really doesn't want to die and will do almost anything not to die. Now, the life expectancy in the United States has increased dramatically. At the turn of the 20th century, that is in 1900, it was about 49 years. It then rapidly increased and you can see here in 1960, it was 70 years and we're now up at 79 years. You probably also will note that it's kind of plateauing here. We've actually had some pretty bad data recently about that. We are nowhere near the maximum country, that's Japan, at 84 plus years. Now, a lot of people who released these data, the sort of life expectancy in the United States, every year the CDC releases what it is and it's usually followed by some big articles, as if this were somehow an important number. I think this is a terrible number to keep track of and I may come back at the end and explain what I think is a better number. But I do think that when we're gonna discuss longevity, life expectancy, immortality, we really have to ask ourselves the following question. Is it quantity of life or is it quality of life? So, we can start now. I want everyone who believes it's quantity of life to raise their hand. Don't be embarrassed. You came to this because you don't agree with me, so you want to see what I have to say. Okay, raise your hands if you think it's quality of life. All right, I've won the discussion as they say. We're now just quibbling about the date. And that's a very important point. By the way, if I had called the article why I want to die at 85, no one would have read it. Let's just be clear. And by the way, for those of you who don't know anything about publishing articles and journals like the Atlantic, the author never chooses the title and I did not choose that title. The editor chooses the title and there's some email back and forth with a few expletives I can't mention here about that title. But there are people who actually do believe in the quantity of life, even if they're not in this auditorium. Probably the most infamous of which is Aubrey DeGray, British biomedical researcher. He claims that Page 2 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt the first person whose ever gonna live to 150 has already been born and that the first person who lives to a thousand will be born in the next 20 years. Now, you know, whether you believe him or not, there are many people who interestingly don't happen to be located in Colorado, but there are concentrated in a particular place where there's a company funded by Google called Calico, which is looking into longevity. There's the Longevity Institute. There's the Buck Institute. And they're all trying to research how to live forever. I think 1000 years is pretty close to forever for us mere mortals. And so there are those people and let's be honest, you know, these are the books that are on the bestseller list in the United States at any one time American Mortal, right, they're pushing for regenerative medicine, anything, and you can sell How to Live to 100. When I proposed to my publisher, my agent, maybe I ought to do a book out of my article, they say Americans don't read that book, they want to live to 100. You can't sell a book Why I Want to Live to 75 and that's it. Says a lot about the United States, right. A hundred, a hundred's no longer good enough, a hundred and ten, you know, you just to keep going up, right. That is people in this country who want quantity. There's a recent, I'll tell you, can I call him out? I'll call him out, there's a recent exchange, my brother organizes this sort of text email exchange with people he knows, this is my famous Hollywood brother and there was something in the news about living to 75 and I said yeah, that's what I want to do and Robert Craft, who owns the New England Patriots said I want to live to 120. Classic, that's just classic of this attitude. So what's the rationale for wanting to live and worrying about quantity of life? Well, there is this view called the deprivation theory, which opposes Epicurus. This deprivation theory was originally developed by a philosopher who was at Princeton, is now at NYU, very famous, one of the giants actually of philosophy, Thomas Nagel, and he wanted to try to think of the argument why actually is that bad? It turns out to be harder than you would think. And it's harder than you would think because of Epicurus. So he put it this way. Death is nothing to us, seeing that, when we are, death has not come. And when death is come, we are not. It's nothing. For with the living, it's not and the dead no longer exist. The wise man does not deprecate life nor does us he fear the cessation of life. So his basic argument is look, when you're alive, you're not dead, so why worry about being dead and when you're dead you're not alive and you can't worry about it anyway. So what's so bad about being dead. Turns out it's not so easy to answer that question. Go back and think about why it's bad to be dead or why death is bad. He's not talking about the process of dying, he's talking about the being dead. You might think about that conundrum tonight. Well, Thomas Nagel tried to answer that question because he thought death is bad, right? And he thinks death is bad for those people who die, not for the relatives, not during the process, but actually being dead. He said by living a shorter life, a person will inevitably miss out and therefore be deprived of valuable life experiences. Death is bad in what philosophers call a counterfactual way. It's not bad in itself. It's bad because we can imagine a life in which we have all these other experiences and we're being deprived of other experiences. That's why we often think death is bad for an 80‐year‐old, but it's worse for a 40‐year‐old because a 40‐year‐old is missing 40 years of those experiences by being dead. So the best theory of why death is bad is a counterfactual theory and if you think death is bad in this way because there's experiences, there really are an unlimited number of experiences we could have and therefore living to 1000 is Page 3 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt better than living to 80 or 100 or 120. The more life you have, the better it has to be because there are more experiences you will have. So thus death is bad compared to having the life and experiences one would have had we been alive. Well, what kind of life might we actually have had had we not died? Well, soon after I published my article in the Atlantic, very soon, like three or four weeks afterwards, someone ran this ad. Two people, maybe about 75, but the tagline says when the view goes on forever, I feel like I can, too. Go long. Right? They could be in Colorado, right, hiking. Now notice down at the bottom, it says look ahead to your future. Consider a Medicare supplemental health insurance plan. I won't tell you that that ad's paid for my AARP. All right, but this is the alternative to my view, which is look, the view goes on forever, life can go on forever. There's always more experiences. We can go hiking in the mountains. Remember to invite me back, I want to go hiking in the mountains, right. And about a month or six weeks, I think it was about six weeks after I published the article, the New York Times ran this. Maybe it was coincidence, searching for the fountain of youth. So they went to various old people's retirement communities in Arizona. And you get this. Snorkeling. You get this, I don't know what that is, but it's supposed to look like vital, and you get this, you know, a 90‐year‐old on a very powerful motorbike. I want you to keep this in mind, because when people talk about the fountain of youth, they talk about living forever, this is what they really have in mind and I want you to keep this in mind because I'm gonna argue this is not what we want. So proponents believe that living longer simply means living additional years of healthy life, living longer will add more years, somehow people think in their 20s and 30s and 40s and they'll go on then. That view, that when you add more life, you're actually adding more, I got a little feedback. I'm sorry, can we turn the mike on the podium off? Okay, great. So there was a theory developed in the early 1980s by one James F. Fries called the compression of morbidity theory. And the idea was that as we live longer, we're gonna live healthier and healthier and life's gonna be more like the rectangularization of life. You live the same healthy life and then you just fall off a cliff. Where do you think this theory came from? Stanford, you're right. The idea is that we're gonna develop disabilities later, later, later. Literally, just minutes before we die, sort of, that's it and you can do everything and this was a very credible academic theory developed out of Stanford and initially tested on Penn alumni in the early 1980s and they said yes, the longer Penn alumni live, the healthier they're getting. And you get this to sort of bolster this view. This is obviously out of the New York Times, again a few years after my article, growing older, getting happier and it says that researchers contacted 1546 people age 21 to 99, via random telephone calls and found that the older age was not surprisingly tied to declines, was not surprisingly declined and tied to declines in physical and cognitive functioning, but it was also associated with higher levels of overall satisfaction. In point of fact, right, if you look at happiness curves, they all look like this, all right, which is, you know, young people, they're really happy and then something happens and it sort of drops. And then something else happens and they go back up such that in the 80s, they're the happiest decade. Now how do you explain this? There's a real simple explanation. It's called children. You know, you're dating, love life is great, then the children come out. It goes down to the bottom. Children leave the house, happiness goes back up. You're laughing, this is absolutely true. The idea of the empty nest Page 4 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt syndrome where people are sad because they're kids have left is total bunk. This is what the happiness curves look like and as a result, if you call people up, you find out that 80 plus is the happiest time of life. Really? What's missing from this picture? If you're a person like me who does a lot of surveys, you have to ask yourself was that selection bias? Did we take an unrepresentative sample. Did AARP somehow, you know, hoodwink us by this picture? Right. So what is missing from that picture of Colorado? Maybe this. Oh, yes when we think of living a long time, we don't think of this, interesting. And when you by the way call up older people, you think you get these people to answer the phone? Selection bias, right. That happiness curve is probably bunk, too. So, there are approximately 46 million Americans over 65, this number projected to grow by double to 98 million by 2060, right. And today we have a million people in assisted living homes, we have 1.7 million in nursing homes. We have 3.6 million who are bound to their homes and can't get out and can't participate in social activities, right. All of this stuff, you know of life's in front of us, we can go on motor scooters, we can go snorkeling, right, we can hike in the Colorado Rockies. Really? Well, let's talk about the true nature of old age for a second and think about what it's like. There are physical disabilities, mental disabilities, dementia, expansion of morbidity, not the compression of morbidity and a decrease in our creativity. I'm just gonna review the literature for you in a totally objective and unbiased way. You don't believe me? Well, 60.5% of adult Americans 65 and over have one basic action difficulty or complex activity limitation. These are things like walking up 10 stairs, walking a quarter mile without shortness of breath. 10.6 percent adults 75 and over need help with personal care, bathing, feeding, going to the bathroom. That's just physical disabilities. We'll talk about a little bit more when we get to the expansion of morbidity, not the compression of morbidity. I also like to say that there's a whole slew of mental disabilities that are natural, normal and I like to say no one gets smarter by getting very old, over 75. I know that's a hard truth, but it's actually true. People's cognitive function declines with age, albeit it at different rates. We don't all decline at the same rate, but we know of normal brain aging, which means that the cognitive power we all have actually declines as we grow older. Certain things do improve with age, very few, but there are certain things such as crystallized intelligence, skills and knowledge that are over learned that we do every day, like our vocabulary tends to stay the same, although many of us have word forgetfulness or if you're men, you particularly have a problem of, it's called anomia, I can't remember her name, right. That's why you go out with your wife so you can always remember the names. It's true women have less anomia than men, but in general, this crystallized knowledge of things which we over learn, we retain, which is why people, even when they have Alzheimer's can remember things from way back when because they've over learned the stuff from five years old. But most cognitive skills have actually decline as we grow older. I know this is painful, believe me, it's painful to me. Right, our fluid knowledge, our problem solving and reasoning, that slows down. Our executive function being able to plan, our ability to process information quickly. I don't know about you, but as a young kid, I used to have this ability. Now we all know that multitasking is garbage, right, there's no such thing as multitasking. If you multitask, what you're doing is focusing on one thing, quickly switching to another and then quickly switching back. And as a kid, I used to be fantastic at that. I could read Page 5 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt an article and have a conversation at the same time and I was really, really good at it. It turns out as I got older, I'm like really crappy. I can either read or have a conversation, but I cannot do both at the same time. And I find myself focusing only on the email or focusing on the conversation, but I cannot jump back and forth. That's brain processing speed just slowing down as you age. Attention span. Most of us older folks cannot focus and keep on task as long as people in their 20s and 30s. And a bunch of other things decline. Memory, acquisition declines across the life span, our ability to remember things just goes down. That's why we can learn new languages at four, five and six, but not at 60 and 70. Episodic memory, memory for personally experienced events, the details of those events gets worse as we age. Working memory, this is probably the most important of all of it, that buffer that we have in our brain, hold information while we're manipulating that information to solve problems for example, goes way down as we age and that's why older people tend to be less good at problem solving than younger people. So this is just a conclusion quote from one of the articles looking at all this data, so it's processing speed refers to the speed with which cognitive activities are performed. This fluid ability begins to decline in the third decade of life and continues to decline throughout the lifespan. Many of the cognitive changes reported in healthy, older adults are the result of slower processing speeds. That's what normal aging looks like. Now we don't all age at exactly the same rate, some of us can retain more than others for a longer period of time, but it happens to all of us. Now how does this mental decline happen? Well, it's a result of a decrease in the number of brain cells we have. They begin dying at 20 and continue. Neuron size and the number of connections between neurons goes down, so we have smaller neurons and the connection between the neurons goes down. Those neurons which we've over learned with, those connections stay because they're just more of them. White matter, that's what surrounds neurons goes down and plasticity, that's the ability of the brain once you have an injury to rewire itself. That continues, we all still have that ability, but it actually becomes less powerful, the plasticity, the ability to rewire the brain goes down. It doesn't disappear, so all of us still have some ability. If you lose sight in one eye, you can adapt with the other, but it goes way down. So there's no doubt that our cognitive processing, our ability to manipulate information declines as we age. And then this is, I think, there are a lot of scary graphs in life and I often say this in my view the scariest graph. I do think it's the scariest. This is a study of prevalence of dementia published in the British Medical Journal and you can see all kinds of dementia, but this Alzheimer's disease, basically nothing, nothing, nothing, there are a few cases of, you know, early dementia, premature dementia, but then 75 and whoop going up to 30, 35% by 85. To some studies it's 50% of the population by 85 have dementia. You go to Japan and you talk to their gerontologist, because Japan has the largest proportion of the population that is 100 years old of any country. There are as many 100 year olds in Japan as there are in the United States, even though we're almost three times the size of Japan. You ask them every 100 year old is demented. Wow. That's what they're physicians who care for this population. If you look at what the data suggests, this is the trajectory we're on for Alzheimer's disease. And, you know, this is not burden free and probably most of you there are more than 15 million Americans who provide unpaid care for people with Alzheimer's disease. Basically three times the number of people with Alzheimer's disease get Page 6 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt unpaid care in the United States and it totals 18 billion hours in the United States alone for care. And then there's that compression of morbidity. Remember the idea that the longer we live, the healthier we would live. And disabilities would come later, later, later, such that we would really outrun the disabilities and they'd only happen at the end of life, this rectangularization of life. Well, this is the latest data on the so‐called rectangularization of life and if you look here at women, right, this is 1996, right, but this is what you end up with. It's moving in, more people with more disabilities. What are these disabilities? Ability to walk a quarter of a mile as I mentioned. Go up 10 stairs, do, I think it's 15 pushups. Finally, there's what I call the age related loss of creativity. Now, I have been accused of being an elitist, and I won't deny it. But, the point of this is not to look at the famous and those who contribute. The point is we can easily assess creativity in those who have published literature and other things, right. It's harder to assess in other people, but there's no reason to think the creative class is different in terms of its decline. So let me just begin with my assertion. It's hard to name anyone in history who's made great contributions after age 75. Work on it. There was a book in the 50s published that went through all the famous people in history and looked at them and what age they stopped declining in participation. I have found four very incontrovertible examples. Goethe wrote Goethe‐Faust Part II, he was 82. Franklin's autobiography he wrote after he was 80. Verdi, who we're gonna get to in a second composed some operas after he was 80. Michelangelo continued to carve and just today, someone who is trying to disprove and throw egg on my face noted to me that Sophocles wrote Oedipus at Colona when he was 82 years old. And I said I thought that proved my case. Very few people right after 75. If we can name them on one hand, even if we could name a hundred times this number all across all of history, it proves my point. It's pretty rare. Go back home, think about it, right. I get a lot of people who call me up or email me who know me, Galileo, two new sciences. He was 73. This is Verdi. So be it, so let's do Falstaff. He was reading Shakespeare, he loved the Shakespeare plays. He said lets do Falstaff for now, let's not think of obstacles of age, of illnesses. What joy to be able to say to the public, here we are again, come and see us. Falstaff, his great opera was first performed in 1893 when Verdi was 80 years old. It's a great example, but it's pretty singular. Find me another. So the list is very, very limited and a limited list suggests contributions after 75 are super rare across all of history. You may come up with a few names. Come up with a few names. Doesn't disprove my point, which is creativity, productivity doesn't happen. Actually if you review all the contributions in science, math, literature, music, where we can actually well document when people were doing things, it turns out that I'm right. So, little question for you Trivial Pursuit experts, what has been the oldest age of a Nobel Prize recipient? Anyone, anyone? And in what field, now we're getting hard. 90 years old, Leonid Hurwicz received the Nobel Prize in economic science in 2007 at age 90. Disproves Zeke, but the real question is what age did he actually complete the work for which he got the Nobel Prize at 90? Sorry, it was 43. So, when do writers produce their greatest works of fiction and non‐fiction, poetry? Turns out 42.6 years of age. On average, poets a little earlier, prose writers a little later. Remember this number. When do classical composers produce their greatest works? Age 40. And for those of you who remember by the time Mozart was age 40, he was dead five years. Right, 646 compositions or Page 7 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt 626 compositions, right. This idea that 40, 42, 43 is the age turns out not to be just happenstance. It's also why, is the provost here, why universities tenure people round about 42, 43, right. I bet your average age of tenure here is about 43. Turns out there is a very consistent curve on creativity. It's true for the sciences, it's true for math, it's true for literature, it's true for music, it's true for art, it's true all across. If you look at age 20, someone typically starts their graduate work somewhere around here. They get productivity, annual productivity. You can measure it in papers, you can measure it in books, you can measure it in other outlets. And it goes up and peaks right around 40, 42, 43. There are slight variation in fields, not very much and then it drops down, right, on the back end and basically stops, not after 75, just doesn't happen. And this is very, very consistent. Now obviously there's noise all across here, right. Some people are gonna be creative down here. Just not a lot of them, right. Of course these relationships are statistical averages across a population, right. There are gonna be outliers. I've heard of lot of Aunt Millies, lots of them, fully competent at 95. I doubt it, but the fact is, of course there are gonna be outliers. Some people are gonna be active and creative into their 80s. For many years, I had a collaborator, one of the giants in health economics, actually one of the three original health economists, a man named Victor Fuchs, who's at Stanford. He's still alive, he turned 94, I'm gonna see him next month, he's still publishing papers. Every so often a paper comes out in JAMA, right. He's an outlier. And so, you know, it's possible, but it's pretty, pretty rare. There will be some people who will be outliers. By definition, outliers are rare. Those statistical things hold for most of us and most of us can be expected to live in that statistical thing and few of us are gonna be outliers. Now, when you think of creativity, why is it that creativity stops at some point, call it 70, 75? Just think about how the brain is wired. You know, inside your head is a basically survival of the fittest. All right, that's how neurons work. The more you fire a neuron, the more connections it makes, right, and the stronger it becomes and the less you fire some neurons, the weaker they become, they die off, those connections disappear. So by the time you get to 70, you've worn certain paths. Certain neurons are connected. And we don't rewire, we work on some similar things for a long period of time. We've worn that path. Hard to be creative once that path is well established, you've set everything, you're gonna stay in that path. Now again, there are some people, Ben Franklin is a great example. If you read his autobiography or his biographies, that guy is just amazing. He dabbled in health, he dabbled in stoves, he dabbled in electricity, he dabbled in politics, he dabbled in publishing. The guy was very broad, right. He made lots of connections which is, I'm sure why he was able to remain creative into his 80s. Most of us aren't like that. We wear a path, we establish very firm connections and that's it. So the true nature of old age, we have more physical disabilities, mental disabilities as natural aging. There's dementia after 75, expansion of morbidity, not contraction and a decrease in creativity. Giving this true nature of aging, how do we want to live? Well, all of you said it's quality of life. So I want to think about quality of life with you and that's what the rest of this lecture is gonna be about. You might not agree with me about 75, but I want to suggest it's a good number to keep in your head. So let me begin by saying that the true aim of life is not happiness in the usual hedonistic sense. Most of us when we talk about happiness, think about, you know, Page 8 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt drinking Pina Coladas on a beach with waves slapping at our feet. The true aim of life is happiness, but in the Aristotelian sense, after all, I'm here as part of the philosophy department. And I would say that more accurately the true aim of life is meaningfulness. We want to make a meaningful contribution in our life. That's what really is gonna give us happiness and Aristotle said by the way happiness you can be sure about whether you have lived a happy life only at the end, at 75. But I would ask you what makes life meaningful for you. We shouldn't care about happiness, what counts is meaningfulness and I would argue that a life dominated by play, even if it's a happy life, is not a meaningful life. So I'm gonna give you my little circle on the meaning of life. There are three things in life that make it meaningful. There's meaningful work, meaningful relationships, and play. And by play, I mean a broad list of avocational interests, religious interests, community interests and other things. What I'm gonna argue is that play is very important, very important, but only in conjunction with meaningful work and meaningful relationships. When play comes to dominate too much of life, it's not meaningful anymore. So I think if you look at those three things, meaningful work, meaningful relationships and play, there's a certain temporal tone to them. So if you take meaningful work, right, goes up, we work for a while and then it goes down, we retire. Not many of us do meaningful work after 75, after 70, right. If you think of relationships, right, goes down because you have kids, then goes back up, right. Then it goes down again when your friends and other people begin to pass on. But remember, both meaningful work and meaningful relationships require intact cognitive functioning. Very hard to have meaningful relationships if you don't have in depth cognitive functioning. Similarly, you can't have meaningful work without it. And then there's play, right. Probably goes down, kids up and up and up and it comes to dominate your life as meaningful work and meaningful relationships become less and less a focus. So as we age, meaningful work declines. Meaningful relationships become more important and play becomes more important. Meaningful work and relationships require intact cognitive function as I just said. As we age, meaningful work and relationships become harder to maintain, just because our cognitive function is harder to maintain. Play naturally comes to occupy more and more of our time. At best play is key when combined with work and relationships. Almost all of us know people who spend too much time at play and they really have a vacuous life. When play is what life's all about. So I think about the meaning of life in this sort of temporal sequence. When we're young, there are vast open expanses. There are a immeasurable opportunities, there are all sorts of possibilities. As we age, things get narrow. We tend to till our own garden, focus in a smaller realm. Our jobs, our relationships with our family, and then you know as we age a little further, work stops becoming important. It's constrained. We spend a lot more time in front of the television, we do more limited things inside the house. And then ultimately it's dominated by crossword puzzles. I hate crossword puzzles. Crossword puzzles are the height of meaninglessness. They contribute nothing. They're self‐contained, no one's better off for someone having completed a crossword puzzle or not. Part of that little photographic montage is to emphasize that we adapt and we accommodate to our declining cognitive and physical abilities. We begin to limit. We do less, we do less complex activities, we focus on ever simpler activities. We redefine our goals in life to be more and more and more constrained. From the big open expanse to our garden, to our television set to Page 9 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt the crossword puzzle. And remember, this picture, searching for the fountain of youth. What are these pictures of? They're purely pictures of play. They're not pictures of anything meaningful. Yes, someone can be vigorous at 80 and do whatever this is. It's meaningless, literally meaningless. So as we age, we stop writing books and articles, that's the elitist in me. We stop speaking and organizing. We stop creating new furniture or clay figures or reconditioned motor scooters or whatever we're actually doing. We stop being active growers and creators of life. We get confined to more limited geography, some people can't even travel. My friend Victor Fuchs is home bound in California and as he likes to tell me as a little joke, my psychiatrist told me it's all in my body. That's right. So as we age, we end up watching TV, we read books, we listen to music, content ourselves with doing more crossword puzzles. We really become passive observers and bystanders of life, not active. As we age, we become consumers rather than producers, bystanders rather than actors. And I would suggest to you that part of the reason all of you raised your hand that it's about quality of life, I would want to urge you to think is it about consuming life or is it about producing and creating and acting and being active and being in life, not watching it. So living longer doesn't mean getting another decade in your 30s, it means getting another decade in your 80s and 90s with cognitive decline, physical decline, dementia at risk. Do you want another decade as a consumer, observer, bystander doing smaller and smaller things, contenting yourself because you've learned to adapt and accommodate to doing ever less in an ever more constrained environment. Do you want to live more years just to do more crossword puzzles. It's the ultimate question. I think Aristotle says this in the ethics. So I would say live as fully as possible as a creator, grower, producer, shaper of life, right. And be content, that's quality of life. And that'll take you to about 75. Everything we know about physiology, brain function, cognitive function. I would say at 75, don't end your life. I'm against suicide and euthanasia. I'm long in the literature about it, but at 75, I would say stop taking your medical interventions to extend your life. So my own philosophy is no cancer screenings after 75, and by the way they're not recommended anyway, no vaccines, stopping to take the statins. If you get cancer, no chemotherapy. I might still say to things like hip replacements to relieve pain, pain relief in general. I was told that Leonard Cohen, the famous singer, right, took up smoking again. He waited till 80. He wanted that buzz, but what the hell, who cares after 80, right. So, I just want to leave you if it's quantity of life versus quality of life and all of you voted for quality of life, there wasn't a single person in this auditorium who had the guts to vote for quantity of life, all right, what makes your life meaningful? When is it enough? And when does it go and seep into, it's not the quality that I wanted. And I would suggest that it's not just about your physical decline, you ought to think about when your activities become more limited and don't just accommodate to them. Don't just adapt to having more limited activities and limit your life goals. That is not how you want to live. Or so I think. Thank you very much. Do we have time for questions? Now I know I'm not popular in the audience, but if you would like to ask questions, I'm willing to defend myself.

‐ [Moty] We've got two microphones. My name is Moty Goren, I'm a faculty member in philosophy and my colleague Ashby Buckner is over there. We will walk around and give you the mike if you have a question. I think we should, it's only fair to Page 10 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt start with somebody who's let's say 75 or close to 75. So do we have any volunteers? Who has a question. Okay, let's open it up to all ages.

‐ It's late at night. Stunned into silence.

‐ [Moty] He's doing crossword puzzles.

‐ [Audience Member] Zeke, thanks for a great talk, really interesting. Obviously this is very much an argument that depends on the empirical components and when you read not just the futuristic literature about this kind of stuff, but serious medical researchers, they make claims about what we might be able to accomplish in the future regarding making those later years not just more years and more and more limited, but also either stopping or reversing some of these cognitive declines and physical declines that you've talked about. What do you have to say to that? I mean if that comes to pass in various ways, wouldn't that change your message?

‐ A, let me just remind you, the last eight drugs for Alzheimer's have all failed. Right, scientists, biomedicine, medical researchers are always this is the golden age, we're just around the corner. That's their mantra. You can go back for a long time. Now I think it's much more likely we're gonna figure out how to rejuvenate bones so that we might not need hip replacements, we might be able to grow organs. Rewiring the brain, you know, I'm a little skeptical. It's a very complex organism, a hundred million, billion neurons, excuse me. Yeah, you might be able to screw around with it and you'll probably screw it up. So, I would be a little skeptical. If it is true that we can get the brain to stay better and, you know, the compression of morbidity was the 1980s version of this, right, just around the corner, you can live longer and you're gonna live a better, healthier life, it turns out not to be the case. Maybe I'd have to change my deadline, but I'm not, you know, I got a lot of human history on my side and I'm not so sure that, you know, the fidelity with which we're gonna rewire the brain is gonna be sufficiently high enough. But I'm prepared to change my mind. I think at the end of my article in the Atlantic, I said that I was willing to have an open mind about it. I have taken on by the way, anyone who's interested, I've taken on a number of bets that I'll change my view at 74‐1/2. My kids are willing to take that bet, too. They know something about me and my pigheadedness. So, I just don't think so. I have a memorial service planned, by the way for 74‐1/2.

‐ [Audience Member] If I heard you correctly, you put religion, which I'm gonna say is also spirituality in the play section and I was wondering what your thinking was in putting that in the play section.

‐ So, there are people for whom religion is very important. I actually go to services every week and so I'm a practicing atheist. I do believe in God, but I do believe in going to service and being part of a religious community. I think it's very important and I put that kind of activity in meaningful relationships because it's a meaningful relationship for me and some people celebrate Easter, I'll celebrate Passover and that's a very meaningful time for me. But I think, you know, play is supposed to be everything besides meaningful work and meaningful Page 11 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt relationships. That's just a placeholder. If you want to relabel it something, a vocational interest, I think I said that inclusive of that. I just don't think when it dominates everything else, those avocational interests, that they're sufficient and I think if you know people for who that's the dominant thing, right, they've stopped the work, maybe they sold their company for 60 million dollars and what they're doing is mostly avocational things and they don't have meaningful contributions to others. Tends to be a pretty vacuous life.

‐ [Audience Member] Thank you for your talk. Please don't laugh in my face when I ask you this question.

‐ It's all right.

‐ [Audience Member] But what do you think the chances are that computers may save us? For example, I know longer have to have the memory that I once had because I can access Google, so you know, we've got iWatches, what if we get to the point where we're going to be able to plant little computer chips in our brains. I mean do you see that as any sort of, is that just a complete pipe dream or do you see that there might actually be some possibility.

‐ It's an interesting question. What do you get out of Google? You get some facts, right. I hope you don't get interpretation and I hope you don't get thinking, right. And just facts are, you need facts to think, but facts are insufficient. They might be necessary, but not sufficient. And I have to say that I'm always amazed by how much less my students actually know, especially know about history that inhibits their ability to actually think. Yes, they rely on Google, but they actually don't know anything. Most of them don't know who Richard Nixon is, they don't know the Vietnam war and they can't tell you when World War II started or ended. It's very hard to think critically if you don't have some of those facts stuck here and not on Google, because you have to make connections, you have to put things together. Just having the facts is not enough. Now, maybe there will be some brain implants that will enhance our memory. The key thing as I tried to stress here and probably not enough of a neuroscientist to stress it accurately, but the key thing is not just the store of knowledge, the key thing is the processing ability and the ability to manipulate that information and that dramatically declines with age, it just does. Now maybe they're gonna have an attachment, I think this just goes back to the question here. Yeah, all right, if they have an attachment, none of our cognitive function declines. I'm just skeptical, you know. Are you from California by the way?

‐ [Audience Member] No, I have a son that lives in California.

‐ Yeah, well, we all are infected by this disease.

‐ [Audience Member] Let me press the point just one step further. So, artificial intelligence, we see all of this incredible advances in artificial intelligence, so is there any chance‐

Page 12 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt ‐ Well, there might be a chance that computers could take over, but I don't think that means that we're gonna get smarter. Those are two different, no those are two different things.

‐ [Audience Member] Zeke, I've got the easiest question for you of the night. How old are you?

‐ What, how old?

‐ [Audience Member] How old are you?

‐ I'm 60. Public information. 15 years to go and my kids bought me this. There's this watch made in Sweden called the death watch. And it counts down. Ran out of batteries.

‐ [Audience Member] Zeke, can you share with us any stories or examples of stimulating pushback that you have read or heard in audiences when you've presented on this topic?

‐ Oh, lots of them. They accuse me of being an elitist.

‐ [Audience Member] No, stimulating to you. Something that you thought was.

‐ Oh, yeah, so I'll tell you this story. So when I wrote this article, I was telling it to some students today. I wrote this article because a very dear friend of mine is an editor at the Atlantic and they were publishing something on the demographic shifts and more people, old age, and he knew of my philosophy of 75 and out and he said you know, you gotta write this article. I said listen, I'm finishing another book and I got all this other stuff, I can't do it. And he badgered me and badgered me about it. I said you got a weekend, all you're gonna get is a weekend, I'm gonna sit down and try to write this thing. I'm never, and I don't write that fast, I'm kind of a slow writer. So I banged this thing out and I sent it to my kids, my youngest daughter especially is like the world's most brutal editor and so I sent it to her and she said, you know, before you publish this, you have to get your father's view because you talk about him and the fact that he slowed down and everything. And so I said okay, I'll get his permission to include those, I think it's two or three paragraphs about him and his slowing down and, you know, I think just sad decline. So we were vacationing in Montana and I said, "Dad, tomorrow morning we're gonna have breakfast "together, just me and you and I got to talk "to you about something serious." So we had breakfast and I read him the passage and he said, "Well, you're right, I've slowed down, "I'm no longer what I used to be, "but I don't agree with your philosophy of life." And he said, you know, he still like swims every day, he listens to classical music, he reads books and he talks to his grandchildren. And he said, "When you have grandchildren," that's the best argument I've heard. And I just had my first grandchild. I don't know exactly what it feels like because I haven't babysat. We already have a noun together which is mischief, we're gonna do mischiefs and we'll see, but I'm skeptical that actually that's gonna change my view. In part because I think, you Page 13 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt know, I have a view or an image of my father, which man, was like I get my high energy and my brothers get our high energy from him. Just running around doing a thousand things and now he can barely walk across the stage, very slowed down. We just celebrated his 91st birthday and he was great for about the first half hour and then, you know, just the energy ran out. And I don't want to remember him that way, right. I'd rather them have lived a shorter life and remembered like the energizer bunny he was. And I do think it's very hard to remember someone, you know, what you remember is the closer, the more recent things, so you have to work at remembering the energizer bunny and I think it's sad and my dad and I, we disagree. We've had a lot of arguments about it. Yeah.

‐ [Audience Member] On that point, I would like to say that later in life that maybe during an illness such as my mother had, I learned about sides of her I never knew existed. There was this incredible sense of humor that erupted. Hence that veneer, that central veneer.

‐ It's called front lobe disinhibition. That's exactly what it's called. Yes, and they make a lot of very inappropriate jokes.

‐ [Audience Member] My mom was such a prude.

‐ Yeah. My father's the same way and I'm not sure I like it. And I'm being honest. You know, he was always a very funny man and I'm not sure some of this jokes are one, by the way, for those of you who want to push back about this, let me just suggest to you there have been, you know, as I mentioned, Japan has, the average age in Japan is 84. It's five years older than the United States. They have a lot more old people and if you read about their lives, it is terribly depressing. There is no other word for it. Old women living alone, having no children around, you know, sometimes dying in their apartment, no one notices for days and weeks and weeks. No activities that give them meaning, limited social interaction. It just, you know, we can add five years of life expectancy, just doesn't seem to me to be worth it. So by the way, I showed you right at the start, the sort of life expectancy curve. Seems to me that's a bad thing to measure. The thing we want to measure is what proportion of the population makes it to 75 and after that we really shouldn't be counting and that's a very different number. It means that what we really worry about is people that die at 65, people that die at 67 and we want to get everyone to 75. It's a very different philosophy than just extending the average life expectancy as if extending the average will being everyone up. That's not the way it works.

‐ [Audience Member] Dr. Emanuel, I'm calling you doctor because this is sort of a heavy question, rather than Zeke, but what would you as a doctor, what counsel would you give to an older person who said, you know, the real reason why I'm trying to perpetuate my life is because I'm afraid of death.

‐ I'm a what.

‐ [Audience Member] I'm afraid of death. I fear death. Page 14 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt

‐ Yeah, well, I would read Epicurus. No, no, I'm being serious. I don't think there's anything after. I am a nonbeliever. I don't think there's anything after. I think this is the life we have. You know, look, in a strange way, this article wasn't for those of us who are past 60. This article was for those of us who were 20, to try to suggest to them you got to think about the end of your life when you want to plan your life. There are lots of things you can do in life that are not meaningful, a whole career that's not meaningful and you really don't want to be in a position when you're 60 and say, you know, or 50 and it's a lot of meaninglessness that happened before. And so I'm less worried about someone who's afraid of death and I'm more worried about people that are about to graduate from CSU and the kind of choices and paths they're gonna go on and that's really what this is a challenge for.

‐ [Audience Member] Zeke, thanks for taking my question. I'm a healthcare professional and I find that physicians are terrible to talking to their patients about end of life. Comments on that?

‐ Yes. But I don't think, you know, so I'm an oncologist, and I started my career in the mid‐1980s working on end of life care. It was one of the first four research groups working on end of life care to try to improve it in this country because when I was a medical student, a third year medical student I went around the wards in Boston hospitals and just, you know, we're doing a crappy job here of caring for people who are clearly dying and I agree with you. But I don't think doctors in that regard are any more unique than the rest of the population, which is we're all scared about talking about this. It's something we don't know how to have, I think, a mature discussion about. And I think doctors find it very difficult to say to someone, look, you know, I'm a cancer doctor and believe me, it was difficult to me, too, is, you know, we've tried everything and there's no more things I can do to throw at that cancer that are gonna make a difference. We have to plan your life a different way. It's very hard for us to say that, it's very hard for people unless they've thought a lot about it all through their life, to accept that. You do, however, find a number of people, I find them in their 80s and 90s, who, you know, they're okay with the way things, you know, with dying now. And they've lived a full life. A lot of their friends have died over time and, you know, enough is enough. And you do see a lot of that attitude. Nonetheless, I think in general, and I don't think this is by the way, there are a lot of people who make fun of Americans, you know. I did call it the American Immortals, but I don't think it's all that unique for just to the United States. I do think that this is a problem for a lot of people in a lot of cultures, talking about death and we ought to think about it and how we ought to orient our life to it. You know, and if I'm honest with you, I don't know what it's gonna be like, when I'm on my death bed. I don't know how afraid I'm gonna be, I really don't. And I've thought about more than probably anyone in this country. I think about it every day, I write about it. Is there another question, yeah?

‐ [Audience Member] What do you think about the book Being Mortal?

Page 15 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt ‐ About what?

‐ [Audience Member] A book Being Mortal by Atul Gawande.

‐ Yeah, it's a great book. What do I think about Atul Gawande's book Being Mortal. He's a very good friend and I think it's a great book. We have slightly different views of the issue, but, you know, he and I are different people. I'm more provocative and he's just a much better writer.

‐ [Audience Member] I appreciated your talk and a lot and I agree with a whole lot of what you said. I'm an Aristotelian in my bones and the curve of life is that way. I was walking in a younger colleague, I'm in the philosophy department and I said I was had to hear this because I'm 76 and she said you're 76 and a lot of people will say that to you, I think they're just being nice, but in any case, when you are 76, you know it on the inside. Physically I think you're right. Things are going, your memory, the names, all those kind of things are true. Having said that, Grosz said something in the Examined Life and I just happened to read it a couple of months ago in which he said in your early 70s, maybe you would get some projects that you might want to get onto and I said wow, that really happened to me, okay, they've actually been growing since then, so here I am at 76 and I don't want to die, I want to keep as much of my brain power as I can and moving, plus I like your father's grandchildren argument, okay, and I'm involved, I've got service going and I've got the freedom to it. I want to say I'm betting that when you get up into your early 70s, you may become more like me and do it. Come back at me.

‐ I haven't waited till my 70s. I have a lot of projects that I do. Every year, I've committed myself to doing something out of the box. I have to do something new. Three years ago I was a chef, I ran a restaurant for a couple of weekends. I don't recommend it as a lifestyle, it sucks. But it was fun and I had the good and the great of Washington, DC come and eat my breakfast food, so it was fun. I've made a chocolate bar from bean to bar and done everything necessary for it. I have a lot of projects. Those are great, they're fun, but they're play. They are not about meaningful activity. They're meaningful to me, I like them, but they're not about adding to the world. Yes, there's a chocolate bar out there, but I do, I agree with you, I think having projects is really important and I think getting involved is really important. Whether it's enough and whether you can sustain it enough, you know.

‐ [Audience Member] It's part of my work, I'm esophilosophical.

‐ Ah, okay. Maybe you're one of those ouliers, I don't know. I'll wait for the next article.

‐ [Audience Member] I raised my hand in response to the healthcare because I'm an ICU nurse and I feel that I personally feel that at age 75, you should no longer be given the option whether you are DNR or not. DNR stands for do not resuscitate.

‐ I know what it stands for. Page 16 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt

‐ [Audience Member] Well, not to you. Because what are you bringing the people back to is really the question and in response to the healthcare doctors, the answer is have the nurses talk to the patients.

‐ [Audience Member] Excuse me.

‐ Other questions?

‐ [Audience Member] Yes.

‐ Oh, yeah.

‐ [Audience Member] What have you found in other cultures that have found ways to bring meaningfulness into their lives as they age?

‐ Well, it's interesting. If you look at cultures, actually if you look at people who live a long time, it turns out that the secret is community. It's being associated with a lot of other people, caring for them, having them care about you, too. You know, I don't know how many of you know this book, the Blue Zones, but it's about, you know, six places around the earth, Okinawa, Loma Linda, Sardinia, someplace in Greece where people live an extraordinarily long time, they're not exercise nuts, they do eat, you know, mostly a plant based, but they are almost all are omnivores, they eat meat and fish and other things, but what turns out is you know, they live in a community, they have meals with other people and, you know, having those not just meaningful family relationships, but larger extended communal relationships are really important. Let's just face it, the United States has always just been bad at that, okay. It's just a matter of fact. A huge proportion of our population moves every year. It's actually gone down in recent years, but until about the last 20 years, America was the mobility place, you know, breaking up communities. We used to send kids to local public schools, maybe still do in fort towns, but lots of bit cities, that's not true anymore. So those arrangements where you lived in a community where you had a lot of acquaintances, people who you actually knew, you lived with, you shared meals with, you know, that's very, very important. We have less and less of this and I don't think it's true in the United States. It turns out yes, they still have more of it in say smaller Scandinavian countries, other places, but almost every big industrialized country, it's gone down and you know look at Europe. Mobility is all over. And it makes it hard to have those kinds of communities for extended periods of time. But those are very fundamentally essential for human beings.

‐ [Audience Member] So you mentioned you were opposed to euthanasia, suicide assisted and I was wondering why?

‐ It's a whole other lecture, it really is. So I'll give you the four quick arguments and then you'll have to read more. One, your idea of who wants euthanasia and assisted suicide is not that person who wants it. Your idea of some person with cancer writhing in pain turns out to be false. Almost all those people are people Page 17 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt who worry about loss of autonomy, loss of dignity. Most people who select euthanasia are actually pain free and it's not about pain. It's about psychological distress, anxiety, depression, hopelessness. I don't think that's a good answer for that, that's the first thing. The second thing is if you look at, if you think about euthanasia or assisted suicide as sort of an answer to the problem of we do a very bad job of caring for people who are dying and the answer, we'll then prove it by euthanasia, assisted suicide, that's also wrong. Even in Oregon, only .3% of the people who die die by assisted suicide there and it's been legal for 18 years or so there. It's just not, you know there are 99.7% of the population for whom it's irrelevant and if you want to improve end of life care, you got to focus on the big numbers, not the small numbers. Third, most people think it's quick, painless and flawless. Turns out all of those are true. There's no medical intervention that's quick, painless and flawless. Right, even a simple blood draw is not quick, painless and flawless. All of them have problems. Assisted suicide and euthanasia, we know from early studies that they've had problems. It's actually quite poorly documented, but the Dutch who've done the best show that patients often can't swallow the pills, you can't find a vein, they wake up, they don't actually die. They have prolonged comas for days and days and days and either die then after four or five days or don't die. So, you know the idea that this is a quick, painless, flawless way is just factually incorrect. And the last point I would make is, you know, people say that there's no slippery slope. I do think that they're, you know, the more it's present, the more it's used, the more it's used, the more it's used on cases which we agree are not the cases we would have permitted had we agreed to it. Right, cases of people who are depressed, cased of people who can't consent, children, et cetera. You know in Belgium, they've taken away the lower bounds of age. It used to be 12, anyone above 12 could get euthanasia. Now they've just taken it away. You know, so for all those four reasons I don't want it legalized and I've had that view for 25 years. And it's ironic. Most of the people who are in palliative care and end of life care share that view. We can do better.

‐ [Audience Member] Over here. First of all, I agree with everything you've said. I've watched my mother die, I've watched my father die from long‐term illnesses, et cetera. I also have a husband who's in healthcare and I hear about the screening colonoscopy on a 90‐year‐old and one of the things is he's done mission trips around the world and in the hospitals, the families have to bring meals to the patients. The families have to bring food and bathe them and take care of them. And they go home to the families after they leave the hospital and we don't do that here. The medical industry keeps taking care of the people and prescribing and doing and I think the number's about 85% of our medical expenditures go to people over 75 years of age and do you think all of that would change if families actually became more responsible for their elderly?

‐ First of all that 85% over 75 is not true. It's a big proportion. As you get older, the wheels start falling off and you need healthcare. So it is a big proportion, but it's not anywhere near 85%. Families do do a lot of caregiving. I think one of the great untold truths about it is people get a lot of caregiving from their families already because our long‐term care provision is pretty sucky in this country and it turns out if you look at the data, 75% of family caregivers are Page 18 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt women, daughters, spouses, daughter‐in‐laws, and so it's a disproportionate weight on women. So I think more caregiving would actually disadvantage the women more, being the father of three daughters, I think that's a bad idea.

‐ [Audience Member] It's a two part, whoa, I agree with a lot of what you're saying, primarily for the cost. You know I don't like to see resources going to somebody 75 years old, so I would do what you suggested. However, I'm unclear on whether you were saying that the meaning that like your father gets or the meaningfulness that these people in the blue zones are getting from their community, are you saying that you don't think in your opinion that their view of what's meaningful to them works for you and therefore it's bad because you don't agree that it's meaningful to them. I just want to be clear before I run around and tell everybody that's what you thought. And secondly, at the end you said really this article was aimed more at the young graduates, like a 20‐year‐old.

‐ I didn't understand the last bit.

‐ [Audience Member] My mike's not working anymore. Oh, that you said primarily the article was aimed at younger people who were getting ready to graduate, so I wasn't clear on what the message is. Is it just to go out and live healthy and then when you're 75, I wasn't quite clear what that message is to them.

‐ Okay, so let's take the first‐

‐ [Audience Member] But the relationships interested me.

‐ Let's take the first question.

‐ [Audience Member] It sounded like you were.

‐ I'm not someone who believes that each of us chooses our own life and we don't have to justify it to other people. I do think that are better and worse ways of living life and those are objective, that they're not, I think there are multiple good ways of living life, but I don't think, but part of what I want to do is to contrast a better way of living life and a worse way of living life and part of what I want to object to is what is called in the literature and what I pointed out to the sort of adaptation and accommodation to the more constrained view of life, limiting our goals of life, limiting our objectives so that we're content with crossword puzzles. Obviously crossword puzzles is a metaphor for very limited range of things that we're doing and I do think, you know, I've had this argument with my father. It is not meaningful what he thinks is fulfilling and I think he can only think it's fulfilling because he has reduced his purview in what's acceptable, whether because of limitations physically or the fact that he's scared shitless of death or whatever it is, right. I do think he has accommodated and part of what I'm arguing is you should not accommodate. We should throw out our life, have bigger goals for what we want to accomplish and we should stick to those bigger goals and be satisfied with watching TV and doing crossword puzzles is not part of it. So being creative. Page 19 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt

‐ [Audience Member] What should he do at that age, though, if that's what he has?

‐ There's lot of medicines he could stop taking. That's true for almost all of us. Gonna be true for all of us. Very hard to get to 75 without taking any medicines and without being kept alive one way or another. It's interesting, people say all right I agree with you, no chemotherapy, all right, I agree with you, I'll stop taking my statins and when I said I'm not gonna take any antibiotics. Oh, well that's the limit. I don't know, why is that different? Because it's cheap? I don't know, I don't, I'm not persuaded. So, 20‐year‐olds, what's the message to 20‐year‐olds? I think the message to 20‐year‐olds is you got about 55 years. Think really well about how you want to spend those 55 years.

‐ [Moty] Okay, so we're just about out of time, but we have two people who have been waiting patiently, so you have a question and you're gonna have the last question and we're gonna have to call it an evening.

‐ [Audience Member] Yeah, I'd like to sort of tap your other expertise. You talk about what proportion getting to 75 is what you want to look at.

‐ Yeah.

‐ [Audience Member] Okay, how does universal healthcare fit into that? And might some of those dips in the 40s and 50s be due to the fact that we don't have a good healthcare system and what do you that it's gonna take to get there?

‐ That really is a whole other lecture. I don't know how to start answering that question. First of all, I don't think the dips, the dips and bumps I don't think are fundamentally about healthcare. Because healthcare contributes, you know, whatever 10 or 20% to our longevity. There's a lot of there things that go into it, exactly what they are, you know, they fall under the social determinants of health, social mobility, kind of factors. So, you know, if you were gonna press me, yes, we do need universal healthcare coverage in this country, why we don't have it, well we've got a lot of ideological divides in the country and we've built up a sort of inefficient system. We've got to get this system to be dramatically more efficient so we can free up some money, part of which would go to universal coverage. I really do think that's a fundamental issue. You know, here I am at CSU and I was told, whatever, 7, 8% of the budget at CSU is given by the state of Colorado, it's been going down, no surprise because it's been going down in every state in the country and the main reason is, you know, Medicaid costs and cost for state worker health insurance and costs for uncovered people have been going up, consuming ever larger proportions of state budgets. And that trade off, you know, you many not draw that line, but that line is drawn by budgeteers in state capitols. Medicaid goes up and up and up, you can't raise taxes to pay for it, they've restricted enrollment by and large and the consequences, you can cut certain things, state budgets don't have that much to cut. Primary and secondary education, higher education, correction facilities, highways, that's the big issues, right. Turns out that cutting higher education is the easiest thing to do. It's the most invisible, Page 20 Bodaken Philosophy Symposium Dr Ezekiel Emanuel.txt you can always raise tuitions until people scream and so you know one of the reasons I personally have spent a lot of time focused on trying to control healthcare costs, redesign the system to be more efficient is because I actually care about education. And the only way you're gonna get money shifted over to education is by making sure healthcare doesn't consume more and more and more. That's not the answer you wanted, but that's the answer I could give. Without giving a whole other lecture.

‐ [Audience Member] I wanted to get back to the medical industrial complex and the way that the money moves in this country and the fact that you need a heck of a lot of savings to pay if you want someone to stay home and be taken care of at home or you trade it for your own income, you leave your jobs and so forth. Do people even actually understand how much it's gonna take and the fact that there are the demographics for people who can care for the elderly are simply not there in this country, so just your take on that.

‐ Just imagine if you were China. And I'm being totally serious. In the United States, we still have more than one kid per family. In China, you have one daughter or daughter‐in‐law for four adults. That's a real demographic disaster happening. We are a little better than that, but I agree, I think I said in response to some question flippantly, we don't have a long‐term care policy, we don't have a solution to the long‐term care policy. It turns out to be enormously expensive any time you look at it. We did have a part in the Affordable Care Act for long‐term voluntary insurance and had to be repealed because we could not certify that it was fiscally sustainable. To make it sustainable you'd have to have everyone contribute into the system. Now if you think it's hard to persuade a 25‐year‐old to buy health insurance, try to persuade a 25‐year‐old that they're gonna need long‐term care insurance when they're 65. Not likely to happen and they don't have that kind of purview. So that's why we have a problem with the long‐term care situation. It's also why we end up sending people to institutions and institutions are enormously expensive, disproportionately expensive for what they do. If you just look at the trends going forward, we are going through, the healthcare system is going through a very steady process of the institutionalization. Fewer hospital days, fewer skilled nursing facilities, fewer rehabilitation days, because those are just too expensive. So more care is gonna have to be delivered at home and we're gonna have to figure out how to do that. So on that happy note, thank you very much.

‐ I do want to make one quick announcement. Thank you Zeke for a provocative talk. The Bodaken Symposium will continue in the fall. Our theme next year is economic inequality. We'll be having workshops in the fall, another distinguished speaker next spring semester, so keep your eye out for emails. They'll distribute across campus for that. Thanks again, everyone and thanks Dr. Emanuel.

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