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Maarten van Swaay / September 24, 2014

‘What If’ or ‘How When’?

In reaction to a recent article by Mr. Ezekiel Emanuel: Why I Hope to Die at 75.

Mr. Emanuel was one of the major architects of PPACA, now mostly known as ACA and as Obamacare. A key provision in that law established IPAB – the Independent Payment Advisory Board, which is charged with the task of identifying and developing (financial) efficiency measures in Medicare. Thus the views of Mr. Emanuel may carry significantly more weight than those of most opinion-makers.

What If … Two rhetorical words often heard, generally without follow-up: the rest of the story is left for the audience to imagine. For a good reason, and for a questionable reason. The good reason is that the future remains as unpredictable as it has always been, with the only safe prediction that it is unlikely to ever be quite what we predict.

The questionable reason is the intent to make the audience choose what it wants to choose, while at the same time leaving the impression that that is precisely what the speaker had in mind. That may be effective rhetoric, but it cannot be called good reasoning or good communication.

Thinking about these two words has made me wonder whether both may be poorly chosen. The future is unpredictable, but it is also boundless, so it is not farfetched to expect that any proposed development or scenario could eventually come to pass. Then the proper phrase should not be ‘What If …’, but ‘What When …’

That exposes the first word to challenge: if the future, and its variability, are unbounded, that must make it impossible to describe any part of it exactly. So it must remain impossible to lay down enumerated choices (‘what’) for all future contingencies. Then we should change the first word as well. I would submit ‘How When …’

Our Courts recognize this reasoning, though not explicitly. The recognition is imbedded in a firm policy: no Court will make a pronouncement on a not-yet-existing scenario. In other words, the Courts will not play ‘what-if’. A Court pronouncement requires a test case.

Is it then a waste of effort to think of ‘what-if’? No: but the merit lies not in the construction of a list of plans, but in the practice of how to evaluate possible contingencies. In other words, the merit of the what-if game lies in the development of a framework of values, and in the practice of reasoning from such a framework to judgments and decisions.

Even that is not immune to challenge. One can play quite conscientiously at some what-if scenario, but at the end of the session one can declare the session over, and return to real life. In other words, the playing of what-if always leaves an escape – an escape that will not be available in reality. The presence of that escape in the what-if game will almost certainly color judgment and affect conclusions.

So what brought all this up? The short answer: transfer of decision-making responsibility, and now Mr. Emanuel’s argument to make ‘75’ a magic number.

All parents have experience in the transfer of responsibility: much of the challenge of bringing up children resides in the balancing act of prudently and gradually handing responsibility to them.

A short note about ‘responsibility’: the word is bigger than it appears to be. Literally, it means ‘obliged to answer to’, e.g., to a superior. But it also can mean ‘expected to perform some tasks’. And finally it can mean ‘expected to stand for the consequences of some actions’, and from that, accepting the obligation to evaluate the consequences of actions before they are taken. This last meaning is at issue here.

I submit there is some symmetry to life: there comes a time when people age to the point where responsibility may transfer back to a younger generation, by choice or by necessity.

Just as with children, it may not be practical to negotiate this process. But it is naive to expect that a transfer of responsibility can be avoided by the construction of a list of ‘advance directives.’ I believe that what will be needed is not so much a list of directives, as an understanding of how emerging situations may be evaluated to lead to sound decisions.

That, too, is something parents know quite well. Instead of trying – in vain – to tell their children ‘what to do’ for the rest of their lives, they try to give their children the tools to evaluate the “slings and arrows” they will encounter, in the hope that they will then be able to choose wisely.

Just as it is difficult for parents to make judgment that is compatible with the perspective of their children it is probably at least as difficult, or even more so, for children to make judgment compatible with the – perhaps no longer dependable – perspectives of their parents. With growing children one has the option to wait a little, until children become more accessible to dialog. But time is not an ally at the other end of life.

Then what to do? I can speak only for myself. I hope that it may be more useful for me to try and reveal some ‘value views’ than to construct some ‘set of wishes.’

The question of ‘how to deal with old people’ did not arise until quite recently in human history: nature had effective ways of disposing of the question before it would arise. But today, humans live well beyond the age at which their offspring gain independence. They may also live well beyond an age at which they themselves can remain independent.

Our society would frown on a return to some ‘natural solution.’ But from the other side I would want to avoid imposing ‘unreasonable demands.’ Of course that raises the question what makes a demand unreasonable. Judgment, inescapably!

Would I appreciate some measure of comfort, e.g., in the form of shelter, living arrangements, and – if still possible – personal contact? Of course I would. But not to the extent where it would require undue intrusion on the lives of those who would be kind enough to provide for me. “Undue intrusion”: another undefinable notion that can be answered only by judgment.

Should I speculate on the kind of shelter and support I might hope to have? Not really. That choice would depend very heavily on the type of arrangement that could become necessary (judgment again!). It would be silly to expect that my freedoms to move and act will remain unbounded forever. But I would hope that neither will be curtailed beyond what prudence demands.

Would I appreciate ‘heroic measures’ to prolong a life that no longer justifies much hope for personal contact? Probably not. Even at the risk of sounding conceited: I can look back with pleasure and satisfaction on a long life, blessed by untold and uncounted privileges, and maybe even some achievements. Sure, one can always dream of a list of things that would still be fun to do. But even if such a list were to remain untouched, I could not claim to be short-changed.

In summary: Mr. Emanuel’s proposal to attach a – literally – life-and-death decision to an arbitrary number is misguided. Delegation of such a decision to rules in the hands of a – remote – bureaucracy I would find immoral. The idea that future contingencies can be enumerated is false; any claim that it can be done is appalling.

Professor Maarten van Swaay retired from Kansas State University in 1995. He can be reached at [email protected]

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