Quantity or quality of life
Myles Leslie, Akram Khayatzadeh-Mahani, Charles Webb
In advance of his 80th birthday in 2014, Canada’s famous singer-songwriter Leonard Cohen announced it was “the right age to recommence” smoking. After 30 years of abstinence he was again taking up cigarettes. Late last year he was dead of complications from a fall that likely had nothing to do with tobacco use. Cohen’s choice draws us back to the clinician’s dilemma. Neither the singer nor his physician could know, based on the epidemiological data, whether 80 was too young an age for him to reengage the pleasures and ills of smoking. As so often happened in his deceptively simple lyrics, Cohen’s decision playfully asks us to consider fundamental values: is it better to prolong life, or to maximise the happiness it delivers? It asks us to consider which moral logic we bring to our clinical work. On the one hand, the logic of longevity is strongly opposed to this sort of late-in-life backsliding. On the other, the logic of happiness suggests there might be a place for an autonomous senior citizen to take up “mindful smoking” as part of maintaining a healthy psyche. Cohen’s return to tobacco challenges us to look more closely at how these often incommensurable moral logics ought to shape our healthcare system.
With efforts to increase life expectancy in the elderly succeeding and the United Nations projecting that the number of people aged 80 years and over will triple from 125 million in 2015 to 434 million in 2030, to what extent might the drive to prolong life need to accommodate, or even give way to, the demands of individual happiness? With many nursing homes now convening Happy Hours where elderly residents are given access to potentially life shortening, but pleasure increasing, fatty foods and alcohol, is there a balance to be struck? A balance between the quantity and quality issues that are wrapped up in measures like the World Health Organization’s Health Adjusted Life Expectancy (HALE) indicator.
As clinicians know, striking this balance is far from an abstract exercise. Consider the care of end-stage cancer patients. With 71.8% of oncologists preferring life-prolonging treatments over quality enhancing interventions, the majority “value length of survival more highly than quality of life when making chemotherapy decisions.” One of the realities of clinical practice is that these sorts of value judgement are constantly being made, and so clinicians owe their patients and themselves some reflection on the moral logics that are in play. Ultimately, their choices may not be any different, but pausing to understand where the logics of longevity and happiness come from, and so how one may seem more or less “obvious” than the other will lead to better informed, higher quality care.
Social theory and history have highlighted the instrumental role that the drive to prolong life has played in the rise, and metrics, of the modern nation state . Epidemiology was not only made possible by the growing “avalanche of numbers” describing the lives and deaths of citizens that rolled out of early modern bureaucracies, it was intimately linked to competition between states who measured success in terms of population size and longevity . The morality of these efforts can be summed up in the admonishment “Thou Shalt Not Die Prematurely” .
This history and morality is the environment in which an individual clinician’s training, enculturation and incentivisation take place. Physicians’ technical training equips them to save life by fixing or supporting biological systems; their enculturation tends to revolve around the ‘rule of rescue’ and their incentives flow, more often than not, from measures that focus on quantity rather than quality of life. The world such physicians live in is one in which clinical trials and their own performance reports explicitly value quantity rather than quality of life. Even if clinicians accept Barnard’s assertion that the primary goal of medicine is to alleviate suffering, not merely to prolong life, their focus turns to supporting a “good death” rather than happiness in life .
In this longevity-focused context it is perhaps unsurprising that relatively recent efforts to combine mortality counts with morbidity statistics to create indicators like HALE find themselves paddling upstream when it comes to clinical decision making. And so, how, with the weight of history and morality against it, might the logic of happiness assert itself, other than in the smile of a trickster troubadour like Leonard Cohen?
Although happiness, along with its pursuit, is by no means new to the human experience, it has not enjoyed the sustained governmental focus – the data collection resources or population health interventions– of longevity. As a measure of subjective wellbeing, however, it is increasingly considered a public policy goal . Governments globally are beginning to use happiness data to gauge how well, rather than simply how long, their populations are living. The most recent World Happiness Report highlights the importance of integrating happiness and wellbeing into a longevity-dominated conversation.
As the medical profession itself wrestles with avoiding burnout by finding happiness in its work, striking a balance between extending life and extending the pleasure of living is becoming critically important. Leonard Cohen’s choice and death remind us that other duties and values need to be part of the discussion. In an era where many of us are living much longer, partnering with patients and their families to find a balance between quantity and quality of life ought to be the new norm.
No financial support and no other potential conflict of interest relevant to this article was reported.
Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
School of Public Policy, University of Calgary, Calgary, Alberta, Canada / Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
President of the Vancouver Medical Association
Books mentioned in the text
- Foucault M. The history of sexuality: The care of the self. New York: Vintage; 2012.
- Hacking I. The taming of chance. Cambridge UK: Cambridge University Press; 1990.
- Bayatrizi Z. Life sentences: The modern ordering of mortality. Toronto: University of Toronto Press; 2008.
- Barnard C. Good life good death: a doctor's case for euthanasia and suicide. London: Owen; 1980.
- Davies W. The happiness industry: How the government and big business sold us well-being. London, New York: Verso Books; 2015.
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