When Is Enough Enough?

Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Our Illusion of Control
by Barbara Ehrenreich
Twelve
234 pages
978-1455535910

Recently, it became clear to me just how accustomed we’ve become to ever longer life spans when a fitness instructor I know complained to me that her father had died too young. “He was only 80!” she announced in an aggrieved tone.

Her words kept replaying themselves in my mind as I read social critic Barbara Ehrenreich’s latest book, Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer. The 76-year old Ehrenreich, a breast cancer survivor who received her initial diagnosis and treatment in 2000, no longer bothers with cancer screenings or other preventive medical procedures. It’s not that she’s suicidal or severely depressed, she insists: it’s that she’s come to realize she’s grown “old enough to die.”

It’s as sobering a reckoning with mortality as I’ve come across. But from Ehrenreich’s viewpoint, this recognition has freed her to take charge of her time in a new way. She can now choose to take a walk outside, rather than sit in an airless medical waiting room. Instead of being enslaved to unending medical appointments, she’s empowered herself to say no to incurring “any more suffering, annoyance, or boredom in the pursuit of a longer life.” Rather than fussing over various cholesterol-lowering meds or chasing around the latest health-food sensation, she eats meals she enjoys, which only coincidentally happen to be what most experts would consider healthy. When she goes to the gym, it’s because working out makes her feel good, not because it’s what a doctor ordered her to do. And speaking of doctors, yes, she’ll seek medical care for an urgent problem, she confesses, but she’s “no longer interested in looking for problems that remain undetectable to me.”

In this category, she places a variety of ailments that naturally come with age but that in recent years, she believes, have been medicalized by pharmaceutical companies seeking to develop and make profits from new medical devices and medications. One such example is osteopenia, a thinning of the bones, which Ehrenreich had been diagnosed with after her doctor insisted she undergo a bone-scan test. Rejecting her physician’s advice, she decided not to spend time worrying about it when her research into the subject persuaded her that, rather than an abnormal condition, it’s a normal result of aging, shared by almost every woman over the age of 35. Her resolve was further bolstered when she learned that the medication that had been most often prescribed to treat osteopenia at the time she was diagnosed was later found to potentially worsen the condition it was supposed to ameliorate.

Clearly, Ehrenreich is a dissenter from the all-encompassing anti-aging mindset that she perceives to have engulfed our youth-worshipping society. As she astutely observes, the older our already aging society grows, the more money businesses can harvest from products that purport to promote longevity. But while promises, often unproven, of a longer life can lead to a healthy corporate bottom line, in what ways, if any, do consumers benefit from pursuing life extension? Ehrenreich’s bottom line is that it’s time to face up to the reality that what we euphemistically call healthy aging is still aging, and resistance to death is ultimately futile. What the anti-aging industry is really selling, and what we’re buying into, she asserts, is based less on medical science and more on the age-old myth—think Ponce De León and his fountain of youth—that we can have the ultimate say in determining the length of our lives.

It’s a myth we’ve long been addicted to, and Ehrenreich is at her best in putting that desire in the contemporary context of how we’ve come to medicalize both our lives and our deaths. She warns us not to be deceived by the medical-industrial complex, as she dubs it, and often uses her training in cellular immunology (she earned a PhD from Rockefeller University) to push back on the narrative that the industry knows how to keep us in control of our aging. For instance, she argues that some cells that are supposed to enhance our immunity and improve our ability to fight disease can turn out, upon closer examination, to themselves be potential sources of further bodily disease and decay.

In further cautioning us, she asks, “How is a doctor—or hospital or drug company—to make money from essentially healthy patients?” Her answer: “By subjecting them to tests and examinations that, in sufficient quantity, are bound to detect something wrong or at least worthy of follow-up.” Whoa now! As much as I respect Ehrenreich as a writer, it was at this point that she lost me.

To her credit, she herself admits to sounding cynical and feeling guilty (as she should) in dissing the value of preventive medicine and screening procedures such as colonoscopies, which have unarguably saved the lives of countless people who have not decided that they’re ripe for death.

She’s correct to point out—as a variety of medical studies have—that the ability of ever more powerful screening tools to pinpoint ever smaller lumps that may, or may not, be cancerous can expose us to unnecessary radiation in further testing. It can also lead to unnecessarily zealous treatment, which can, in turn, lead to further side effects, even death, caused by operating-room error, bacterial infections contracted in the hospital, or allergic reactions to medications. But these studies remain controversial. I don’t think she gives enough weight to the fact the same procedures can and do uncover malignancies that left untreated would be fatal. Readers would be better served with a less polemic and more in-depth explanation that for any medical decision, there’s always a risk–benefit analysis to be weighed based on a long list of factors ranging from, yes, age, to medical history, to personal viewpoint.

Ehrenreich moves to firmer ground when she argues that, given the uncertainty of the cause or course of any number of serious illnesses, it shouldn’t surprise us that incapacitating or fatal diseases can and do befall even those who pay the strictest attention to their health and fitness. The fact that it does surprise us speaks to our disbelief that, even in our age of research breakthroughs, we don’t actually know what combination of genetic, environmental, and behavioral factors can lead, for example, to the “early” death of the fitness instructor’s father at age 80.

Rather than accept the truth that our bodies all have expiration dates, we find it more comforting to seek a culprit in the patient’s diet or lifestyle, and use that personal flaw to cast blame on those who are ill for “causing” their own ailments. Witness the fact that whenever someone dies of lung cancer, we congratulate ourselves on the fact that we don’t smoke. In a similar vein, obituaries these days will often absolve the deceased from guilt in their own demise by noting that this particular lung-cancer victim didn’t smoke.

Ehrenreich is certainly correct in pointing to the socioeconomic factors at play in this blame game. Being affluent enough to join a gym, regularly buy and cook “healthy” fresh ingredients, and not go broke forking over the ever-increasing cost of good healthcare coverage are “class cues,” which further divide rich and poor, she says. “The objection raised over and over to any proposed expansion of health insurance was, in so many words: Why should I contribute to the care of those degenerates who choose to smoke and eat cheeseburgers?” she writes, pointing out the lack of compassion and empathy in this argument.

Given her views, you’d think that she’d put in a kind word for mindfulness as a nonmedical method for dealing with stress. But Ehrenreich regards it with skepticism, tracing its popularity to the tech-wealthy scions of Silicon Valley who’d rather preach about mindfulness than find actual solutions for helping consumers control their addictions to and dependence on the devices Silicon Valley developed and got rich on. Really? Mindfulness originated long before the term Silicon Valley was coined. Nonetheless, it would be a great initiative—and a fabulous public relations move—for those companies to step in and help us heal from the relational, emotional, and social havoc their inventions let loose in the world.

Ehrenreich is provocative as always, but the overall mood in her book is dour. At the close, she tells us that she finds comfort in knowing that the world will go on living, even after she has departed from it. But I was disappointed that a writer with such a rich and distinguished career shared so few personal glimpses of the sense of purpose and larger perspective she’s found at this advanced stage of her own life. Nevertheless, she’s forcefully made the case that how one goes about reconciling oneself to life, and to death, is a personal choice. What that choice may be, in any particular instance, is another matter altogether.