Dienstag, 22. Januar 2013

Embrace death... or not

The idea of death can reduce us humans to sputtering and mumbling. I know this from experience. Therefore the author of this article does not need to be embarrassed by being so horribly and totally wrong about almost everything he said.
At times death is so scary to people that they embrace it as something useful and desirable. Or they elevate quality of life on a golden pedestal as if quantity didn't matter at all. This form of cognitive dissonance is sometimes called "deathism".
I will take this opportunity to explain why living a very long and healthy life is worthwhile:

It starts with a reasonable objection: "...trying to link what is really a very small part of life to mortality. [is problematic or wrong]"
Yes, but that's a known issue in nutrition science. We use corroborative evidence and studies of dietary patterns to avoid bias.

All-cause mortality is the best (or at least it's exceptionally useful) and hardest endpoint in epidemiology, but the author does not like it, because it has something to do with dying:
You are going to die...
Everyone has their own motivations for pursuing a lifestyle that has more fitness and better nutrition in it. But one prevailing theme, not usually explicitly stated, is (and I'm going to make up a word here), "life maximization"...
Here's the thing: You don't know when you're going to die... 
Here's my main beef with long-term correlational mortality studies: The underlying assumption is that these events are not only bad, but preventable. I'm not talking about heart attack studies or stroke studies in which the subjects survive, but the ones where the subjects have heart attacks, or strokes and DIE. Or worse yet, the baffling, "All-cause mortality" variable. Somehow removing or adding a single food item or group increases or decreases ALL-CAUSE mortality (i.e. your chances of dying--from anything, including, but not limited to, being struck by a falling piece of space debris.)
So avoiding food that kills you is somehow supposed not to reduce your chance of dying during a given time-frame? How is that? (We can even show that food alters all-cause mortality during a given time-frame  in the lab!) Conceptually, this is similar to lifespan and we know for a fact that it can be increased. Since some 80% of people die due to CVD and cancer it is obvious why we can ignore meteorites and black holes as a first approximation.
All-cause mortality can tell us for instance if cancer risk offsets CVD benefits of a treatment/life-style choice, or in a real world example, perhaps, if death from bleeding offsets the cancer and heart benefits of aspirin.

Or is mortality supposed to be a futile approach because we are all going to die anyway? If so, what good would be any other endpoint?

Fitness? Everyone will suffer muscoskeletal decline eventually making you bed-ridden and moribund.
Cardiovascular health? Nope, cardiorespiratory decline is a universal component of aging and usually the cause of death.
Skeletal health? What good is it if rates of osteoporosis approach 100% in the very old.
Cancer? Everyone gets it given enough time.
Why do you dress so fashionably? Why do you get up in the morning to buy milk? You are going to be ugly and dead anyway?
What, you are forming all those nice memories and enjoying the juicy flow of your neurotransmitters? Carpe diem. They will wither away with your intellect anyway! Neurodegeneration is obligatory to aging and the dead, rotting brain doesn't remember a thing.
OTOH, heroin is supposed to be better than sex. So does the author suggest we shoot some junk? After all, this will maximize quality of life and minimize quantity. (before coming down you inject more, obviously)

If anything, this is a very good reason to eliminate aging and disease altogether! Maximizing both quality and quantity of life. They are rarely uncoupled and a period of disease often precedes death, so that's another reason to study all-cause mortality (=all-cause morbidity).

All this can be avoided if you die early, but I suppose the author does not suggest suicide? "In general, people would rather have shorter, but higher quality lives." Maybe they will choose longer and better lives?

Is quantity really irrelevant? If you knew you are dying suddenly one year from now, would you ask for one more day before the deadline, or one less, to kiss your beloved ones goodbye and/or shoot some heroin? (What if the numbers were different?) So you really don't want to live longer while maintaining quality of life? To quote the voice of reason: "I simply cannot fathom why anyone would think that there is going to be a time when a basically healthy person will decide that they've had so much joy, love, intellectual challenge, engagment, sexual fire, fine music, or even gustatory experience that they just couldn't stand another day of it -- and in practice, I don't think anyone does."

I hope the above reductio ad absurdum clearly shows what is wrong with his line of thought:
Nothing makes sense in the face of death. The only possible response is complete moral, societal, intellectual and practical nihilism. Without exception this is rejected by some 99,9% of people intuitively and after reflection.
We fight for survival and a better life and we always did. Quality x Quantity. Not because we can win. We do it because it is the best of our terrible options. Ultimately, we are all doomed but we want to die with some fucking dignity on our own terms, as late as possible. The universe is a cold, harsh shit-hole, so be it.

The author simply does not realize that only considering quality of life leads to massive contradictions and problems:
If we accept the tenets that each of us has finite willpower to accomplish our goals, that our bodies do not differentiate between physical and non-physical forms of stress, and that death is inevitable and individually unpredictable, then we should all stop paying attention to long-term correlational mortality studies, because the very construct of all-cause mortality and its reduction is ridiculous. Any energy spent on following through on eliminating or adding said food item or intervention is energy taken away from that finite pool of willpower that could be used to live your life as opposed to attempting to circumvent death. Any stress caused by trying to keep said food item or intervention in or out of our lives is stress that is grounded on a faulty construct that death is avoidable and somehow controllable (or at least somehow predictable), and therefore, also ridiculous. 
Gee, by that logic we should do anything we like, no matter the risk, since we are going to die anyway. Personally, I always wanted to know how it feels to get blown over by a tornado and I do like the idea of playing Russian roulette or even living out my life as a gangster. Somehow I don't see this happening.

"No lifestyle decision comes without cost. Arguably, no decision at all comes without cost."
Trivial and true. That's why we use different external incentives as public health measures. Taxes, for example.

Somehow, in total, people are making much better choices today than they did 150 years ago as proven by Dr. Actuarial Tablèz, past and present. Even though they have limited decision capabilities. (My thanks go out to science. We don't eat charred or spoiled food anymore. We wash our hands after taking a dump and before performing open heart surgery thanks to Dr. Semmelweis. We don't throw feces out the window, instead we flush the toilette. We vaccinate, etc. All of this comes easy to us. We need to make all new public health measures also feel that easy - but the options are endless)

However, when it comes to making life choices based on evidence, and the cost of these choices in the face of what appears to be a faulty gamble for death-avoidance, the trade-off might not be worth it...
Again, having enjoyed your life will be somehow useful when you are worm-food?

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