Aging and the Goals of Author(s): Source: Report, Vol. 24, No. 5 (Sep. - Oct., 1994), pp. 39-41 Published by: The Hastings Center Stable URL: http://www.jstor.org/stable/3563499 . Accessed: 29/12/2013 03:49

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This content downloaded from 193.0.118.39 on Sun, 29 Dec 2013 03:49:40 AM All use subject to JSTOR Terms and Conditions Hastings Center Report, September-October 1994

aging as if it is tantamount to a dis- ease to be overcome is to open the way to an unlimited and insupport- and the Goals able claim on health care resources. Aging If the diseases associated with aging bring about pain and suffering, as Medicine they do, then there is the basis for a of time-honored claim to throw at them the same kind of research and re- by Daniel Callahan sources as we throw at them at other stages of life. There are many who make exactly that claim, in the name of equality and age-blind social policy. If, in contrast, we want to pursue the ging poses a peculiar puz- ago and pursued most recently by idea of building policy on the basis of zle for medicine.As a bio- Dr.James Fries: accept aging as a bio- some kind of reasonable natural or logical reality, aging is an logical given but work medically to cultural limits to such unlimited inherent part of organic reduce the illness and disability asso- claims, we are open to the charge of life, affecting humans no less than ciated with it. That heuristic ideal, the ageism and to that of turning our animals, plants, and microorganisms. "compression of morbidity," seems back on medical advances that could It is in that sense beyond the realm of the perfect answer;and it might be in improve the life of the elderly. medicine, a permanent backdrop to the best of all possible worlds. Unhap- There is no easy way out of these all of life. But aging is also ordinarily pily, nature has not nicely played its dilemmas of policy, but they might be accompanied by disease, bodily de- assigned part and, so far, there is not helped if we can sensibly frame the cline, and disability. It is thus well much evidence that any such thing is right questions to pursue about two within the realm of medicine, whose happening to any significant degree. principal ingredients of the dilemma: historical mission has been the cure It has been little noted, moreover, the nature of medicine as a practice of disease and the relief of pain, each that for the compression of morbid- and an institution, and of aging as a much desired by those who grow old. ity to actually work we would also problem of biology and human mean- Yet is it necessarily true that aging have to forswearintensive medical in- ing. Let me propose two broad ques- as an inherent part of life is beyond tervention at the end of life. Might it tions we might begin with, each bear- the realm of medicine? If genetic en- not happen that many of those who ing on the other: gineering or other scientific advances lived so nicely and well until eighty- * What could fundamentally change the phe- five would be unwilling to let go-just understanding of the nature nomenon of aging--extending life becausethey had lived so well-there- and goals of medicine is most likely significantly, for instance, to forestall by setting the stage for a resumption to be helpful to the aging and aged the sicknesses of age-would it not of the now-familiar technological in the future? then come within the traditional battle against death? Another possi- * What understanding of the mean- of sphere medicine? Why should bility presents itself also: if we do not ing of old age is most likely to foster medicine not attempt to manipulate achieve a compression of morbidity, the most helpful kind of medicine? the biology of aging rather than, as it and lengthening life spans bring in- now does, only the deadly and un- stead an increased burden of illness Of course what I mean to suggest pleasant clinical and psychological and disability, will we not then feel by these two questions taken together manifestations of that biological compelled to intervene more deci- is that there is, and must be, a recip- process? Should we go so far as to sively into the biology of aging to rocal relationship between medicine make the moral judgment that aging combat that trend? Put another way, and aging. On the one hand, the bio- is in and of itself humanly unac- could it already be the case that we logical and technological possibilities ceptable, a worthy candidate for have come so far along the road in of altering the aging process will scientific intervention and even for the extension of life, and so far along shape our ideals and expectations eradication if we are clever enough? the road in the accumulation of the about aging. On the other hand, what There is, to be sure, a classical com- chronic and degenerative diseases of we want aging to be will help shape promise response to those questions, aging, that only some radical the research and clinical agendas of first mentioned by the French philo- can save us? medicine. We cannot, in short, any sopheCondorcet two hundred years I want to suggest with these trou- longer think about human aging bling questions just how difficult it purely as an independent biological will be to come up with good answers, phenomenon (though on occasion Caahan is the The Daniel presidentof and just how portentous any set of it is worth trying to do just that). Center Hastings answers is likely to be. At the least, Human aging is, we now know, plastic with a and num- to some as unknown and Daniel Callahan, "Agingand the Goals of Medi- growing proportion yet degree cine," Hastings CenterReport 24, no. 5 (1994): ber of elderly in every society, there is open to scientific change. We no less 39-41. a critical policy issue at stake. To treat know that cultural attitudes and prac- 39

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tices affecting our conceptions of the for the time being it is sufficient to that it does not entertain unlimited social and individual meaning of add additional years slowly. And if a progress as a goal of medicine or a aging are open to change as well. full compression of morbidity is not goal of aging. It is based on the Aging is as good a place as any to yet on the horizon, there is no reason rhythm of the life cycle as a way of observe the social consequences of we can't do something about osteo- providing a biological boundary to medical progress, most notably the porosis, Alzheimer disease, and ar- medical aspiration. This view looks to historical move from palliation to thritis in the reasonably near future. find a decent harmony between the cure as a principal goal of medicine; More generally, progressive incre- present biological reality of the and then from a narrow definition of mentalism is sustained by the belief human life cycle and the feasible, af- health, focused on the body, to a that medicine has no final, inherent fordable goals of medicine. It seeks, broad definition, centering on the teleological goal for the elderly, and that is, to prudentially balance bio- entire well-being of a person; and that it can and ought to go as far as logical possibilities and economic then awayfrom a static, nature-bound we want it to go. There are no intrin- constraints on realizing those possi- picture of the possibilities of living a sic biological limits-or at least we bilities. This view need not deny that life to a more open, wish-driven pic- will not know that unless we keep considerable future progress in lon- ture where nothing seems utterly im- pushing the present limits, which al- gevity is possible. What it does deny is possible. What that process shows is ways seem to give way-and there are that such progress will necessarily be not just medicine changing but, no necessary moral limits, assuming of great human benefit, or that it is simultaneously, the culture with we are sensible enough to use ordi- worth a great economic investment, which it interacts. In the case of our nary common sense and sociomedical even if it may only satisfythe wishes of culture medicine is drawn to the pro- prudence along the way. There is no some individuals. Neither does it motion of autonomy and scientific in- reason we should not seek both to deny the value of aiming for a com- novation, the fashioning of an old extend average life expectancy indef- pression of morbidity, even though it age of one's choosing with whatever initely and to aim for a compression holds that there is nothing in nature, technology lies at hand, not bound by of morbidity as we do so. or the evidence to date, to suggest previous biological or historical mod- There is a social dimension to this that compression will easily be ob- els. The ideology of the anti-ageism incrementalism. It is, first of all, con- tained. It would, however, point out of campaign recent decades is in part sidered dangerous to think of the that if longevity and a compression of rooted in deeply individualism, cele- elderly in the aggregate as a discrete morbidity are sought simultaneously, brating the diversityand heterogene- group, or to think of individual elder- the outcomes of the former may con- ity of the old-not what they share, ly in general terms. Here the individ- tinually undermine the achievement which is the fact that they are at the ualism of anti-ageism comes to the of the latter. end not the beginning of their lives. fore, arguing that for policy purposes The goals of medicine that lie be- The article by Harry R. Moody in age is no more relevant than height, hind life cycle traditionalism are this issue skillfully sets forth some eye color, or ethnicity. Just as medi- those of helping people to remain in different scenarios about the elderly cine should have unlimited horizons good health within the boundaries of and the allocation of resources, each in treating the elderly, so our culture a finite life span, and helping them to of them drawing upon different no- should focus on the possibilities of cope well with the poor health they tions of how we might think about individual development in the elder- may have. It is thus a more modest and health care. I want aging to sug- ly, shorn of stereotypes or fixed boun- view of medicine's appropriate goals, gest another cut at the issues, com- daries. We need not worry about in- aiming to restore and maintain plementing his but moving in a some- tergenerational strife because we will health within a limited time frame what different direction. Two distinct all pass through each stage of life: the rather than substantiallyimprove the models of the goals of medicine and sensible young will not see themselves human condition. It does not treat response to aging can be discerned, in competition with the needy old but aging as a disaster to be overcome, not formally articulated perhaps but will see in the old their own future but a condition to be alleviated and nonetheless in implicit some familiar lives. ameliorated. Even though individual ways of discussing the problem. I will Progressive incrementalism, in elderly people will differ in their phys- call one of these models "progressive short, combines a view of medicine ical and mental condition, they share incrementalism," and the other "life and its possibilities with a view of ag- the common trait of being elderly, cycle traditionalism." ing and its possibilities. They work that is, they are proportionately together, each stimulating the other: much closer to the end of their life Progressive Incrementalism medical progress provokes new vi- cycle than to its beginning or middle; sions of what old age could be, and and as a are incrementalismI mean consequence they more By progressive what people hope for from old is to illness and death an to that is dedi- age subject than approach aging an impetus to medicine to provide it. Old combines a cated to unlimited in the younger people. age progress in life and a run but cultivates in- biological stage social long small, Life Traditionalism status in and cremental in the short run. Cycle society, it is not inappro- steps priate that they be understood as in- life can be in- An alternative view I call "life Average expectancy cycle tertwined. The same is true of creased to an unknown extent, but traditionalism." It is traditional in every other age group. 40

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For policy purposes, the group of any substantive meaning it might a pertinent social category, by re- characteristics of the elderly are as once have had as an honored stage in sisting the notion that the diseases of important as their individual varia- an inevitable life cycle. Apart from aging are just one more biological tions. Those characteristicslegitimate ideological commitments, no one re- accident to be conquered with better age-based entitlement and welfare ally knows now what to make of old medicine, and by accepting the possi- programs as well as social policies de- age. bility that an excessive individualism signed to help the elderly maintain so- My own bias is that the life cycle in thinking about the elderly could cial respect. They could also be used to perspective is the most promising run roughshod over the needs of the sanction a limit to those entitlements way of making medical and human young. in the face of resource scarcity.The sense of our aging. It remains the The goals of medicine in the face of campaign against stereotyping the most compatible medically with the biological aging should be, above all, old as demented, frail, and burden- actual results to date-still more to target those physical and mental some is valid and badly needed. But hope than reality-of efforts to over- conditions that tend to rob old age of there is a difference between a stereo- come the disabilities of old age. It human meaning and social signifi- type and a policy generalization. All offers a better possibility as a frame- cance. Medicine cannot create that elderly are not demented or frail. Yet work for individuals to come to meaning, which must come from in- it is a reasonable generalization to say terms with their aging, not holding dividual reflection and social policy that the elderly are at greater risk for out the expectations that the vigor and practices. But it can enhance the dementia and frailty than young of youth or healthy middle age will background physical and mental people-and thus to devise special be indefinitely sustained-and thus conditions necessary to make that policies to help the elderly based on not engaging in that most subtle but task a little easier.Yet it can only do so those generalizations. devastating disparagement of old if it strenuously resists that most age that the scientific fantasies in- powerful of all medical temptations, Setting a Course for the Future evitably feed, seeing it as nothing the vision of a direct and invariable more than a condition to be over- correlation between medical prog- The two contrasting models I have come. The life cycle perspective also ress and human happiness, which offered differ both in their interpre- enhances the possibility of devising conflates the quest for meaning and tation of the proper goal of medicine an equitable health care policy--by the quest for health. They do not go and in the meaning of old age. Pro- recognizing the relevance of age as hand in hand. gressive incrementalism has soaked up the optimism and ambition of modern science, its sense of wonder and hope in the face of a sometimes hostile nature. The nature that brings ConferenceAnnouncement human beings down at the end of their lives can be changed. For its Care TheSearch part, the meaning of old age is no less Health Crisis? forAnswers malleable, and medical progress can, 31March-I April 1995 together with enlightened social policy, change that meaning. Cosponsored by Life cycle traditionalism is more University of Florida Health Science Center skeptical, noting the difficulty that The American Medical Association science is actually having in sunder- The Hastings Center ing the connection between getting old and getting sick, in overcoming Topics the sheer stubbornness of those Medical chronic and conditions Futility degenerative Health Care Reform that mark our modernized old age; Health Care and it sees no reason to in- Rationing special Lessons from Other Cultures dulge the dream of a transformed old age. It notes as well a certain perver- KeynoteSpeakers about the we have actu- sity progress Daniel Callahan ally witnessed: there has not been a Arthur Caplan heightened, or rejuvenated apprecia- Leighton Cluff tion of the social role of the elderly because of their longer lives and larger number. Instead, because of a For information: Kathy Murphey, Division of Continuing Education, pervasive ambivalence about whether PO Box 100233, University of Florida, Gainesville, FL 32610-0233; aging is to be fought, rejected, and (904) 392-3143; (904) 392-7337 fax. resisted, or graciously accepted and embraced, old age has been robbed 41

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