When it comes to the issue of ageing global trends are clear: people are living longer. According to a report by the US Department of Health and Human Services, people over the age of 65 will soon outnumber children under the age of five. By 2030 the number of people aged 65 and older is projected to reach 1billion. Falling birth rates only help to further compound the effects which an ageing population pose.
Consequently ageing is an issue which simply cannot be ignored and one which will undoubtedly cause us all to assess our attitudes towards the aged and address moral, ethical and social questions concerning medical care.
It was with these issues in mind that BioCentre was pleased to co-host a seminar on the topic of ageing with King’s College London’s Institute of Gerontology and UCL Grand Challenges of Wellbeing on Thursday 14th October 2010.
Entitled “Living longer: who wants to live forever?”, the seminar was the third in a series funded by the ESRC and convened by the Institute entitled The 'New' Ageing Populations: Mapping identities, health, needs and responses across the life course.
The potential of new ageing populations’ extending lifespans opens new fields for discussion of bioethics and in particular the issue of limits to longevity. As a result the seminar sought to explore what bio-gerontology can tell us about increasing longevity as well as considering the social implications of increasing lifespans. A cohort of older adults is emerging who engage the most high-tech life extension therapies in later life. This population is growing exponentially in the U.S., and perhaps elsewhere, and will continue to do so as technologies for longevity-making proliferate.
Speaking at the seminar were three speakers who together represented a wide range of expertise and knowledge in the field of gerontology and longevity studies. Professor Sharon Kaufman, professor of Medical Anthropology at Institute for Health & Aging, University of California, San Francisco; Dr. Chris Gilleard, Honorary Research Fellow in the Division of Research Strategy at University College London Medical School and Dr. Guy Brown, Senior Lecturer at the Department of Biochemistry, University of Cambridge with a particular interest in ageing from the angle of cell physiology and pathology.
The present
Professor Kaufman gave a particularly engaging and nuanced paper on ‘Making longevity in an ageing society-Linking technology, policy and ethics’. Kaufman sought to address two key questions; first how do we know and live old age today and secondly, what does it mean to be old in a time of high-tech medical intervention?
Drawing upon her research in the US, Kaufman ably demonstrated that the ripple effect of significant advances in technology has been tremendous with the result that a plethora of life extending interventions now stand on offer to older people. Moreover, medical knowledge has been transformed as has societal expectations of longevity, normal old age and time for death. Kaufman commented that there is now a deeply entrenched tension emerging for families and patients to balance between a desire to and ability to cure disease and extend life by any means on the one hand and a widespread societal cry (particularly in the US) to resist interventions that prolong suffering and dying on the other. The ensuing cultural assumptions and expectations about growing older have given rise to what, in her view, is a new form of ethical rationality. This has been formed through new political economic structures and enabled through structures of clinical care. In essence this new rationality, according to Kaufman, has helped to build upon early bioethics and to some extent also helped to displace it. Whilst normative concerns of bioethics remain there are new complex problems which emerge where politics and economics of health care, along with powerful technologies and the bureaucracies which affect their use, help to impinge upon medical practice and the lives of patients and families.
It is 'located' in and shaped by health care policies, standard technologies and clinical evidence. It emerges in what physicians understand as standard care and in what patients and families come to need and want. Certainly the simple but profound statement, “changing the means, changes the end” seems to ring true. With every increasing technologies being trailed and tested and brought to practice, there comes with it a transformation of what is regarded as the end of life. If you are suffering from a life threatening condition which could be addressed by a new intervention which could give you an additional 5-10 years of life, who would not take serious time to consider the implications?
Throughout this discussion, Kaufman illustrated her points with field research she had undertaken in the USA, which touched upon cases to do with cancer treatment, organ donation and cardiovascular disease. Such examples helped to ‘earth’ the rest of her material in a very poignant and succinct way.
To close, Kaufman helpfully summarised and posed some critical questions for further consideration. Medicine has always pushed the boundaries of what is possible. But the difference today is found with regard to greater age, greater expectations and the new kinds of clinical and emotional burdens that these interventions foster. For the medical profession those burdens include weighing the clinical evidence against the technological imperative and what some refer to as ‘indication creep’ in reference to the expanding use of drugs and devices. For patients, those burdens include the pursuit of treatments in order to stay alive, in certain cases sometimes for their families. For families, the burden is living with questions which are becoming all too common. Should I encourage him or her to have this treatment? What are the consequences if I do not? Am I a good enough spouse or child if I do not offer part of an organ or push for aggressive intervention? Clinicians need to be aware that these questions exist and although they may not be articulated during consultation, nevertheless they do remain and are often uppermost in the minds of patients and family members. The new ethical rationality, fostered by evidence based medicine, policy decisions and the technological imperative and the ways in which technology shift the ends of medicine, guide people towards the new treatments which are constantly emerging. Clinicians are aware that certain treatments are a double-edged sword for the very old and yet they want - and we want them to – to provide life-extending options. Older persons on the other hand are mainly ambivalent towards these treatments but do not want to authorise their own deaths to reject a potential life prolonging therapy. Conversely, families do not want the responsibility of saying no. Thus, the science, the policy, the culture of medicine, doctors, patients and families all help to shape the contours of longevity making today. The tension between the desire of making the older body ever more malleable and to extend life because we can and the desire for a death without technological interference will not disappear. In Kaufman’s view, this tension will become all the more pronounced given the open ended promises of bioscience to increase longevity, but also due in part to the recent focus in academic medical centres on translational research which connects the promise of the medical laboratory with clinical practice like never before. This connection focuses the attention on the technological imperative which becomes an ethical obligation. The ancient ethical question of ‘how to live’ now includes, at least in the USA, reliance on medical intervention and at every life stage. This fact is new and creates new ethical dilemmas in the USA and may well become dilemmas for Britain and other European countries.
Past
Shifting the focus from the present back to the past, Chris Gilleard presenting an enlightening paper entitled Renaissance treatises on ageing well. In the late fifteenth and sixteenth centuries, numerous books were written on the subject of ageing, longevity and living well. Gilleard set out to consider why these books were written and their intended audience and secondly to address the key themes covered in the books. Gilleard suggested that much of the literature at this time derived much of their content from Galen and his Muslim commentators, the idea of the natural and the non-natural aspects of ageing and the particularly contested status that ageing had in his writing and the implications that had for prolongevity doctrines.
Gilleard gave the audience a rich tour of medieval writings including that of Galen but also of Cornaro’s Discourse on a temperate life and Gabriele Zerbi. During the course of his talk, Gilleard also made mention of virtue within the context of approaches to ageing. Possessing a much broader meaning than perhaps with Aristotle’s list of virtues, during the renaissance it meant goodness. Thus, a virtuous life was regarded as a long life because of how you have lived it. Consequently, in summary the renaissance perspective on ageing linked on the one hand the medieval tradition rooted in Christian tradition and on the other a more classical tradition informed by the teachings of Cicero et al of a life lived well.
Turning to address his second question, Gilleard proceeded to draw out similarities as well as points of difference between these treatises and contemporary writing on successful ageing. For example, there was preoccupation in Italian city states with food and drink, much like it is today! For example, Cornaro was often regarded as someone who advocated eating very little, yet in actual fact he was someone who ate fairly well. This contrasts significantly with the likes of Zerbi and Fercunio a 15th century writer who approached the issue with a far more esoteric perspective, advocating such actions as drinking human blood as being good for the ageing process, particularly if the blood was taken from a young virgin and drunk when the moon was full! On the matter of sleep, sleeping during the day time was not recommended but a good and complete sleep during the night was strongly recommended. Moreover, once you had had a good night’s sleep, lying around in bed was not advocated; once awake you should get out of bed promptly. Furthermore, other writers of the time event wrote on the position to taken when asleep. Concerned with issues such as liver cancer, one such writer advised should the liver fall upon on the stomach and depresses it, sleep on the right hand side and then change to the left hand side so that the vapours retained whilst sleeping on the right may be breathed out.
In contrast to contemporary advice on the matter of sex, during the renaissance it was shunned with advice being given that if it was to be engaged in at all it should not be during the summer. This was framed by the understanding of ‘sexual emissions’ at that time and how they were regarded as draining the life blood of the body. In general, a certain amount of blood letting, vomiting and purging was preferable but not in excess. Likewise, in stark contrast to contemporary culture, rest was advocated in abundance with little attention given to exercise. In fact, those who were of a scholarly disposition were even strongly advised not to exercise!
Gilleard concluded that renaissance writings focused on lifestyle and how to live life well. There was a merging of religious understanding from the medieval tradition with that of the classical. At is heart it was not so much gerontology but more how to live well.
The Future
Turning to the future, Dr. Guy Brown talked on ‘The Future of Ageing’ drawing upon key points made in his recent book ‘The Living End’.
Brown approaches the issue of ageing from the perspective that ageing is not natural: it was rare in humans and wild animals prior to the modern age. In last 200 years, human longevity doubled, while the rate of ageing remained largely unchanged. The result is: an ageing population, a degenerative end to life, and a switch from digital to analogue modes of death. This is perhaps one of the most interesting points to Brown’s argument - ‘digital’ and ‘atomistic’ theories of the self. The mixture of continuity and change that characterise our lives, he argues, maps poorly onto the on-off model of life and death that our culture tends to espouse. Instead, Brown proposes a ‘wave’ model of the self, which emphasises continuity and the change that form human ‘selves’.
Using a good mix of statistical analysis (as covered in his book), Brown posited his main argument of preventing the end-of-life from becoming a living hell depends on rebalancing our investments in life (preventing age-related disease, disability and dementia) relative to simply preventing death. Otherwise we are doomed to the Tithonus scenario, as found in Greek mythology.
In essence, Brown sought to argue from the position in favour of an analogue model of death, but focusing above all on the maximisation of live worth living. Rage, against the dying of the light, he implores, because the deaths we are dying today are unnatural and should be resisted by research into aging and dementia; we should seek medicine that does not turn acute diseases into chronic ones, but that maximises life.
Reflections
By providing three different presentations which helped to span the time frame of past, present and future, the afternoon’s seminar provided the audience with a rich and diverse range of material with which to ponder the future of ageing.
From Kaufman’s presentation it was plain to see the impact of new emerging technologies on helping to shape policy decisions and clinical practice when dealing with the older person. Once again the issue of just because we can do something does not necessarily mean we have to comes to the surface. With the debate over euthanasia continuing to bubble away here in the UK and in other parts of the world, one cannot escape the perennial question of what is the physician’s obligation. Hippocratic Oath versus principlism, epitomised in Beauchamp and Childress? To heal or to work with the patient in order that they make an informed decision? One of the more poignant points in Kaufman’s presentation was when she relayed details of some field research where a family member, who was working through with a relative whether or not to accept treatment for a life threatening condition, said “If you have cancer but reject treatment, is that suicide?” ; a question that has clear association with questions surrounding euthanasia. As a starting point, might the principle of double effect, despite its weaknesses and criticisms levied against it, has something to offer in terms of answering this question?
Gilleard’s presentation served as a helpful reminder that in fact a “good life” can so easily hinge on lifestyle choices and decisions whilst at the same time realising that life is finite and rather than try and cheat death, acknowledge its existence whilst maximising the life lived. In many respects as one considers the afternoon’s discussions and the implications of an ageing population, one cannot fail to realise the impact of death and how fear of it probably helps to undergird much of the work done to try and overcome it. To be clear I do not look forward to death with eager anticipation and would seek to live out my life as much as possible. Nevertheless the question demands an answer - how comfortable are we with the finitude of our lives? When so much of our lives are framed by time, deadlines and restraint, surely one might conclude knowing we have a set time frame to live would be something to be embraced.
Brown picked up on this theme of maximising life as he looked to the future of ageing. His impassioned plea to channel attention to not only dealing with acute disease but also towards chronic disease so as to maximise life is a worthy one and warrants further discussion. Just how this would work Brown appears to offer no initial pointers – either in his presentation or his book. Yet the strength of argument demands further engagement.
Despite the difficulty of these issues, as the new ageing population continues to rise this set of questions will not disappear but rather increase. The impact of ageing and whether or not death is a disease to be cured at all cost will no doubt continue to shape and have a profound effect on the development of medical practice in the days to come. If Kaufman’s proposal of a new ethical rationality is anything to go by, the need for a new and fresh ethical discourse on these issues has never been so pressing.
Audio downloads from this seminar will be posted shortly on this website.
The next seminar in the series, Should we try to live forever? will be held at King’s College London on Wednesday 26th January 2011. The speakers will be Bryan S Turner, Alona Evans Distinguished Visiting Professor of Sociology at Wellesley College, Yale University and Aubrey de Grey, Chief Science Officer of the SENS Foundation. BioCentre is pleased to announce it is co-hosting this event once again with King’s College London.
To book a place at this free event, please email newagepop@kcl.ac.uk
