Junto Boys

THE AGING OF AMERICA

Our aging population creates serious economic, social, legal, medical, and ethical dilemmas with important cultural implications. This excellent article treats the issues with sensitivity and intellectual honesty, albeit with a conservative bent.

Following are excerpts from the long article, with some summarizing and paraphrasing by this editor. I attempted to maintain the core content and flow intended by the authors.

Cast Me Not Off in Old Age

Commentary, January 2006, by Eric Cohen & Leon R. Kass

Today, old age is the norm. Average life expectancy in the United States is now seventy-eight years and rising (up from forty-seven in 1900), and those over age eighty-five are already the fastest growing segment of the population.

Roughly 40 percent of deaths in the United States are now preceded by a period of enfeeblement, debility, and often dementia lasting up to a decade. That number will rise substantially in the coming years.

Yet precisely as the need is rising, the pool of available family caregivers is dwindling. Families are smaller, less stable, and more geographically spread out.

All this creates a perfect social storm.

Medical progress often leads to greater debility in later years even as—and precisely because—it cures deadly diseases at earlier ages. This is the paradox of modern aging: we are vigorous longer and we are incapacitated longer.

Medicare and Medicaid are costlier because more people are living longer

Endless chatter about “healthy aging” is at bottom a form of denial. Our vitality, our faculties inevitably degenerate.

In 2001, the completion rate of living wills nationwide remained under 25 percent, and even the chronically ill do not draft living wills in significantly higher numbers. Further, living wills often do not get transmitted to those making medical decisions. Finally, the written instructions contained in living wills—even when they are consulted—often have little effect on the actual decisions made. What mattered most was a lifetime of familiarity: family members predict patient preferences better than physicians, and primary-care doctors better than anonymous experts reading legal documents.

Is a daughter simply to be the executor of her father’s wishes, or is she first of all a moral agent with her own moral responsibilities?

And what about the professor himself? One can admire his desire to spare his child the burdens of long-term care and the pain of witnessing his extended demise, but he is probably deluded in thinking that accelerating his death will prove less painful to her.

No legal instructions written in advance can replace the need for loving and devoted caregivers. The living will perpetuates an illusion of perfect independence, isolating individuals at the very moment when they need others most of all.

However, trusting others makes sense only if there are others who are trustworthy—willing to care, able to care, wise enough to care well. Sad to say, this is often not the case—either in medicine or in families.

We stand in greatest need of family doctors and general practitioners just as medical super-specialization has turned them into endangered species. One doctor treats our failing heart, another our wheezy lungs, a third our sluggish bowels, a fourth our tired blood, and a fifth our fraying nerves, but often no physician is willing or able to look after us.

In an aging society, we stand in greatest need of families just as family life has been most weakened. When a neglectful parent needs care from their children, the sins are often repaid in kind.

Studies indicate that only someone with three or more daughters or daughters-in-law can reasonably expect to escape institutionalization for long-term care. It is passing strange for a whole society of adult children to be summoned to care on a long-term basis for those who once cared for them. As the Yiddish proverb has it, “When the father helps the son, both laugh. When the son helps the father, both cry.” No child wants to uncover the nakedness of his father or mother. No mother or father wants to stand incompetent before the children.

More fundamentally, there is also a disruption of the naturally forward-looking thrust of intergenerational life. For a grown child best “repays” the gifts of his parents by raising children of his own, and grandparents have a greater interest in seeing grandchildren flourish than in maximizing the comfort of their own last days.

Are we really helping Dad by extending a life that seems so diminished? Is that life still worth living? Until now, our society has been largely spared such questions. Most Americans are committed—at least in the abstract—to the view that all human beings are “created equal.” But as we saw in the Schiavo debate, this general agreement regarding equal human worth can disappear in certain cases. As the American population ages, we can expect to hear even more talk of people with “low quality of life,” unworthy of the resources “wasted” on them.

Against this danger, the assertion that “life is sacred and should always be sustained” will prove an insufficient defense. Is it love or is it cruelty, for instance, to cure the pneumonia in an elderly person suffering from a painful form of terminal cancer?

Traditional medical ethics has been very clear about its duty never to kill, always to care. But traditional medical ethics has also long taught that benefiting the life a debilitated person still has does not mean taking every possible medical action to extend it. And so, while “active killing” may be incompatible with true caregiving, “letting die” is always part of it. Yet as we enter the mass geriatric society, it is clear that our new technological capacities are putting pressure on these sensible distinctions.

Here then is the most poignant dilemma faced by caregivers: not wishing to condemn the worth of people’s lives, yet not wanting to bind them to the rack of their growing misery; not wishing to say they are better off dead, yet not wanting always to oppose their going hither.

How we age and die are not only private matters. Our communal practices and social policies shape the environments in which aging and caregiving take place.

We cannot pretend that individual families, or society as a whole, will have unlimited resources, particularly in a populace with more elderly persons and fewer young workers. Americans will need to make hard choices among competing goods, and to confront the limits of even our own affluent society.

Americans increasingly regard old age as a bundle of needs and problems demanding solution, or as a time of life whose meaning is defined largely by the struggle to stay healthy and fit. This outlook has generated discontent with the life cycle itself, producing an insatiable desire for more and more medical miracles, and creating the fantasy that we can transcend our limitations—or that death itself may be pushed back indefinitely. More deeply, this same outlook has engendered the illusion that independence is the whole truth about our lives, causing us to undervalue those attachments and obligations that bind and complete us.

We live already in a world in which the life cycle has largely lost its ethical meaning. Aware as we may be that we are on a solitary journey that ends inevitably in the grave, few of us take our bearings from nature’s eternal teaching that there is a time to be born and a time to die. We learn little from the rhythm of growth and decay, everything in its season, our own finitude transcended and redeemed by generation upon generation of new birth and renewal, transforming each singular finite trajectory into a permanently recurring cycle of life.

This cultural myopia is no trivial matter. Indeed, in the mass geriatric society it could have deadly consequences. For unless we learn to accept both our frailties and our finitude, we are likely to find the burdens of caregiving intolerable. And unless we learn how to let loved ones die when the time comes, we will be tempted to kill—self-righteously, in the guise of a false compassion. Sooner or later, when the medical gospel of healthy aging and the legal gospel of living wills are shown to have been false teachings, we may easily fall prey to the utilitarian gospel of euthanasia, whose prophets are patiently waiting in the wings for their time upon our cultural stage. Paradoxically, a dogmatic insistence that patients must be kept alive regardless of the depth of their disabilities—that severe dementia or unmanageable suffering deserves no consideration in deciding when to “let nature take its course”—may only make mercy killing appear to be the more compassionate remedy for the miseries of extended decline.

In the end, there is no “solution” to the problems of old age, at least no solution that any civilized society could tolerate. But there are better and worse ways to see our aging condition. The better way begins in thinking of ourselves less as wholly autonomous individuals than as members of families; in relinquishing our mistaken belief that medicine can miraculously liberate our loved ones or ourselves from debility and decline, and instead taking up our role as caregivers; and in abjuring the fantasy that we can control the manner and the hour of our dying, learning instead to accept death in its proper season as mortal beings replaced and renewed by the generations that follow.