In its long-standing ambition to forestall death, medicine has in the care of the aged reached its last frontier. It is not that death is elsewhere absent -- for children and young adults still die of maladies that are open to potential cure -- but that the largest number of deaths occur among those over the age of 65, and the highest proportion of all in those over 85. If death is to be humbled, that is where the essentially endless work needs to be done.
Yet however tempting that challenge, medicine should now restrain its ambition at that frontier. It should give up its relentless drive to extend the life of the aged, turning its attention instead to the relief of their suffering and an improvement in their physical and mental quality of life.
So great is the desire for life and the fear of death that I have no hope that such a view of the goals of medicine in the face of aging could have any persuasiveness were it to stand alone. A fresh understanding of the ends and meaning of aging, encompassing two conditions, should complement it.
The first condition is that we need, both young and old, to understand that it is possible to live out a meaningful old age that is limited in time, one that does not require a compulsive effort to turn to medicine for more life to make it bearable. The second condition is that as a culture we need a supportive social context for aging and death, one that cherishes and respects the elderly while at the same time recognizing that their primary orientation should be to the young and the generations to come, not to the welfare of their own group.
A common classical view of old age was that it should be accepted and that old age was actually superior to youth because of its ripeness, wisdom and experience. A more recent belief, common in the 19th century, was that because of the rapid pace of social change, the future is best left in the hands of the energetic and adaptable young. The modernization of aging, a view potent in our century, represents a still more advanced stage, far more radical: To be old is potentially (if not quite yet) better than to be young because it is the new frontier of medical progress, of personal freedom and individualism, and of styles of life that could transform our society.
Under this last dispensation, the aged are not at all a surplus group, or merely "senior citizens" serving out their time until death. They are the new pioneers. The kind of healthy, self-directing, self-realizing, past-transcending life they are now in principle able to live becomes the medical, social and political goal, the ultimate reward of a progressive and medically enlightened culture.
The terms "modern maturity" or "prime time" have, after all, come to connote a life of travel, new ventures in education, the ever-accessible tennis court or golf course, and delightfully periodic but gratefully brief visits from well-behaved grandchildren. That this idealized picture leaves out the elderly poor, the chronically ill, minorities, and single or widowed women over 80 is beside the point. Its importance as a utopian reference point lies in its projection of an old age to which more and more believe they can aspire and which its proponents think an affluent country can afford if it so chooses.
This is a picture of old age that is, in fact, a rejection of decline and debility. It is instead a vision of old age as endless middle age, where one remains in full power and control for as long as that is medically possible; and with enough research and social support, there is no fixed limit on how long that might be. The self-pretense of most of us who are on our way to old age -- that we are not actually aging at all -- becomes the norm and the actuality.
That a goal of this kind requires a biomedicine that is single-minded in its aggressiveness against the infirmities of old age is of a piece with its hopes. Just as the old do not have to live, as they did in the past, in graying self-effacement, so neither do they have to tolerate the disease-riddled bodies that were the fate of previous generations. Why not in effect declare aging a disease and lavish upon it the same attention once devoted to high infant-mortality rates and smallpox? The success of campaigns against the latter provides ample ground for hope that the same can be done with aging. Why not? Why not indeed? Iconfess to a certain sheepishness in judging that this wonderful idea of a modernized aging is fatally flawed. It surely and undeniably has its attractions, and I will benefit from many of them. But quite apart from some still-to-be-conquered social and biomedical realities that may prove to be permanently elusive -- the vast increase in chronic illness that has been part of the life-expectancy extension of the elderly, the persistent and so far intractable poverty of a significant minority of the elderly, the growing number of small, often fragmented families and thus most likely isolated elderly people in the future -- there are more serious reasons to be skeptical.
The modernizing project lacks that most important of all ingredients for old age: a sense of collective meaning and purpose. It is instead simply a prospectus for an individualistic old age as more of the same -- more freedom and less responsibility, more years and less poor health -- but with no illumination whatsoever about the meaning or significance of those added years, no purpose or goal for which those goods are to serve as a means.
In the face of this drive, too little examined, two questions now need to be posed. How should we specify and pursue the appropriate goals of medicine in the light of the new possibilities of old age as a stage of life? The second question is the converse of the first: How should we specify the meaning and role of aging in light of the new possibilities of medicine?
I want to argue that medicine should be used not for the further extension of the life of the aged. Instead, it should be used only for the full achievement of a natural and fitting life span -- which can be achieved by the late seventies or early eighties -- and thereafter for the relief of suffering only. At the same time, we need to clarify the goals of aging.
The primary aspirations of the old should include, among their own reasonable needs, the needs of their fellow elderly and of their families, as well as the welfare of the young in general and of the coming generations. The complementary goal of medicine should be to help the aged maintain a physical and psychological life sufficient to enhance the realization of those aspirations; that is, not more life as such, but a life free of whatever pain and suffering might impede these ends.
There are now and will be in the future better ways to spend our money than on indefinitely extending the life of the elderly. That is neither a wise social goal, an economically affordable goal, nor one that the aged themselves should want, however compellingly it must attract those of us who are either already old or close to it.
Unlike the goal of extending life, that of seeking to improve the quality of life of the elderly points to an additional set of considerations that should be part of medicine's self-reflection. How should the good that is health, a primary good certainly, be understood in the constellation of other human goods? Those include education, culture, economic prosperity, national defense, scientific research, and so on. Health itself, we sometimes need reminding, is a means and not an end. We can do nothing with good health itself; it makes other human goods and values possible. But we need to know what those goods are and how they are to be balanced against the value of health.
A goal of the extension of life combined with an insatiable desire for improvement in health -- a longer and simultaneously better life for the elderly -- is a recipe for monomania and bottomless spending. It fails to put health in its proper place, fails to accept aging and death as part of the human condition and fails to present to younger generations a model of wise stewardship. A goal of aging that stresses the needs of the future generations, not only those of the old, and a goal of medicine that stresses the avoidance of premature death and the relief of suffering would together provide an alternative to our present situation.
Why is Congress willing to pay for acute
hospital care, to cater to such technological advances as organ transplants for the elderly, but resistant to those forms of support -- long-term and chronic care, good home care, for instance -- that can make the difference between a good life and a terrible one? No good answer can be found to that question. Yet the former is the kind of care that should be curbed -- expensive high-technology medicine.
A Medicare system that clearly and openly established some limits to the most expensive and most problematic care would show a sensitivity to the deepest needs of the elderly now missing in the present system. More generally, it makes no sense to improve medical care for the elderly while some 35 million Americans have no health insurance at all. That represents an enormous neglect of other age groups. New goals must be shaped in any case for the elderly. Given the number and proportion of elderly coming along in our society, no other choice is possible.
A medicine that accepted as its appropriate goal helping people to live out a full and natural life span, not simply more life without discernible end, would have a plausible and coherent task. The same could be said of a health policy that worked toward helping each age group prevent or avoid as much illness and disability as possible, that provided adequate care when illness struck regardless of ability to pay, that tried to avert premature death and that sought to enable everyone to live out a natural life span -- but no more than that. None of those goals would be possible or sensible without a more sober understanding of old age, one less bemused by dreams of medical liberation and fantasies of bodily transcendence. We require instead an understanding of the process of aging and death that looks to our obligations to the young and to the future, that sees old age as a source of knowledge and insights of value to other age groups, that recognizes the necessity of limits and the acceptance of decline and death, and that values the old for their age and not for their continuing youthful vitality.
In the name of accepting the elderly and repudiating discrimination against them, we have mainly succeeded in pretending that old age can be abolished. In the name of meeting the needs of the elderly -- in combatting "ageism" -- we have let commerce and technology, not an analysis of what old age should mean and signify, shape our attitudes and control our behavior. In the name of medical progress we have carried out a relentless war against death and decline, failing to ask in any probing way if that will give us a better society. The proper question is not whether we are succeeding in giving a longer life to the aged. It is whether we are making old age a decent and honorable time of life. Neither a longer lifetime nor more life-extending technology is the way to that goal.
Daniel Callahan is the cofounder and director of the Hastings Center, Briarcliff Manor, N.Y. This article is an excerpt from his new book, "Setting Limits: Medical Goals in an Aging Society" (New York: Simon and Schuster, 1987).