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Acta bioethica

versión On-line ISSN 1726-569X

Acta bioeth. v.7 n.1 Santiago  2001

http://dx.doi.org/10.4067/S1726-569X2001000100007 

 

Acta Bioethica 2001; 7(1)

ORIGINALES

AGING AND DYING: MEDICAL AND ETHICAL CONSIDERATIONS

ENVEJECER Y MORIR: CONSIDERACIONES MÉDICAS Y ÉTICAS

ENVELHECER E MORRER: CONSIDERAÇÕES MÉDICAS E ÉTICAS

VIELLIR ET MOURIR: DES CONSIDERATIONS D'ODRE MEDICAL ET ETHIQUE

James F. Drane

Russell Roth Professor of Biomedical Ethics Edinboro University, PA, United States.
Correspondencia: jdrane@edinboro.edu


Abstract: The idea of writing a chapter on aging seems particularly appropriate. I'm at the right age to address this topic. As I did the preparatory reading and research, I had an unusual experience. For the first time in my life, I felt like an expert. I could judge what people were saying about aging by my own experience. Besides facing aging myself, I work mainly with rural hospitals and nursing homes and hospice organizations where most of the patients are elderly. Both in my personal life and in my work, I am surrounded by the realities of aging and dying.
In a recent book entitled Gray Dawn(1) on the economics and politics of aging, the author, Peter Peterson used a gripping metaphor to describe the challenge of an increasing aging population. Global aging, he said, is like a massive iceberg which very well could destroy even the most powerful economic vessels in the world. The aging population worldwide, according to this author, threatens human survival and is the most important challenge we face in the 21st century. His iceberg metaphor highlights the danger of global aging and the fact the all human beings are exposed to this danger1.

Keywords: Aging; dying; global aging; depression and aging.


Resumen: La idea de escribir un artículo sobre el envejecimiento, parece particularmente apropiada. Estoy en la edad precisa para abordar este tema. Como realicé toda la lectura e investigación preparatoria, tengo una experiencia poco común. Por primera vez en mi vida me siento como un experto. Puedo juzgar lo que se dice sobre envejecer desde mi propia experiencia. Además de enfrentar personalmente el envejecimiento, trabajo principalmente con hospitales rurales, casas de reposo y hospicios, donde la mayoría de los pacientes son ancianos. Tanto en mi vida personal como en mi trabajo estoy rodeado por las realidades de envejecer y morir.
En una publicación reciente, titulada Gray Dawn (Gris Amanecer)(1), sobre la economía y política del envejecimiento, el autor, Peter Peterson, usó una impresionante metáfora para describir el desafío de una creciente población que envejece. El envejecimiento global -dice este autor- es como un sólido iceberg que perfectamente podría destruir aun los barcos económicamente más poderosos del mundo. La población mundial que envejece, de acuerdo con Peterson, amenaza la supervivencia humana y constituye uno de los desafíos más importantes que enfrentamos en el siglo XXI. Su metáfora del iceberg destaca el peligro del envejecimiento global y el hecho que todos los seres humanos estamos expuestos a ese peligro.

Palabras claves: Envejecimiento; envejecimiento global; morir; depresión y envejecimiento.


Resumo: À idéia de escrever um artigo sobre envelhecimento me parece particularmente apropriada, pois estou em idade compatível para abordar o tema. Como já realizei toda leitura e investigação preparatória, tenho uma experiência incomum. Pela primeira vez na vida sinto-me um especialista. Posso julgar o que se diz sobre envelhecer através de minha experiência própria.
Além de enfrentar pessoalmente o envelhecimento trabalho essencialmente em hospitais rurais, casas de repousos e "hospices", onde a maioria dos pacientes são idosos. Tanto em minha vida pessoal como em meu trabalho estou cercado pelas realidades do envelhecer e do morrer.
Em publicação recente, com o título Gray Dawn (Amanhecer Cinzento)(1), sobre a economia e política envolvida no envelhecimento, o autor, Peter Peterson, usa impressionante metáfora para descrever o desafio de uma crescente população que envelhece. O envelhecimento global, diz o autor, é como um sólido iceberg que pode perfeitamente destruir as embarcações economicamente mais poderosas do mundo.
A população mundial que envelheceu, de acordo com Peterson, ameaça a sobrevivência humana e constitui um dos desafios mais importantes que enfrentaremos no séc. XXI.
Sua metáfora do iceberg destaca o perigo do envelhecimento global e o fato de que todos os seres humanos estão expostos a esse perigo.

Palavras chaves: Envelhecimento; Morrer; envelhecimento global; depressão e envelhecimento.


Résumé: L'idée d‘écrire un article sur le vieillissement me semble tout à fait appropriée, car je suis justement dans l'âge précis pour aborder ce sujet. En outre, ayant lu de façon exhaustive et effectué des recherches préparatoires dans ce domaine, je dispose d'une vaste expérience sur le sujet. Pour la première fois de ma vie, je me sens un véritable expert, et je peux juger ce qui ce dit sur le vieillissement en fonction de mon expérience personnelle. Par ailleurs, je travaille principalement dans des hôpitaux ruraux, des maisons de repos et des hospices, où la plupart des patients sont des personnes âgées. Je suis entouré, aussi bien dans ma vie personnelle que professionnelle, par les réalités du vieillissement et de la mort.
Dans une publication récente, intitulée Gray Dawn (Aurore grise)(1), sur l'économie et la politique du vieillissement, son auteur, Peter Peterson, a utilisé une surprenante métaphore pour décrire le défi d'une population âgée de plus en plus nombreuse. En effet, le vieillissement global - selon l'auteur -, est comme un solide iceberg qui pourrait détruire même les bateaux les plus puissants du monde. La population mondiale qui vieillit, d'après Peterson, menace la survie de l'humanité et constitue l'un des défis les plus importants du XXI siècle. Sa métaphore de l'iceberg souligne parfaitement le danger du vieillissement global, et le fait que tous les êtres humains s'y trouvent exposés.

Mots clés: Viellissement; mourir; viellissement global; dépression et viellissement.



The senior period today: a cultural phenomenon

The modern industrial system with its pension plans and a specified time to stop working has created and defined the new period in contemporary culture which we call retirement. As the numbers of retirees grew, older people achieved a separate social status. The elderly became seniors. Now we have a senior period, with senior people and senior moments and senior discounts and senior cruises and senior housing. A new nursing care industry has been developed for handling the worst medical problems of this population. The government has stepped in to defray some of the medical costs with Medicare and Medicaid. A whole new academic discipline (Gerontology) has developed to try to understand this period.

Spain's greatest 20th century philosopher sub-divided the senior period into la tercera edad, the healthy senior period, and la cuarta edad, the disabled or infirmed senior period. He used new concepts and categories for one and the other stage: viejos-the old, senesentes-the senescent, ancianos-the aged, senectos-the decrepit, longevos-the long lived, valetudinarios-infirmed or sick. Often, he made a distinction between knowing that one is a senior, and feeling old(2).


Death and old age

At the fringes of every aging experience is increasing pressure from the reality of death. Many of the senior activities in American culture come over as distractions from or even denials of this reality. Death in the U.S. often is treated as a taboo topic. Sooner or later, however, death and the questions about how to die, force themselves into consideration. Aging anticipates something else, and that something else is death. Death is a part of the aging experience that cannot be ignored, no matter what the cultural peculiarities of the newly designed period.

As people age, ignoring death becomes more and more problematic. What once may have been conveniently ignored inevitably re-enters the picture. At first it may be a vague "deadline". The invisible referee in the game of life at some point will call "time out". And yet, even people in the senior period, can glance at death only to look away and move to the next distraction.


Meaning and old age

If death is not given due attention in our culture, neither is the issue of the meaning in old age. Modern industries and government programs have helped to define the senior period but they have done little to provide it with meaning. What is the meaning of life when we retire, or when we get old, or when we become decrepit, or when we get close to death? These questions do not get that much attention despite the number of retired persons who slip into depression once the meanings linked to their work and parenting are lost.

Industrialists and legislators created the senior period but in doing so they created some moral and existential problems. Industrialization linked with Protestantism created what we call the work ethic. It is an ethic in the sense of inner attitudes or dispositions. The work ethic linked the meaning in life, even eternal salvation, with an inner commitment to work. A work commitment became the essential inner disposition. It was the key to wealth in this life, and then salvation in the next.

In pre-industrial society a different ethic operated. Different inner attitudes or dispositions or background personality traits provided moral direction and meaning. The theological virtues (faith, hope and charity) gave meaning to life. The cardinal virtues (prudence, justice, fortitude and temperance) gave moral direction. In the pre-industrial society, many good people never worked. Aristocrats didn't work. Contemplatives didn't work. But their lives had meaning and they were respected members of society.

Following industrialization and unionization of workers, working conditions and public health infrastructures gradually improved. Consequently, working people started living longer. Now we have a large segment of the population retired from work. The majority of these people, however, were formed in the work ethic. Understandably, many run into problems when they stop working and enter the senior period.

Some retired people have money and have made a transition from membership in the working class to membership in a consumer society. Shopping now gives meaning to many lives. ("I shop, therefore, I am"). It gives meaning because people become identified with the things which they buy. In our commercial culture, things give meaning. Shopping is important because "I am the things which I purchase". Some people would not be caught dead wearing or using something from a competing brand. But these commercial identities and meanings create an existential superficiality. Personalities are as passing as their purchases and their new products.

In addition, elderly persons cannot consume the way they once did. And things gradually cease to provide real identity and meaning. Even when shopping and things give meaning, the meaning is superficial and people are not happy. The new secular meaning system fails to satisfy most seniors. Extending longevity and creating pensions for seniors has not been accompanied by a culturally rich and a socially shared vision of the meaning of being old. Rather, current secular developments have created a moral and existential problem for seniors.

This situation and the challenges it creates was captured in a poem by a retired man in Galveston, Texas. Thomas Cole, a bioethicist and medical humanist at the Institute for Medical Humanities in Galveston, Texas, organized a project to promote emotional growth among elderly people by the use of auto-biography. Mr. Bob Burdett, captured the point I am making in a short poem entitled What Now?.


Retired

Off the treadmill.
Out of the rat race.
Affairs in order.
Paper read.
Bills paid.
Laundry washed and folded.
It'll only take a minute to put it away.
Enough time for everything.
Then some.
Too much of a good thing.
Too many crossword puzzles.
Too many naps.

Errands I used to do on the way from Point A to Point B have become major events.

Is this what it's supposed to be like?
I'm retired on insufficient data.
Now I'm expected to live another 25
years.
Almost 10,000 days.
A slow death.
Travel?
Romantic involvement?
Don't think so.
Need to do something
Productive,
Significant,
Meaningful,
Gratifying.
Like re-invent myself.
Start all over.
The meaning of aging in history
Pagan cultures

The classical cultures of Greece and Rome had theories of aging which provided meaning by dividing life into specified stages from birth to death. Stages were numbered and arranged in ascending and descending order. Certain years were especially important because the organism was believed to be ordered in 7-year cycles2. Seven was the age of reason, 14 the beginning of adolescence, 21 the beginning of maturity. Between 28 (4x7) and 49 (7x7) the adult lives and develops. After 49, the decline starts. At 7x10, life is expected to be over. Both aging and death were understood to be a part of the natural order.

The 7-year cycles correlated with inner attitudes and expected behavior. There were some differences of opinion about behavior in the final period. Aristotle thought that in old age, a person's normal failings were magnified and physical decline depressed the human spirit.

Plato urged the elderly to enjoy the time free of passion. Cicero too thought that old men were relieved of the drive for sexual pleasure. This relief in turn provided the climate for wisdom.

Greeks and Romans gave meaning to aging through their system of natural stages and through submission to the natural limits embedded in the stages. Cicero made the point that "the burden of age is lighter for those who feel respected and loved by the young." (De Senectute, 8, 26). Classical literature, however, is also full of ridiculous characters who behave inappropriately for their age. Old men who lust after young women were the butt of jokes. Only the old people who behaved properly for their age received respect from younger members in their communities.


Religious cultures

In religious cultures which preceded our secularized industrial age, the lives of persons who made it into old age were full of meaning. Even ordinary and pedestrian experiences had meaning, indeed they had eternal significance. The realities of this life were connected to the possibility of yet another life beyond this one. In religious culture all of life is understood as a journey. Aging means approaching the end of the journey. Death is a passage to yet another life.

Old age had a built-in respectfulness in Jewish culture. A long life was seen as a sign of God's favor (Gen 11:10-32). In Hebrew Scripture, God often chose old people for mighty deeds. The elders in Jewish culture were given prestigious community tasks which gave them respect and dignity.

The same system is reflected in Christian Scripture and later in Christian culture. The aged Simeon and Anna recognized Jesus as the anointed one when he is brought to the temple as an infant. This was fulfillment in their old age. (Luk 2:29). The elderly Nicodemus was praised for his courage in helping with the burial of Jesus (John 19:38). St. Paul in the Epistle to Titus (2:2-5) addresses the issues of meaning for the elderly and their social roles. "Bid the older men be temperate, serious, sensible, sound in faith, in love and in patience. Bid the older women likewise to live in a way appropriate to believers…; they are to teach what is good and so train the younger women to love their husbands and children".

Job showed how to handle the worst losses imaginable in aging. Jesus too suffered through tough experiences of loss: first the anticipation of loss of his life in the agony in the garden ("Lord, take this cup away from me…Mark 14, 36.); then, the total sense of loss on the cross ("My God, my God, why have you forsaken me". Mark 16, 34). Jesus and Job can help old religious persons to find meaning and to endure their losses without falling into despair. In both the Jewish and Christian cultures, old age is a time to face loss and to bring life to fulfillment. In Judeo-Christianity, it is the expectation of what follows this life that gives meaning and the courage to face losses. In light of eternal life, this life becomes a short path, along which we walk in order to mature morally and prepare for what will follow.

By contrast, in the contemporary American secular culture, the senior period is expected to be a stage of continued and unlimited development. Death is not even part of the discussion. But such denial collapses either gradually or suddenly into illness and disability. At some point the elderly are forced to face both death and absence of meaning. Consequently, aging and dying are frequently plagued with depression.

No matter what one's culture, aging always involves increasing physiological and psychological vulnerability and the increased probability of death. Aging and dying are physically and conceptually linked. As we age, we have to ask, how should we age, and then at some point how should we die. We have to ask, about the meaning of aging and dying. For us human beings, aging and dying cry out for reasons and meanings. Here the Church can and should enter with programs designed especially for older people.


Finding meaning in medicine

One frequent source of meaning for contemporary persons is medicine. Doctors are for many people today what priests were for people in more religious periods. Health is equivalent to salvation. Disease and disability are hell.

Whether or not aging is a disease depends upon one's philosophy of medicine. Certainly there are biological and psychological alterations as years go by, but not all philosophers of medicine would classify these as disease. Medical interventions can often modify these alterations. Physicians have a large arsenal of interventions for age related changes in the organism. Doctors provide meaning in old age by creating an important resource for elderly persons and by keeping their worst fears in check. Down the line, medicine promises remedies for memory problems, osteoporosis, vision loss, and the control or elimination of chronic illness associated with aging.

Doctors who appear on TV and write daily columns in the newspaper frequently talk about aging. They tell us about the molecular and cellular damage which cause aging. They tell us about the organic and environmental factors which are involved: radiation, toxins, oxygen radicals, stress hormones, modified lipids and proteins, cytokines, glucose, etc. All of the above are subject to medical interventions. Currently, a great deal of medical research is focused on cellular and genetic manipulation which has more than doubled longevity in certain worms and animals. The possibility of making spare human parts adds even greater possibilities for extending life, first in animals but ultimately in human beings.

Environmentally-caused pressures on life, certainly, can be relieved. Harmful environments can be changed for the better. Life style practices like lack of exercise and poor nutrition can be improved. People can stop smoking and lose weight. These alterations can extend life span by as much as 50% without recourse to any of the new medical interventions. Doctors and pharmaceutical firms continually endorse these recommendations.

Recent pharmacological discoveries promise to eliminate or at least to reduce the effects of life-shortening diseases. Vitamins and food additives like anti-oxidants can prevent some of the damage from products of cellular metabolism. Effective cures joined with enhancing vitamins and food supplements can postpone aging and add many years of life. Life enhancing hormone replacements like estrogen can also make a big difference in aging for women. At the beginning of the 20th century, the average life expectancy in the U.S. was in the forties. As we begin the 21st century the average life span is in the 70's and 80's. The declines that create aging and move every human being toward death are undergoing modification by medical interventions and public health improvements. These declines tend to be more precipitous in developing countries and less so in the developed world. Physicians in first world countries have more control over infectious and parasitic diseases. Public health systems have had the greatest influence on aging statistics.

A small percentage of persons survived into old age in every culture and every historical period. What has changed in the past century is the greater number of those who become old before they die. Aging, in other words, has become the experience of an ever-expanding number of persons. Whether the increases in longevity can continue is a matter of controversy. Most experts today agree that the 30-40 year increases in longevity during the past century will not be repeated in the next, but further extension in life span is anticipated.

Persons over 85 are the fastest growing group in the U.S. population. They are 21 times more numerous then they were only 100 years ago. Persons over 65 are 8 times more numerous then at the turn of the century. There are 68 men per 100 women over 65. Early in the 20th century, it was the younger population that was saved from early death by medicine in the form of public health improvements and vaccinations. The challenge for medicine in the 21st century is to save the aging population from vascular disease and cancer. This will be more difficult and it will likely have a lesser effect on overall life span extension.

Even with all the attention which medicine has given to aging, still the issue of meaning or lack of meaning, threatens the elderly population. Extending life span and curing disease has not solved the problem of meaning. Does it make any sense to extend life span when the added years are devoid of meaning? Is it right to spend scarce resources to extend meaningless existence? Wouldn't it be ethically preferable to design strategies for more humane dying? Try as we may to push away the link between aging and dying, it will not budge. We cannot talk about the meaning of aging without addressing the meaning of dying. And if there is no shared view of the meaning of aging and dying, then despite all the medical advances, old age and proximity of death are going to be plagued by the scourge of depression.


Depression and old age

To despair or not to despair, that is the question elderly people face. Even for persons who enjoy good health and are surrounded by family, being old means being lonely. Loneliness involves a sense of a loss, and depression is failure in handling loss.

Human identity is a construct, and the building blocks of this construct are social roles and relationships. A loss of either can shake one's identity and create the conditions for depression. If my family is gone and I have no social role, who am I?

Loneliness is more likely to cause depression when compounded by dependency. It is even more likely to cause depression if poverty is added; or the loss of one's home and the necessity of living in someone else's space.

Loss is everywhere in the last stage of life. For the infirm elderly, old age means physical loss; sight, hearing, mobility, continence. The last loss is the most embarrassing. The next to last means that someone else has to go to the store and has to take care of everyday needs. Sight and hearing loss close the old person in on him or herself. All these physical losses are tough to manage.

Old age means mental loss as well: especially reasoning ability, and remembering. It means not to be able to find your glasses or to keep things in order. It may even mean the loss of security and independence. Who wouldn't be depressed under such conditions?

If there is any doubt about the pervasiveness of loss and depression in old age, listen to some of the lines spoken by elderly characters in Shakespeare's plays:

I shall despair. There is no creature loves me,
And if I die no soul will pity me
And wherefore should they, since that I myself
Find no pity to myself.
-Richard III, V, iii, 200-203

Here I stand your slave
A poor, infirm, weak and despised old man.
-King Lear, III iv, 19

A poor old man,
As full of grief as age.
-King Lear, II iv, 271.

I have lived long enough.
My way of life Is fallen into the sear,
the yellow leaf,
And that which should accompany old age,
As honor, love, obedience, troops of friends,
I must not look to have.
-Macbeth, V iii, 22

Grief makes one hour ten
-Richard II, I, iii, 260

Even if the connection between old age, loss and depression is not a recent or a new phenomenon, the question today is, how do we help the growing population of elderly to maintain meaning and hope? In the U.S. secular culture today, we try to keep them distracted. We take them on trips. We teach them how to play cards. We start exercise classes and dance classes. We take shopping and buying tours. Rarely do we honestly confront the experiences of loss. Rarely do we try to make sense of these experiences. Rarely is depression in the elderly either accurately diagnosed or adequately treated. Focus is concentrated on the external aspects of life. The internal or existential or psychiatric aspects are not addressed. This is certainly one of the ethical problems associated with aging.


An ethics of aging

Any ethics of aging and dying must address the problems of loss and depression. Ethics must grapple with the issue of meaning in the aging experience (an existential ethics). A humane ethics must be grounded on Nature and must establish limits based on the structure of human reality. Then humane ethics must provide a response to the many social changes brought about by the big increases in the aging population. (social ethics).

The elderly 12% of population consume 33% of medical expenditures. Increases in the number of older people inevitably involves increases in medical costs. Pressure is already being felt to shift spending away from the elderly toward younger people who have to bear most of the health care costs. Increases in the number of elderly persons place health care burdens on younger people. More and more frequently, younger family members express resentment over the sacrifices which they are expected to make to care for elderly and needy parents and grandparents. A reasonable ethics has to address this issue.

Ethical questions are being raised about the limits of associative or relational obligations. And questions are being raised about whether resentful younger family members can act as surrogate decision makers for elderly members. Serious consideration is now being given to rationing certain life-saving medical interventions based on age: e.g. no renal transplants or open-heart surgery after a certain age(3,4,5). Other bioethicists, besides Daniel Callahan, who have addressed this issue include Norman Daniels, Richard Lemm, and Samuel Preston.

The elderly population also has its advocates and lobbyists and they have different ethical concerns. Besides attention to mental and emotional problems among the elderly, they insist that increased attention be paid to traditionally-ignored medical problems. People over 65 years old are finally being included in research trials which address their most prevalent conditions (e.g. heart disease, cancer, diabetes, hypertension). It was wrong to exclude this population from trials of medications which may improve their condition.

The expanding population in la cuarta edad -the disabled elderly-, translates into an expanding population of disabled persons who need some form of long term care: day care, in home services, convalescent home care, intermediate and skilled nursing home care. Seventy per cent of persons over 85 need some kind of help in order to live from day to day. And this help can be very expensive. It can quickly exhaust an elderly persons' savings. As family size goes down in developed nations, more and more pressure is created on fewer and fewer younger, (usually female), family members. This is a major ethical concern.

Outside help for infirm elderly is commonly provided by informal caregivers. But this kind of help is in short supply in government programs. For most elderly people who need care, family and friends have to provide the help. Government programs for the elderly tend to be for acute care rather than long term care. They cover a broken hip, but not the inability to feed oneself.

An infirm elderly person may need expensive drugs, a prothesis, some structural changes in their homes or apartments, a rehabilitation program, meals, shopping assistance, etc. Human beings need help of some sort at every period of life, from birth to death. The very well off elderly can avail themselves of expensive assisted-living arrangements but most elderly need some form of social or government program. Otherwise, they have to depend on the charity of family and friends. But what kind of program, for whom, at what cost? These are the critical, factual elements in any decent social ethics for the elderly.

Some elderly people live for many years with chronic problems and needing chronic care. Others live relatively healthy lives until some acute incident throws them into need: a stroke, a fall, a heart attack, a cancer, the death of a spouse. Suddenly, functional abilities decline and help from other persons is needed. If the other persons are not family members or friends, they are likely to be nonprofessionals, poorly paid, and unreliable because they themselves are needy. This is a problem.

A more humane bioethics of aging being suggested by the above considerations takes the form of agreed- upon public polices which address the most pressing needs of the infirm elderly. If care is provided by nonprofessional outside sources, these should be licensed, and the help they provide should be monitored. If family or friends provide care, the limits of what these persons can provide should be stipulated. Family and friends should not be overwhelmed by the care giving. Policies should not deny support to family care givers. Finally, professional care givers supported by public policies should maintain communication with family caregivers and help them when necessary. The ideal goals of a social ethics are easier to identify than the concrete policies required to fulfil the goals.


Conclusion: the ethical challenge

The specific aid and support which is ethically required for the infirm elderly is not clear. Socio-political movements to establish long-term care, if they exist, have not yet reached extensive public recognition. Specific, practical, affordable and democratically-acceptable policies have not yet been developed which articulate precisely what help humane communities should provide for needy old person. Standards for determining need in other areas of life may not apply to the situations of elderly people.

Abstract ethical principles like equity and concepts like the common good obviously are important but these abstract ethical standards do not by themselves show what practical concrete policies are appropriate. Sound, effective, affordable, concrete policies for long term care are more of a challenge than easily identifiable ethical abstractions. Good policies meet real needs with basic benefits.

The exact content of basic rights of elderly people is not yet clear. The right to health care is a credible concept but like the concepts of equity and common good, it is still an abstraction. Its application to broad groups of persons requires the involvement of social sciences, medical sciences, economic sciences, organizations like the World Health Organization. Even after issues of macroallocation of resources for needy elderly have been settled, still the basic rights concept requires practical application in the sense of microallocation, i.e. which particular needs of individual elderly persons can be met. The frail elderly as we have seen have both physical and mental needs. It makes sense to start with the basic Natural law perspective, and move from there to a right to health care for the elderly concept as the foundations of a humane bioethics. The remaining challenge is to apply these concepts to concrete individual situations. Developing a balanced and workable ethics of aging is a task which has hardly begun.

Finally, we cannot continue to ignore the existential ethical problems in aging. We cannot forget the issue of meaning in the senior period. If shopping will not do, what kinds of roles and responsibilities for aging people can communities agree upon and then implement? A reasonable ethics of aging has to address the superficiality, artificiality and hollowness of the aging experience in contemporary secular culture. If religious meaning is gone, some kind of meaning system has to be invented to take its place.

One project that might generate cooperation between conservative and liberal Catholics would attempt to restore religious meaning to ever-increasing numbers of aging people who have lost their faith. Liberal and conservative perspectives might both have a place in such a project. Instead of competing with one another or continuing to argue about doctrinal and ethical issues, liberals and conservatives could come together on the project for those who are aging and dying.


Notes

1 A different analogy from Gray Dawn was used by Laura L. Carstensen in an op. Ed piece in the N.Y. Times, Jan. 2, 2001. She wants to redesign old age so that aging can be healthy and the elderly can make positive contributions to society.

2 In Hippocratic medical theory, the 7 year cycles were correlated with the four humors (black bile, yellow bile, phlegm and blood) and the 4 elements (fire, earth, air, water).


References

1. Peterson PG. Gray Dawn: how the coming age wave will transform America and the world. New York: Random House; 2000.

2. Aranguren J. La vejez como autorrealización personal y social. Madrid: Instituto Nacional de Servicios Sociales; 1992.

3. Callahan D. Setting limits. New York: Simon and Schuster; 1987.

4. Callahan D. Troubled dream of life. New York: Simon and Schuster; 1993.

5. Callahan D. False Hopes. New York: Simon and Schuster; 1998.


Recibido: 5-3-2001/Aceptado: 16-4-2001

 

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