Four Scenarios for an Aging Society

In Gulliver's Travels Jonathan Swift gives a portrait of the Struldbruggs, a race condemned to immortality without the blessing of good health: "They were the most mortifying sight I ever beheld. . . . Besides the usual deformities in extreme old age, they acquired an additional ghastliness in proportion to their number of years, which is not to be described." Do the Struldbruggs conjure up a gloomy image of our own future? There is reason to think so. Modem health care permits growing numbers of people to live to advanced age under circumstances that call into question the meaning of continued survival. Yet some answers to questions about the meaning of survival are indispensable as we ponder how much it is worth spending on geriatric health care. But can we talk coherently about meaning? No topic seems less promising for public debate than the "meaning of life." In advanced industrialized societies, public silence about the ultimate ends of life has become i ruling dogma. The problem, if anything, is even more troubling when we try to think about the meaning of the last stage of life.[1] Chronological age by itself no longer carries an agreed-upon set of meanings for people at any point in life. The coming of an "age-irrelevant society" means loss of consensus about the values appropriate for different stages of life, including the last stage. It is no longer possible to say what a "rational person" of advanced years might prefer concerning medical treatment to prolong life, especially if the conditions for survival are drastically different from conditions that previously gave meaning or purpose to life. As the aging population itself becomes more diverse, we confront ethical dilemmas raised by cost-containment, self-determined death, and biomedical technologies to postpone aging. Without confronting questions about the meaning of old age, we risk impoverishing discussion of public allocation choices that we must face. Perhaps the best we can do is to frame the issues clearly in terms of contrasting ideas about "meaning" and examine what resource allocation policies might follow from those contrasts. What follows are four scenarios about the future of an aging society, each based on plausible extrapolations from present empirical trends along with assumptions about the meaning of old age. 1. Prolongation of Morbidity How shall we escape the prospect of joining the Struldbruggs? How do we avoid burgeoning numbers of demented but healthy Struldbruggs whose caregiving cost could bankrupt the health care system? The first scenario to be considered takes its point of departure from recent debates about the so-called compression of morbidity or postponement of sickness in later life.[2] Recent data suggest that life expectancy among the aged has risen.[3] But the paradoxical result is longer periods of both health and sickness among different subgroups of elderly. The young-old (ages 65-75) tend to be healthier, but more and more of the old-old (75+) face decrepitude. What will the future bring? Under a pessimistic assumption, the period of morbidity will grow longer. Even modest medical technology--for example, antibiotics for Alzheimer patients--permits survival to advanced ages for those with very poor quality of life. If the meaning of old age is defined by the quality of life, then allocation policies should favor easing termination of treatment as a means of saving money. The quality-of-life standard could apply to all age groups, but prolongation of morbidity among the elderly means that this group would bear the brunt of cost-containment. The choice of death could be made either by individuals or by society, though the two levels are always intertwined, as the following case reveals. Case Example. Mr. Y, aged eighty-five, has long had a pacemaker and has been on a downhill course from Parkinson disease in recent years. Even with help, his wife can no longer care for him at home, but both reject the idea of entering a nursing home. …