Aging and the goals of medicine.

Aging poses a peculiar puzzle for medicine. As a biological reality, aging is an inherent part of organic life, affecting humans no less than animals, plants, and microorganisms. It is in that sense beyond the realm of medicine, a permanent backdrop to all of life. But aging is also ordinarily accompanied by disease, bodily decline, and disability. It is thus well within the realm of medicine, whose historical mission has been the cure of disease and the relief of pain, each much desired by those who grow old. Yet is it necessarily true that aging as an inherent part of life is beyond the realm of medicine? If genetic engineering or other scientific advances could fundamentally change the phenomenon of aging--extending life significantly, for instance, to forestall the sicknesses of age--would it not then come within the traditional sphere of medicine? Why should medicine not attempt to manipulate the biology of aging rather than, as it now does, only the deadly and unpleasant clinical and psychological manifestations of that biological process? Should we go so far as to make the moral judgment that aging is in and of itself humanly unacceptable, a worthy candidate for scientific intervention and even for eradication if we are clever enough? There is, to be sure, a classical compromise response to those questions, first mentioned by the French philosophe Condorcet two hundred years ago and pursued most recently by Dr. James Fries: accept aging as a biological given but work medically to reduce the illness and disability associated with it. That heuristic ideal, the "compression of morbidity," seems the perfect answer; and it might be in the best of all possible worlds. Unhappily, nature has not nicely played its assigned part and, so far, there is not much evidence that any such thing is happening to any significant degree. It has been little noted, moreover, that for the compression of morbidity to actually work we would also have to forswear intensive medical intervention at the end of life. Might it not happen that many of those who lived so nicely and well until eighty-five would be unwilling to let go--just because they had lived so well--thereby setting the stage for a resumption of the now-familiar technological battle against death? Another possibility presents itself also: if we do not achieve a compression of morbidity, and lengthening life spans bring instead an increased burden of illness and disability, will we not then feel compelled to intervene more decisively into the biology of aging to combat that trend? Put another way, could it already be the case that we have come so far along the road in the extension of life, and so far along the road in the accumulation of the chronic and degenerative diseases of aging, that only some radical science can save us? I want to suggest with these troubling questions just how difficult it will be to come up with good answers, and just how portentous any set of answers is likely to be. At the least, with a growing proportion and number of elderly in every society, there is a critical policy issue at stake. To treat aging as if it is tantamount to a disease to be overcome is to open the way to an unlimited and insupportable claim on health care resources. If the diseases associated with aging bring about pain and suffering, as they do, then there is the basis for a time-honored claim to throw at them the same kind of research and resources as we throw at them at other stages of life. There are many who make exactly that claim, in the name of equality and age-blind social policy. If, in contrast, we want to pursue the idea of building policy on the basis of some kind of reasonable natural or cultural limits to such unlimited claims, we are open to the charge of ageism and to that of turning our back on medical advances that could improve the life of the elderly. There is no easy way out of these dilemmas of policy, but they might be helped if we can sensibly frame the right questions to pursue about two principal ingredients of the dilemma: the nature of medicine as a practice and an institution, and of aging as a problem of biology and human meaning. …