Aging and the Aged: VI. Anti-Aging Interventions: Ethical and Social Issues
VI. ANTI-AGING INTERVENTIONS: ETHICAL AND SOCIAL ISSUES
An estimated 2,500 physicians in the United States had established specialty practices devoted to "longevity medicine" by 2003, and the American Academy of Anti-Aging Medicine (A4M) boasted 11,000 members in that year. The goal of this clinical community is to extend the time their patients can live without the morbidities of the aging process; namely "memory loss, muscle loss, visual impairment, slowed gait and speech, wrinkling of the skin, hardening of the arteries, and all the other maladies we call aging" (Shelton). At the beginning of the twenty-first century, however, there was little the practitioners of anti-aging medicine could prescribe that had any scientific validation (Olshansky, Hayflick, and Carnes; Butler et al.). But the scientists who study the biology of human aging, known as biogerontologists, are slowly making headway, and a central research agenda for this community is to provide clinicians with the tools they require to make anti-aging medicine a reality (Kirkwood; Olshanksy and Carnes).
Biogerontologists pursue a wide array of scientific strategies, based on a variety of different theories about the biological process of aging. However, their research programs generally fall into one of three basic types, depending on their goals. The most conservative model is commonly described as seeking compressed morbidity (Fries). The goal of biogerontological research under this paradigm is to forestall the chronic ailments of old age so that humans will be able to live long, healthy, and vigorous lives within the limits of the maximum life span for the human species. Its approach, however, is to prevent age-associated maladies by intervening in the underlying aging processes that make people vulnerable to them, rather than attack them piecemeal (Kirkland). In this model, biogerontologists are actively seeking increases in the average human life expectancy, but not increases in the maximum human life span. The successful realization of this paradigm will result in a society with many more very old people playing active social roles right up until their death.
A second, more ambitious paradigm seeks to produce decelerated aging. Here, the research goal is to develop ways to slow the fundamental processes of aging to the extent that both average life expectancy and maximum life span are increased beyond the species' prior experience. Under this model, people would continue to move through the same stages of senescence (decline) as they age, but the process would take place against an elongated timescale, providing more years of vigorous life before the declines of old age. One prominent biogerontologist suggests, for example, that it may be possible to produce ninety-year-old individuals who are as healthy and active as today's fifty-year-olds, as well as to achieve a mean life expectancy of about 112 years for Caucasian American and Japanese women, with an "occasional outlier" reaching an age of about 140 years (Miller).
The most radical paradigm being subscribed to by biogerontologists is arrested aging. Here the hope is to develop the ability to continously reverse the processes of aging as they occur in adults, in order to maintain vitality and function indefinitely (Fossel; De Grey et al.). Some scientists envision that "negligible senescence" could be accomplished by finding ways of removing the damage inevitably caused by basic metabolic processes, and thereby attaining an indefinite postponement of aging. They expect that substantive progress toward this objective will be feasible by the second decade of the twenty-first century (De Grey et al.).
Should Scientists Attempt to Control Aging?
The fundamental philosophical and cultural challenge of anti-aging research is the blow that it could deal to aging's historical role as a constant in human affairs. If it is not necessary to assume the universality of aging in the ordering of society, new choices present themselves. From the point of view of the public good, is aging, as it is now known, a human experience to be encouraged or discouraged? Both biomedicine and American culture reinforce the inclination to interpret the biological changes that accompany human aging as losses that harm those who experience them (Cole and Gadow). Society in general and health professionals in particular have a fundamental obligation to do what they can to protect people from the harms to which they are vulnerable, whether those harms originate with terrorists, epidemic disease, the accumulated insults of the environment, or genes. Though not everyone would choose to avoid the "harms" of aging, should those who wish to use these interventions be discouraged from doing so?
It is clear that there is a powerful psychological dynamic at work behind the bioethical debates over anti-aging research. Against the mythic power of rejuvenation, almost any form of social and personal risks involved in pursing the mastery of aging fade away. This is because it has so often been rejuvenation—in the forms of resurrection, reincarnation, renewal, or rebirth—that defeat deterioration and death in human belief systems (Gruman).
Critics of anti-aging medicine suggest that cultural and medical assumptions about the biological changes of late adulthood might be different if society were not so pervasively influenced by the perspective of those who have not yet undergone them (Callahan, 1993). Perhaps, when seen from the other side, not all the changes that young adults view as the harmful losses of aging are harms at all. One familiar example of this is menopause—this loss of reproductive capacity, though fraught with physical and emotional turbulence, is one that many women come to celebrate as opening new opportunities and life pleasures (Martin; Logothetis). Similarly, in many societies the loss of physical strength and endurance that comes with aging allows the individual to relinquish responsibility for the labor of survival and move into an even more important role as an elder for his or her community (Moody, 1986).
Traditionally, even the health challenges of aging (e.g., failing senses, vulnerability to disease and accident) have been seen as contributing to the life experiences of older adults in a way that gives them a level of equanimity and insight difficult to achieve at earlier stages in life (Post). The psychologist Erik Erikson has looked to old age as a crucial source of generativity in the human life cycle, and the philosophers Daniel Callahan and Leon Kass have argued that growing old provides special opportunities for teaching, wisdom, and altruism. This does not mean that the major diseases that threaten human health in late adulthood are not a cause of concern, but it does suggest that attempting to intervene in the aging process itself, for all its attendant complaints, may be shortsighted and harmful because it would deny adults the wider benefits of growing old.
On the other hand, advocates of anti-aging medicine claim that, at best, this argument leads to the position that it would be wrong to deny people the right to "grow old gracefully" if they value the benefits of doing so (Stock). The physical burdens that accompany aging can be very serious, and modern society is not designed to optimize the role of the elderly. Given the social realities of aging in modern Western culture, many adults would consider the price of the late stages of human development high enough to warrant attempts to postpone and compress them as much as possible. Advocates of anti-aging research point out that respecting that human ability to project and pursue a life plan is at the heart of what it means to respect self-determination and personal autonomy.
Is There a Natural Life Cycle?
In reply, the critics of anti-aging medicine ask us to imagine our reactions to a hypothetical biomedical intervention that would interrupt the development of a child and extend childhood by delaying puberty (Hayflick). What is worrisome about that is not simply the psychological harm such a developmental distortion might produce. Nor is it just a matter of violating the child's rights to self-determination—those rights are not yet in full flower and it is their parents' role to protect, and to some extent define, the child's best interests. If interrupted, the child's bodily development is no longer progressing on its own schedule, nor is it being driven by the complex, automatic interplay of genes and their reactions to the environment. Such a disruption of the child's "developmental autonomy" alienates his or her life story from the temporal narrative that characterizes the human species.
Postponing the normal biological changes of aging, the critics argue, constitutes a similar disruption. Whether or not the biological changes of aging are beneficial or harmful, they are meaningful: They and their natural timing constitute part of the normal life cycle for human beings, and thus part of what it means to be human (Kass, 2001). Intentionally distorting that cycle alienates the elderly from the definitive human life story, and dehumanizes them in the process. In this view, adults should be taught to seek the meaning of the later stages of human development, and biomedical research should focus on making the experience of that part of life as healthy and pleasant as possible, but not interfere in its essential rhythm (Callahan, 2000).
Of course, arguing that the traditional human life cycle is normative for human beings requires a good bit of philosophical work if it is not be reduced to a statement of religious faith or accused of making a virtue of necessity (Overall). Just because human beings have always lived their lives within a traditional time frame is not necessarily a reason to continue doing so. In fact, the social and technological dimensions of the "typical human life story" have been rewritten continuously during human history, without diminishing the moral status of those people whose lives are made possible by that evolution (Gruman). Given this history of pushing back the natural limits of human life through science and technology, the burden of proof, the advocates argue, is on the critics to complete their philosophical project convincingly. Until then, theirs is one ideology among many, which autonomous adults (and researchers) in a free society should have the right to assess, adopt, or reject as they will.
The Limits of Medicine
Interestingly, one sector of medicine that is strongly wed to a naturalist ideology is biomedicine. Human health is usually understood by biomedicine not merely as the absence of diagnosable disease, but as functioning within a range that is typical for human beings of one's age and gender (Boorse). For functionalists in biomedicine, the statistically "normal" is morally normative; that is, it represents the state of health that is supposed to be the goal of research and the priority of practice. This is why biomedical professionals strive to draw a line between their work devoted to addressing health problems and the use of their work for cosmetic, aesthetic, athletic, or social enhancements (Juengst). The use of medical tools for enhancement might be tolerated in a free society, but to the extent that they do not address bona fide health needs, they should not be given a high priority by health professionals and researchers. On what side of this professional boundary line should human growth hormone (HGH) replacement fall? If there is nothing pathological about the aging process itself, critics argue, all the current efforts that health professionals are mounting to combat it seem wrong-headed and wasteful (Callahan, 2000).
From this perspective, it becomes crucial for the ethical debate over anti-aging research to answer the question of whether or not intervening in human aging is a legitimate form of healthcare. Part of the problem, of course, is the current limited knowledge of the fundamental causes and dynamics of the aging process. In this debate, the scientific contest between the theories of aging that rely on accumulated insults and those that look to genetics is crucial. If the aging process turns out to be a confluence of conditions that would individually be considered health problems, and that vary between individuals and across populations, it would be plausible to conceptualize the process as ultimately accidental, and thus to medicalize the causal cofactors as individual health problems (Caplan).
On the other hand, if aging is a natural and inevitable consequence of normal physiology, then the process itself is normal, and therefore healthy. This is a matter of scientific interpretation, but to the extent that cellular, metabolic, and organismic senescence is inherent in the human species, the less legitimate anti-aging research appears as a field of health science. This in itself does not mean that there is anything intrinsically wrong with anti-aging research, of course, any more than research into advanced tattoo techniques is wrong. It only means that anti-aging researchers must give up their claims to be promoting human health—and the measure of public support that mantle provides (Murphy).
It is unlikely that anti-aging researchers will be able to offer any intervention that could address the genetically programmed aspects of the aging process in the foreseeable future. Instead, partial interventions, such as HGH replacement, will be developed in response to genuine health concerns. Almost any intervention that would postpone specific milestones of normal aging would also help prevent the health problems common to those milestones. Would successful HGH replacement prolong the vitality of the musculature or prevent the onset of aged-related weakness? As long as these are two sides of the same coin, the anti-aging effects of such interventions will always be eclipsed by the medical obligation to prevent disease, effectively deciding the question of the intervention's appropriateness and the need for its development (Juengst). Against this conceptual backdrop, anti-aging researchers might insist, it would be better to embrace the anti-aging goals of the patients and researchers interested in these interventions, rather than foster increased off-label (unapproved) use of interventions without appropriate safety and efficacy testing. A well-regulated and thoughtful program of anti-aging research, they could argue, will ultimately do more to protect the public welfare than relegating the effort to the margins of biomedicine (Mehlman).
Fairness in Anti-Aging Medicine
Critics might reply that appeals to the public welfare change the terms of the debate once again. At the level of social policy, the dangers of the off-label use of medical interventions for anti-aging purposes dim in comparison to the injustices that might be facilitated if anti-aging interventions are treated as elective enhancements. Public attitudes toward the enhancement technologies already available suggest that the demand for truly effective anti-aging interventions will be so substantial that legal prohibition would simply produce a robust black market in these interventions. On the other hand, if the interventions are seen as "elective" or "cosmetic" enhancements, they are likely to be left to the market to distribute, according to the ability of consumers to pay.
If anti-aging interventions are, like other cosmetic uses of medical tools, available only to those who can afford them, society would see the disparities between the haves and the have nots exacerbated in a particularly insidious way. For example, if wealthier older adults can maintain their youthful features, they may come to have more interests in common with young adults than with the poor elderly population, and this may lead to a shift in political allegiances. If they were to continue to identify with their age cohort, a larger population of youthful elderly might benefit the interests of the aging elderly. If other interests realign allegiances, however, the poorer aging elderly could find themselves increasingly marginalized. If anti-aging medicine ultimately stigmatizes the aging process as a pathology of the poor, this political disadvantage could be compounded even further by social intolerance (Seltzer).
One alternative, of course, is for the government to play a role in financing and distributing these interventions. For candidates of equal age, should the previously treated or the untreated have the highest priority? For candidates of equal health status, should the chronologically younger or older take precedence? Finally, how should the benefits of these interventions be measured in order to determine the amount of public funds that should be spent on making them widely available?
These are critical public-policy questions that will have to be addressed as anti-aging interventions become available. On the other hand, they are not problems that should guide the progress of scientific work. In practice, medicine is not likely to police anti-aging interventions for social policy reasons unless it becomes clear that the social problems created by their availability as elective medical services are severe enough to compare with public health emergencies. According to some critics, such crises are not unforeseeable in a long-lived society (Hayflick). But until it is clearer that medicine should steer by social justice as well as patient welfare, the advocates argue complicity that with these social problems is not likely to stand in the way of anti-aging medicine.
The prospect of anti-aging interventions raises searching questions for individual families, biomedical professionals, and public policy. Most of the issues described here are questions that need to be addressed at all three levels, and they call for both social-scientific research and deep cultural reflection on the meaning of aging. Nevertheless, it not too early for anticipatory public discussions of these questions to begin.
eric t. juengst
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