In September 2005, the President’s Council on Bioethics issued a report entitled Taking Care: Ethical Caregiving in Our Aging Society. The report addresses one of the gravest ethical, political, and economic questions now facing us — how to live well with aging and decline and how to care well for those who suffer debilitating diseases like Alzheimer’s. In Washington, most committee reports are ignored or forgotten unless they offer a series of “solutions,” “proposals,” and “action items.” For practical people bearing the weight of making public policy, this penchant for “can-do” documents is understandable and often necessary. Act first, think later. But wise policymaking occasionally benefits from deeper kinds of reflection about who we are as individuals and what we aspire to become as a society. And the dilemmas of growing old ourselves and caring for loved ones in decline are surely policy matters, but they are hardly policy matters alone. In this spirit, we offer the following brief excerpt from the council’s latest report — the seventh and last report to be issued under the stewardship of Dr. Leon Kass. What follows is perhaps the least “practical” section of the whole document — a reflection on what it means to be an aging person in the modern world, for better and for worse.
Aging is at once a biological, psychological, and social phenomenon. It is a universal feature of human life. We grow, we grow up, we grow older, and — if we are lucky — we grow old. In the broadest sense, we are aging from the moment of birth until the moment of death. In the beginning of life, to age means to develop — our bodies grow larger, our mental capacities expand, our physical powers develop. We learn to crawl, walk, run, speak, and write. In the long middle of life, aging means developing and declining all at once — developing new faculties and new perspectives while gradually losing abilities that once came easily. For many, growth amid decline is possible until the very end; the aging individual is still gaining in wisdom and experience even as the body enters its final senescence. But for others, at the end of life, biological aging eventually means loss and decline almost entirely; it means the gradual or swift eradication of one’s physical and mental powers. In some cases, the body declines in advance of the mind; in other cases, the mind deteriorates in advance of the body. But in the end, for everyone, aging leads to death and, with it, the loss of the whole person as body-and-mind. This fact of being human and thus mortal is unavoidable for everyone.
Biological aging is not unique to human beings. All animals grow and die, and the capacity for growth seems intertwined with the reality of death. But for human beings, aging is not only a biological experience but a psychological, existential, social, and religious one: it involves seeing oneself in a new light as one’s life progresses and one’s body changes; it involves looking back on one’s past experiences and looking ahead to one’s shortening future; it involves treasuring life and independence as long as possible and accepting dependence and death when they can no longer be resisted. It involves changes of familial and social roles, changes of responsibility at work and at home, and differing forms of participation in civic and communal life.
Today, we have many images of being old — some perennial and some unique to our time. There is the revered matriarch who commands the respect of her entire family; the immobile and lonely resident of a nursing home; the old man who gives youngsters a run for their money on the tennis court; the doting grandmother who gives her grandchildren sweets when their parents aren’t looking; the senior executive given “early retirement” by his younger and more ambitious colleagues; the elder statesman who advises those who now stand where she once stood; the demented elder statesman who no longer knows his own name. Old age comes with many faces, and our image of old age varies almost as much as the elderly persons we know most intimately. Sometimes we revere the old and sometimes we pity them. Sometimes we admire the timeless lessons they have to teach us and sometimes we belittle them for not adapting to the times.
The two most prominent images of aging today stand in deep opposition to one another: there is the idealized image of healthy old age, with vigor and vitality until the end, and there is the sorrowful image of extended decline and dependence, with the ravages of long-term dementia and physical deterioration. Ours is the age of both extended youth and extended degeneration — and often, for many individuals, a life trajectory that is marked by one after the other. We are younger longer and we are aged longer. Living well with this paradox of modern aging is perhaps the special challenge of our time.
Aging well is thus a deeply ethical activity. It does not simply mean having the good fortune of staying healthy and vigorous until the end, but requires exhibiting certain virtues for as long as one has the capacity to do so. As William F. May reflects in his seminal essay on the ethical life of the elderly:
Such virtues do not come automatically with growing old. Even limited dealings with the elderly disabuse us of that sentimentality. Rather, the virtues grow only through resolution, struggle, perhaps prayer, and perseverance. Further, these virtues hardly appear only in the elderly. Some common human virtues — which men and women of all ages might do well to cultivate — simply take special form in the later years. When they do appear in the elderly, however, they can instruct and sometimes even inspire. Their example can encourage particularly the fainthearted among the young who believe that full human existence is possible only under the accidental circumstances of their own temporary flourishing.
May reminds us that the virtues required to age well are the universal virtues needed by human beings of every age; the old are not a separate species but human beings living human lives who should be held to human standards. These virtues do not develop and manifest themselves simply by living a long time; they require active cultivation throughout life, culminating but rarely beginning in old age.
Yet these virtues do take a special form among the elderly; old age is a particular time of life with particular ethical and existential demands, a time when vigor and ambition begin to wane and when the very meaning of one’s existence presents itself with looming finality. May also reminds us that the old live (or should live) among the generations, not separate from them. He reminds us that the young often benefit from the moral example of the old, and that the old are more likely to age well when the rising generations stand with them — as caregivers, to be sure, but also as recipients of the gifts that the old alone are equipped to give. Even in their days of total dependence, the old can still be a gift to the young.
There is great human variation in how people age — variation dictated by the particularities of each person’s circumstances and by the culture in which the aging person lives. But certain traits of character, as May suggests, are always necessary to age well: courage, including the capacity to keep one’s fears in check even as one’s prospects worsen; simplicity, including the capacity to “travel light” on one’s final journey; wisdom, including the avoidance of excessive nostalgia and excessive remorse; and humor, including the wit that sometimes flourishes when the carefulness of middle age is no longer required. These virtues of the elderly — to which could be added gratitude and acceptance, among others — draw strength from a society that honors the old even when they can no longer produce at the high levels they once did, and these virtues give strength to a society where the old always seek to benefit those who must replace them in the cycle of generations. The need to face aging and death — our own and that of our loved ones — with clear minds, caring hearts, and human solidarity reminds us that virtue has not become obsolete in our high-tech world.
The personal experience of aging is, of course, more than a matter of virtue. The particularities of that experience are shaped by many factors — biological, psychological, and sociological — that we might review in turn.
Gerontologists define “normal aging” as follows: “A time-dependent series of cumulative, progressive, intrinsic, and harmful changes that begin to manifest themselves at reproductive maturity and eventually end in death. Primary aging would describe those changes that occur over time independent of any specific disease or trauma to the body, whereas secondary aging would describe disabilities resulting from forces such as disease.” While aging is a shared biological fact for human beings as a species, the trajectory of biological aging differs dramatically from person to person, due both to one’s unique genetic inheritance and to variable environmental influences that shape each person differently throughout life. For some, nature tragically prevents even the possibility of old age, death arriving before the person can grow old or grow up; for others, genetic predilections toward longevity are inherited from long-lived ancestors. For those fortunate enough to live a long life, the process of aging and decline takes many different shapes: some live vigorously until the end, then die a swift or sudden death; some suffer a gradual period of bodily decline, with sufficient time and self-awareness to see aging as the final chapter of a complete life; some suffer dementia and live through long years of diminished awareness and total dependence.
This biological trajectory is influenced significantly in our time by the possibilities and limits of modern medicine. Medicine can prevent, reverse, or slow down some ailments; before other diseases and disabilities, medicine stands — at least for now — relatively helpless. Sudden and premature deaths are far less common than in the past; extended decline and disability are far more common. But the process of growing old always moves toward decline and death, even if the route is very different from person to person. The vital trajectory varies; the post-vital outcome does not.
In crucial respects, everyone ages alone: for it is the self’s body alone that changes, the self’s faculties alone that decline, and the self’s death alone that looms; these personal realities cannot be shared fully by others. But at best, individuals do not age and die by themselves (even if they must age and die as themselves alone), but with family, friends, and caregivers who stand with them. The rhythm and happiness of old age are shaped greatly by the presence or absence of loved ones: by living with or outliving one’s longtime spouse; by having one’s adult children and grandchildren live nearby or far away; by living at home with family or in a nursing home; by having or not having family altogether. It is precisely because we must age and die alone that we need the presence of others to help us age purposefully; to remind us that life does not end with us but carries forward beyond us; and to show us that we are valued for what we have to offer and even when we can offer little in return.
Perhaps no friendship in life is deeper than that between husband and wife. As spouses think together about aging and dying, the meaning of being alone presents itself sharply: what loving spouse would not give his or her life to save a husband or a wife, and yet what spouse wants to leave his or her beloved to age and die alone. As with spouses, so it is with lifelong friends: It is a great blessing to live a long life, but also a burden to outlive all one’s closest friends, and to face death without the camaraderie that they alone might offer. The weight of loneliness is also felt in the relation between an aging father or mother and his or her adult children and grandchildren: The noble desire not to disrupt the children’s lives with one’s own neediness co-exists with the desire to be needed by them even in one’s days of dependence, and cherished by them when one’s usefulness has passed. In the face of aging, our devotion to others is both most tested and most required. There is sometimes a powerful temptation to believe that elderly persons’ lives are so limited that fellowship is insignificant, a temptation to regard being with them as little more than sitting awkwardly in a small room in a smelly nursing home. If, because they remind us of our own inevitable decline, we shun their company, we isolate them even more. But often, it is precisely because the elderly have nothing else that they need our fellowship most of all.
As the body ages, health problems proliferate and worsen. The capacity to face these problems — not only medically, but existentially — is affected significantly, often decisively, by one’s economic condition. Money alone hardly ensures that wealthy individuals can age well; the absence of money alone hardly means that poor individuals will age poorly. Many wealthy persons suffer terribly in old age despite the best medicine that money can buy, and many lack the character to live well as their powers diminish. At the same time, many poor persons demonstrate heroic virtue despite the lack of economic means, and they still savor the gift of life despite its many hardships. But it is quite obvious that having reliable health care, good nursing, and the wherewithal to make life decisions free from severe economic pressures often makes it significantly easier to age well. Being wealthy ensures that one’s bodily needs are attended to as well as possible, and it allows the elderly person (for as long as nature cooperates) to enjoy his or her final phase of life without living in a constant state of economic anxiety.
Of course, there will always be large disparities in the economic condition of the elderly; this fact is unavoidable in any free society (not to mention un-free societies, where the disparities between the wealthy and the poor are usually much starker). But as a society, we should aspire to provide every aging person some basic level of economic security and medical care — including long-term care — while always recognizing that providing support for the elderly is but one great civic good among many, and while always remembering that wealth alone is never a sufficient answer to the human dilemmas of aging. Economic security does not translate simply into existential security. Money does not give life meaning in the face of death. But as one faces great physical trials and ultimate human questions in one’s final days, it is surely a great blessing to do so without the constant fear or present reality of economic disaster, or the constant worry that good care for oneself means years of hardship for one’s spouse, children, or grandchildren.
Since old age is a distinguishable phase of human life, it makes sense to consider the distinct purposes and obligations that define it and the connection of these purposes and obligations to the other phases of one’s life. The answer is hardly the same for everyone, and it obviously shifts from one period of old age to the next. For some, old age is a time for novel pursuits — a time to explore interests that have been put off year after year in order to meet the demands of full-time parenting and full-time work. For others, it is a time to return to old passions or to renew the existing bonds of family and friendship. For some, aging is a time to continue one’s life work. For others — and eventually for everyone — aging means learning to “let go” of the things one has done throughout life; it means “retirement” in the true sense — no more fixing cars, taking hikes, sailing boats, or attending concerts. To age is to experience intermittent finitudes on the way to the ultimate finitude that is death. And for some, the central work of growing old is learning how to die — how to let go, how to say goodbye, how to ask forgiveness, and how to put one’s existence and one’s memory in the hands of others.
At best, the vocations and avocations of old age are not mere distractions to pass the time, or simple amusements that temporarily blur the realities of finitude. Amusement is not to be disparaged; it is as essential to old age as to other phases of life, and being amused is sometimes an achievement of character in circumstances where there are many reasons to be miserable. But constant amusement — cruises, bingo, television, and so on — may not be the best way to confront the seriousness of being old. Aging rightly forces reflection on the character of one’s life as a whole. It often involves living with opposites: cultivating new interests, new sensibilities, or new understandings of the world, while letting go of old loves, old jobs, and old pursuits that once loomed large in one’s identity. Pursuing the ideal of aging well is never work for the weak-spirited. It invites us to see our final years as the culmination of a human whole, with a deepening sense that one’s life is not simply an arbitrary sequence of events but a coherent narrative with a beginning, a middle, and a meaningful end. Not everyone, alas, is so fortunate as to be able to do so.
While aging is a common human experience, it would be a mistake to ignore some differences between men and women during this time of life. As a sociological and demographic fact, women tend to outlive men, and thus more often face the burdens of living as widows than do men the burdens of living as widowers. This means that women are more likely than men to sleep in beds that now feel empty, having spent months or years caring for the person who once slept alongside them. This comparatively longer life also means that women are more likely than men to become impoverished in their golden years, spending down their final assets on long-term care, including the kind of care they may once have provided to their husbands free of charge.
There may also be certain inherent differences between men and women when it comes to aging, both biological and psychological. As William May suggests:
[W]omen receive an earlier and clearer biological preview of aging — if not of mortality; menopause gives them a clear signal that the wheel of existence turns downward toward the ground, while men find ways to obscure in themselves whatever signals they receive. Women tend more often than men to associate aging and death with the corruption of bodily form; men, with a flagging vitality. The corruption of the body shows up relentlessly in the morning mirror; the failure of vitality overtakes in more elusive ways and is suppressed more easily in men.
Other existential realities — such as the transition from work to retirement or from a full nest to an empty nest — once affected men and women in profoundly different ways. But as the familial and social roles of men and women have become less clearly demarcated, the differential effect of these experiences on men and women is perhaps less significant, even as the experiences themselves are no less profound. Yet despite the fluidity of male and female roles, it still remains the case that women serve much more extensively than men as caregivers for the dependent, including and especially for the dependent elderly. And it may be that this experience of caregiving makes women more attuned to the realities of aging, and thus more prepared existentially and ethically when they age and decline themselves.
Although aging proceeds in one direction — toward the gradual breakdown of the whole body, ending in natural death — senescence is not a unified process that affects equally all systems of the body and mind. Different people age in different ways, in part because they lose different capacities at different times, and in part because they lose some capacities and not others before they die. Some individuals suffer long-term physical disability with their mental capacities and self-awareness firmly intact until the very end of their lives. For others, cognitive disability or dementia sets in and grows severe even as the body remains relatively healthy, with the total breakdown of the body’s systems coming only much later, often years later. The experience of aging is thus shaped profoundly by the health of the body in relation to the health of the mind, and the health of the mind in relation to the health of the body. It is also shaped by the specific manner in which the body fails or the mind deteriorates — as well as by how well the individual is able to adapt to and compensate for any diminution of function.
The combination of physical debility and cognitive health can bring a host of personal frustrations: the powerful desire to do something for oneself or another, even the simplest thing, but not being able to do it; the inability to control one’s bowels, with enough awareness to be embarrassed by it; the heartache of watching loved ones sacrifice so much on one’s behalf, when all one wants is for them to flourish themselves. Yet the gift of self-awareness until the end is also great. The aging individual with a healthy mind and sick body can still savor some of life’s greatest joys — experiential, interpersonal, and intellectual. He might still be able to read his favorite books, listen to his favorite music, see a grandchild off to the prom, and thank a devoted family caregiver. But the grave imbalance of physical and mental powers also often brings its own special misery — including the feeling of being trapped inside a body that does not respond to one’s desires, needs, and efforts at control.
The gradual and extended loss of one’s mental powers brings different dilemmas, frustrations, and miseries, both for the suffering person and for his or her caregivers. With a disease like Alzheimer’s, some people suffer at first by knowing what is coming — by seeing one’s mental powers decline, one’s memory erode, one’s grasp of one’s surroundings becoming hazy. Eventually, this self-awareness of decline fades into the loss of self-awareness entirely — including the inability to understand how to behave appropriately, the incapacity to recognize loved ones, and the confusion that comes with not remembering life from one minute to the next or the paranoia that comes from not understanding what others are doing and why. Eventually, with Alzheimer’s and other senile dementias, this cognitive disability becomes so severe that it leads to physical disability — the inability to speak, to control one’s bowels, to eat and drink. Eventually, as the mind shuts down completely, so too does the body.
As we contemplate the imbalances of physical and mental health that often shape how we age, we confront the puzzling unity and disunity that is the human person. We come to see that we are an indivisible unity of the mind-and-body, but that often our will wants what our bodies cannot do and cannot be. The individual both has a body and is a body, even when he resents all the things the body cannot do or all the pain the body causes, experiences, and endures. And eventually, in death, this experience of imbalance leads to a unified ending: the death of the whole self, mind-and-body together.
Our views on death obviously shape how we age, though these views often take firmer shape only as we age. Aging leads to death — the final limit on earthly life and a fact of our humanity that cannot be disputed or avoided. But there is deep disagreement about what the end of embodied life means for the human person who once lived. Many of us live with great uncertainty about the meaning of death. We live between faith and doubt, fear and serenity, obsession and blindness. Many others have firmer ideas about what death is — whether a supreme faith in redemption and resurrection after death, or a firm belief that life here-and-now provides no evidence for life hereafter, or a belief that an obsession with personal death only blurs the perfect nothingness (or nirvana) that is being itself.
Moreover, there is no simple formula for judging how one’s views on death will shape one’s approach to aging. Some of those who believe that the self disappears entirely after death will resist death at all costs, struggling to preserve bodily life against the prospect of total oblivion. Others with the same belief conclude that the self is the final judge of its own existence, including the arbiter of its own exit. In this view, the ravages of aging might be justifiably preempted by choosing or embracing death, on the grounds that happiness here-and-now is the only measure of life’s worth and that some kinds of old age are too miserable or undignified to endure. For still others, a belief in the utter finality of personal death might lead to a kind of stoic virtue, enduring aging and death as an example of uprightness for those who will one day die themselves.
The widespread belief that life does not end here — that salvation, resurrection, or reincarnation is possible after death — can also influence how one views one’s own aging. For some, this means that aging is both a burden that must be endured and a sacred passageway to divine salvation. Such an emphasis on the hereafter might make death seem less horrible because it is less final; or it might make death seem more frightening because one fears eternal judgment. To believe in heaven often means believing in hell; the comforts of faith often coexist with terrible anxiety about the fate of one’s immortal soul.
In the modern age, as suggested above, many people live somewhere between certainty and doubt about the meaning of death: they hope for salvation, but cannot be sure; they see little reason to believe in life hereafter, but know that the origin and destiny of life is a mystery they cannot finally solve. But whatever one’s views on these ultimate questions, death is both an evil and a necessity for all bodily beings: Death is an evil, because it can strike at any moment, because it robs us of those we love, and because the overwhelming fear of death can deform how we live. And death is a necessity, because as biological beings we are not made to live forever, and because much that is good in human life depends on accepting and living out our roles as self-conscious mortals. In death, one generation stands aside for the next. The ripeness of age gives way to the freshness of youth. In some ways, aging appears as a series of small dyings on the way to death, but also the drama of taking one’s place in the ongoing chain of generations, ideally with more gratitude than bitterness for the life one has lived.
This drama of growing old, passing down, and passing on is hardly new. It has always been at the heart of the human lifecycle, recognized by the wise men and women of every age (even before old age as we know it today became so commonplace). In De Senectute, Cicero gave voice to this human reality of ascent and decline: “The course of life is fixed, and nature admits of its being run but in one way, and only once; and to each part of our life there is something specially seasonable.” The question we now face, however, is whether the idea of a “cycle of life,” with its several and differently meaningful stages, still makes sense to us — both as a lived experience and as a guiding belief. Do we still regard each phase of life as possessing its own “seasonable” quality, where the trajectory of one’s own life interlocks with the trajectory of the generations? Or do we live, in some sense, “after the lifecycle,” with the expectation of extended youth or extended decline, and with a confused sense of how life’s many phases fit together or how the self’s demise relates to the ascent of those who will stand in our place?
Already, we seem to be extending youthful vitality into what once seemed like old age, and at the very least, we now expect healthy living and medical progress to keep us “feeling young” at ages that were once considered old. In the future, we may not see 70 or 80 as part of old age but rather as part of the long middle of life. At the same time, however, we may be entering an age in which extended decline and dependence also become widespread, and when a long period of being unable to care for oneself becomes the normal pathway to death. These changes in how we age are taking shape alongside myriad changes in the rhythm of the earlier phases of life — including when people marry, when they have children, how many children they have, and the kind of work they perform. The old increasingly care for the very old, and the young increasingly see the old at a distance — both geographically and pedagogically, shaped by a culture that often prizes mobility and novelty over stability and tradition.
To say that we live “after the lifecycle” is surely an exaggeration: The outlines of growth and decline still hold in our lives, as does the sense that life has a shape, with different phases, each with different qualities. But we also seem to be living in a new moment, both sociologically and psychologically: The age structure of society has changed and is changing; the decades of life are starting to hold new meaning; and the expectations we impose on old age are evolving both positively and negatively, with high hopes and great fears. These changes have been brought about in part by modern medicine’s transformation of the trajectory of life, illness, and death and by modern culture’s emphasis on independence, individual self-rule, and career as the major sources of self-esteem.
The rising prevalence of Alzheimer’s disease and other dementias in old age only makes these questions about the trajectory of life more acute. Besides the normal fear of senescence and death, many people are horrified at the thought of ending their lives only after a long period not just of physical frailty and disability but also of mental incapacitation, impaired memory, diminished awareness, loss of modesty and self-control, distortion of personality and temperament, inability to recognize friends and loved ones, and general dullness and enfeeblement of inner life. It seems a cruel irony that the very medical advances that have kept many of us reasonably healthy into a ripe old age have, by the same token, exposed us to the ravages of incurable and progressive dementia, and to the prospect that our life’s drama may well end with an extended final act marked by a gradual descent into mindlessness.
The Aging Self