Planning Later Life

Bioethics and Public Health in Ageing Societies

Mark Schweda, Larissa Pfaller, Kai Brauer, Frank Adloff, Silke Schicktanz

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781317080015
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

This book examines the relevance of modern medicine and healthcare in shaping the lives of elderly persons and the practices and institutions of ageing societies. Combining individual and social dimensions, Planning Later Life discusses the ethical, social, and political consequences of increasing life expectancies and demographic change in the context of biomedicine and public health.

By focusing on the field of biomedicine and healthcare, the authors engage readers in a dialogue on the ethical and social implications of recent trends in dementia research and care, advance healthcare planning, or the rise of anti-ageing medicine and prevention. Bringing together the largely separated debates of individualist bioethics on the one hand, and public health ethics on the other, the volume deliberately considers the entanglements of envisioning, evaluating, and controlling individual and societal futures. So far, the process of devising and exploring the various positive and negative visions and strategies related to later life has rarely been reflected systematically from a philosophical, sociological, and ethical point of view.

As such, this book will be crucial to those working and studying in the life sciences, the humanities, and the social sciences, particularly in the areas of bioethics, social work, gerontology and aging studies, healthcare and social service, sociology, social policy, and geography and population studies.

Part 1
Conceptions of ageing and old age

1
“A season to everything”? Considering life-course perspectives in bioethical and public-health discussions on ageing

Mark Schweda¹

About 15 years ago, the newly elected chairman of the German conservative party’s youth organization declared in a newspaper interview that he did not think it right that 85-year-olds should receive hip replacements paid for by the welfare state. The German media as well as the public were scandalized. Colleagues accused the junior politician of advocating an ideology that destroys the solidary structures of our community. And the minister of family affairs even warned that a society that allowed such discussions was on its way to “a Brave New World in which 60- or 65-year-olds were expected to take the death pill.” (Schweda 2013, 149).

In retrospect, what appears striking in this debate is the disparity between moral outrage and argumentative elaboration. Neither the young politician nor his opponents actually made great efforts to substantiate their respective stances on age-based limitations of medical care. What specifics of old age make it seem acceptable (or not) to withhold medical treatment from the elderly that other citizens are usually granted without any reservation? What exactly is it in senior citizens’ conditions and situations that lets specifically hip replacement appear dispensable (or not)? And why does an 85th birthday mark such a significant threshold in a person’s life that their whole standing within the ‘welfare state’ is fundamentally altered (or not)?

The controversy illustrates increasing socio-economic anxieties in ageing societies. On a more general level, it can also be regarded as a twofold example of many contemporary public, political, and academic debates on ethical and public-health questions in the context of ageing. On one hand, such questions gain relevance and immediacy as demographic ageing and its consequences move to the focus of political attention, media coverage, and public awareness. At the same time, however, the corresponding debates often express a rather limited perspective on ageing and old age. Ageing is usually only considered and discussed inasmuch as it poses a practical problem – that is, to the extent that it interferes with the standardized, predefined, and desired course of things within the existing framework of clinical or health-policy practices and institutions. Thus, the issues raised include the problem of meeting the special needs and requirements of elderly, frail, and demented patients; the problem of making medical decisions regarding the prolongation of life; or the problem of distributing limited health-care resources in ageing societies (Fenech 2003).

This contribution is based on the conviction that this problem-centered perspective is itself problematic. First, it considers only those aspects in ageing that seem to pose the problems, and thus it hampers a more comprehensive understanding of the phenomenon as such in its interplay of biological, psychological, and socio-cultural dimensions. At the same time, however, the problem-centered perspective itself usually tacitly relies on certain implicit, often rather traditional preconceptions and prejudices regarding ageing and the life course, thus slipping questionable assumptions into the debate without further reflection or justification. For example, the proposition to withhold hip replacements from the elderly draws upon a forceful traditional image of old age that has prevailed and has been taken for granted for such a long time that we have come to accept it as natural: the frail, decrepit elderly. In fact, the aforementioned junior politician explicitly acknowledged this traditional image in his interview when he added offhand that, after all, elderly people, in the past, also used to walk on crutches. This finally highlights a further serious issue of the problem-oriented perspective: it has a tendency to frame ageing or the elderly themselves as the problem, thus reinforcing negative stereotypes of old age and fostering ageism – that is, discrimination against individuals due to their (advanced) age (Butler 2005).

In the following, I therefore argue for broadening the theoretical perspective. The problem-oriented perspective has to be embedded in a more fundamental and comprehensive approach to ageing. Solving specific problems in bioethics and public health in the context of ageing requires an explicit discussion about what it actually means to age and to be old. I will argue that the so-called life course paradigm developed in the fields of developmental psychology and social sciences provides a suitable starting point for such a discussion. It allows for conceptualization of human life as a socio-culturally standardized sequence of phases, stages, or steps, each linked to a particular status as well as to specific roles, moral expectations, and life prospects. To substantiate my claim, I first discuss a few more examples for the relevance of implicit conceptions of ageing and the life course in contemporary bioethical debates on medical care and futility, on anti-ageing medicine and life extension, and on age-based rationing of healthcare resources. I then introduce the life-course perspective as a theoretical framework for the ethical analysis, reflection, and discussion of such conceptions. Two pertinent categories appear particularly useful and productive from an ethical point of view: ‘age norms’ as normative standards of age-appropriate behavior and ideals of ‘ageing well’ as evaluative standards of personal self-fulfillment and flourishing at different stages of life. Finally, I discuss benefits and challenges of a life-course approach to bioethics and public health, concluding that ethical reasoning needs to appreciate and theoretically accommodate the normative implications of the temporal structure of human existence.

Implicit conceptions of ageing and the life course in contemporary bioethical debates

As demographic ageing and its consequences move to the focus of public attention and to the center of public and media discourses, bioethical and public-health questions regarding old age are gaining in relevance and urgency. After all, the general changes in most Western industrialized nations’ overall age structure have a particularly pronounced impact on the field of medicine and healthcare. Those belonging to the fastest-growing age groups of 65 years and older display an especially high demand for medical services and products (Congressional Budget Office 2014). They change the prevalent disease panorama and thus the focus of medical research and practice (World Health Organization 2011). This consequently also directs the attention of medical ethics and health policy toward problems that become relevant in the context of providing care to the old and the very old (Jecker 1992; Moody 1992; Wicclair 1993). In the respective debates, at least three major thematic strands can be identified: The first revolves around the adequate consideration of autonomy and care in physicians’ and caregivers’ interactions with elderly people (Agich 2003); the second, around the prospects of well-being and a good, fulfilled life at old age in light of new medical possibilities (Post and Binstock 2004); and the third, around the just distribution of healthcare resources among different generations (Binstock and Post 1991). As the following examples show, normative conceptions of ageing and the life course pervade and inform many of these discourses.

Conceptions of ageing and the life course in the debate on appropriate medical care

Social research clearly indicates that a person’s chronological age makes a significant difference in medical practice and healthcare. Thus, there is evidence that, in the UK, doctors have a tendency to not resuscitate older people (Ebrahim 2000). Studies in the US found that the proportion of recommended healthcare patients received declined with age (Asch et al. 2006). And an analysis of hospital-discharge data from Germany’s largest public health-insurance company shows that older individuals receive less costly treatment than younger ones with the same diseases (Brockmann 2002). One explanation is that physicians simply withhold certain kinds of medical measures from the elderly (Kapp 2002). This suspicion is supported by qualitative studies that indicate that age-related value judgments play an important role in treatment decisions for the elderly – for example, the notion that physical decline and, ultimately, death are somehow more natural and thus also more acceptable at an older age (Ubachs-Moust et al. 2008). Indeed, it is a common intuition that physical impairment and dying carry a different moral weight at different points in life – for example, that it makes a difference whether someone still has their whole life to live ahead of them or whether they have almost completed it (Jecker and Schneiderman 1994). We would probably be perplexed to read an obituary for a 97-year-old containing phrases like ‘died unexpectedly,’ ‘untimely passing,’ and ‘torn from the midst of life.’ However, it is important to acknowledge that the corresponding expectations and value judgments imply some normative conception of ageing and the human life course.

Such implicit normative conceptions also play an important role in many academic bioethical debates on medical decision-making. Take, for example, the central issue of determining the appropriate type and amount of care, usually discussed in terms of medical benefit and utility (or futility). Notwithstanding widely recognized claims to patient autonomy, most bioethicists agree that medical treatment should be beneficial to the patient and that it is therefore legitimate to withhold or withdraw treatment that promises minimal or no benefit (Schneiderman and Jecker 1990). Of course, the methods and criteria for determining the benefit or futility of a given treatment option are notoriously unclear and controversial. Statistical data indicating the probability of certain outcomes is often inconclusive, leading to widely diverging prognoses (Gabbay 2010). Moreover, judging treatment outcomes in terms of benefit or utility necessarily involves some sort of normative standard. Thus, one of the most prominent measures of utility, the concept of quality-adjusted life years (QALY), is based on the assumption that what matters in healthcare is maximizing healthy life years. This rationale has been criticized as inherently ageist since, statistically speaking, treatment of older individuals per se yields lower gains in both life years and well-being (Harris 1987). The idea that there is a connection between age and medical futility may mirror immemorial patterns of the normal course of human life and corresponding traditional notions of natural decline and inevitable death at old age (Tsuchiya 2000). Against this background, the death of an elderly person may even be seen as the “paradigm case” (Callahan 1977, 36) of a natural death. However, the mere empirical fact of a certain statistically average life expectancy alone cannot justify the normative decision to terminate a patient’s treatment. Indeed, a closer look reveals that the ‘natural death’ at old age only appears more acceptable due to a “biographical standard” – that is, a normative conception of the life course suggesting that most of a person’s history has “been achieved by that stage of life” and death now takes its “proper place as a necessary link in the transition of generations” (Callahan 1987, 24f.). The underlying traditional image of human life as an ascending and then descending curve that frames ageing as a natural process of decline, self-containment, and acceptance of finitude may have seemed inevitable in the past. In light of new technological possibilities and changing life plans, however, it is increasingly contested.

Conceptions of ageing and the life course in the debate on anti-ageing and life extension

Like under a magnifying glass, the sustained influence of such normative assumptions on ageing and the life course becomes particularly clear as soon as old age itself shifts to the focus of biomedical interventions and, consequently, bioethical discussions. This is the case in the highly controversial debates on so-called anti-ageing medicine. Starting in the 1990s, the anti-ageing movement has advocated biomedical methods to prevent or fight the effects of ageing – to decelerate, stop, or even reverse the underlying processes of biological senescence – and radically prolong human life (Mykytyn 2006). Indeed, some of the more ambitious anti-ageing protagonists explicitly announced that modern medicine is about to “forever alter our very notion of age, life, disease, and death,” promising the “elimination of the disability, deformity, pain, disease, suffering and sorrow of old age” (Klatz and Goldman 2003, 13). According to them, “the traditional enfeebled, ailing elderly person” will soon be “a grotesque memory of a barbaric past” (Klatz and Goldman 2003, 13). The self-proclaimed British biogerontologist Aubrey de Grey even speculated that “the first person to live to 1,000 might be 60 already” (2004).

Declaring a biomedical ‘war on old age’ apparently presumes that ageing is some sort of disease that calls for medical treatment. In fact, this assumption is spelled out in the statements of the American Academy of Anti-Ageing Medicine, which explicitly addresses ageing as “a treatable medical condition” (Klatz and Goldman 2003, 12). While the diagnosis and treatment of diseases have usually been based on age-relative standards for health and functionality, implying a notion of age-associated decline as a natural physiological process, anti-ageing protagonists demand the same standards be applied to the young and the elderly. Under these premises, a process such as a decrease in hormone levels is no longer considered as a normal sign of physiological ageing but as a kind of deficiency syndrome calling for “hormone replacement therapy” (Klatz and Goldman 2003, 119). The ultimate consequence of this perspective is to view ageing itself and even “death as an unnatural process” (Caplan 2005). In contrast ...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures and tables
• Notes on contributors
• Introduction
• PART 1 Conceptions of ageing and old age
• PART 2 Perspectives and problems of old age in the context of medicine and healthcare
• PART 3 Individual provisions and public policies in ageing societies
• Index