February 28, 2011

Aging in Black and White

“Never Say Die: The Myth and Marketing of the New Old Age,” a new book by Susan Jacoby, is a tour de force. If you can get beyond the strident rhetoric and the relentless anger, you will find a much needed dose of reality about aging. Jacoby’s perspective, much like the one I articulated in “The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies,” is that frailty and dementia are part of aging for many, many people and death comes for us all. To pretend otherwise—and the hype about exercise and diet leads many to believe we can remain vigorous until we die peacefully in our sleep (if we die at all)—has pernicious consequences. Those consequences, as Jacoby argues, are that we die badly; we undergo needless pain and suffering, at great financial cost, in exchange for living longer in a condition of dependence and debility; and we neglect to provide the kinds of social and economic remedies that could support a dignified old age.

For all of Jacoby’s incisive analysis and prodigious research, she leaves out of her discussion the most difficult decisions that frail people must make about health care. She focuses on dying, certainly a critically important domain, but omits the choice faced by 80 or 85 year olds about whether or not to receive an implanted defibrillators or palliative chemotherapy or bypass surgery. It is all very well to talk about the absurdity of extending the life of a person after a massive stroke by tethering her to a ventilator in an intensive care unit. This is an approach that the overwhelming majority of older people do not want for themselves. When a medical intervention is invasive, expensive, and ultimately unsuccessful (the 85 year old with a massive stroke is near the end of life, no matter what treatment is administered), virtually all reasonable people would agree—if only the alternative were presented in these terms—that it should not be used. The challenge is to figure out what to do for the person with mild dementia who has had a stroke that selectively interferes with swallowing. Should she be given a feeding tube to provide nutrition artificially? Or should she be kept comfortable using ice chips and mouth swabs?

Jacoby finds Ted Kennedy’s approach to his malignant brain tumor an inspiring model: accept maximally aggressive care as long as there is a chance of regaining a satisfactory quality of life; when there is no longer any reasonable likelihood of improvement, then enroll in hospice. But what about treatments that have a 20% chance of improving quality of life—but an 80% chance of causing increased pain and suffering in the short run and failing to improve quality of life over the longer run? What if the chance of improvement is only 10%? Lest this sound like Abraham arguing with God about his plan to destroy Sodom and Gomorrah if there are still 50 wise men in the city (or 40 or 30), what if the chance is 50% but the 50% who don’t get better are instead excruciatingly miserable? What if the chance of temporary improvement is 50%, but the cost of the treatment will wipe out the patient’s savings and there is an alternative approach that will extend life by 2 months instead of 4 (a huge differential in oncology circles) but at far more modest cost?

Perhaps it’s not fair to criticize “Never Say Die” for what it could have dealt with but didn’t. After all, Jacoby has tackled a number of interesting issues: she talks about how the tribulations of old age disproportionately afflict women (true, in part since women live longer); she is at great pains to trace the historical origins of a youth-oriented culture at least to the Civil War (compelling for those of us who love history, but what would perhaps be more illuminating is a contemporary cross-cultural comparison of attitudes to old age); she skewers those who claim that ‘wisdom’ comes with old age, suggesting that there is continuity between our middle aged and older selves (yes, there are wise 45-year-olds and foolish 80-year-olds); and she gets a bit tangled up in the controversy about the ethics of longevity research, asserting forcefully that there’s nothing wrong with living longer but the problem is that longer life inevitably brings with it debilitating diseases (perhaps not fully appreciating the longevity researchers’ argument that finding the master switch for the aging process and learning to turn it off would enable us to live longer precisely because we wouldn’t develop one disease after another).

But in the end, Jacoby falls victim to what Thomas Cole, in his book “The Journey of Life: A Cultural History of Aging in America,”
calls the duality of old age: the historical tendency to swing from one pole (aging is glorious) to its opposite (aging is a time of unremitting misery). What we must aspire to instead is a more balanced, dialectical view that sees aging as multifaceted. Painting old age in shades of gray rather than in stark black and white would better serve the goal of helping us design medical care, long term care facilities, and socio-economic policies for the oldest old.