The President's Council on Bioethics click here to skip navigation

 

This staff working paper was discussed at the Council's June 2004 meeting. It was prepared by staff solely to aid discussion, and does not represent the official views of the Council or of the United States Government.

AFTER THE LIFE CYCLE: THE MORAL CHALLENGES OF LATER LIFE

By Thomas Cole

"Men die because they cannot join the end to the beginning."

--Alcemeon of Groton

INTRODUCTION

In almost 30 years of reading and writing about later life, my favorite book is still a slender volume by the Catholic theologian Henri Nouwen and Walter Gaffney, entitled Aging: the Fulfillment of Life. (1974)1 .  Like many books on aging in the 1970's and 80's,  Nouwen struggles against negative stereotypes and attitudes toward older people, offering images and ideals emphasizing our shared humanity in the universal process of growing older.   The book's central motif is a large wagon wheel leaning against a birch tree in the white snow.  The photo invites each of us to think of ourselves as a spoke on the great wheel of life, part of the ongoing cycle of generations.  It also implies that each of us has our own cycle to traverse, a moving up and a going down, moving forward, yet also somehow returning to the beginning.  Nouwen's wagon wheel resembles the Christ-centered circular life cycle, which his medieval forbears rendered on stained-glass cathedral windows.  

But while medieval Christians considered earthly time as a mere shadow of eternity, the late 20th-century Catholic theologian asserts that "we have only one life cycle to live, and that living it is the source of our greatest joy."2    Modern Western culture since the Reformation has placed great emphasis on the affirmation of everyday life, on relief of suffering, and on respect for the dignity and rights of individuals.3

As a modern, Nouwen sets the issue of a good life squarely in the province of ordinary living.  Leaning heavily on Erikson's work, Nouwen writes that our "greatest vocation" is to "live carefully and gracefully."  Aging, then, becomes the gradual fulfillment of the life cycle, "in which receiving matures in giving and living makes dying worthwhile."4  With elegant simplicity, he describes the three-stage life cycle as it cogwheels with previous and future generations:

"The rest full accomplishment of the old wheel tells us the story of life.  Entering into the world we are what we are given, and for many years thereafter parents and grandparents brothers and sisters friends and lovers keep giving to us, some more,  some less, some hesitantly,  some generously.  When we can finally stand on our own feet, speak our own words, and express our own unique self in work and love, we realize how much is given to us.  But while reaching the height of our cycle, and saying what a great sense of confidence, "I really am," we sense that to fulfill our life we are now called to become parents and grandparents, brothers and sisters, teachers, friends, and lovers ourselves, and to give to others so that, when we leave this world, we can be what we have given." 5

I love the lyrical beauty of this passage, and its view that an individual's personal development naturally entails self-transcendence and moral responsibility in later life.   As Nouwen puts it, "receiving matures in giving."  But contemporary American culture seems to emphasize individual development without a clear consensus-even a rich debate--about the meanings of later life and the responsibilities of older people to future generations.  With the rise of mass longevity--and ever lengthening life expectancy--the roles, responsibilities, virtues, vices and meanings of an extended old age take on new urgency in both private and public life.  Strangely, there is virtually nothing written on this subject.  

There is a plethora of literature focusing (appropriately) on the ethics of care giving, on private and public responsibilities to older people, and on the rights of older people.  But there is virtually no discussion of the reciprocal responsibilities of older people.  In the bioethics literature, older people (or their proxies) are viewed solely as bearers of rights, as individuals entitled to make their own choices regarding health care. But there is precious little work on the content of those choices-or on the larger issues of accountability, responsibilities, virtues and vices of older people.

To address these issues, I will first provide a brief interpretation of Nouwen and Erikson, focusing on the normative dimension of their views on aging and the life cycle.  Next, I will offer a historical argument that we are living "after the life cycle" both normatively and structurally. Finally, I will tentatively sketch the moral challenges of later life--both for healthy active older people and for those who are frail, sick, and dependent.

Moral Norms and the Life Cycle

Let me begin with a brief analysis of Nouwen's perspective and that of his more famous counterpart Erik Erikson.  Philosophically, Nouwen's view rests on an ancient doctrine shared by Greeks, Romans, and Christians alike---that the human lifespan constitutes a single natural order and that each stage possesses its own characteristics and moral norms.  "Life's racecourse is fixed," wrote Cicero in De Senectute, "nature has only a single path and that path is run but once, and to each stage of existence has been allotted its appropriate quality."6   With the rise of Christianity, this normative life cycle was set within a divinely ordained natural order--and the Stoic ideal of rational self-mastery was replaced by a journey toward salvation. 

While Nouwen writes as a Catholic, his view of the life cycle is couched mostly in secular psychological terms which echo Erik Erikson's famous psychoanalytic formulation of the eight "Ages of Man," each with its own psycho-social conflict and its corresponding virtue.  First formulated at mid-century, Erikson's version of the life cycle virtually dominated American academic thought and public imagination for over twenty-five years.  Erikson's theory is actually a restatement of the Stoic ideal, supplemented by evolutionary and psychoanalytic theories.   Like the Stoics, Erikson argued that the cycle of human life contained its own stages, each with its own moral virtues and norms.  Erickson saw virtues not as "lofty ideals" formulated by theologians and moralists, but rather but as essential qualities rooted in human evolution.  As he put it, ". . . man's psychosocial survival is safeguarded only by vital virtues which develop in the interplay of successive and overlapping generations, living together in organized settings."7   

According to Erikson, the central psycho-social conflict in old age is Integrity versus Despair. Wisdom is the corresponding virtue arising from successful resolution of that conflict.  Integrity for Erikson is "an experience which conveys some world order and spiritual sense.  No matter how dearly paid for, it is the acceptance of one's one and only life cycle as something that had to be and that, by necessity permitted no substitutions."8 Wisdom is described as "detached concern with life itself, in the face of death itself.  It responds to the need of the on-coming generation for an integrated heritage and yet remains aware of the relativity of all knowledge."9

Erikson understood that the life cycle itself does not biologically generate the prescribed virtues, values, and behaviors associated each stage.  Rather every version of the normative life cycle is created by the combined forces of biology, culture, demography, history, social structure and patterns of family life.  While many of Erikson's followers have treated the "Eight Ages of Man" as if it were a universal paradigm of human development, I belief that Erikson's model represents culmination of the ideal life cycle in modern Western culture.  This ideal of a long, orderly and secure life cycle first emerged durng the Reformation and became fully realized in the middle third of the 20th century.10  Ironically, modernization removed the traditional structural underpinnings of the normative life cycle and replaced it with the life course

In both modern and postmodern society, old age emerges as a historically unprecedented, marginal and culturally unstable phase of life.  Herein lies the poignancy of our situation.  We are living "after the life cycle."11  In this context, Erikson's extensive life cycle writings take on an almost numinous quality. They offer hope for an ideal of the life cycle we desperately want to believe in.12   But however attractive, Erikson's ideal cannot accommodate the social, cultural, and demographic complexities of our era.  To say that we are living "after the life cycle" means in part that we are living "after Erikson."13  We need a richer, pluralistic dialogue about how to live the ever lengthening years of later life.  But first, let me sketch the historical context of our uncertainty about the roles, responsibilities, purposes, and meanings of old age.

MODERNIZATION:  FROM THE CYCLE  OF LIFE TO THE  COURSE OF LIFE

The modern life course began to take shape with the rise of urban, industrial society.  Set free from older bonds of status, family, and locality, aspiring individuals increasingly came to view their lives as careers -as sequences of expected positions in school, at work, and in retirement.  In the twentieth century, this pattern of expectations became both statistically and ideologically normative, constituting what Martin Kohli aptly calls a 'moral economy of the life course.'  By the third quarter of the twentieth century, Western democracies had institutionalized this 'moral economy' by providing age-homogenous schools for youthful preparation, jobs organized according to skills, experience, and seniority for middle-aged productivity, and employment based and publicly-funded retirement benefits for the aged who were considered too slow, too frail, or too old-fashioned to be productive.14 This stable sequence is sometimes referred to as the three boxes of life: education for youth; work for adulthood; and retirement for old age.15  Old age was roughly divided into a period of active retirement supported by Social Security and pensions, and a period of frailty supported additionally by the Medicare, Medicaid, and private insurance.  

During this transition to modernity, the cycle of life was effectively severed from the course of life.  In pre-modern society, when generations of people lived on farms, in villages and small towns, local traditions of practice, belief, and behavior provided external moral norms as each generation visibly cycled into the next; the problem of identity as we know it did not arise.  In Germany and Austria, for example, the burial plot of the older generation (even today) was often reused when their children died, just as houses, farms, and businesses were passed down.   "The idea of the 'life cycle,' writes Anthony Giddens ". . . makes very little sense once the connections between the individual life and the interchange of the generations have been broken."16  In a modern, mobile society life stages of life are disembedded from place; the individual "is more and more freed from externalities associated with pre-established ties to" family, individuals, and groups.17  Under these conditions, the life course becomes a career, a trajectory in which individuals choose their projects and plans; segments of the life course are marked by 'open experience thresholds' rather than ritualized passages.  Life course transitions are often accompanied by crises of identity; individuals are socialized to confront and resolve such crises, and identity becomes an ongoing, reflexive project.  

For many older people in an urban, mobile, and rapidly changing society, achieving a stable identity, knowing one's obligations, one's place in the cycle of generations and  in a worldview of ultimate meanings-these things became problematic. At a practical level for example, "Many skills that parents and grandparents knew are no longer useful in the information age, although emotional balance, love, and wisdom are still in short supply.   Grandmothers have little need to tell granddaughters how to bake bread . . . except as a story of the past.  There is little utility in having a grandfather" show his grandson how to sharpen a tool on a grindstone."18

Even as older people in the last half of the 20th century experienced vastly improved medical and economic conditions, they encountered a culture with no clear consensus about the meanings and purposes of later life. For the first time in human history, mass longevity became the norm in developed countries. People who retired often surprised themselves and the rest of us by living an additional 20 or 30 years. Continued increases in life expectancy now permit four-and even-five-generational families. What were we to do with this abundance of life? 19  This incredible gift of human longevity?  

I do not mean to imply that all or even most older people were or are unable to live morally coherent lives by drawing on the resources of religion, family, community, and personal conviction. My point is that the dominant social identities available to older people have been narrowly confined to the roles of patients, pensioners, and consumers.  Consumer culture, the leisure industry, the welfare state, and the medical establishment each had their own interest in shaping the culture of aging.

In the last quarter of the 20th century, this relatively stable institutionalized life course began to unravel.  The 1970's witnessed a powerful movement of older people and their advocates to overcome negative stereotypes of older people as frail and dependent.  Mandatory retirement was challenged under the banner of age-discrimination.  The 1980's initiated a rebellion against the bureaucratized life course and against restrictive age-norms.  Writers and scholars called for an "age-irrelevant" society that allowed more flexibility for moving in and out of school and the work force.  At the same time, serious doubts about the proportion of the federal budget devoted to old people were voiced in the name of "generational equity".  Others voiced specific fears of an unsupportable public obligation to sick and dependent older people.  Political support for the welfare state began to erode.

And finally, the transition to an "information economy"--spurred by the rise of computers and decline of industrial manufacturing--accelerated the pace of life and the speed of technological and social change.  Amidst a globalizing economy, declining corporate commitment to long term employment, seniority and defined pension benefits undercut expectations for income stability during retirement.  Postmodern or late modern society confirmed with a vengeance Marx's famous observation about capitalism:  "All that is solid melts into air." 

Zygmunt Bauman characterizes the resulting ontological insecurity in terms especially apt for older people:  ". . . the boundaries which tend to be simultaneously most strongly desired and most acutely missed are those of a rightful and security place in society . . .  (a place where) the rules do not change overnight and without notice . . . It is the widespread characteristic of men and women in our type of society that they live perpetually with the "identity problem" unresolved.  They suffer, one might say, from a chronic absence of resources with which they could build a truly solid and lasting identity, anchor it and stop it from drifting."20 Identity is not a purely personal issue; it is crucial to the development of wisdom and to knowing one's responsibilities.

AFTER THE LIFE CYCLE:  THE MORAL LIFE OF OLDER PEOPLE

When we begin to think about the issues of identity and morality in later life, we immediately run into an obstacle articulated by Erikson himself in 1964: "Our civilization," he wrote, "does not really harbor a concept of the whole of life, as do the civilizations of the East.  . . .  As our world-image is a one-way street to never ending progress interrupted only by small and big catastrophes, our lives are to be one-way streets to success-and sudden oblivion." 21 The absence of a culturally viable image of the life cycle set within a larger frame of transcendent meaning makes it difficult for many people to grasp the possibilities of spiritual growth and moral purpose amidst physical decline. 

In his seminal work After Virtue, Alasdair MacIntyre argues that we no longer possess a commonly shared moral language; in a world of moral strangers, MacIntyre claims that the only alternatives are Aristotle or Nietzsche-that is tradition or chaos.22  By analogy, I think that we are living "after the life cycle"--after the collapse of widely shared images and socially cohesive structures and experiences of the life cycle.  But I do not think we are forced to choose between idealized tradition or exaggerated chaos. First of all, the lack of a scholarly literature or articulated norms does not imply that most older people are leading morally incoherent lives. And second, the very search for identity itself holds important moral promise.  Here I am drawing on the work of Charles Taylor, who argues that despite the moral limitations of liberal individualism, the biblical tradition lives on as a kind of background cultural inheritance.  For Taylor, selfhood or identity is inextricably bound up with some historically specific (and often unarticulated) moral framework or notion of "the good." The quest to become one's authentic self need not degenerate into self-indulgence, emotivism or moral relativism.  It can (and logically does) entail becoming aware of and articulating the implicit moral framework of one's family, community, or religious tradition, which provide standards of conduct against which the fully developed person must measure herself. 

In Taylor's view, human life and identity are fundamentally dialogical.23  We become full, self-aware, and responsible human persons by engaging with others.  Our identities must be confirmed or recognized in dialogue and negotiated with others.  Self-definition is not possible in isolation, apart from social forms of expression and the expectations, needs, and values of others.  Taylor acknowledges that the contemporary culture of authenticity often encourages a purely personal understanding of self-fulfillment.  But he calls on us to retrieve the full moral potential of authenticity.

A person in search of identity always exists within a "horizon of important questions" which transcend the self.  Attempts at self-definition and self-fulfillment that ignore questions and demands outside the self suppress the very conditions of meaning and purpose.  As he writes, "Only if I exist in a world in which history, or the demands of nature, or the needs of my fellow human beings, or the duties of citizenship, or the call of God, or something else of this order matters crucially can I define an identity for myself that is not trivial.24

We should not, in other words, view the search for identity in old age as a narrowly personal quest.  Of course we are all familiar with examples of late life narcissism.  Yet the effort to live an authentic life is itself a moral ideal--an attempt to understand and fulfill the uniqueness of each human life.  Older people trying to make sense of their past through various forms of life review, spiritual autobiography, reminiscence, storytelling, lifestory writing groups, are often doing important moral and spiritual work with genuine implications for others.  And those who are passionately involved in the arts, in public service, religious communities and new forms of self-exploration exemplify models of elderhood.  As Erikson puts it at the end of Childhood and Society, without elders who possess integrity, children will be unable to trust.25 

Authenticity in itself, however, cannot provide standards of conduct and character to guide moral development in later life.  Authenticity alone provides no reasons to restrain the person who authentically chooses selfishness or evil.  It contains no intrinsic moral norms or prohibitions.  The dominant ideal of late life today seems to be what the Austrian sociologist Leopold Rosenmayr calls Die Spate Freiheit - or "the late freedom."26   Free from social obligations, retirement-for those who possess good health and adequate income--is equated with leisure activities (visiting family or friends, golf, mahjong, bridge, travel, taking up new hobbies, attending classes at Elderhostel or Institutes for Learning in Retirement, visiting family and friends). 

The problem here is not that these activities are wrong or bad.  Rather they are based on the concept of freedom from-i.e. the obligations of mid-life---with little or no attention paid to what the freedom is for--i.e. which principles or commitments should govern the choices being made.  Today,   senior marketing and advertising specialists have a primary influence on activities, programs, and products for seniors looking for ways to spend their free time.  While maintaining one's health necessarily occupies more time and energy as one ages, the commodification of the body has elevated health from a means to and end in itself.

Services, products, and programs for healthy aging are perhaps the most lucrative segment of the senior market.  Health is increasingly construed as   physical functioning divorced from   any reference to human meaning or purpose.  The reduction of health to physical function fits hand-in-glove with the notion of freedom as unfettered free choice.  In the 1970's, for example the biologist Alex Comfort wrote two popular books-The Joy of Sex and A Good Age.27 In both cases, Comfort celebrated technique, functioning, and achievement.  In the early 1980's, I invited Comfort to participate in a conference on "Aging and Meaning," where Bill May gave his prescient paper on "The Virtues and Vices of Aging." 28  Comfort bluntly declined to participate on the grounds that he had no interest in "grannyology."  His response revealed an obvious disdain for frail older women, a single-minded focus on control and functioning, and a (common but rarely expressed) discomfort or   contempt for existential concerns embedded in most contemporary discussions of "successful aging."  More specifically, by implicity linking sex, aging and achievement, Comfort anticipated the contemporary redefinition of sexual decline and impotence--which occur in individuals--into treatable sexual dysfunctions, which occur in organs.   In contrast, our culture needs to revision the notion of health along lines suggested by the American Association of Medical Colleges:  "Health is not just the absence of disease but a state of well-being that includes a sense that life has purpose and meaning"29

In today's consumer culture, drug companies, peddlers of over-the-counter products, and anti-aging hucksters make billions of dollars selling the false hope that aging is an option or a treatable disease.  Before the 20th century, health was understood as a means to an end-living a good life according to the standards embedded in religious traditions.    After "the triumph of the therapeutic," health was transformed from a means to an end in itself.  Rarely does one hear the question: "what do we want to be healthy for?"   A medicalized consumer society crowds out the cultural space necessary for grappling with the most important questions of all--to whom am I accountable? What makes life worth living?  Am I living a life   I can look back on with pride and satisfaction? What legacy am I passing on to my family? How can I prepare for my death in ways that minimize disruption and give hope to my children?

Given the limitations of authenticity, individual freedom, and health as adequate ideals, how should we begin to explore the moral challenges of aging? Ronald Blythe offers a penetrating, if harsh, starting point: 

Perhaps, with full-span lives the norm, people may need to learn how to be aged as they once had to learn to be adult.  It may soon be necessary and legitimate to criticize the long years of vapidity in which a healthy elderly person does little more than eat and play bingo, or who consumes excessive amounts of drugs, or who expects a self-indulgent stupidity to go unchecked.  Just as the old should be convinced that, whatever happens during senescence, they will never suffer exclusion, so they should understand that age does not exempt them from being despicable.  To fall into purposelessness is to fall out of real consideration.30

Learning to grow old is an important and relatively neglected concern in our aging society--one that  calls for human development policies (job retraining, creative use of leisure time, lifelong learning, volunteer networks, self-help groups) that help people develop the strengths and skills to solve their own problems.  As Harry R. Moody has pointed out, aging policy that responds only to problems intensifies "depreciation of the strengths and capacities of older people," and may inadvertently increase dependency rather than try to prevent it.31  Falling into purposelessness is not only a matter of individual will and character but also a matter of culture and public policy.   Older people-like all people-need to be needed.

In approaching the moral challenges of aging from the individual's point of view, I have always appreciated Rabbi Hillel's ancient three questions: "If I am not for myself, who will be for me?  If I am only for myself, what am I?  If not now, when?"  I take these each of these questions to stand for a phase of the life cycle, harkening back to Nouwen's formulation.  As children and adolescents, there is a natural tendency to see the world as one's oyster.  In mid-life, we realize that to mature we must attend to the needs of others.  And in later life, with time running out, we must learn to how balance our own needs with the needs of future generations.  Interestingly, whereas Nouwen speaks only of giving as we age, Hillel speaks of balancing competing needs and interests.

If we take Hillel's questions and apply them to later life today, we can begin to specify key questions which demand careful and balanced responses:

1)  As citizens, what responsibilities do we have to our community, the larger society, the environment? To the poor and vulnerable?   To our communities of faith? How do we balance these against our personal interests?

2) What are our responsibilities to our children, grandchildren? What level of caregiving and economic support do we owethem?  How do we balance these against our own needs and interests?

3) What responsibility do we have for older parents who may be in their 80's or 90's? How do we balance these against responsibilities to our children?  To our own personal interests and well-being?

4) What responsibilities do we have to future generations to minimize the national debt they will pay? to help safeguard the environment, to work for  sustainable sources of energy?

5) What responsibility  do we have for a spouse who is permanently disabled, perhaps by the later stages of dementia? Can we say, this isn't the person I married and I need to live my own life? Do we owe a degree of loyalty that includes daily visits and care? 

6)  What responsibilities do we have to shoulder, depending on circumstances, the burden of our economic support?

7) What responsibility do we have for our own health?    For exercising prudence in using limited health care resources?

8)  What responsibility do nursing home residents have to assist each other?

9) What responsibility do we have to pursue a path of continued growth and spiritual development which aims at self-transcendence, compassion, commitment to others, acceptance of physical and mental decline, and preparation for death?

I will not here attempt to answer these questions. But I believe they are urgent and call for personal wrestling, public debate, academic inquiry, and perhaps public policy.  A careful study, for example, advice literature about aging32 over time would reveal much about the changing values and norms conveyed to a reading public of older people. We need a great deal of social and behavioral study of what older people think about these issues as well as how they act.  We need studies of the moral and spiritual lives of older people in various geographic, ethnic, racial, gender, and class situations. We need diverse religious reflections and their translation into practical programs in congregational life.  We need philosophical inquiry and public conversation.  And we need to listen carefully to the life stories of both ordinary and exemplary old people.       

I do not think we can expect universally true, decontextualized norms and values to which all elders should be held accountable. In a pluralist society, we need to hear from various religious, ethnic, racial, political, groups. We need to hear, for example, from the AARP, which is often perceived merely as a powerful lobbying group for older people.  I think we need new models and ideals.  One example is Rabbi Zalman Schacter's   "spiritual eldering" program, which sponsors a series of workshops around the country for older people who would like to grow in genuine elders.33 Another is the "Civic Engagement" project currently underway in the Gerontological Society, or Marc Freedman's efforts to generate strengthening voluntary movements of older people offering their care and their skills with underprivileged urban youth.34 

The complexity and nuance required to grapple with these moral questions were aptly described by John Cowper Powys in his book, The Art of Aging (1944):  "If by the time we're sixty we haven't learnt what a knot of paradox and contradiction life is, and how exquisitely the good and the bad are mingled in every action we take, and what a compromising hostess Our Lady of Truth is, we haven't grown old to much purpose."35 

In other words, we need to strive for the wisdom and spiritual development to understand and respond to the moral challenges of aging.  (Sadly, our dominant culture lacks the very awareness needed to begin this personal, cultural, and social "work".)   As Powys points out, life is a "knot of paradox and contradiction." What are the paradoxes and contradictions one faces on the way to wisdom (one is always on the way of course, one is never there)?

One prominent paradox is that wise people know that they don't know; they can tolerate uncertainty because they understand the limits (especially their own) of any attempt to grasp the entire truth and the need for multiple points of view.   As Florida Scott Maxwell puts it: "I cannot speak the truth until I have contradicted myself."36  Wise people cultivate habits of self-examination and self-awareness; they do not attempt to impose their will on the world but learn to observe and accept reality as it is and acceptance changes the reality.  Consider the paradox that loss is gain: failed expectations are a precondition for acquiring experience which reflection may turn to growth.  Or the paradox is that unless a person accepts her own limited subjectivity and projections, she will be unable to work on transcending them.  Likewise, until a person understands and accepts the transitory illusions of their self-image, they cannot develop a higher understanding of themselves.37 

These paradoxes and contradictions are not solvable problems to be mastered with competence and expertise.  They must be worked through by each individual in search of spiritual growth; yet this rarely happens without guidance and community.  Our society, therefore, needs to support various multicultural contemplative practices including prayer, meditation, self-reflection, yoga, tai chi, new religious rituals, etc.  And then we run up against the ancient problem of the active versus the contemplative life--another contradiction which needs revisiting.

One of the most difficult and important the paradox of physical decline and spiritual growth.  How can we learn to work hard maintaining our physical health, while at the same time preparing for our own decline and death?  How do we learn to hold on and let go at the same time? One of the central obstacles to wrestling with the challenges of old age lies in the intractable American hostility toward and denigration of physical decline, decay, and dependence.  Rather than acknowledge these harsh realities, we pretend that we can master them and we feel like failures when we don't.  Hence the elevation of physical functioning to the criteria of "successful" aging and the virulent fear and denial of frailty and dependency.  Let me turn next to the moral and spiritual aspects of dependency.

THE MORAL CONTOURS OF DEPENDENCY

Dependency raises a special range of moral challenges for older people.  There are no guidelines about how to be a "good" dependent person, and I doubt that such guidelines would be a worthwhile goal.  We must first enter dependency's inner workings before we can understand its moral challenges.  Imagine a life in which you cannot walk, cannot carry out your accustomed activities of daily living, are perhaps blind, demented, or incontinent--a world where you must wait for others to bathe you, take you to the grocery store or the doctor. 

Time stretches before you like a desert, shame and self-loathing lacerate for the loss of your independence.  You are tempted both to false displays of self-sufficiency and to letting yourself go, lapsing into pure passivity.  Your family relationships become strained, especially when givers and receivers of care are dutifully playing their proper roles, without acknowledging their own and each other's emotional turmoil.

When my grandmother became demented in 1986, I asked if she would consider going into an excellent Jewish home for the aged.  "What do you think I am" she replied, "a no-goodnik?" she replied.  This woman, who had postponed marriage to care for her own mother, lost her husband and her only son, had still managed to scrape together enough money to leave her grandchildren an inheritance.  Stripped of an acceptable identity and the ability to be useful, she tried to jump off her twelfth story balcony.  Before slipping into deep dementia, she agonized as the money intended for her grandchildren was spent on her round-the-clock health care. 

It is often a terrible burden to be a burden to others.  What Wendy Lustbader calls "the alchemy of successful frailty," depends on finding ways to turning "the 'nothing' of empty time into the 'something' of good days.38  The possibilities of "successful frailty" depend on innumerable factors, not the least of which is reciprocity.

In her book Counting on Kindness: the Dilemmas of Dependency, Lustbader makes an unusual and controversial point about mercy.  The word in old French, merci, originally meant compassion and forbearance toward a person in one's power.  In Latin, merces, signified payment or reward, referring to aspects of commerce.  "Mercy" writes Lustbader, is based entirely on exchange.  "Giving help eventually embitters us, unless we are compensated at least by appreciation; accepting help degrades us, unless we are convinced that our helpers are getting something in return.  As much as we might prefer to reject this stark accounting, we discover in living through situations of dependence that good will is not enough.  [There is] a delicate balance at the heart of mercy . . . reciprocation replenishes both the spirit of the helper and the person who is helped".39 

We seem to lack language to acknowledge the difficulty of receiving.  Hence the dependent person may feel doubly burdened-- "disliking the help that cannot be repaid and feeling guilty for the dislike."  Increasing frailty shrinks the opportunities to be useful, eliminating external obligations: "no one expects our presence and no one needs our efforts."40 Finding ways to be useful requires imagination and will power, for example, among nursing home patients who figure out ways to look after one another.  For a resident to feel useful sometimes require special sensitivity of the caregiver.

As a geriatric social worker and therapist, Wendy Lustbader spent many years going to the homes of frail elders who were ashamed of their needs and struggled to conceal them.  Lustbader once visited a woman who allowed her in only because of a sudden illness.  The woman's light bulbs had burned out. She was reading by daylight and sitting alone in the dark.  Having nothing to offer her neighbors in return, she decided not to ask them for help.  The woman refused to allow Lustbader to stand on a stool to change her light bulbs; Lustbader said she hated thinking of the woman unable to sleep, tossing fitfully in her bed, and unable to read.  At last the woman's pride relented and Lustbader changed the bulbs.  "As I left, I thanked her for giving me the honor of helping her.  She understood what I meant, for it was she who was carrying the burden of uselessness and I who was being granted satisfaction."41  

Despite an extensive literature search in English, I have been able to find only two contemporary articles on the virtues and vices of dependent older people. One by the theologian, culture critic, and ethicist William May; and the other by the feminist, secular philosopher Sally Ruddick.  Before I  turn to the topic of virtue and age, I want to offer three words of caution:  1)  although I'll be discussing ideals of virtue in a relatively decontextualized way, any full exploration must take in account  differences in culture, gender, race and ethnicity, and social class;  2) contrary to Cicero's exclusive emphasis on character, exercising virtue is not simply a matter of individual will; virtues occur amidst social conditions and relationships which foster or inhibit them;  and 3) a given person's capacity for exercising virtue (especially the more subtle and demanding virtues) also depends on her prior level of emotional and spiritual development.  For some people, obeying the "thou shalt nots" of our society may be a more reasonable expectation. Such important caveats lie beyond the scope of this paper.

In "The Virtues and Vices of Aging,"- an elegant essay written over twenty years ago --William F. May contextualizes his discussion by reminding us of the power imbalance between older patients and health professionals.  He observes that caregivers who unwittingly display their health and youth are "like a bustling cold front that moves in and stiffens the landscape."  They cannot see that their vocation depends on patients, which compounds the power imbalance, and obscures the moral the significance of reciprocal dependency. 

Writing across the boundaries of psychology, ethics, and theology, May warns against the common confusion of infirmity with moral failure.  He emphasizes that virtues do not emerge automatically with age; rather, they "grow only through resolution, struggle, perhaps prayer, and perseverance."42  May begins with four virtues appropriate to later life: Courage, Public Virtue, Humility, Patience.  One needs Courage to rise to the occasion of loss and the certainty of death.  Aquinas defined courage as "firmness of soul in the face of adversity."43  Courage requires "keeping one's fears, one's dislikes, one's laziness under control for the sake of the good as well as one's own good."44 Public virtue requires older people (as well as others) to temper pursuit of self-interest for the sake of the common good.

Care-givers and care receivers alike need the virtue of humility.  Humility restrains the arrogance of care-givers' power, even as it removes the sting of humiliation from those assaulted by disease and disability.  Like humility, Patience, is a desireable response to anger, frustration, and bitterness; but patience, on May's account, is not a form of passivity or detached Stoic endurance.  "Patience is purposive waiting, receiving, willing; it demands a most intense sort of activity."  For May, the moral is never far from the spiritual: "precisely when all else goes out of control, when panic would send us sprawling in all directions. . . . [patience] requires us once again  to become centered in the deepest levels of our lives as purposive beings."45 

Drawing from the Benedictine tradition, May adds three more virtues: simplicity, benevolence, and integrity.  The aged pilgrim learns to travel light, to cast off the extraneous and embrace the path to God.  "Benevolence opposes the tightfistedness of avarice, not with the empty-handedness of death but with the open-handedness of love."46  May sees integrity not as a particular virtue of old age but as an all-inclusive virtue that binds all other virtues together in a unity of character. 

Character is a moral structure that has integrity when it is at one with itself.  Integrity requires a re-collection of the self which is not fragmented or dispersed.  Creating a unity of inner and outer, word and deed, depends upon the spiritual work of autobiography.  In Augustinian terms, one can commune with God only after the disciplined work which yields integrity, which itself rests on conviction of forgiveness for sin.  May also believes that integrity in old age requires that one's death be framed in a context of transcendent meaning or ultimate concerns.  These however, are not mere abstractions but rather patterns of ritual and behavior woven into the fabric of everyday life.

To Erikson's rather vague definition of wisdom, May adds three additional virtues originating in medieval Christianity.  Integrity and wisdom are made possible by prudence, which consists of the temporal virtues of memoria, docilitas, and solertia.  A person who resists nostalgia and regret--as well as the temptation to airbrush her past--earns the virtue of memoria.  In contast,  many contemporary approaches to psychotherapy, life review, and life story work, are not so much interested  in the historical truth as in achieving a narrative truth which may enable a person to achieve a healing that comes from new meanings of old events.  Docilitas does not connote the meanings of docility; rather it "signifies a capacity to be silent," to be alert, attentive to the present moment.  Solertia is a characteristic of those who "learn to sit loose to life;" it signifies openness to the future, readiness ready for the unexpected. 

The Stoic grounds wisdom on rational self-mastery and detachment.  The Biblical tradition on the other hand, grounds wisdom "through a primordial attachment . . . to the divine love [which] sustains, but also orders and limits all other attachments and fears.  In the Christian tradition, attachment to God makes possible the virtues of nonchalance and courtesy.  Nonchalance signifies the capacity to take life's gifts and assaults in stride; courtesy is the capacity to "deal honorably with all that is urgent, jarring, and rancourous."47  The evils and tragedies of life are understood to be "real but not ultimate."  Love rather than death has the last word.  Hilaritas is the final virtue handed down by the Benedictine monks.  Or in common parlance, humor is a "saving grace," allowed by the capacity to see life's experience from a more spacious perspective.  

May aptly criticizes academic ethicists who focus chiefly on moral dilemmas and provide critical guidelines to professionals.  It has been over twenty years since he since he observed that ethics "does not offer much help to patients facing the ordeal of fading powers. [The aged] need guidelines for action, to be sure, but more than that they need strength of character in the face of ordeals." 48

I have been able to find only one significant essay that takes up May's challenge. In her essay "Virtues and Age," Sara Ruddick (who does not cite May) argues that there are indeed virtues especially salient in the lives of people "situated between a lengthening, unalterable past and short future, where loss is predictable, but its timing and form is not."49  Ruddick writes as a secular, feminist philosopher who is quite wary of articulating ideals that become burdensome to those who are meant to be governed by them.   She states, quite convincingly, that the elderly, like people at any age, "struggle to maintain conceptions of themselves as good people.  Many also try both to preserve relationships and to do well by the people to whom they are importantly related. These efforts of virtue are intrinsically rewarding for the elderly themselves, confirming their sense of agency, accountability, and moral standing." These efforts also benefit "they people they care for and who care for them." 50

Ruddick's account of virtue focuses particularly on the vulnerable, needy elderly and those who care for them. She draws not only on philosophical reasoning but also on her experience of care-giving and witnessing in nursing homes.  Ruddick acknowledges that being virtuous is sometimes beyond the control of demented elders, but she insists that mental deterioration which occurs slowly allows time for adaptation and rarely makes efforts of virtue impossible. 

She lists a set of five virtues especially appropriate for those in their 70's and older, people "whose future is dwindling, and who will likely experience multiples losses and decline."  These include: curiosity; a capacity for pleasure and delight; concern for near and distant others; capacities to forgive and let go, to accept, adjust, and appreciate; and 'wise independence" which the ability to plan and control one's life as well as the ability "to acknowledge one's limitations and accept help in ways that are gratifying to the helper.  Wise independence also includes "the ability to manage pain, to mourn and integrate the loss of people dear to them, to handle, without bitterness, their increasing disabilities, and to prepare for death and its effect on those they care about."51 

Ruddick criticizes theories which characterize virtue primarily as a characteristic of individuals, a charge which may be leveled against May.  Such theories, she argues, show little tolerance for "outlaw emotions" such a righteous anger, and they are conceptually unable to guide the moral challenges facing receivers and givers of care.  Ruddick is also wary of the stereotypical vices which shadow any list of virtues.  She therefore speaks of "ongoing efforts of virtues" (rather than achieved dispositions or traits) that individuals strive to acquire and maintain.

Reversing traditional theological arguments, Ruddick argues that "being virtuous is something one sometimes does, not something one is."  She not only focuses on process rather than achievement, she also believes that virtue is created between and among people, and is therefore inherently relational.52  

Ruddick also takes pains to avoid creating an unrealistically burdensome account of virtues that requires continuous and unremitting effort, which she criticizes another form of the masculine Protestant work ethic-perhaps another challenge to May.  She reformulates her definitions this way:  "So being virtuous is something people sometimes do together. . . .  there are days when one isn't up to creating virtue alone or with others.  Hours, days, even weeks of sadness, sloth, and apathy are an integral part rather than an interruption of ongoing efforts to be virtuous.  They do not mark a person as bad; processes of doing virtue are marked by vicissitude, not failure.  Over a period of time, a virtuous person may do more rather than less. . . . But no one needs to be counting or judging."53

Ruddick, then, presents a secular feminist account which is rooted in experience.  She emphasizes process over achievement, relationships over individual virtue, behavior over character.  She avoids discussion of the vices by waiving off surveillance or the moral judgement of others.  May on the other hand, offers both secular and theological theories of virtue, emphasizes individual character, and does not shrink from  light-handed and contextually sensitive moral judgement.

To the analyses by May and Ruddick, I will add only two brief suggestions (to be developed in further work).  First, I believe that moral development in mid-life and later life must include cultivating reverence for the human life cycle and especially for future generations-a reversal of the "reverence upward" tradition.  Second, I believe that human beings at all ages have a basic spiritual need for expansion and liberation of the self.  This universal human need for transcendence has implications for human development amidst frailty and the process of dying.  By consciously and actively working toward an embrace of loss and death (when they are unavoidable), we may be able to embody beauty and spiritual development amidst decline.  In Rilke's words:

"For beauty's nothing but the beginning of Terror we're still just able to beat, and why we adore it so is because it serenely disdains to destroy us"

What can we expect from this kind of analysis of character and action among the frail elderly?  What is missing from these accounts?  Can we educate care-givers on the importance of acknowledging reciprocity and fostering relationships which allow their patients to be useful?   What would relationships look like if moral language and reciprocity of dependent patients was introduced in nursing homes or home care? 

How can we educate clergy, both in the pulpit and at the bedside, in the moral challenges of aging?  Seminaries have only recently begun to provide some gerontological education to their students, focusing entirely on the needs of older people.  What should be added to revitalize religious understanding of older people as moral agents? 

Finally, with the proliferation of lifelong learning through Elderhostel and Institutes for Learning in Retirement, can older people be engaged in seminars and workshops about moral issues in their lives?  (I am skeptical about this later idea, since older people notoriously avoid classes in aging.  But the use of Biblical material, films, fiction, and theatre might slip behind psychological defenses and open up new moral and spiritual horizons.  Think of the old King Saul, or King David, King Lear, Oedipus at Colonnus, or Driving Miss Daisy, Cocoon, and the Trip to Bountiful approached through the lenses of ethics and the human spirit).

CONCLUDING THOUGHTS

Where do these thoughts about life cycle norms, mass longevity, postmodernity, moral obligations, spiritual development, vices and virtues leave us?  Personally, I feel a sense of awe and amazement at the sheer abundance of life made possible by the gift of mass longevity.  But what is the price of that gift? Perhaps, as Theodore Roszak argues in America the Wise,54 the wisdom of a maturing population promises to be our richest resource.  Or perhaps, as a voice from the Talmud suggests, a man who is a fool in his youth is also a fool in his old age; while a man who is wise in his youth is also wise in his old age.

I believe that the answer to the "gift" vs. "burden" of mass longevity will depend in no small measure on how well we learn to identify, support, and accomplish the moral and spiritual work of aging in our era.  As Plato understood, one of the best ways to learn is by listening to those who have traveled this road ahead of us.  Let me close by listening again to one of my favorite elders, Florida Scott Maxwell.  Writing in her 80's as a Jungian analyst, she encourages us to learn "that life is a tragic mystery.   We are pierced and driven by laws we only half understand, we find that the lesson we learn again and again is that of heroic helplessness.  Some uncomprehended law holds us at a point of contradiction where we have no choice, where we do not like that which we love, where good and bad are inseparable partners to tell apart, and where we-heart-broken and ecstatic, can only resolve the conflict by blindly taking it into our hearts.  This used to be called being in the hands of God.  Has anyone any better words to describe it?"55

_______________________

ENDNOTES

1. Henri Nouwen and Walter Gaffney, Aging: The Fulfillment of Life  (New York:  Bantam Doubleday Dell Publishing Group Inc.,1976).

2. Ibid., 13.

3. Charles Taylor.  Sources of the Self  (Cambridge:  Harvard University Press 1989),  11-14

4. Nouwen and Gaffney, Aging,, 14.

5. Ibid., 13

6. Thomas Cole.  The Journey of Life:  A Cultural History of Aging in America   (New York:  Cambridge University Press 1991), xxxii.

7. Erik H. Erikson.  "Human and Strength and the Cycle of Generations."  Identity, Youth, and Crisis.  New York:  Norton (1968):  142, 114.  Not correct but not clear on the book. 

8. Erik Erikson.  Childhood and Society  (New York:  W. W. Norton   & Co., Inc., 1986).

9. Erikson, "Human and Strength and the Cycle of Generations," Identity, Youth, and Crisis, 133 (needs redone see above)

10. Cole, The Journey of Life, Ch. 1

11. Alasdaor MacIntyre.  After Virtue:  A Study in Moral Theory  (Notre Dame, Indiana:  University of Notre Dame Press; 2nd ed. 1984).

12. Harry  R. Moody.  "The Meaning of Life and the Meaning of Old Age," in Thomas R. Cole and Sally Gadow. Eds   What Does It Mean to Grow Old?  (Durham, N.C.:  Duke University Press, 1986),  11-40.

13. In her own nineties, Joan Erikson began to address these issues by adding short chapters on "The Ninth Stage" and "Gerontranscendance" to a new edition of Erikson's The Life Cycle Completed   (New York: Norton, 1998), chs. 5,6.

14. Cole, The Journey of Life,, 240.

15. Richard Nelson Bolles.  The Three Boxes of Life and How to Get Out of Them:  An Introduction to Life-Work Planning.  (Berkeley,CA:  Ten Speed Press,1978).

16. Anthony Giddens.  Modernity and Self-Identity:  Self and Society in the Late Modern Age  (Stanford, CA: Stanford University Press,1991).

17. Ibid.,147.

18. James and Betty Birren, "Our responsibilities for our old age" in Kimble and McFadden . . .8

19. Harry R. Moody.  Abundance of Life:  Human Development Policies for an Aging Society ( New York:  Columbia University Press, 1988).

20. Chris Phillipson. Reconstruction Old Age. (London, Sage Publications, 1968), p. 49.

21. Erikson.  "Human and Strength and the Cycle of Generations."  Identity, Youth, and Crisis., 132 (per above)

22. Alasdair MacIntyre.  After Virtue:  A Study in Moral Theory.  Notre Dame, Indiana:  University of Notre Dame Press; 2nd edition (June 1, 1984).

23. Charles Taylor, Ethics of Authenticity (Cambridge: Harvard University Press, 1992), 28-29.

24. Ibid 40-41.

25. Erickson,  Childhood and Society, p. 380

26. Leopold Rosenmayr.  DieSpate Freiheit,.  Paris, France:  Edition Atelier (1990).

27. Alex Comfort.  The Joy of Sex  (New York:  Crown,,, 2002).

28. William F. May, " The Virtues and Vices of Aging," in  Thomas R. Cole and Sally Gadow. Eds., What Does it Mean to Grow Old? (Durham, N.C.: Duke University Press, 1986), 45.

29. AAMC Task Force, 1999, Report 3.

30. Ronald Blythe, The View in Winter  (New York: Harcourt, Brace and Jovanovich, 1979), 22-23

31. Moody, Harry R.  Abundance of Life:  Human Development Policies for an Aging Society (New York: Columbia University Press, 1988), pp.   4-5. 

32. Carole Haber and Brian Gratton, Old Age and the Search for Security: An American Social History, (Bloomington: Indiana University Press, 1994), ch. 6; Thomas R. Cole, The Journey of Life, ch. 7

33. Rabbi Zalman Schacter Shalomi and Ronald S. Miller, From Age-ing to Sage-ing, (New York, Warner Books, 1995)

34. Marc Freedman, The Kindness of Strangers, (New York: Jossey Bass, 1996); find his newer book.

35. John Cowper Powys, The Art of Aging (place, pub. 1944) , page number unavailable

36. Florida Scott Maxwell, The Measure of My Days, (London, Penguin Books, 1978) p. ??

37. I have borrowed heavily here from an excellent forthcoming paper by Monika Ardelt and W. Andrew Achenbaum, "The Paradoxical Nature of Wisdom and Its Relation to Human Development".

38. Wendy Lustbader, Counting on Kindness: the dilemmas of dependency (New York: Free Press, 1991), 15.

Ibid., 18.

39. Ibid., 30.

40. Ibid., 34.

41. May, "The Virtues and Vices of Aging," 50.

42. Ibid., 51.

43. Ibid., 51.

44. Ibid., 52-3.

45. Ibid., 53.

46. Ibid., 59.

47. Ibid., 49

48. Sara Ruddick, "Virtues and Age," in Margaret Urban Walter, ed., Mother Time (New York: Rowman and Littlefield, 1999), 45.  Interestingly, Ruddick does not cite William May's piece on "The Virtues and Vices of Aging."

49. Ibid., 46.

50. Ibid., 50.

51. Idem, 53.

52. Idem, 54

53. Theodore Rilke, Dueno Elegies (1921), p. 12

54. Theodore Roszak, America the Wise: The Longevity Revolution and the True Wealth of Nations, (Boston, Houghton Mifflin, 1998).

55. Maxwell, p. 24-25.


  - The President's Council on Bioethics -  
 
Home Site Map Disclaimers Privacy Notice Accessibility NBAC HHS