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This paper was discussed at the Council's September 2004 meeting. The views expressed here do not represent the official views of the Council or of the United States Government.

Challenges Posed by the Changing Age Structure and Dependency Ratio in the United States

Mary Ann Glendon

I.  AN AGING SOCIETY

Otto von Bismarck never dreamed, when he established the world's first social security system, that a large proportion of the populace would live long enough to draw old-age pensions.  With a tight grip on the public purse, the Iron Chancellor set age 65 as an eligibility threshold that few could be expected to cross.  In the developed countries at the time, including the U.S., the average life expectancy was less than 50 years.  When the American version of the welfare state came into being in the New Deal period, the labor force was relatively large in comparison to the population of those likely to receive benefits, and death was seldom preceded by a long period of disability. Today, with greatly increased longevity and low birth rates, the United States is on the brink of a care-giving crisis that will affect young and old alike.

Thanks to medical advances, especially in the area of infectious diseases, most Americans are living healthier, longer lives.  In 2000, the average life expectancy for a man was 73 and for a woman 77.  These dramatic advances in health and longevity have been accompanied, however, by an equally striking development that presents our society with novel problems:  Nearly all elderly Americans will spend two or more of their final years with chronic illness and in need of assistance with routine daily activities.       

Treatment for this expanding dependent population is becoming more expensive, straining our health-care system.  The prospect of lengthy disability due to physical illness or dementia affecting large numbers of people poses an even more daunting challenge:  the country's supply of caretakers, paid and unpaid, is dwindling just as the need for them for them is appearing on an unprecedented scale.  Both of these problems will become increasingly acute as the baby boom generation approaches the traditional retirement age of 65.   The first wave of the nation's 77 million boomers will reach that age in 2011, with the crest in 2015, and with significant numbers still to come for six years after that.

At present, all indications are that the United States is unprepared to meet the needs of the large and expanding number of people facing a lengthy period of disability before death.  Yet, remarkably, there has been relatively little public discussion of the dilemmas facing an aging society.  What discussion there is, moreover, has been focused primarily on the economic consequences, e.g., the statement of the Senate Special Committee on Aging in a 2002 report that, without significant reform, "the United States could be on the brink of a domestic financial crisis."   Alan Greenspan warned in a March 2004 interview that the country "will almost surely be unable to meet the demands on resources that the retirement of the baby boom generation will make."

The coming economic crunch, however, is only one of the dilemmas our society will soon have to confront.  As the age structure changes, so does the culture, and so do the meanings and values that people attribute to aging and mortality, sex and procreation, marriage, gender, parenthood, relations among the generations, and life itself.  Testimony on aging, dementia, and care-giving at the June meeting of the President's Council on Bioethics suggested that important medical, psychological, ethical, and social issues have been neglected in discussions of these matters.  

The Council was undecided whether to further explore the dilemmas presented by an aging population.  The purpose of this memorandum is to suggest that the Council could perform a valuable public service by producing a report that would aid in the search for practices and ideals adequate to a new society quite unlike anything we have seen before.  Even a short report could usefully heighten awareness of the looming crisis and promote public deliberation of its human and ethical, as well as economic, dimensions. 

The major questions to be faced are fairly clear:  How will society care for its dependent, aging members?  How can the supply of caregivers be increased?  How can this new set of needs be accommodated without compromising other important social goods such as the education of the young and the stability of the economy?  How can this new set of needs be accommodated without compromising human dignity?  What are the implications of the new situation for the debate over treatment for elderly persons whose life expectancy is drastically limited by serious chronic illnesses?  What do we as a community owe to our most dependent members, young and old? 

The search for feasible and humane approaches to these dilemmas is complicated by two other twentieth-century demographic developments:  the sharp decline in birth rates which has decreased the ratio between the active labor force and the dependent population; and the steep increase in women's labor force participation rates which has limited the availability of family-based care-giving for the very young and the frail elderly alike.   

When welfare states came into being, it would have been difficult to anticipate the combination of increased longevity, low birth rates, and changes in women's roles that would strain all the networks and institutions that traditionally have provided care and support for the very young, the frail elderly, the sick, and the incapacitated.   Declining birth rates plus improved longevity mean that the dependent population now includes a much smaller proportion of children and a much larger proportion of disabled and elderly persons than ever before.  The mass movement of women into the paid labor force, the dispersal of family members through geographic mobility and family breakdown, plus the declining proportion of active workers to the dependent population have shaken the main pillars of our society's system for dealing with dependency:  the family, pensions, social assistance, and community services. 

Families are still the central pillar of our care-giving system, but they are losing much of their capacity to care for their own dependent members just at a time when government is becoming less capable of fulfilling the roles it once took over from families.  Ironically, the ambition of welfare states to free individuals from much of their dependence on families, and to relieve family members of some of their most burdensome responsibilities, may have succeeded just well enough to put dependents at heightened risk now that welfare states are faltering. 

II. CHILDREN IN AN AGING SOCIETY

Less visible, but equally grave, are the likely effects of an aging society on children and child-raising households.  When welfare states came into being, the dependent population was composed largely of children, most of whom were cared for at home. Now, with declining birth rates and greater longevity, the dependent population is predominantly elderly.  Yet, with increased divorce and single parenthood, the poverty population is composed largely of women and children.  Political support for measures that address the needs of child-raising families is already difficult to rally.  That difficulty can be expected to increase as the proportion of childless households grows.  As society becomes more adult-centered, the general level of concern for the well-being of children may well decline.

It is puzzling that the building pressure on economic and human resources from both ends of the life cycle has elicited relatively little public discussion and has received relatively little attention from policy makers.  That may be due at least in part to the complexity of the problems and the fact that many of the novel dilemmas are by-products of genuine advances in medicine and in opportunities for women.  But if measures to address the new situation are developed solely within a framework based on the idea of competition for scarce resources, the outlook for children and child-raising families is troubling.    Thus, no small part of the challenge facing an aging society is that of avoiding divisive competition for resources.

Developments in the ambitious welfare states of northern Europe provide an early warning of the type of inter-generational conflicts that may lie ahead in the United States.   There, the pinch is already being felt because birth and immigration rates are lower than in the United States.   In places where the state once ambitiously took over many roles that formerly belonged to the family, governments are less and less capable of fulfilling their commitments, while the family has lost much of its capacity to care for its own members.  Yet even quite modest proposals to cut back on pensions or to raise the retirement age in France and Germany have met with strikes and protests from the groups affected--the elderly who there as here wield considerable political clout and their family members who have become accustomed to relief from much of the economic burden of caring for the elderly.  At the same time, young Europeans are complaining about the high cost of health care for the elderly. (One German youth leader recently gained notoriety by suggesting that old folks should use crutches rather than seeking expensive hip replacements).

III. THINKING ABOUT AUTONOMY AND DEPENDENCY

Confronting the problems of an aging society will require searching for ways to maximize the ability of individuals and families to plan and provide for periods of dependency.  Clear thinking about dependency, however, may require re-examining some widely shared ideas about autonomy.     

Paradoxically, the concepts of the human person that are currently prominent in social science and social policy both over-emphasize individual self-sufficiency and under-rate individual human agency. The ideal of the autonomous individual exerts such a powerful attraction in our culture that we tend to relegate obvious facts about human dependency to the margins of consciousness.  Nevertheless, human beings still begin their lives in the longest period of dependency of any mammal.  It is still a fact that circumstances can catapult anyone at least temporarily from a secure to a dependent position.  It is still a fact that almost all persons spend much of their lives either as dependents, or caring for dependents, or financially responsible for dependents.   While contemporary social thought tends to emphasize self-sufficiency, our approach to welfare tends to under-rate human capacities by treating human beings as passive subjects.  Surely social policy and social science would benefit from closer attention to the fact that human beings are both able and dependent, with variations over one's life span.    

To adapt to the increasing strains on all our systems for dealing with dependency will also require a certain tragic sensibility, for there will be no solution that will not entail striking balances among competing goods.  However, if political deliberation proceeds within a framework based solely on the idea of competition for scarce resources, the outlook for dependents is grim.  And to state the obvious:  If the outlook for dependents is grim, the outlook for everyone is grim.   The most ominous development, of course, is the growing carelessness about respect for human life when the dependency of some becomes burdensome to others. 

III.  A PROJECT FOR THE BIOETHICS COUNCIL?   

Should the Council attempt to raise the level of public discussion of the dilemmas facing our aging society?   In favor of the project is the fact that hard decisions will soon have to be made by individuals, families, health care providers, and governments.  The only question is whether these decisions will be taken in haste, in the midst of crisis, or whether they will be preceded and informed by adequate information, study, deliberation, and planning.  There is still time for purposeful planning, but time is running out fast.  The role of the Council would not be to undertake new research, but rather to heighten the visibility of what is already known; not to offer policy prescriptions, but rather to broaden the framework for discussion.  If the Council does not assume this task, it seems likely that important ethical and human aspects of the coming challenges will be ignored in the scramble to adjust to the pressures of the new situation. 


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