December 2, 2004
Session 1: After the Life Cycle: The Moral Challenges of Later
Thomas R. Cole, Ph.D., Professor and Director, John P. McGovern,
M.D. Center for Health, Humanities and the Human Spirit, University
of Texas-Houston School of Medicine
CHAIRMAN KASS: In this first session, we will
be returning to a theme that was introduced to us in the June meeting
by Thomas Cole, whom we welcome back to the Council. Since we last
saw him, Professor Cole has been appointed Professor and Director
of the McGovern Center for Health, Humanities, and the Human Spirit
at the University of Texas-Houston School of Medicine.
In June, Professor Cole presented a paper, "What Does It
Mean to Grow Old?", richly illustrated with iconographic illustrations
that illuminated the absence, in our time, of a clear cultural script
for the meaning of old age, precisely at a time when most of us
can expect to enjoy a fair stretch of it.
He raised for us really one of the very most fundamental questions,
rarely asked and rarely discussed, which is to say, what is old
age to be like in the New World? Such questions — though
they don't immediately lend themselves to specific policy recommendations,
consideration of these questions, it seems to us, is crucial to
thinking soundly and wisely about public policy.
As a result of conversations we had after that meeting, we have
commissioned Professor Cole to develop further the ideas that emerged
in the June discussion, and we look forward to hearing his presentation,
giving us an overview of a paper, which you have at your place,
newly arrived (at least an early draft of this paper), "After
the Life Cycle: The Moral Challenges of Later Life".
Before letting Professor Cole begin, I would also like to welcome
Professor Carl Schneider, who is the Chauncey Stillman Professor
of Ethics, Morality, and the Practice of Law at the Law School of
the University of Michigan. He will present in the second section.
Welcome to both of you. It's nice to have you here.
Professor Cole, the floor is yours.
DR. COLE: I very much appreciate the chance to return
and to really, in particular, respond to a question that Bill Hurlbut
asked at dinner when itwas too late to be coherent. Basically,
he asked, how should we be thinking about the moral and spiritual
sources of inspiration in later life? Here is an attempt, a first
attempt, to think about that with you.
Here's just a quick overview of what I'll be covering.
After my introduction, I'm going to talk very briefly about
the normativity of the life cycle. I do this with some hesitation,
knowing that people here have written elegantly about the normal
and the natural and the moral.
Then I'll talk briefly about the modernization of the life
cycle, basically, showing how we don't really have a life cycle
anymore in our culture; what we have is a life course. We really
have a life course, not a life cycle.
Then I'll begin to get into the meat of what I've tried
to think about, which are, what are the moral challenges that older
people face, both people who are healthy and relatively physically
intact, and those who are frail and unable to really carry out the
activities of daily living?
In almost 30 years of reading and writing about later life, my
favorite book is still a very slender volume by the Catholic theologian
Henri Nouwen and a co-author named Walter Gaffney. It's entitled,
"Aging: A Fulfillment of Life," written in 1974. Like
many books on aging written in the seventies and eighties, Nouwen
really goes after negative stereotypes and attitudes toward older
people. He's trying to offer us images and ideals that emphasize
solidarity, based on our shared humanity in the universal process
of growing older.
The book's central motif if a large wagon-wheel leaning against
a birch tree in the white snow, beautifully photographed. The photo
invites us each to think of ourselves as a spoke on the great wheel
of life, part of the ongoing cycle of generations. It implies that
each of us has our own life cycle to traverse, a moving up and a
going down, a moving forward, yet somehow also coming back to the
beginning in relationship to generations before us and after us.
It resembles the Christ-centered circular life cycle from the
medieval period which I showed last time that I was here. 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 cycle to live and that living it is the source
of our greatest joy.
Well, modern western culture, since the Reformation, has placed
great emphasis on the affirmation of everyday life, on relief of
suffering, and on the respect and dignity and rights of individuals.
So, as a modern, therefore, Nouwen sets the issue of a good life
squarely in the province of everyday living. He leans heavily on
Erikson's work, which I will come to, and he 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.
With elegant simplicity, he describes a three-stage life cycle
as it cogwheels with previous and future generations. The restful
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 in love, we realize
how much is given to us.
But while reaching the height of our cycle and saying, with 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.
Now I must say I love the lyrical beauty of this passage and,
in particular, its view that an individual's personal development
naturally entails self-transcendence and moral responsibility in
later life. As he puts it, "receiving matures in giving."
But contemporary American culture seems to emphasize individual
development without a clear consensus or 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 the
ever-lengthening life expectancy, the roles, responsibilities, virtues,
vices, and meanings of an extended life take on urgent meanings
in both public and private life.
Strangely, there is almost nothing written on this topic. There's
a plethora of literature which focuses appropriately on the ethics
of caregiving, on private and public responsibilities to older people,
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, responsibility, virtue, and vice in later life.
So let me contextualize this issue with a brief interpretation
of Nouwen and of Erikson, on whom he really basically relies, focusing
on the normative dimension of their views of aging and the life
cycle. Then I'll offer an historical argument that we are living
after the life cycle, both normatively and structurally. Finally,
I'll provide a tentative sketch of the moral challenges of later
life for both healthy older people and those who are frail and sick.
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 contains a
single order, it's a natural order, and that each stage possesses
its own characteristics and moral norms. "Life's race
course 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."
With the rise of Christianity, this normative life cycle is folded
into a divinely-ordained natural order, and the stoic ideal of rational
self-mastery is replaced with a journey to salvation. Nouwen writes
as a Catholic. His view of the life cycle is couched mostly in
secular psychological terms which echo Erikson's famous psychoanalytical
formulation in the "Eight Ages of Man," each with its
own cycle/social conflict and corresponding virtue.
First formulated in the mid-twentieth century, Erikson's version
of the life cycle virtually dominated American academic thought
and public imagination for over 25 years. I think 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 life contained
its own stages, each with their own moral norms and struggles.
He saw virtues as not as lofty ideals formulated by theologians
and moralists, but rather 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
I don't want to spend too much time on Erikson. Most people
are very familiar with him. The key virtues that he emphasizes
are integrity and 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.
Wisdom, therefore, is described as detached concern with life
itself in the face of death itself. It responds to the need of
the oncoming generation for an integrated heritage and yet remains
aware of the relativity of all knowledge.
Erikson understood that the life cycle itself does not biologically
generate prescribed virtues, values, and behaviors associated with
each stage. Rather, every version of the normative life cycle is
created by forces of biology, culture, demography, history, social
structure, and patterns of family life.
Many of his followers, however, tended to treat the eight ages
of man as if it were a universal paradigm of human development.
In my view, the model that developed through Erikson and used by
Nouwen really should be understood as the culmination of the modern
western life cycle ideal first imagined in early modern Europe and
then fully realized in the middle third of the 20th century.
But the irony here is that modernization removed the traditional
structural underpinning of the normative life cycle and replaced
it with the life course. So in both modern and post-modern society,
old age emerges as an historically-unprecedented, marginal and culturally-unstable
phase of life.
So herein lies the poignancy of our situation: We are living
after the life cycle, and 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
But however attractive, Erikson's ideal could not accommodate
the social, cultural, and demographic complexities of our era.
We need a richer, pluralistic dialog about how to live the ever-lengthening
years of our later life.
But, first, let me briefly sketch this historical context of our
uncertainty about roles, responsibilities, purposes, and meanings.
I'm not going to go through each of these topics in any detail,
but I basically want to make the point that the modern life course,
as opposed to the ideal of a life cycle which is lived in a place
in which generations after generations live together and cogwheel
with each other, the modern life course begins in an urban, industrial
society. The older bonds of family and status and locality are
really loosened, and individuals become increasingly encouraged
to see their lives as careers, as sequences of expected positions
in school, at work, and in retirement.
So by the third quarter of the 20th century, western democracies
had pretty much institutionalized this life course by providing
age-homogeneous schools for youthful preparation, jobs organized
according to skills, experience, and seniority for middle-aged productivity,
and publicly-funded retirement benefits for the aged who are considered
too slow, too frail, or too old-fashioned to be productive. This
is often referred to as the three boxes of life: education for
youth, work for adulthood, retirement for old age. And old age
is then roughly divided into a period of active retirement, supported
by Social Security and pensions, and a period of frailty supported,
additionally, by Medicare, Medicaid, and private insurance.
So, again, the cycle of life becomes essentially severed from
the course of life in modernity. Again, when people lived in farms
and villages, small towns, local traditions of practice and belief
and behavior provided the external norms as each generation visibly
cycled into the next, and the problem of identity did not arise.
But, as we've seen, this is really no longer the case in an
urban, industrial, and now post-modern society. As the British
sociologist Anthony Giddens puts it, "The idea of a life cycle
makes very little sense once the connections between an individual
life and the interchanges of generations have been broken."
So, until the last quarter of the 20th century, this institutionalized
life cycle which effectively had structurally and in some ways normatively
undermined the cycle of life, it was fairly stable. But, by the
1970s, what you found was an unraveling of this institutionalized
life course, a powerful movement by older people and their advocates
to overcome negative stereotypes of older people as inevitably frail
Then in the eighties we saw 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 workforce.
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, as were fears of an unsupportable public obligation to sick
and dependent older people. As we've seen, political support
for the welfare state began to erode.
So, finally, the problem of the transition to an information economy
has made things even more culturally and psychologically unstable.
Amidst a globalizing economy, declining corporate commitment to
long-term employment, to seniority, and defined pension benefits,
there has been a steady erosion of the expectation of income stability
Zygmunt Bauman characterizes the result of a speedup of life in
the Information Age and the decline of long-term stability and benefits
in the corporate life as resulting in kind of an ontological insecurity
which is especially apt for older people. He writes, "The
boundaries which tend to be simultaneously most strongly desired
and most acutely missed are those of a rightful and secure place
in society, a place where the rules do not change overnight and
without notice. It's 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."
So identity, then, is not merely a personal issue. It has much
broader social implications, and I believe it's crucial to the
development of wisdom and to knowing one's responsibilities.
So how are we going to think about the moral life of older people
after the life cycle? Well, even Erikson realized early on that
there's a basic problem built into sort of western ways of thinking
about the life cycle. In 1964 he wrote, "Our civilization
does not really harbor a concept of the whole of life as do the
civilizations of the east. As our world images 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."
So the absence of a culturally-viable life cycle set within a
larger frame of transcendent meaning makes it difficult for many
people to grasp 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
and that, in a world of moral strangers, the only alternatives are
Aristotle or Nietzsche, which means basically tradition or chaos.
So, by analogy, I think we're living after the life cycle,
after the collapse of widely-shared images and socially-cohesive
experiences of the life cycle. But I do not think that we are forced
to choose between idealized tradition on the one hand or exaggerated
chaos on the other.
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, secondly, the very search for identity itself I think
holds important moral promise.
So here I'm going to briefly just draw on the work of Charles
Taylor, who believes that, despite the moral limitations of liberal
individualism, the Biblical tradition he believes lives on as a
kind of underground moral resource in most lives, and for Taylor
selfhood or identity is inextricably bound up with some historically-specific
but often unarticulated view of the good.
So for Taylor, then, the attempt to be authentic need not degenerate
into self-indulgence and motivism or moral relativism. He thinks
that 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, crucially matters, can I define an identity for myself that
is not trivial."
So my point here is that we should not view the search for identity
in old age as a narrowly-personal quest. Of course, we're all
familiar with examples of late-life Narcissism, but the effort to
live an authentic life is itself a moral ideal, an attempt to understand
and fulfill the uniqueness of each life. Older people trying to
make sense of their past and imagine their futures through various
forms of life review, spiritual autobiography, reminiscence, storytelling,
life story writing groups, and so on, these people are doing important
moral and spiritual work with genuine implications for others.
Those who are passionately involved in the arts, in public service,
and in new forms of exploration begin to exemplify models of elderhood.
As Erikson puts it at the end of "Childhood and Society",
"Without elders who possess integrity and identity, children
will be unable to trust."
So authenticity, basically, by itself is not going to be able
to provide standards of conduct and character to guide moral development
in later life. Authenticity provides no reasons to restrain the
person who authentically chooses selfishness or evil, and it contains
no intrinsic norms or prohibition.
Perhaps the dominant ideal of later life today is what the Austrian
sociologist Leopold Rosenmayr calls "Die Späte Freiheit,"
"the late freedom." Free from social obligations, retirement
for those who possess good health and adequate income is equated
with leisure activities: visiting family and friends, golf, mahjong,
bridge, travel, taking up new hobbies, attending classes at elder
hostel, institutes for learning in retirement, visiting family and
The problem here is not that these activities are wrong or bad,
but they are based on the concept of "freedom from," freedom
from obligations that we have at midlife, with little or no attention
paid to what the freedom is for, which principles or commitment
should guide the choices being made.
Today senior marketing and advertising specialists have, I think,
the primary influence on activities, programs, and products for
seniors looking for ways to spend their free time. And maintaining
one's health is the primary goal spurred on, I think, by the
commodification of the body.
So the next real ideal after authenticity and freedom seems to
be the ideal of health, and, of course, services, products, and
programs for healthy aging are probably the most lucrative segment
of the senior market. Health is becoming increasingly construed
as physical functioning that's divorced from any reference to
meaning or human purpose. The reduction of health to physical functioning
fits hand-in-glove with the notice of freedom as unfettered choice.
Let me give you an example.
In the 1970s, the biologist Alex Comfort wrote two popular books,
The Joy of Sex and The Good Age. Comfort celebrated in both of
these books technique, functioning, achievement. Well, in the early
eighties, I invited Comfort to participate in a Conference on Aging
and Meaning, which, by the way, is the Conference where Bill May
gave his prescient paper on the virtues and vices of aging. In
a letter he wrote back to me, he bluntly declined to participate
on the grounds that he had no interest in "grannyology."
Well, this response I think reveals the obvious disdain for older
people, single-minded focus on control and functioning, and a common
but rarely articulated discomfort or contempt for existential concerns
that underlies most discussions of successful aging today.
More specifically, by linking sex with age and achievement, Comfort
anticipated the contemporary redefinition of sexual decline and
impotence — these are things which occur in individuals —
into treatable sexual dysfunctions which occur in organs; again,
another way in which medicalization has separated the images and
ideals of illness and disease from actual people.
I think one of our options here is to try to reclaim the notion
of health suggested by the AAMC. "Health is not just the absence
of disease, but it's a state of well-being that includes a sense
that life has purpose and meaning."
So, given the limitations of authenticity, of individual freedom,
and of health as adequate ideals, how should we begin to explore
the moral challenges of aging? Ronald Blythe offers this penetrating,
if harsh, starting point, which Bill May also used in his essay.
"Perhaps with full lifespans the norm, people may need to learn
how to become aged as they once learned 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."
Now that sounds harsh, but, actually, his interviews with older
English people both in the countryside and the city was incredibly
humane and wonderful. That's a wonderful book which is not
judgmental about older people.
So the point here, I think, is that learning to grow old is, indeed,
an important concern in our aging society, and it calls for human
development policies. We need job retraining, creative use of leisure
time, lifelong learnings, stimulation of volunteer networks and
self-help groups. These kinds of things help people develop the
skills and the strengths to solve their own problems.
As Harry Moody has pointed out, aging policy that responds only
to problems intensifies the depreciation of the strengths and capacities
of older people and may inadvertently increase the tendency rather
than try to prevent it. Falling into purposelessness is not only
a matter of individual will and character, but it's also a matter
of culture and public policy. Old people, like all people, they
need to be needed.
Well, in approaching the moral challenges of aging from the point
of view of the aging person, I've really 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 each of these questions to stand for a phase of the life
cycle, harkening backs to Nouwen's formulation. As children
and adolescents, there's a natural tendency to see the world
as one's oyster. In midlife we realize that to mature we must
attend to the needs of others, and in later life, with time running
out, we must learn how to balance our needs against the interests
and needs of others.
Interestingly, whereas Nouwen speaks only of giving as we age,
Hillel speaks of balancing competing needs and interests. So if
we take Hillel's questions and apply them to later life, I think
we can begin to specify key questions which demand careful and balanced
As citizens, what responsibilities do we have to our community
and the larger society, to the poor and the vulnerable, to our communities
of faith? How do we balance these against our personal interests?
What are our responsibilities to our children and grandchildren
for caregiving, for economic support? Again, how do we balance
these against our own needs and interests?
What responsibilities do we have for older parents who may be
in their eighties, nineties, or even a hundred? And, again, how
do we balance these with our own personal interests and well-being?
What responsibilities do we have to future generations to help
safeguard the environment, to work for sustainable sources of energy?
What responsibilities do we have for a spouse who is permanently
disabled perhaps by the later stages of dementia? Can we say, as
some people do, "This isn't the person I married and I
need to live my own life," or do we owe a degree of loyalty
that includes daily visits and ongoing care?
Recently, you may have seen the movie and read the book "The
Notebook" by — I'm blocking on his name. Anyway,
it's a love story in which it goes back and forth between the
present with a severely-demented wife and her husband and the past
when they first fell in love. It's based on a continuing daily
visiting which ends in somewhat sentimental but actually quite beautiful
restatement of their love.
What responsibilities do we have to shoulder, depending on circumstances,
part of the burden of our own economic support? What responsibilities
do we have for our own health, for exercising prudence in our use
of health care responsibilities? What responsibilities do nursing
home patients and residents have to assist each other? What responsibilities
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'm not going to attempt to answer these questions. I want
to raise them. I believe they are urgent and that they call for
personal wrestling, public debate, academic inquiry, and perhaps
some kinds of public policies.
If we look, for example, carefully at advice literature about
aging over the years, we could really see a whole lot about changing
values and norms that are 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 and congregational life. We need philosophical
inquiry and public conversation, and we need to listen carefully
to the stories of both ordinary and exemplary older people.
I don't 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, and political groups. We need to hear, for example,
from the AARP, which some people think has actually sold out to
the market an enthusiasm of the young-old and is always perceived
as a powerful lobbying group on the part of older people.
We need new ideals. We need new models. One example is the Spiritual
Eldering Project that was initiated by Rabbi Zalman Schacter and
sponsors a series of workshops around the country for older people
who would like to become real elders in a sense of becoming mentors,
in a sense of becoming devoted increasingly to the environment and
to the communities that they live in.
There's a civic engagement project currently undertaken in
the Gerontological Society where Marc Freedman, for example, has
long been working on strengthening voluntary movements of older
people, offering their care and their skills with underprivileged
But I think we need to step back from some of these more normative
applied ethics kinds of questions and recognize the complexity and
the nuance that's required to grapple with these moral questions.
John C. Powys' wonderful book on the art of aging ("The Art
of Growing Old") writes, "If by the time we're 60
we haven't learned 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."
In other words, we need to strive for wisdom and spiritual development
to help us understand and respond to the moral challenges of aging.
As Powys points out, life is a "knot of paradox and contradictions."
So what are the paradoxes and contradictions one faces on the
way to wisdom? And, of course, one is always on the way; one is
Well, one prominent paradox is that wise people know that they
don't know. They tolerate uncertainty because they understand
the limits of any attempt to grasp the entire truth, especially
their own attempts, and they understand the need for multiple points
of view. As Florida Scott Maxwell put it, "I cannot speak
the truth until I have contradicted myself."
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 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 that, unless a person accepts her own
limited subjectivity and the way she projects herself onto the world,
she will be unable to work on transcending these things. Likewise,
a person who understands and accepts the transitory illusions of
their self-image are then able to go onto a higher level of understanding
Now these paradoxes and contradictions are not solvable problems.
They must be worked with by each individual in search of spiritual
growth, but, of course, this does not happen without guidance and
So our society, therefore, needs to support a variety of contemplative
practices, including, for example, prayer, meditation, self-reflection,
yoga, tai chi, and so on. So here we have, again, the ancient problem
of the active versus the contemplative life, another contradiction
which needs revisiting.
And one of the most important and difficult paradoxes of aging
is 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 hostility that America has towards
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.
So let me turn, then, to moral and spiritual aspects of dependency.
Dependency raises a special range of challenges for older people.
There are no guidelines for how to be a good, dependent person,
and I doubt that such guidelines would be a worthwhile goal.
Hence, we must enter first into dependency's innerworkings
before we can understand its moral challenges. Imagine a life in
which you cannot walk, cannot carry out your accustomed activities
of daily living. Perhaps you're blind, demented, or incontinent,
a world in which you must wait for others to bathe you, take you
to the grocery store or to the doctor. Time stretches before you
like a desert. Shame and self-loathing lacerate for the loss of
your independence. You're tempted to both false displays of
self-sufficiency and to letting yourself go completely, lapsing
into pure passivity. Family relationships become strained, especially
when caregivers and receivers of care are dutiful playing their
proper roles without acknowledging their own and each other's
Wendy Lustbader has a lovely book called Counting on Kindness:
The Dilemmas of Dependency. She makes here an unusual point about
mercy. The old word "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 entirely based 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 goodwill
is not enough. A delicate balance exists at the heart of mercy.
Reciprocation replenishes both the spirit of the helper and the
person who is being helped.
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 opportunity to be useful, eliminating
external obligations. No one expects our presence and no one needs
Finding ways to be useful requires imagination and will power;
for example, among nursing home patients who often figure out ways
to help each other. Feeling useful will 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. She once visited a woman
who allowed her in because of a sudden illness. The woman's
lightbulbs had burned out. She was reading by daylight and sitting
alone in the dark. The woman refused to allow Lustbader to stand
on a stool to change her lightbulbs. Lustbader said she hated thinking
of the woman unable to sleep, tossing fitfully in her bed and unable
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
The next section that I had planned to talk about is the section
on virtues and vices. I think I will skip over most of this because
it's provided by the readings that you have from William May
and Sara Ruddick, who come at this from very different points of
But just let me say, despite an extensive literature research
in English, these are the only two articles I was able to find on
the virtues and vices of dependent older people. And I think I
would like to offer a couple of words of caution before going into
this because I think this is a very dangerous, politically and morally,
For example, friends on my left are going to argue that I'm
singling out the elderly for judgment, and friends on my right are
going to use moral arguments for responsibility of older people
to dismantle necessary state support. So I want to just sort of
say I'm in neither of those camps.
So I think any full exploration of virtues and vices must take
into account differences in culture, gender, race, ethnicity, and
social class. And 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.
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 example, for
some people simply carrying out the thou shalts and the thou shalt
nots of our society may be a more reasonable expectation than expecting
them to be exemplary elders.
So, again, rather than spend time talking about these two essays,
which you can read for yourself, I'm going to move on to what
I think are the limitations of this kind of analysis and then on
to some concluding thoughts, so that there will be some time for
The one thing I want to say, however, is the importance of humor
as a virtue. Bill May touches on this in his discussion of "hilaritas."
He says, "Humor is a saving grace, allowed by the capacity
to see life's experience from a more spacious perspective."
I remember George Burns, who was performing in his nineties, who
before he got started, he said, "I want to ask for applause
So, without trying to compare or contrast May and Ruddick or see
what they have in common, I just want to ask, what can we expect
from the analysis of character and action among the frail elderly?
And, again, these are issues for the future.
What's missing from these accounts? Can we educate caregivers
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 the reciprocity of dependent patients
was introduced into geriatric and gerontological education and into
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 for their students, but they focus entirely on the needs
of older people. What should be added to revitalize religious understanding
of older people as moral agents?
And, finally, with the proliferation of lifelong learning through
elder hostels, institutes for learning in retirement, could older
people themselves be engaged in seminars, workshops, about the moral
issues in their lives? I'm fairly skeptical about this latter
idea since in my experience older people are notoriously absent
when you offer a course in aging. That's something that they
don't want to know about.
But I think that the use of Biblical material, films, fiction,
theater might slip by their defenses and open up new moral and spiritual
horizons. Think of old King Saul or King David, King Lear, "Oedipus
at Colonus," or "Driving Miss Daisy," or "Cocoon"
or "A Trip to Bountiful," if these were examined through
the lenses of ethics and the human spirit.
So where do these thoughts about life-cycle norms, mass longevity,
post-maturity, moral obligation, spiritual development, and virtues
and vices leave us? Where, 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? I think
that's an open question and it's a political question in
Perhaps, as Theodore Roszak argues in America the Wise, the wisdom
of a maturing population promises to be our greatest resource.
I suspect he's overly optimistic, just the way he was when he
wrote The Greening of America back in the 1970s.
Perhaps, on the other hand, education and policy will make no
difference whatsoever, and in that case we might think, as the Talmud
suggests, that 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 suspect that the truth between these points of view
is going to depend on how well we learn to identify, support, and
accomplish the moral and spiritual work of aging in our era.
As Plato understood in The Republic, one of the best ways to learn
is by listening to those who have traveled this road ahead of us.
So let me close by listening again to one of my favorite elders,
Florida Scott Maxwell. If you don't know her slender volume,
The Measure of My Days, I strongly encourage you to take
a look at it.
She's writing in her eighties, mid-eighties. She's very
frail, and she's writing from the perspective of a Jungian analyst.
She encourages us to learn that life is a tragic mystery. She writes,
"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 the 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, broken-hearted 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?"
CHAIRMAN KASS: Thank you very much, Professor Cole.
The floor is open for the discussion of this paper.
PROF. MEILAENDER: Thank you. There's a lot there
that I agree with, but it will be interesting if I ask you a question
about something that I'm unsure about.
DR. COLE: Sure.
DR. HANSON: And it has to do with this notion of the late
freedom that you discussed, and discussed as a problem in a way,
the sense that we think of our lives as moving toward a freedom
that's simply a "freedom from" rather than a "freedom
I'm always bothered when — and I'll grant this may
just be a defect of character, but I'm always bothered when
I learn that I have an obligation to continue to grow indefinitely
— (laughter) — and that I need lifelong learning, things
like that, since I sort of await the day when I can stop worrying
I wonder if you don't do sufficient justice to that "freedom
from" idea. I mean it is a "freedom for." As you
described it after all, it's a period of life when one worries
less about being productive and more about certain relationships
with family and friends, and so forth. Those are great goods in
human life, which we might well set over against the good of being
productive and think that they are at least as important. To find
that I am given the gift of a time in life when they can take a
kind of priority doesn't seem to me to be necessarily something
to worry about, but something to be appreciated.
So I wonder if you could just say a little more about what you
take to be the problem here, whether there's any truth to the
caveat that I've tried to articulate, and just reflect a little
more on that notion of the late freedom.
DR. COLE: Sure. I think that's a very good question,
and I agree with the spirit of it.
I think there's a great deal of good in the late freedom,
and it's a freedom we may be increasingly losing as we find
that older people are being forced by economic circumstances to
retire and go back to work to make ends meet, but I think it's
there for a significant portion of the population. And I think
people choose to do wonderful things with it.
A level of volunteering, for example, that people with free time
have is pretty impressive. It ranges pretty much, for people 65
and over, it ranges about 25 percent of people choose to volunteer
in some kind of public service. It's usually in a church situation
or religious situation, and they tend to give about 96 hours a year.
They choose to spend time with their children and their grandchildren.
They choose to spend time to read. And these are all good things.
But I think the late freedom is not a complete idea because I
think we do need guidance, more general guidance, and efforts to
create ways of understanding our place in a cycle of generations,
so that we use our freedom in ways that benefit the next generation.
I've read one theologian recently who argues that the primary
obligation of older people is to show the next generation how to
die, which is an interesting sort of point of view. It is more
a pre-modern point of view than a contemporary point of view.
So I think it's an appropriate caveat, and I certainly choose
to use my late freedom, if I'm lucky enough to get it, to enjoy
the hill country in Texas, where we have some land, and it's
a beautiful area. I just want to be there. I just want to spend
On the other hand, I really have in my mind — and my wife
and I were talking about this — I really have in my mind
questions about how much of our resources we ought to put into building
a house out there and, as Dan knows, clearing cedar and taking care
of the raw land, which in many ways will bring back the native grasses
and bring back wildlife, and so on.
How much resources should we put into that versus establishing
trust funds for our grandchildren? So if we put a thousand dollars
a year in a trust for each of our grandchildren, by the time they're
18, with any luck, most of their college expenses will be paid.
And what about siblings who have not flourished, but who may need
help when they get older because they don't have adequate savings?
So, again, it is a question of balance. My hope is that we can
explore the late freedom culturally, personally, and publicly in
a more thoughtful way, and especially in ways that are not manipulated
by consumer society, which wants to tell us how to buy our health,
how to buy potence, how to buy health and happiness, and so on.
Anyway, I won't go on there, except to say I accept the caveat
and appreciate it because I certainly don't want to come across
as somebody who thinks that the late freedom is a bad thing. I
just think we need more reflection on what it's for.
CHAIRMAN KASS: Mary Ann, and then Mike, and then Paul.
PROF. GLENDON: I want to thank you for coming back. I
know that when I look back on these years on the Bioethics Council,
I'm going to think of your two presentations as among the high
I can't find much to disagree with. There is something I
hope that one of your sources is wrong about, and that is the idea
that, if you were a fool in your youth, you have to be a fool in
your old age.
But what I wanted to ask you about, it's not so much a question
as to ask you to say a little bit more about the political implications
of those very interesting questions you raise on, I think it's
pages 14 and 15 of your paper. You stressed two things overall,
it seems to me. One is that we're living in an unprecedented
situation, and the other is that the past toward coping with the
challenges lies in attending to relationships and context.
So here's the problem, I think, when you're trying to
imagine what a group like ours might be able to contribute, some
of the things that make the situation unprecedented, the greatly
increased need for long-term care on the part of so many people
suddenly, and at the same time the sharp drop in the availability
of paid or unpaid caretakers.
If you could just peer into your crystal ball a little bit, what
do you think a group like ours might be able to do to set better
conditions for coping with those challenges?
DR. COLE: Thanks for that question and thanks for the
I think one thing that can be recommended is the development of
human development policies to strengthen people's ability to
solve their own problems, to be less dependent, because most of
our policies are aimed at solving problems, and appropriately so,
but I think there's much that can be done to educate, enhance,
give incentives for people to become more independent and more self-sufficient
in ways that are gratifying to themselves.
But, of course, the downside of emphasizing that is that I in
no way want to add to the current tendency to begin to dismantle
the welfare state, and especially Social Security and Medicare.
We know that half of the people who are supported by Medicare would
be impoverished without it. We know that, as you said, long-term
care is a looming crisis both in terms of funding and in terms of
availability of caregivers.
So that's why I have so much trepidation really in raising
these issues. I guess I would say, from a political point of view,
that it's very important to develop awareness and political
support for taking care of the most vulnerable, which is a sort
of primary principle, and not blaming people. There is a tendency
to blame people for their dependency.
In the 19th century, for example, during a health reform craze,
Alexander Graham, who developed Graham crackers, was in a frenzy
of health reform, which is kind of the predecessor to health promotion
today. He said, if people were sick, it was because they were not
leading good lives, and that if Methuselah, he said if Methuselah
had arthritis, it was his own fault, and Methuselah lived to 969
years. So encouraged commitment of resources and development of
community participation in caring for the vulnerable and the needy
I think it absolutely essential.
One thing that I've seen in terms of older people volunteering
their time, there are some networks around the country in which
people sign up as part of a group. I think this takes place in
San Antonio. When they volunteer their time to deliver Meals on
Wheels, to look in on somebody who's house-bound, to help clean,
or whatever, their hours are clocked. They clock their hours over
the years, and then when they become dependent, they're entitled
at least to the number of hours that they have put in, which is
an interesting kind of idea. So there's an attempt.
CHAIRMAN KASS: Mike Gazzaniga. You're first and then
DR. GAZZANIGA: This is maybe just a reference that will
bridge these two talks this morning. There's an ongoing, three-year
study that has been sponsored by the National Institute on Aging,
a report that will be put together by the National Academy of Science
on the social implications of people in an aging community. People
are showing growing interest in the nature of the mentation of older
people and how that impacts the decisions that they are making in
their professions and in their personal social life.
The good news is that, actually, as we age, we get happier. One
of the reasons we get happier is we ignore negative information.
So the actually great body of research that has gone on, to give
you an example of it, you show older people a series of pictures,
some of which are horrendously objectionable and some very pleasant
pictures, and you subsequently test their memory of the two classes
of pictures, and they have no memory of the objectional pictures
and only of the bucolic ones. So the point being then that —
I kind of feel this myself (laughter) — just getting happier
and happier, and so, therefore, maybe I should be removed from certain
tough decisions because I ignore or deny the tough data that might
make you want to modify your position.
But, anyway, there's a large report that will certainly be
of interest to this committee, and to others, coming out on these
DR. COLE: Yes, I think that's very interesting. I'm
not aware of that.
But I am aware of studies that show in people who are considered
old-old that there seems to be a decline in the functioning of frontal
lobe brain work, and the implication there is important for ideas
about autonomy because I'm not scientifically versed enough
to be able to give you the specifics, but when these frontal lobe
disorders take place, older people are less able to take initiative
and pursue their choices and a course of action. They're more
vulnerable to being influenced by others than they would have been
if this functioning was in place, which is an interesting finding,
I think, and yet another problem for the idea of autonomy in bioethics.
CHAIRMAN KASS: Paul McHugh.
DR. McHUGH: I, too, very much enjoyed your talk, and it's
wonderful to see you back here.
But I'm following on from a number of the comments already
made in relationship to how to understand and give more teeth perhaps
to the process of development that you have, I think, happily said
has transformed itself from the cycle idea to the stages idea of
life. I've always felt that the cycle idea was pointless.
It didn't talk about the fact that people went through development
and learned things and lost things in the process, and that was
the natural reason for there being stages.
So when I hear you talk a lot about Erikson and the like, I have
to tell you I have a visceral aversion to Erikson.
I'm not quite sure where it comes from, but I think partly
it comes from the fact that he was embedded in the Harvard of the
1950s and 1960s where I was embedded, too, and he accepted the commitments
and virtues of that place at that time and didn't wonder about
In fact, part of the difficulty in much of our writing about elderly
people and the way we should think about them does emphasize the
softer virtues rather than the vigorous virtues, a distinction that
I draw from a brilliant woman, Shirley Letwin, who said, we can
have both those virtues; you can be both courageous and compassionate;
you can both be faithful and nonjudgmental; you can be critical
in your judgment and kind, too.
That kind of sense of who we are and how we develop, and how at
each stage the vigorous virtues have to be emphasized and given,
well, to some extent, given authority, I think falls away often
in discussions such as we're having today. So that's the
first thing. Bill and you both do touch upon the vigorous virtues,
but perhaps, in my opinion, not emphasize them enough.
The second thing is that there are reasons why young people have
certain responsibilities and older people have other responsibilities.
This was brought home just a couple of days ago when I was listening
to a woman who had been embedded with our marines in the Fallujah
campaign, and she came to realize that, boy, you've got to be
19 or 20 to go in there and knock down a wall. She was following
after them and she got very foot sore. She was very brave, I thought,
to be with them, of course, and it was wonderful that she was there.
I saluted her for that. I also salute her for the fact that she
realized that hardy and robust youth have these tasks and are ready
for them in ways that 40- and 50-year-old people are not. But that's
to emphasize the humorous side.
Perhaps the issue that I want to see emphasized here is what Mike
is saying in part. There are reasons why we are asked to give up
certain tasks that we're doing in our lives. For example, anyone
who is going to run a corporation, a department, an organization
of any sort needs physical energy; he needs vision, but he also
very much needs the capacity to fight entropy. Everything is always
falling apart. Let me tell you, fighting entropy is an exercise
that you weary of in the sense that it begins to fill your week,
and you begin to shy away from it.
In fact, to some extent, what Mike is saying is absolutely right:
The reason why old executives need to be replaced is that they have
stopped looking at the problems that they need to fight and are
accepting them as part of benevolent vision that they have. You've
got to get rid of them.
The Dean and I agreed that, when I reached a certain age, it was
time for me to step down as Director, and it did, then, allow me,
because I no longer had to fight so much entropy except my own entropy,
to emphasize my interest in the vision side of my discipline, and
the like, to write more, to think more, to spend time with bright
young people, and older people, too, to develop that.
So I missed two things in your wonderful demonstration. I missed
the emphasis on the vigorous virtues and I missed the idea that,
in contrast to what Erikson says and this soft stuff, the "open
sesame" school of human development (laughter), that's
the humorous side. My mother said I would go far if I forgot that
side but didn't emphasize it.
Nonetheless, there are reasons why hardy and robust youth have
to be the ones that go into Fallujah; middle-aged folks, educated
and powerfully developed and things, need to run organizations.
And, finally, and it's best to take an age somebody should step
down if that organization is going to flourish in the future with
new people who can fight the entropy that the old have permitted.
CHAIRMAN KASS: Some of us, those of us who have senior
cards, resemble that remark, Paul, but never mind.
DR. McHUGH: There's truth in it, though, Leon.
CHAIRMAN KASS: Oh, I was joking.
DR. COLE: Let me try to respond to those comments which
were eloquently put, and I would like to read the source of the
woman who wrote about the stronger virtues and the weaker virtues.
But, first, let me say something that I couldn't find any
way to say in the paper, so I'll say it here. My favorite definition
of virtue is Jonathan Edwards' definition of true virtue. It
comes from a book he wrote late in life, when he was beginning to
think in more aesthetic terms than purely theological terms.
He said, true virtue is absolute love of God and benevolence towards
being in general. I have never heard a statement about the highest
virtue that inspires me any more than that does. Now that's
not an answer to any of your questions at all. It was just a chance
to say something I wanted to say.
I should have listed as one of my questions, when do people have
a responsibility to step aside? That's a key issue, and for
One, because they may not have the capacity to fight entropy,
and the other because they may be holding back the development of
people who need to put their stamp on things and have a limited
amount of time.
If I understand you right, I think there's a contradiction
between your first question and your second question. In other
words, you want to hear more about the vigorous virtues and I need
to know more about what they are to understand them, but you also
make the point that older executives have a declining capacity to
fight entropy in their organizations and in themselves, which would
suggest that they don't have vigorous virtues. That's one
of the reasons why they need to step aside. So I may be missing
something there, but it looks to me like there's a contradiction
in those comments.
Finally, let me say that I think what you're pointing to here
is the difficulty our culture has in making room enough for the
contemplative life. We are a "can-do" society. We want
to get things done. We don't much respect, although we're
seeing a resurgence of this, we don't much respect the virtues
of contemplation, of self-reflection, of quiet study, prayer, meditation,
the kinds of things which have the capacity, I think, to help people
grow quieter, calmer, and more benevolent, even though I understand
that Gil Meilaender doesn't really want to have to develop any
more because he just wants to be left alone; I feel that way myself
sometimes, too. But, anyway, that's an attempt to respond.
DR. McHUGH: Let me just respond by saying I see how you
could see those two questions as being contradicting one another,
and it does depend on what I mean by the vigorous virtues. The
vigorous virtues include things like courage, self-reliance, fidelity,
and critical judgment. Amongst them, of course, would come the
recognition that certain powers do decline in that manner, and just
as one doesn't try to necessarily join in the same vigorous
physical activities with hardy and robust youth when you're
in your seventies, so at the same time I think you can have courage
and vigor and vision and at the same time say this is an appropriate
time for another person to take over the running of this matter
because fighting entropy may be not only something that you begin
to shy away from after you've been doing it for a number of
years, and knowing what the fight is about, but also that you may
not even recognize the ways that the corporation is failing, and
it needs these younger people who have vigor of a physical kind
and a vision that's complementary but perhaps expanded on yours;
they need to have a chance.
Those are the things.
DR. COLE: Thanks.
CHAIRMAN KASS: But thank you very much for your comments.
Let me make a suggestion. We're at the place we were scheduled
to break. We started a little late. There's still three people
in the cue. If you don't mind, let's take the three comments
and then you would respond to them in one piece, if you wouldn't
I have myself, Peter, and Dan, Dan Foster.
It seems to me that, agreeing with all that Paul has said about
responsibility of stepping aside and those things, the brunt of
your talk really wasn't about that question as much as it was
about what life should be like for people who have stepped aside
and what one can reasonably expect from them.
I like very much the emphasis in the paper that authenticity and
indeterminate freedom, or even the preoccupation with health, are
somehow, while desirable in themselves, are insufficient because
they are relatively content-free in terms of what healthy, authentic
freedom should be used for, so that life is somehow fulfilling.
I mean, I'm seduced by the paper and the sort of idea of life
that informs it, but — and this may be another one of these
paradoxes that is simply ours to struggle with — but it seems
to me in a world that's after virtue, it seems to me increasingly
difficult to begin to talk about the virtues of those who are past
their prime and to somehow begin to talk the language of the virtues
that one should expect from them or try to cultivate them in a community
in which the language of virtue has ceased to be the coin of the
real, but where we talk about rights or various things of that sort.
So that would be the first point.
And that's made even worse by the fact that, in answer to
Mary Ann's question and nervous about contributing to blaming
the infirmed for their infirmities or trying welfare programs, you
continued to emphasize the neediness rather than the aspects of
the humanity of the old, other than their neediness, which is precisely
the problem that we have fallen into. I mean, to treat the elderly
as either actual or soon-to-be objects of need and care is to cultivate
a certain kind of condescension toward them and the community as
a whole; whereas, what we really want to do is to remember the older
you get, the more you realize what an injustice you have committed
against the elders in previous ages, when you realize that from
the inside they're still the same person they always were, at
least until the very end.
So, to the extent to which we somehow think that what we have
to do is promote the vision of care and the vision of neediness,
we are in ways undermining the very kind of thing that you're
trying to achieve here.
Lastly, it's just kind of a riff on this same point: If,
on the other hand, you are emphasizing the need to enable people
to solve their own problems, to be more independent and self-sufficient,
you're getting in the way of the kind of nice dialect about
receiving with which the paper ended. That is, on the one hand,
you want to say to the old, "Well, don't be objects of
need and care. Be independent. Learn to develop. Learn to grow,"
and do all these sorts of things. That makes it much more difficult
to acknowledge exactly what is true of life as a whole, but especially
in old age, that one of the gifts we have to those who are our descendants
is we provide them with the opportunity, in fact, to care and to
establish those bonds that really are enriching.
Now I don't expect you to solve those paradoxes. I maybe
simply caught the point of the talk. But these are just things
that are prompted both by the talk itself and the way in which you've
proceeded to respond to previous questioners.
I then have Peter. If it gets too much, just interrupt, but let's
take Peter and then Dan, and if you can hold comment until the end.
DR. LAWLER: Mass longevity is not so much a gift, but
a deliberate project of human beings to overcome the life cycle
or biological constraints. The goal of this effort to overcome
these biological constraints really is freedom from necessity, and
this "freedom from" is especially enjoyed today by the
old. So the question is, what is this "freedom from"
for, and the answer was given very properly by Gil. It was for
family, friends, and you added contemplation. That makes good sense.
But the problem is the process that won us this "freedom
from" is bound to be somewhat bad for families, friends, and
contemplation. This is a problem. This is a paradox. This is
the downside of the upside of the great victory which has brought
us mass longevity.
This is good to know because we can avoid this in our own cases.
During our productive years we shouldn't be so productive that
we're not virtuous enough, so that when we get old, we don't
have family, friends, or the ability to contemplate.
Maybe it will be proper for our Council to highlight this problem,
so that many Americans can avoid this. Nonetheless, I don't
know of any government policy that could solve this problem or even
alleviate the downside of mass longevity.
So it seems to me the government policies you pointed to had nothing
to do with the problem you raised, which was a very good problem
CHAIRMAN KASS: Dan Foster.
DR. FOSTER: Well, I was going to say more, but let me
just say two things. Another interesting conflict that Peter hinted
at right here is that in much of the world today the essential problem
is to get an aging population — if you look in southern Africa,
the life expectancy because of AIDS is 40 years. If you look in
the developed countries, we may have a solution to the aged in the
long run because the birth rate has gone down dramatically in the
developing countries which are there.
You could solve the problem of the aging in this country if you
dismantle Medicare, and so forth, because they would die. The best
health insurance in the world is to not keep people alive, you know,
to do that. So you could have a correction simply by saying, well,
okay, we're not going to treat people.
But the other side of that is that where the birth rate is high
and where disease is not overwhelming, most of the children are
coming out of resources and out of parents who don't have the
opportunities to develop in a sense. So what is happening is —
and it's, I think, happening, will happen in our country and
every place where there are lot of immigrants who have come from
places that they can't help, but they don't have the opportunities
to do things, is that you're going to have a big increase in
the population without the resources to do it.
So my only point is that in much of the world the problem is that
people are dying way too early, and there's a huge moral consequence
that we have treatable diseases that we can't do anything from
a humanity standpoint, but if you want to solve the problem of too
old a population, then you just let that go.
And I would say one other sentence and then I'm through.
Because all of you know that I work in a teaching hospital that
takes care of the poor. Much of what we've talked about today
is applicable to the healthy aging, as people have talked about.
Then you might think of moral things.
Survival is what we talk about every day, just survival. We have
more re-admissions to the hospital for congestive heart failure
than you should possibly have, just because the people, even with
Medicare, can't get their drugs, and a huge number of persons
in Dallas, Texas don't even have Medicaid or Medicare. So you
get them in the hospital, get them out of their congestive heart
failure; two weeks later they're back in — survival.
I mean most of the people that I see that are aged would not understand
one single word of what we're talking about here. They're
talking about mere survival, and to be a recipient and understand
all the arguments for reciprocity, and so forth — anyway,
there are a lot of other things I could say, but I do think it's
an interesting paradox for humanity as a whole, what to do about
life expectancy, whether that's a good thing or a bad thing.
I think a 40-year life expectancy, whether it's in certain
neighborhoods in Washington, D.C., because of drug murders, and
so forth, or anywhere else, or Dallas, or an AIDS epidemic that's
out of this world — and then, of course, we also, with all
the wars that are going on all over the world, we also have wiping
out the elderly, too.
CHAIRMAN KASS: Please, as you wish.
DR. COLE: Okay. Thanks for those questions. I'm
not sure I got precisely every point in each comment. So maybe
during lunch we can pick up some of these conversations.
DR. FOSTER: May I interrupt to say don't comment on
whatever — I don't have to have any comments on anything.
DR. COLE: I think there were some real interesting points
I would like to respond to there.
One of Leon's questions was, where does the language come
from that helps us understand what life should be like for people
who have stepped aside? One of the things I need, I think we need
— and, actually, there's an enormous research agenda in
this area. One of the things that the committee could do is suggest
the importance of setting aside funding to study these issues because
it's not there. It's very, very hard in the National Institute
on Aging for humanistic and even social science, qualitative social
science projects to be funded.
I think that the language will come from the people. The language
will not be in our theoretical ideas. I think it will be an ordinary
language, which is why I think we need studies of how people construe
this, even in impoverished, especially in impoverished situations.
Because the woman who comes in for congestive heart failure and
keeps bouncing back in, and is only seemingly concerned about survival,
when she goes back to her home, she may have grandchildren living
with her. She may be in a church environment. She may have a world
view and a world order, independent of the health care, that helps
her make sense of things.
So studying the language, I mean listening to different communities
of older people and how they articulate their relationships to their
churches, to their families, I think we would find an enormous amount
of strength, moral strength, in ordinary life and from ordinary
people, which then could become raised up as exemplary.
On the question of my seeming to emphasize the neediness of dependent
elders, which seems to undercut the idea of their responsibilities,
I think it's very important to begin to try to think about reciprocity,
the need for people who are dependent, are necessarily dependent,
either on their children or people who come in for home care or
in nursing schools, these people need to be needed, too. Finding
ways, however subtle, to allow these people to reciprocate, and
this can happen in genuine relationships that get started —
this is part of Wendy Lustbader's point in her book The Kindness
of Strangers — is one answer to this, by respecting the fact
that these people are not just the demented patient or COPD patient
on a certain floor, but have a whole life, and it's possible
for that life to become intertwined with the lives of others who
might like the stories, who might like the relationships, and caregivers.
On the issue, Peter's issue of mass longevity being a goal
of human effort, I think that's a good point. That's the
Baconian project. That's clearly what modern medicine has been
And you're right that the downside of mass longevity is something
we hadn't anticipated, just the way we didn't anticipate
that, once we were able to cure infectious disease and create public
health conditions that allowed people to live, so their lifespan
went from, life expectancy went from 40 to 75, we didn't anticipate
the emergence of chronic disease and the debilitation that would
come from those added years.
I don't think that means that in either case we shouldn't
embrace and look for the possibilities in those experiences, and
we shouldn't shirk our responsibilities for caring for people
who suffer from those conditions, but I think we should also find
ways to encourage people to take care of themselves and to know
that it really makes a difference.
Compliance rates for so many things among patients is notoriously
low, and I know it's a continuing problem for physicians and
people who work in hospitals to have people bouncing back because
they're just not doing what they need to do to take care of
I don't think I have much more to say in response to Peter's
comment, except I would like to learn more about it.
And the last thing is in response to Dan's comments. My understanding
is that, except for southern Africa and Russia, life expectancy
is growing almost everywhere else in ways that we would not have
anticipated, we would not have expected. It represents a serious
crisis because those countries, those states, in the developing
world do not have welfare states in place, do not have resources
set aside to care for declining elders.
A couple of years ago, I was on a committee for the U.N.'s
attempt to conceptualize aging during the International Year of
the Older Person. One of the things that that committee was working
on with this in mind was to reformulate the image of aging in these
countries and in our own country, so that older people became understood
as resources, as people with potential to give, and wouldn't
be seen just as people to marginalize and set aside, because that
is going to be one of the only ways that these countries are going
to be able to allow their older people to flourish, is if there
can be ways for people to understand and cultivate their abilities
to mentor, to keep contributing, to be useful.
So that's my response.
CHAIRMAN KASS: Thank you very much, Tom, for a very rich
discussion. You have given us lots and lots to think about.
We are about 20 minutes behind. That means I'm going to try
to hold you to a 15-minute break, and we'll reconvene at five
(Whereupon, the foregoing matter went off the
record at 10:48 a.m. and went back on the record at 11:10 a.m.)