A wise man, according to Spinoza, does not think about death. In our day, however, he would be regarded as very unwise if his failure to think about death led him to neglect making provisions for his family by leaving a proper will, arranging adequate insurance, and in some metropolitan centers even choosing where to live. Modern society, at least American society, confronts a problem, a whole series of problems, resulting from increasing longevity, changes in the pattern of family life, and a greater concern about the quality of life of the aged. Scientific medicine has been able not to renew life but only to prolong it. In a world of finite resources, physical and human, the public costs of prolonging life at some point become disproportionate to the social benefits. This is especially so when choices must be made about the investment of research funds and medical services for different age groups in the population, and for the study and treatment of different ailments.
Most human beings take for granted that since life is a good, if not an intrinsic good, then at least as a necessary condition for any other experienced good its preservation and extension are always a good. This assumption also seems to be behind the unsophisticated desire for immortality.
For many years, when I would ask my classes whether they would accept the gift of immortality, students would invariably respond that they would, until I reminded them of the Greek myth about the goddess Eos or Aurora, who fell in love with the mortal Tithonus. Eos besought the gods to make her lover immortal. They refused, but to console her they bestowed on Tithonus never-ending life. Not until Tithonus had become aged and feeble but could not die did the goddess and her lover discover what a poisonous gift they had accepted.
It is clear not only after a moment’s reflection but from a study of the representations of immortality in all ages and in virtually all the visual arts that when human beings desire immortality it is not eternal life they seek or yearn for but eternal youth. William Blake’s Reunion in Heaven shows a man and his wife in the prime of life, their small children, and even the family cat. The denizens of Heaven in all paintings I have seen seem hale and hearty even when gray-bearded, never in the last stages of doddering decay.
The progress of scientific medicine and industrial society has led to a changing conception of old age and of its place in society. It is still true that biology sets limits on what can be done, yet it is not biology but society that determines the place of old age in a culture, its authority, what is to be regarded as appropriate for the elderly, and the time and degree of retirement from active life because of old age. Regardless of what we deem desirable for the aged in our society, we must take our point of departure from the fact that until the last century or so average life expectancy was approximately thirty years but that today in the United States it is close to two and a half times as much and rising. The fastest growing age group in the population is made up of those who are over eighty-five, and in a couple of generations it is anticipated that 24 percent of the population will be sixty-five and older. At present, those over sixty-five, who constitute 11 percent of our population, account for more than 31 percent of total medical expenditures.
These figures and a discussion of the numerous problems arising from the health costs of providing decent medical care for the aged are contained in a thought-provoking, in some ways profound, work by Daniel Callahan, former editor of Commonweal, founder of the Institute of Social Ethics and the Life Sciences (The Hastings Center), and author of The Catholic Case for Contraception. His is a morally courageous book, challenging current widespread assumptions that we should prolong life by increasing medical care even if the result is worsening health throughout the United States.
Callahan argues in language more circumspect and sensitive than that of former Colorado Governor Lamm a few years ago that it is possible to limit care for the aged without any diminution of respect and concern or lack of appreciation for their worth to society. Callahan offers three principles to guide us in the medical treatment of the aged. “After a person has lived out a natural life span, medical care should no longer be oriented to resisting death.” By a “natural life span” he means a life whose opportunities “on the whole” have been fulfilled. He explains that he means by this “something very simple: that most of those opportunities which life affords people will have been achieved by that point.” These include “work, love, the procreating and raising of a family, life with others, the pursuit of moral and other ideals, the experience of beauty, travel, and knowledge, among others.” He does not deny that new “opportunities” may arise later in life, only that this is not “what occurs ordinarily.”
He admits that we cannot be very specific about the idea of a natural life span; it will vary from case to case and embrace personal as well as objective factors. But Callahan believes substantial agreement can be established when it has been reached in particular cases by the disinterested inquiry of responsible physicians. There is to be sure something inherently vague in Callahan’s first principle. He does not adequately define what an “opportunity” is, nor does he clarify how opportunities are “afforded” us by “life”; it seems instead that the kind of opportunities we have depend upon the kind of society we live in—on its political organization and its level of technological and economic development. The obscurity of Callahan’s notion of “opportunities” extends to that of a “natural life span.”*
Determining when a “natural life span” has been reached, or when an “opportunity” has been fulfilled and when it is open, is admittedly difficult if not impossible to do by any formula or rule. Callahan, I presume, would agree that we can only decide case by case, but he does not present clearly the kinds of considerations that should be taken into account in making such decisions. My guess is that even those who rule out anything except age and medical condition as relevant would in most cases make the same decision.
Of course, one may argue that living under any conditions, costs, and consequences is worthwhile in itself no matter what. This does not seem to me to be true. I believe I can convince anyone of a sound mind, even if he doesn’t care a fig about honor or moral decency, that sometimes it is better not to be than to be.
Callahan’s second principle is that “provision of medical care for those who have lived out a natural life span will be limited to the relief of suffering.” But suppose the temporary relief of suffering prolongs life without generally alleviating a person’s suffering. Suppose pain cannot be relieved. Suppose we are dealing with the current California case in which a man who has been permanently unconscious for five years as a result of a car accident can be maintained indefinitely by a nasogastric feeding tube. Under no circumstances would Callahan approve of active intervention to end life. At most he would approve of hospitals forgoing heroic measures such as the use of mechanical ventilators or expensive forms of intravenous nutrition to sustain life; but, surprisingly, he is resolutely opposed to voluntary euthanasia and medically assisted suicide even in cases of prolonged agony that can be terminated only by death. (He does not give an extensive account of his reasons for opposing euthanasia. He writes that “a sanctioning of mercy killing and assisted suicide for the elderly would offer them little practical help and would serve as a threatening symbol of devaluation of old age.”)
The third of his principles forbids the mandatory use of medical technologies to extend life for the elderly who have outlived their natural life span. Presumably this would apply to all, the elderly poor and rich alike.
Callahan’s position in some respects is not as radical as it sounds and is not far removed from attitudes and actual practices in some parts of the country. One does not have to agree with his views about the “natural life span” of individuals to agree with him that since our social resources are limited, we cannot regard medical research, treatment, and care as unlimited.
Preventive medicine is preferable, if successful, to any other kind, but without a sense of proportion the community can bankrupt itself by its programs of preventive medicine. The financial cost of prolonging the lives of the aged beyond the shifting natural life span is a relevant consideration not simply because so much money and effort are involved but because the cost may prevent us from using our resources to save and prolong the lives of those who have not had the opportunity to live out their natural span. The current allocation of public funds for safeguarding the health of different groups of the population, and for engaging in research to overcome the diseases that afflict them, can often be explained by the fact that old people vote, are well organized, and have well-paid and outspoken lobbyists, whereas children do not.
The Association for Retired Persons, for example, lobbies extensively for increased allocation of funds to scientific research designed to cure or control the diseases of the elderly. Other groups, such as the Gray Panthers and the National Association of Mature People, promote legislation that will protect the right of older people to work and to freedom from discrimination. It cannot reasonably be denied that longer lives increase the prospects of chronic illness, such as degenerative joint disease (osteoarthritis), Alzheimer’s, and senility secondary to cerebral atherosclerosis, which entails heavier medical costs.
Some policy to limit the kind and nature of medical treatment seems warranted. Just how such a limitation should be applied Callahan does not say precisely; but it is not difficult to conceive of a system by which a medical board would withhold various kinds of expensive treatment, including such procedures as kidney dialysis and administration of prolonged intravenous treatment, from very old patients whose condition had already deteriorated. That a man has the money to pay for all the medical care and skill available does not necessarily entitle him to them, because what his money buys is not merely a private good but a form of social capital cumulatively built up over generations that someone without much money but in greater need may require.
Because Callahan writes with sensitivity and common sense, I find surprising his opposition to euthanasia and assisted suicide. The reasons he offers seem to be inconsistent with his other views. We are dealing here with a matter not of money but primarily of compassion for the suffering of the terminally ill, the agonies of the irremediably stricken that may last for years, and their right to die with dignity, which should extend to those lying comatose and paralyzed, unable to control their natural functions. We do not know the relative number of people in these conditions, but in absolute figures they run into many thousands. Every nursing home has a few.
A New York Times article of several hundred words that I wrote in defense of voluntary euthanasia brought a greater outpouring of letters than anything else I have published during my lifetime. Many of the letters were poignant expressions of grief and despair at the suffering of a beloved parent, ill beyond recovery, in torment or lying in a coma unaware of anything. Some revealed a sense of guilt and shame over their hope for an early death of those they loved. A few mentioned the drain of family resources that would have been cheerfully accepted if there was any hope of recovery but that was impoverishing the family and blasting the life plans of its younger members. Most were sympathetic to the various proposals to legalize voluntary euthanasia.
Under some of these proposals a patient, whether suffering or not, would have to ask to die on grounds that his or her condition was hopeless and intolerable; and a doctor would have to certify that the patient’s physical condition justified his demand. The doctor would either allow the patient to die by withholding medical treatment or would intervene to cut short his life. In other cases, in which patients are incapable of making a request—because they are in a coma, for example—some advocates of euthanasia believe the patients’ families should be allowed to make the request.
As Callahan notes, “the traditional basis for a claimed right to euthanasia” is that people have “absolute dominion over their own bodies. If their death will not do harm to others, then they have a right to will their own death and to seek the means necessary to achieve it.”
In rejecting such arguments and proposals, Callahan asks:
What larger significance might the elderly in general draw from the new situation? It would be perfectly plausible for them to interpret it as the granting of a new freedom. It would be no less plausible for them to interpret it as a societal concession to the view that old age can have no meaning and significance if accompanied by decline, pain, and despair. It would be to come close to saying officially that old age can be empty and pointless and that society must give up on elderly people. For the young it could convey the message that pain is not to be endured, that community cannot be found for many of the old, and that a life not marked by good health, by hope and vitality, is not a life worth living.
Legalizing voluntary euthanasia would not convey anything of the sort. What Mr. Callahan deems in the above passage “no less plausible” is in my view sheer fantasy. We are not here discussing voluntary euthanasia for old people—or people of any age—whose lives are marked merely by decline, pain, and despair. The proposals for voluntary euthanasia concern only those people who are in an acutely painful or hopeless condition that can terminate only in death, and who have expressed a strong desire to be free from their racking pain and total dependence on others, and who are in despair that the mercy shown to a suffering animal is denied them. To advocate legal and voluntary euthanasia is not to say that society must give up on elderly people, only that elderly people should be free to have surcease from further treatment when the insults to their body and mind degrade and dehumanize them.
I venture the opinion that Mr. Callahan does not know what very many old people actually fear. Probably most of those who are medically knowledgeable fear that they may be stricken by a catastrophic and lingering illness, with their vital and natural functions impaired, that will result in a painful death, and that they will be utterly dependent on the attentions of strangers. The lessons Callahan sees conveyed to the young—for example that “community cannot be found” for many old people—presuppose that they are extraordinarily stupid. We are speaking here only of voluntary euthanasia for those who do not want to endure a life in which “community” is literally impossible. I doubt that any intelligent young man or woman who learns that someone suffering from terminal cancer has the legal right to terminate a life he deems not worth living would conclude that pain from a head-ache or toothache or even a heartache is “not to be endured.” I doubt that anyone old or young who witnessed the final scene of the televised version of Warwick Deeping’s novel of 1925, Sorrel and Son, where the son relieves the agony of his father in the last stages of cancer, felt that his was anything but an appropriate act of filial affection. When I was young I was told that kindly family physicians in extreme situations of terminal illness discreetly helped their patients “to pass over.” But in our litigious age, the practice has largely died out.
A recent Chicago case of medical intervention reported in the Journal of the American Medical Association (JAMA) is so bizarre as to raise doubts about its authenticity. According to the report, a resident gynecologist—tired, exhausted, and irritable at the end of a long day in a large private hospital—was awakened by a call that a patient was in distress. Rushing off sleepily to do his duty, he learned that the patient, whom he had never seen before, was suffering severely from ovarian cancer. Moved by her plight and her request: “Let’s get this over with,” he administered a fatal dose of morphine “to give her a rest.”
I do not know of any advocate of voluntary euthanasia who would approve of this irresponsible action. The resident didn’t know the patient’s history, made no effort to reach the physician in whose primary care she was, and by his own admission was in no fit state to make a judgment. For all he knew, he may not even have understood her properly. No one proposes that a decision of this kind should be made by a single physician. Any legislation providing for medically assisted termination of life would require cautionary and checking procedures that could not be disregarded without risking criminal sanctions. That the gynecologist publicized an act that would have made him criminally liable, and did so in language that made him seem crude in thought and feeling, suggests the possibility that the report was a scam by a prolifer seeking to discredit the movement for humane voluntary euthanasia.
The irony of Callahan’s words is that his objection to legally approved euthanasia applies far more strongly to his own view that medical treatment to prevent death should be discontinued for all the aged after they have lived beyond their natural life span. Even so, the objection would be invalid. I have a half-suspicion that Callahan has taken his stand against euthanasia and legally assisted suicide to divert attention from the less dramatic but far broader sweep of his own recommendations to limit the medical treatment of large numbers of old people. I hazard the guess that the latter are more likely to win public acceptance only after state legislatures enact laws for the special class of aged that would be affected by the practice of voluntary euthanasia.
Callahan is very much concerned with the symbolic importance of accepting the practice of euthanasia. But his reading of its symbolic significance seems to me arbitrary and his eloquent sentences paying tribute to the elderly when he discusses the issue end in a flat non sequitur. “If one believes,” he writes, “that the old should not be rejected, that old age is worthy of respect, that the old have as valid a social place as any other age group, and that the old are as diverse in their temperaments and outlooks as any other age group, an endorsement of a special need for euthanasia for the old seems to belie all those commitments.” But why? On the contrary, it recognizes that the old suffer from greater hazards than others, that we respect the diversity and freedom of their choices, that we are not imposing a mandatory medical regimen on them from which they cannot escape, regardless of the degree of their torment and physical (or mental) degeneration.
Callahan is careful not to imply that the symbolic significance of the practice of euthanasia is to encourage community insensitivity to the medical needs of other and younger groups of the community. For if that were true, it would hold all the more for his own recommendations. But there are others who invoke the argument of the slippery slope and assert that the practices of euthanasia would necessarily coarsen our sensitivity to the medical needs of those who are not terminally ill, particularly old people, and lead to the slackening of our moral responsibility to anyone gravely ill. The ultimate result, they claim, would be the abandonment of the rights of infants who are ailing or handicapped to the special care required for them to survive.
The argument from the slippery slope is rarely a valid one. Any policy may be abused under some conditions. To the inevitable question: where will you stop? the answer always should be: where our intelligence and sense of proportion tell us to stop. There are special problems concerned with the attitude of society toward infants born without necessary organs or doomed to a life of pain, but how they are resolved is not related to any decision we make about voluntary euthanasia, which would be chosen principally by old people. It seems to me extraordinary that anyone can believe that the adoption of such a policy would even indirectly erode the customary attitude of parents toward their newborn infants. After all, we cannot reasonably assume that women as a rule are looking for an opportunity to get rid of or dispose of their children. If a child is born seriously ill or crippled it seems to evoke more intense protective feelings on the part of many parents.
On the whole, old age has been honored and revered more in Oriental, especially Chinese, civilization than in Western civilization. At a meeting of the East-West Philosophers Conference in the late 1950s a group of Chinese scholars, mostly Confucian, but not from the mainland, proposed that reverence for age be a cardinal principle in unifying world civilizations. When I made a counter-proposal that without disparaging the elderly in any way we would have a greater likelihood of agreement if we stressed the needs of children, they delicately implied that this was the outlook of young barbaric peoples. There have certainly been shifts in the attitude toward old age and, in recent years, especially in the United States, a growing increase in awareness that age by itself is not incapacitating, and that the elderly have the right to be judged by the same criteria of performance and excellence as other groups. It would be foolish, however, to pretend that there is no natural decline in physical and intellectual energy with advanced years. It would be equally foolish to claim that certain precautions—for example, in approving driving licences—that are intended to safeguard us against dangers arising from the natural tendency of the old not to recognize the effects of age are invidiously discriminatory.
It is one thing to accept old age and ultimately death with serenity and to make life, as long as it lasts, comfortable, with as little pain as possible. It is something else to glorify it. “Grow old along with me / The best is yet to be,” addressed to a youth on the threshold of his career makes stirring sense. It would be a mockery addressed to a person of advanced years, as if life were without limits or possessed perpetually expanding frontiers, not only for the human race but for the individual. I still recall Bertrand Russell, who said he deliberately lied only once in his life (in the hope of mitigating the death sentence of a mathematician in Horthy’s regime), turning to me and saying, long before he died, “Hook, don’t let anyone tell you about the great satisfactions of old age!” He himself strove gallantly to live to the top of his form but because he refused to recognize no limits succumbed to the foolishness of old age.
These days institutions and individuals are being charged not only with racism and sexism but with “agism.” Like the charge of racism and sexism, the term is used too loosely. It would be absurd to demand an affirmative action program for the aged with numerical goals and time-period objectives. Where there are no rational grounds for making age a general criterion for a policy, it is ethically if not legally wrong to discriminate against the elderly. But sometimes there are situations in which desirable social policy is affected adversely by the denial that age is relevant. I wish briefly to consider two of them.
In the near future, according to federal law, as I understand it, most mandatory retirement laws based on age are to be abolished, with only a few exceptions. In 1978, the upper age limit was raised from sixty-five to seventy for most nonfederal workers and any such limit was abolished for most federal civilian workers. As a result of recent legislation, the upper age limit of seventy will be abolished for most non-Federal employees as well; but there will be seven-year exemptions for civilian public safety workers, such as prison guards, and for tenured professors, so that studies can be made to determine whether a required age of retirement for these occupations is justified.
A decision to abolish mandatory retirement for university professors would seem to me unfortunate. Most professors at the conventional retirement age of sixty-five or sixty-eight or seventy have reached the height of their earning power. Their pensions and social security income are usually sufficient to sustain them and their wives. Their children are no longer dependent upon them. In the past, mandatory retirement applied to everyone, the gifted as well as the ungifted, the productive and the unproductive. As a matter of fact, only a very small percentage of tenured faculty continue fruitful research, and the percentage declines with age. In most universities mandatory retirement is the only way of getting rid of dead wood, of correcting mistakes in faculty appointments for which students are the main sufferers. It would be insidious to dismiss some professors and retain others, even though there may be a consensus in the university community on who is first-rate and who is not. Outside of the sciences, faculties are more divided on ideological issues.
A mandatory age retirement for all is not discriminatory. On retirement, nearly any first-rate scholar or teacher, if willing, can teach for years as a visiting professor elsewhere. There need not be any loss to the discipline or its students. The philosopher Brand Blanshard after his retirement from Yale had more invitations to teach at other institutions than he could accept. Even professors who are not of Blanshard’s stature but are competent scholars and teachers have many opportunities to work elsewhere. The abolition of mandatory retirement in universities would lead to an over-tenured faculty, and delay or denial of opportunity to younger scholars, especially to those who are not women or members of minorities. Such delay or denial is not in the public interest.
It is easy to suggest that the situation be met by the abolition of tenure or by its periodic renewal. But anyone familiar with universities, and our courts are not, will realize that this is not feasible. Once the probationary period has been served and tenure won, the life plan of most people in the academy is set. When I was chairman of a department, I would take it for granted that young scholars at first-rate institutions normally would not get tenure when the rule “after six years—up or out” was first applied. But if a scholar has acquired tenure and is then, when he is up for renewal, dismissed as unfit to continue, I would be very suspicious of his qualifications for further employment. After twelve or fifteen or twenty years in a department, it is very unlikely that a professor’s colleagues, with families and children all involved with one another in community life, would vote for dismissal. For it would be tantamount to a sentence of academic death, not only at his own university but at others as well. If someone hasn’t made good after such a prolonged period, why should we assume he or she will prove more satisfactory at our own institution, which may not be as good as University X but will not regard itself as a dumping ground for University X’s discards?
My second illustration of a field in which the policy of no mandatory retirement seems dubious is the airline industry, about which I confess to no competence. But even if I were assured that pilots of any age would still have to pass tests of competence, I would be uneasy. Even assuming that the criteria of competence would be rigorously enforced and not bent for the veterans of long service, age may affect judgment and energy in sudden emergencies. Recently one of the airlines paid a penalty for limiting the age of flight engineers eligible to fly in the cockpit to sixty years. But it is not only the knowledge of engineering that is necessary in an emergency. Anyone in the cockpit should be strong enough to help the passengers in extreme situations, and what people of sixty can do may be too much for those of seventy or more.
It seems to me to be unwise to apply mechanically the rule that age is irrelevant to performance or a host of other activities. It may be true for selling or editing or publishing, as this change in the federal law would reflect. It may not be true where physical performance affects the lives and safety of others.
April 28, 1988
The notion is even frightening if it is interpreted to mean that access to medical treatment depends on whether one is held to have completed his life span. But as I understand Callahan he is not urging denial of medical care but only of the continued, indefinitely prolonged care “oriented to resisting death” and all the heroic measures and mobilization of resources that this involves. ↩