“Do Not Cast Me Off in the Time of Old Age”–The Christian Worldview and the Challenge of the Aged, Part One

“Do not cast me off in the time of old age; do not forsake me when my strength fails.” This is the prayer of the Psalmist in Psalm 71:9. Like so many before and after him, the Psalmist fears being forsaken when he is old. In our own times, this concern takes on an entirely new magnitude, as the ranks of the elderly and aged grow at an unprecedented rate.

This is the concern raised by Eric Cohen and Leon R. Kass in their essay, “Cast Me Not Off in Old Age,” published in the January 2006 edition of Commentary. Cohen, director of the program in biotechnology and American democracy at the Ethics and Public Policy Center, and Kass, the former chairman of the President’s Council on Bioethics, have combined to write a most compelling essay on the challenge represented by millions of the aged among us.

Looking back to 2004 and the tragedy of Terri Schiavo, Cohen and Kass understand that the Schiavo case “revealed deep divisions in how Americans view debility and death.” As they explain, “Some saw pulling her feeding tube as an act of mercy, others as an act of murder. Some believed she possessed equal human dignity and deserved equal care despite her total lack of self-awareness; others believed keeping her alive year after year was itself an indignity.”

Beyond this, the Schiavo case indicated the limits of our national consensus about such matters as end-of-life ethics, the use of extended medical technologies, the validity of “living wills,” and the overarching theme of personal autonomy.

Yet, Cohen and Kass understand that the Schiavo case, while not unprecedented, did not represent the usual context in which such issues arise. “In our aging society, most severe disability involves instead the frail elderly, who gradually but inexorably decline into enfeeblement and dementia, often leaving grown children to preside over their extended demise. The greatest challenges involve not only deciding when to let loved ones die, but figuring out how to care every day for those who can no longer care for themselves.”

Death, disease, debility, and the challenges of growing old have been part of the human experience since the Fall. Once death became a natural part of the human experience, the question became how and when death might come and what kind of experience would precede natural death. Yet, as Cohen and Kass understand, “the circumstances in which most Americans age and die are increasingly ‘unnatural’ and surely unprecedented.”

In making this judgment, Cohen and Kass point to the fact that the development of high-tech medicine, the elimination of so many causes of natural death among the young, and the demographic reality of an increasing percentage of the population counted among the elderly, represents a new experience, not only for this generation, but for the human race.

Interestingly, the authors cite Thomas Jefferson who, when asked if he would choose to live over again, said yes–but only between the ages of twenty-five and sixty. Jefferson saw no purpose in reliving his childhood and adolescence, and he nurtured few illusions about the reality of advanced age when, he wrote, “the powers of life are sensibly on the wane, sight becomes dim, hearing dull, memory constantly enlarging its frightful blank and parting with all we have ever seen or known, spirits evaporate, bodily debility creeps on palsying every limb, and so faculty after faculty quits us, and where then is life?”

Jefferson’s experience–living into such advanced age–was relatively unusual in his own generation, but it will be the normal and normative experience of millions now living. As Cohen and Kass understand, previous generations saw so many persons die “in the nursery of life or at the peak of their flourishing.” In other words: “Living to old age was the dream of the vulnerable many; living with old age was the problem of the fortunate few.”

The “fortunate few” of previous generations is now the “vulnerable many” of our own day, who, along with their loved ones and the larger society, must come to terms with what it means to age and to be a part of a society in which so many others are also aging.

As the authors report, the average life expectancy in the United States is now seventy-eight years and rising. As recently as 1900 the life expectancy of the average American was only forty-seven. Those over the age of eighty-five represent the fastest growing segment of the American population.

The good news is that many of these older Americans are living fulfilled and relatively healthy lives, extended into many years of retirement and continued contributions to society. Accordingly, “On balance, it is a wonderful time to be old, and the democratization and expansion of old age are among modernity’s greatest achievements.”

But this is not all there is to the picture. Cohen and Kass warn that we are now witnessing the development of a “mass geriatric society” which will present this country with massive economic, social, medical, political, and ethical challenges.

Cohen and Kass have both been deeply involved in the President’s Council on Bioethics. Kass served as chairman of the Council, and Cohen currently serves as senior research consultant. Thus, their essay should be read in light of the Council’s recently-released report, Taking Care: Ethical Caregiving in Our Aging Society. For any number of reasons, most having to do with the fact that the news media generally do not see this issue as adequately sensationalistic, the report has not received the attention it demands.

Cohen and Kass see a coming “perfect social storm” represented by a fast-growing proportion of the elderly and a shrinking number of younger adults who will be able to care for family members, loved ones, and others. Americans are living longer, but the process of death now often involves an extended period of enfeeblement and, in all too many cases, dementia. The authors cite a recent Rand study that indicated that approximately forty percent of current deaths in the United States are now preceded by a period of physical, and often mental, debility that may last as long as a decade. Of course, this may include the onset of Alzheimer’s disease. At present, an estimated four million Americans suffer from Alzheimer’s. Cohen and Kass report that the number is expected to rise to over thirteen million by the middle of this century, “all of them requiring many years of extensive, expensive, and exhausting full-time care.”

One of the benefits of the analysis offered by Cohen and Kass is the focus on how the rise of a “mass geriatric society” is complicated by the decline of the natural family. Put bluntly, Cohen and Kass recognize that “precisely as the need is rising, the pool of available family caregivers is dwindling. Families are smaller, less stable, and more geographically spread out.” Beyond this, most women are now employed outside the home, and there are already shortages of trained medical personnel available to tend to those who can’t afford such assistance.

Thus, an explosion in the number of older Americans needing assistance and care comes at the very moment that finds the family weakened by ideological, cultural, economic, and social forces. The problems of old age are now routinely assigned to institutions, nursing homes, hospitals, and other settings – a far cry from when most Americans aged and died at home surrounded and aided by family members.