Rolf Zinkernagel, a Swiss immunologist who won the Nobel Prize in Physiology or Medicine in 1996, believes that the lifespan of human beings has far exceeded what it was intended for: ‘I would argue that we are basically built to reach 25 years of age. All the rest is luxury.’ Wealthy older Americans spend a lot of time and money maintaining their health and postponing death. Dinner-party conversations centre on colonoscopies, statins (drugs which reduce blood cholesterol) and new diets. Many lay Americans subscribe to the New England Journal of Medicine. I have noticed a similar trend in well-off, older acquaintances of mine: health, and its maintenance, has become their hobby. All quite laudable, but let’s take this trend to its logical conclusion. What are the consequences for society if average life expectancy rises to a hundred, or even more? We have already seen radical changes to pension provision as life expectancy increases and the birth-rate (among white Europeans) falls. We face the prospect of an army of centenarians cared for by poorly paid immigrants. The children of these centenarians can expect to work well into their seventies, or even eighties. The world of work will alter drastically, with diminishing opportunities for the young.
What if powerful new therapies emerge which can slow down the ageing process and postpone death? Undoubtedly it will be the rich and powerful who will avail themselves of them. Poor people in Africa, Asia and South America will continue to struggle for simple necessities, such as food, clean water and basic health care. There will be bitter debates about whether the state should fund such therapies. The old are a powerful lobby group and, compared to the young, are far more likely to vote, and thus hurt politicians at the ballot box. We have seen politicians in the UK and Ireland performing U-turns on social provision for the old after concerted political action by that constituency. Politicians and policy-makers mess with welfare provision for the old at their peril. The baby-boomers of rich Western countries are now in their sixties and seventies, and are aiming for a different kind of old age to their parents. They demand a retirement that is well funded, active and packed with experience. They are unfettered by mortgage debt and are the last generation to receive defined benefit pensions. The economic downturn of the last several years has only strengthened their position. They are passionate believers in the compression of morbidity.
But this vision of ageing is wishful thinking. Many now face an old age where the final years are spent in nursing homes. There are several societal reasons for this: increased longevity, the demise of the multi-generational extended family and the contemporary obsession with safety. None of us wants to spend the end of our life in a nursing home; they are viewed (correctly) as places which value safety and protocol over independence and living. There have been several nursing-home scandals in Ireland over the last few years, which has led to demand for even tighter regulation and surveillance of these institutions. The use of hidden cameras (to monitor the staff) is now routinely proposed, on the grounds that inspections by government agencies are toothless, as the nursing homes are pre-warned of the inspectors’ visit. The people who work in nursing homes – commonly poorly paid, uneducated immigrants – will find themselves under constant scrutiny. The surgeon and memoirist Henry Marsh observed how working in a long-stay dementia ward when he was a student taught him ‘the limits of human kindness’. In Ireland, the nursing-home scandals have demonstrated these limits, yet we are outraged when the poor and uneducated strangers to whom we have subcontracted the task of caring for our old people are found wanting.
What are we to do? We will not see a return of the pre-industrial extended family; the future is urban, atomized and medicalized. The American bioethicist Ezekiel Emanuel (older brother of Rahm, Mayor of Chicago) outraged the baby-boomers with his 2014 essay for The Atlantic, ‘Why I hope to die at 75’. He attacked what he called ‘the American Immortal’: ‘I think this manic desperation to endlessly extend life is misguided and potentially destructive. For many reasons, 75 is a pretty good age to aim to stop. Americans may live longer than their parents, but they are likely to be more incapacitated. Does that sound very desirable? Not to me.’
Auberon Waugh (who died aged sixty-one), son of Evelyn Waugh (who died aged sixty-two), once remarked: ‘It is the duty of all good parents to die young.’ Montaigne put it like this: ‘Make room for others, as others have made room for you.’
Charles C. Mann wrote an essay in 2005 for The Atlantic called ‘The Coming Death Shortage’, which envisaged a future ‘tripartite society’ of ‘the very old and very rich on top, beta-testing each new treatment on themselves; a mass of ordinary old, forced by insurance into supremely healthy habits, kept alive by medical entitlement; and the diminishingly influential young.’ Mann cites the case of Japan, where one in three men over the age of sixty-five is still in full-time employment; the Japanese are ‘tacitly aware’ that the old are ‘blocking the door’. Meanwhile, one in three young adults is either unemployed or working part-time, leading lives of ‘socially mandated fecklessness’. The American philosopher and physician Leon R. Kass predicts a future of ‘protracted youthfulness, hedonism, and sexual licence’.
I am broadly in agreement with Kass and Mann that ever-increasing longevity is bad for society, but the problem is this: given the opportunity of a few extra years, would I take them? Of course I would. There is an old joke: ‘Who wants to live to be a hundred? A guy who’s ninety-nine.’ And this problem of the interests of the individual clashing with the interests of society runs right through modern medicine, as we have seen with cancer treatment and assisted suicide. The menu of options is increasing all the time, and it looks so attractive.
We are familiar with the contemporary hubristic and bellicose use of military metaphor: the war on this, the battle against that. We regularly hear outlandish calls to arms: Prime Minister David Cameron has pledged that ‘a cure for dementia’ will be found within ten years. This is as likely to be successful as Richard Nixon’s ‘War on Cancer’. William Haseltine, Chief Executive Officer of Human Genome Sciences, claimed in 1999 that ‘death is nothing more than a series of preventable diseases’. However, neither the Human Genome Project nor stem-cell technology has so far delivered the cures that had been predicted, though biomedical research grows in size and scope. The biomedical research industry is just that: a business, not an exercise in altruism.
Medicine has taken much of the credit, but longevity in developed countries has increased owing to a combination of factors, which include not only organized health care, but also improved living conditions, disease prevention and behavioural changes, such as reductions in smoking. Interestingly, the maximum human lifespan has remained unchanged at about 110–120; it is average longevity which has increased so dramatically. Where do we draw the line and call ‘enough’? We can’t. John Gray has eloquently argued that although scientific knowledge has increased exponentially since the Enlightenment, human irrationality remains stubbornly static. Science is driven by reason and logic, yet our use of it is frequently irrational. Does this phenomenon have any relevance to my daily work as a doctor? Well yes, it does. Irrationality pervades all aspects of medicine, from deluded, Internet-addled patients and relatives, to the overuse of scans and other diagnostic procedures, to the widespread use of drugs of dubious benefit and high cost. Cancer care, as we have seen, has been described as ‘a culture of medical excess’. Overuse and futile use is driven by patients, doctors, hospitals and pharmaceutical companies. The doctor who practises sparingly and judiciously has little to gain either professionally or financially.
Technology ever increasingly fuels our utopian hunger. Sam Parnia, an English intensive care specialist working in New York, has written a book called The Lazarus Effect (2013). Parnia is an evangelist for a technique called Extracorporeal Membrane Oxygenation (ECMO), which is used to resuscitate people who have had a cardiac arrest. The blood of the patient is removed entirely, put through a membrane which oxygenates the blood, and pumped back into the body. The idea is to buy time while the problem that caused the arrest can be fixed. Parnia claims:
It is my belief that anyone who dies of a cause that is reversible should not really die anymore. That is: every heart attack victim should no longer die. I have to be careful when I state that because people will say, ‘My husband has died recently and you are saying that need not have happened’. But the fact is heart attacks themselves are quite easily managed. If you can manage the process of death properly, then you go in, take out a clot, put a stent in, the heart will function in most cases. And the same with infections, pneumonia or whatever. People who don’t respond to antibiotics in time, we could keep them there for a while longer [after they had died] until they respond.
Parnia’s idea is very attractive in the case of say, a fifty-year-old man with cardiac arrest caused by myocardial infarction (James Gandolfini), or a footballer collapsing during a match with a disorder of the heart rhythm (Fabrice Muamba). However, were ECMO to become standard treatment and widely available, I could easily envisage frail, elderly, wealthy patients, dying of pneumonia (in theory, reversible), receiving this therapy. And this is the problem with every new exciting treatment: you can’t be seen to ration it. Isn’t the life of the old lady with pneumonia just as worth saving as that of Fabrice Muamba? And all death is ultimately preceded by the heart stopping: ‘the one thing that is certain about all our lives’, says Parnia, ‘is that we will all eventually experience a cardiac arrest. All our hearts will stop beating.’ The definition of illness that is ‘reversible’ is so vague that most dying patients could qualify for ECMO. This technology is highly likely to take root and flourish in America. The cost, financial and spiritual, is likely to be steep. And this technology blurs even further the line between life and death, a line that is becoming increasingly more difficult to identify.
Sam Parnia and William Haseltine’s belief that death is mainly preventable, finds an echo in the contemporary reluctance on the part of doctors to write ‘old age’ as the cause of death in a death certificate.
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John Gray, in his book The Immortalization Commission (2011), wrote about a prevailing belief in Victorian Britain and later, in Soviet Russia, that science could deliver immortality. He describes the bizarre attempts by the Soviet scientist Krasin to preserve Lenin’s body, an undertaking that failed disastrously:
[In] 1924, he constructed a refrigeration system designed to keep the embalmed cadaver cool. But the cryogenic technology failed to work, and the body began showing signs of decay... Told of these problems, Krasin was adamant the freezing could succeed. Any condensation that might be damaging the cadaver could be dealt with by installing double glazing and obtaining a better refrigerator from Germany, always the best source of technology in Bolshevik eyes. The German refrigerator was imported, but the process of deterioration continued...
Gray referred to cryonic suspension as a variety of ‘techno-immortalism’. Ray Kurzweil, the American ‘visionary’ is a modern Krasin, and is currently engineering director of Google. In Transcend: Nine Steps to Living Well Forever (2009), he and his co-author, medical doctor Terry Grossman, suggest that a rigid regimen of diet, vitamin supplementation, regular exercise and preventive medicine could keep us going long enough until the time when technology can help us transcend our biological limitations, and give us a form of virtual immortality: ‘if you stay on the cutting edge of our rapidly expanding knowledge, you can indeed live long enough to live forever.’
In The Singularity is Near: When Humans Transcend Biology (2005), Kurzweil claims that we are on the verge of a scientific revolution, which will allow us to ‘remodel’ ourselves. Tiny robots – ‘nanobots’, operating at a molecular level – will ‘have myriad roles within the human body, including reversing human ageing (to the extent that this task will not already have been completed through biotechnology, such as genetic engineering)’. Fusing human and artificial intelligence will create an immortal entity, in which ‘the non-biological portion of our intelligence will ultimately predominate’. Kurzweil currently leads a project called ‘Calico’, under the aegis of Google, a programme of medical and genetic research with the goal of ‘ending ageing’. He has specified a time when this sudden acceleration in human knowledge could make immortality technically possible: ‘I set the date for the Singularity – representing a profound and disruptive transformation in human capability – as 2045.’ (I would then be eighty-five; if I keep myself alive until then, maybe I, too, could become an ‘Immortal’.)
Kurzweil is not alone: there are many ‘immortalists’ and ‘transhumanists’ who believe that the technology which may dramatically lengthen human longevity is just around the corner. Perhaps the most famous of these is Aubrey de Grey, a Cambridge-based, self-taught biologist of ageing. Grey, who started as a computer scientist, is a proselytizer for what he calls ‘Strategies for Engineered Negligible Senescence’, a range of putative molecular therapies to prevent ageing.
It is entirely possible that de Grey and his fellow immortalists are right; but I disagree with their assumption that this is a good thing. Bryan Appleyard, in his book How to Live Forever or Die Trying (2007), has speculated on how a dramatic rise in longevity would affect our work, our relationships, politics, our sense of self, art, philosophy and religion. For meliorists – those who believe in the inexorable progress of mankind – prolongation of life and avoidance of death are core beliefs. The still-wealthy baby-boomers are enthusiastic believers; those who are sceptical have been dismissed as ‘mortalists’. The boomers, the richest generation in human history, are most definitely not content to make room for the next generation.
Madeline Gins was an American artist and poet who died, aged seventy-two, in January 2014. She and her husband, the Japanese conceptual artist Shusaku Arakawa, were ‘transhumanists’ and believed that people died because they lived in surroundings that were too comfortable. They designed buildings which were uncomfortable enough to ‘counteract the usual human destiny of having to die’. They called this philosophy ‘Reversible Destiny’. Her obituary in the Daily Telegraph reported:
Their ideas remained largely theoretical until 2005 when they unveiled a small apartment complex in the Tokyo suburb of Mitaka, known as the Reversible Destiny Lofts. Painted in lurid blues, pinks, reds and yellows, each apartment features a dining room with a warped floor, making it impossible to install furniture, a sunken kitchen and a study with a concave floor.
Gins and Arakawa invested all their money with Bernie Madoff, and Arakawa died in 2008. This sad little tale reminds me of the photograph of a dejected-looking man, posing with a huge, defrosted refrigerator, containing the mortal remains of his wife; he had hoped, at some unspecified future date, to have her resurrected by whatever technology would become available. An unanticipated electrical failure had dashed any such hope.
But not all transhumanists are deluded eccentrics. There is a critical mass of sober, objective scientists who predict that the technology which could significantly extend our longevity is highly likely to become available in the coming decades. Advances in stem-cell biology and regenerative medicine may make organ replacement as routine as replacing a used battery. It is more likely, however, that maximum human lifespan will remain static at 110–120, and average life expectancy will increase dramatically, but only among the well-off and well-educated. Professionals retiring at sixty-five are now expecting thirty years of healthy, active retirement. The poor, even in developed countries, may experience a fall in longevity, mainly because of obesity and smoking. Meanwhile, the rich and well-informed, with the help of diet and exercise, screening for disease, and preventive medications, will fuss and jog their way to a hundred years old. For £125, the US company 23andMe will analyse your DNA for your risk for a variety of diseases. The CEO, Anne Wojcicki, is the estranged wife of Google co-founder, Sergey Brin. Brin’s DNA tests showed a risk of Parkinson’s disease. He responded to this news by ‘increasing his coffee intake and intensifying his workout regimen’, two factors thought to have a preventive effect against the disease.
St Paul believed that death was caused, not by inevitable biological decay, but by sin: ‘Sin entered the world through one man, and through sin death, and thus death has spread through the whole human race because everyone has sinned.’ St Anselm, writing in the eleventh century, also attributed death to human sinfulness:
Moreover, it is easily proved that man was so made as not to be necessarily subject to death; for, as we have already said, it is inconsistent with God’s wisdom and justice to compel man to suffer death without fault, when he made him holy to enjoy eternal blessedness. It therefore follows that had man never sinned he never would have died [my italics].
In our own post-Christian society, we have come to believe in a similar doctrine. But the sins are not those I learned about in my catechism as a child; the sins that cause death are not old-fashioned ones, such as avarice, sloth, gluttony, anger, lust and so on, but newer ones, such as smoking (now also an official Catholic sin), low fibre intake, lack of regular exercise, failure to take advantage of preventive measures against ill-health and ‘internalizing’ anger. Healthiness has become the new godliness.
Many within medicine view with alarm the direction modern health care has taken. Much of what Ivan Illich predicted in the 1970s (and which was dismissed at the time) has come to pass. Many health economists believe that spending on medicine in countries like the US has passed the tipping point where it causes more harm than good. We have seen the rise in the concept of disease ‘awareness’, promoted, not infrequently, by pharmaceutical companies. Genetics has the potential to turn us all into patients, by identifying our predisposition to various diseases. Guidelines from the European Society of Cardiology on treatment of blood pressure and high cholesterol levels identified 76 per cent of the entire adult population of Norway as being ‘at increased risk’. This ruse of ‘disease mongering’ (driven mainly by the pharmaceutical industry) has identified the worried well, rather than the sick, as their market.
A growing resistance movement has taken root, with various strands to it, such as the Slow Medicine movement, founded in Italy in 1989, inspired by the Slow Food movement. At a meeting of the movement in Bologna in 2013, Gianfranco Domenighetti listed the characteristics of health systems as follows: ‘complexity, uncertainty, opacity, poor measurement, variability in decision-making, asymmetry of information, conflict of interest, and corruption’. The British Medical Association has backed a ‘Too Much Medicine’ campaign, which shares some of the aims of the Slow Medicine movement. The ‘Choosing Wisely’ campaign in the US has created an evidence-based list of medical interventions that are frequently futile and unnecessary.
The founders of the NHS naïvely believed that a free health-care system would result in a healthier society, and thus less demand for its services. Enoch Powell, who held office as a health minister, was among the first to point out the fallacy of this argument. Ivan Illich coined the term ‘Sisyphus syndrome’, meaning the more health care given to a population, the greater its demand for care: ‘I invite all to shift their gaze, their thoughts, from worrying about health care to cultivating the art of living. And, today, with equal importance, to the art of suffering, the art of dying.’
We cannot, like misers, hoard health; living uses it up. Nor should we lose it like spendthrifts. Health, like money, is not an end in itself; like money, it is a prerequisite for a decent, fulfilling life. The obsessive pursuit of health is a form of consumerism and impoverishes us not just spiritually, but also financially. Rising spending on health care inevitably means that we spend less on other societal needs, such as education, housing and transport. Medicine should give up the quest to conquer nature, and retreat to a core function of providing comfort and succour.
Julian Barnes’s 1989 novel, A History of the World in 10½ Chapters, concludes with a parable about immortality. The narrator wakes: ‘I dreamt that I woke up.’ He is attended by a woman, ‘like a stewardess on some airline you’ve never heard of’, who brings him the most delicious breakfast he’s ever eaten. It gradually transpires that he is in some form of paradisical afterlife, which will last for eternity. Every fantasy he has ever had comes true, and he indulges every desire he has ever had. He meets all the famous people he has ever admired, and even gets to have sex with them. (Barnes’s paradise echoes the afterlife promised to Islamist suicide-bombers.) He completes every round of golf with eighteen shots. Eventually, he runs out of new experiences. He discovers, to his dismay, that most of his fellow occupants of this paradise (‘Heaveners’) tend to choose a second death – oblivion. ‘It seems to me’, the narrator remarks, ‘that Heaven’s a very good idea, it’s a perfect idea you could say, but not for us. Not given the way we are.’