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Conundrums: The Ethics of Old Age

Course Authors

John E. Morley, M.D.

During the last three years, Dr. Morley has received grant/research support from Vivus, Merck & Co., Upjohn, B. Braun McGaw, Bayer Corp and Nestec, Ltd. He has also served on the Speakers' Bureau for LXN, Organon, Ross, Pharmacia & Upjohn, Glaxo Wellcome, Hoechst Marion Roussel, Searle, Merck & Co., Roche, Bristol-Myers Squibb, Novartis, Pratt, B. Braun McGaw, Pfizer and Parke-Davis.

This article is also being published in the "Aging Successfully" newsletter of Saint Louis University.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • Recognize the inherent worth of older persons

  • Determine the importance of an individual's autonomy in ethical decisions

  • Discuss the need for advance directives.

 

Introduction

The story of Tithonus, the morning lover of Aurora, the Goddess of dawn, illustrates the long-standing social attitudes about aging:

Whatever Tithonus did for Aurora was so wonderful that she asked her father, Zeus, to give him immortality. Zeus, being a doting father, granted this request; unfortunately, Aurora had forgotten to ask for eternal youth as well. As the story goes, by 50 years of age, Tithonus' libido had started to decline; by 60, potency was in question; at 80 he walked with a stoop and became frail; and by 100 he had developed age-related cognitive dysfunction and "babbled" incessantly. At this stage, Aurora's love for Tithonus had worn thin but she could not kill him, as he had immortality. As she became more annoyed by Tithonus, she decided to change him into a cicada. The next time you hear the chirping of cicadas, you are listening to old men talking with one another!

These physiological changes and the catastrophic effects of illness shape the attitudes to aging. Each era filters this physical vision through its societal mores. In the end, our view of aging represents a compilation of the economic, political and spiritual ethos of the moment. It is curious that elders have been venerated in rigid, unchanging, totalitarian societies while fairing less well, until recently, in vibrant, changing democratic societies.

There are three great ethical conundrums of aging which every society must face:

  1. The right to autonomy
  2. The worthiness of the elder as it pertains to the needs of the individual versus the state; and
  3. The ethical issues surrounding the "good" death.

Autonomy

She left the market.
Walked to the intersection.
Waited for the light
to turn red,
hunched low,
knees high,
lurched out in front
of oncoming traffic,
waved madly at
the skidding cars,
her wire basket
with coffee, doughnuts
and smoked oysters
bouncing right behind her,
chuckling and muttering
about insane drivers,
one eyeball rotating
in an orgasm of fear.

It was her little joke.

Once a policeman stopped her.
She kicked him in the shin,
scattered his citations
all over the street,
yelled rape
in her reed-piped voice
and scurried home
muttering about cops.
After that
the police left her alone,
but sometimes they
spoiled the fun
by stopping the traffic
at her favorite crosswalk.

Michael Andrews
All the Time

As the poem shows, an older person's autonomy may be in conflict with the needs and goals of the society. In the U.S., most bioethicists and courts have generally favored autonomy over beneficence (whether a patient should receive a treatment of questionable benefit) in medical decision making. In other countries, individual autonomy is considered less important -- medical authorities make the tough individual decisions that are more likely to override the individual's autonomy (medical paternalism) and consider society's interests.

In contrast, we in the U.S. have medicalized bioethics, focusing on the physician-patient interaction rather than those issues that involve the society as a whole. This is consistent with American society's protective maternalism -- we have mandatory seat belt laws, laws against alcohol consumption by minors, consumer product recalls and anti-smoking campaigns. Among elders living in the community, we have made it difficult for them to choose autonomously to "go gentle into the good night." Protectionism is the watchword applied to elders. Children of elderly parents won't allow lifestyle choices that are in reality less dangerous than the autonomy their parents allowed them to have when they first climbed a tree. They will demand, prematurely, that their parents be declared incompetent and force them to give up the lifestyle they wish to maintain. This complex issue of maternalistic intervention within the family unit was first explored by Mallory and Gert in 1986 but has received little attention by ethicists subsequently.(1)

I have previously reported the case of an elderly women who managed to regain the weight she'd lost when she was given "permission" by her children to refuse therapy.(2) As a nursing home physician, I have often faced the dilemma of dealing with an older person "tricked" into coming to the nursing home and "abandoned" there by his/her spouse or child. I have been threatened with lawsuits when I have discharged older persons of borderline competence back home at their request. I have struggled with my conscience when I have failed to discharge an abusive husband with Korsakoff's syndrome at the request of his spouse. I have seen tragedy occur when a much loved, but abused wife, was removed from her adored husband by a hospice. Upon separation, the woman became absolutely miserable and declined more rapidly than expected.

"Coercive" removal of elders from their home represents one of the most difficult ethical conundrums of aging. Dr. Harry Moody has suggested that we "respect the person within their full concrete reality." In other words, the physician and the family should together determine whether or not the patient is capable of being involved in the decision. As a result, a sliding scale of capability could be developed which would vary from case to case. This approach would take us beyond the legal model that, in my opinion, allows us to escape from these ethical dilemmas. Remember that the current legal model of ethics (competency, consent and confidentiality) allowed slavery, virtual extermination of Aborigines, hottentots and bushmen, the holocaust and McCarthyism but prohibited giving adequate doses of morphine for pain. Is there any reason to believe that this model can be trusted to do the right thing, ethically, for elders.

Gerontologist Christine Cassel has argued against the dominance of the three C's of early nineties ethics, i.e., competency, consent and confidentiality. She would prefer an ethical approach that stressed care, commitment and courage. Harry Moody has called for a genuine social ethics based on discourse. He characterized this model as communication, clarification and consensus building. It is perhaps time to move away from the three C's and go "back to the future" with the CARE model, viz.

Compassion and
Autonomy is the
Right of
Elders.

Clearly, one of the great ethical conundrums of aging in our times is the right of older persons to "flirt" with death as they chart their course through their journey of life. It would seem to me that those of us who are young and middle-aged have "found ourselves astray in a dark wood, where the straight road has been lost sight of." Let us return to the straight path and allow those who have gone before us to exert their autonomy just as they allowed us to flap our fledgling wings when we were searching for our autonomy as their children.

For the Greater Good

Where should we draw the line between the needs of the individual and the needs of society? Two Western philosophers stand in opposition to each other: John Stuart Mill who advocated that the greatest good for the greatest number should prevail and Immanuel Kant who believed, in a sense, that the individual, through his ability to reason, was pre-eminent. Kant showed that we can arrive at what is right or wrong using pure reason. We didn't need a God to guide us. We were, ourselves, worthy. But are we equally worthy throughout our lives? In other words, does the worth of the individual change with age?

The renowned psychoanalytic pioneer, Carl Jung, claimed to believe in the inherent worth of older persons. In Modern Man in Search of a Soul, Jung wrote:

"A human being would not grow to be seventy or eighty years old if this longevity had no meaning for the species to which he belongs."

But for Jung the elderly are worthy only in so far as they protect the species, i.e., the younger segments of society. Arguments at this level can carry particular weight in developing countries where children may be starving. Mexico, for example, has had to decide whether money be spent on improving the medical care of retired government workers at a time when Mexico City is surrounded by a ring of poverty and its streets are populated by homeless children.

The elderly are said to be worthy because they exert a stabilizing influence over the younger more volatile elements. U.S. Supreme Court justices are often elderly and, according to Nina Totenberg, a radio commentator, they tend to provide less radical decisions as they age. Politicians are often older and, presumably, offer perspective and wisdom to younger officials, though this can sometimes be self-serving and relative -- septuagenarian Congressman Henry Hyde, who presided over President Clinton's impeachment hearing, recently characterized an extra-marital affair that he had at age 41 as a "youthful indiscretion." The important potential role of older persons in society is illustrated by the exhortation of Simone de Beauvoir in Coming of Age:

"There is only one solution if old age is not to be an absurd parody of our former life and that is to go on pursuing ends that give our existence a meaning -- devotion to individuals, to groups or causes, social, political and/or intellectual or creative work...One's life has value so long as one attributes value to the life of others by means of friendship, indignation and compassion."

A third argument for the worth of the elder is the importance of aging to one's spiritual growth as one completes the journey through life. This argument has been well enunciated by the historian, Thomas Cole. Old age is perceived as a time to reflect on one's life and prepare for the afterlife. The elderly are seen as being closest to God. The suffering of many elderly is seen as a rite of passage, similar to the journey of Christina in Pilgrim's Progress. God is testing our faith as he did with Job. Such a spiritual argument carries tremendous force if one's ethical beliefs are based on one's religion.

For Harry Moody, the rites of passage in old age carry equal importance to those of adolescence. The elderly are not held to be morally superior but rather further along on a journey of life, with life seen as a movement of lifelong fulfillment whose consummation is found only in death and afterlife. A corollary to this worth of the elderly is the worth gained by those who have the privilege of interacting with their elders. As pithily put by Rabbi Abraham Herschel:

"Reverence for the old, dialogue between generations, is as important to the dignity of the young as it is for the well-being of the old. We deprive ourselves by disparaging the old."

Worth of the elderly is often underestimated because the young are unable to understand old age or elders' perception of their quality of life. Malcolm Cowley in The View From 80 wrote:

To enter the country of old age is a new experience, different from what you supposed it to be. Nobody, man or woman, knows the country until he has lived in it and has taken his citizenship papers."

Elders perceive the world differently from the young. Robert Pearlman in Seattle has demonstrated that physicians' views of their heart patients' quality of health consistently underestimate their patients' opinions.(3) In our nursing homes, I am repeatedly surprised that so many residents perceive their quality of health and life as better or much better than anyone else.

If you accept the worthiness of the elder, then you must place an individual's needs ahead of those of the group. If, however, you and the society do not value aging, your focus must necessarily shift -- from the interpersonal values of the elderly person to the distribution of resources. Witness the example of the ethicist, Daniel Callahan from the Hastings Institute.

In 1987, Callahan argued, in his influential book, Setting Limits: Medical Goals in an Aging Society, that in an era of spiraling medical costs the worth of the elderly should be devalued to allow limiting their access to medical care. Embraced by baby boomers, the Callahan non-ethic has resulted in decreasing access to care for the Medicare population. Cost containment is the order of the day. Little thought has been given to approaches that could improve care while containing costs.

In a society where sports figures and movie stars become millionaires, the logic of decreasing care for the elderly to allow taxes to be reduced for the rich is beyond me. The U.S. gross domestic product is sufficiently large to enable adequate services for both the young and the elderly. The failure to do so has grave ethical consequences. As Agich declares: "The striking injustice of Western society and culture is its inability to find a place for old age that acknowledges it for what it is....The very fact that they have lived into old age bestows an honor."

The importance for human beings to act to reverse ethical inequities is clearly delineated by Anne Michaels in Fugitive Pieces:

"It is Hebrew tradition that forefathers are referred to as "we" not "they". 'When we were delivered from Egypt....' This encourages empathy and a responsibility to the past but, more important, it collapses time. The Jew is forever leaving Egypt. A good way to teach ethics. If moral choices are eternal, individual actions take on an immense significance no matter how small: not for this life only."

We need a new meme, a societal collective thought that will reverse this pernicious trend that divides us, whether by income, by sex, by citizenship or by age.

The Good Death

The major ethical issue, lurking behind the others, that faces the elderly, is death. To understand death is to lose our fear of it, according to Thich Nhat Hahn:

"Enlightenment of a wave is the moment the wave realizes that it is water. At that moment all fear of death disappears."

In the United States, we have industrialized death. Death, mostly violent, is brought into our homes on a daily basis. Slowly, we become numbed and treat human death like that of the death of a comic strip character. Burial of the dead has become an event rather than a spiritual good-bye. Scientifically, Kubler-Ross has given us her stages of dying, producing a clinically sterile approach to dying, divorcing it from the individual and the spiritual. Technology has allowed us to postpone death for hours, days or months while, at the same time, suspending living. Though studies show that a majority of older persons would prefer not to enter an ICU, rarely is their opinion sought.(3) The SUPPORT study demonstrated that older persons' advanced directives are rarely documented and even more rarely followed.

Our obsession with death is demonstrated by the continued best-selling status of Tuesdays with Morrie. Morrie, the old teacher, "walks the final trip between life and death and narrates the trip" to Mitch. Morrie's greatest lesson, perhaps, is that "the truth is once you learn how to die you learn how to live". This sentiment is perhaps nowhere better captured than by the daily greeting of a Dakota warrior: "It's a great day to die." A greeting that exhorts one to live everyday to its full potential. In the sacred text of the Sikh tradition, Guru Granth Sahib, this thought is embodied in the following: "The privilege of life in human form is great and death is the price we pay for the gift of the body." For death to reach its full meaning, it needs to be seen as a spiritual moving on while leaving life's baggage behind. As Buddha said "You don't need to carry the raft after you've already crossed the river."

The concept of death as being an ongoing journey of spiritual growth has been best described by Kathleen Dowling Singh in her book The Grace in Dying. The concept is encapsulated by Walt Whitman:

"Who need to be afraid of the merge."

For modern societies, the most difficult ethical issue surrounding death is euthanasia. The word is derived from the Greek eu = good and thantos = death. Most contemporary ethicists have accepted withholding and withdrawal of treatments, such as ventilation and the delivery of food and water by artificial means, as being acceptable, though such behavior is still proscribed by some religious beliefs. In these cases, withdrawal is usually considered more unacceptable than withholding. Mainstream ethics, on the other hand, tends to see both acts as equally acceptable.

Based on our contemporary ethical beliefs and legal practices, active mercy killing to prevent terminal suffering should be acceptable. Christine Cassel has argued, in fact, that arguments against active euthanasia appear duplicitous and self-serving. Certainly a society which has reinstated the death penalty can hardly assert that taking a life is amoral. Against these beliefs are the concerns of St. Augustine and subsequent Catholic ethicists that the sixth commandment, "Thou shalt not kill," prevents humans from removing from God the right to decide when the gift of life should be terminated. Other religious philosophers, such as Thomas More in Utopia and Martin Luther, did not agree. The 1980 Declaration on Euthanasia of the Roman Catholic Church stated that euthanasia is against the law of God.

The euthanasia debate entered the circus arena with the advent of Dr. Kevorkian. In his efforts to publicize euthanasia, this pathologist seems to put little effort into determining whether suffering could be appropriately treated and instead offers assisted suicide seemingly to all comers. His motives would at the least seem questionable, as he has brazenly attempted to carve his place in history, sometimes with the cooperation of the popular media. Kevorkian's performance needs to be juxtaposed against that of other more rational physicians, such as Timothy Quill, who quietly provided what he felt to be appropriate euthanasia for a patient well known to him, an act of compassion not theater.

Ethical arguments against euthanasia become most compelling when seen in a societal perspective. Not only may a person's religion forbid euthanasia, but society needs to consider continuously the 'slippery slope' hypothesis. Our society is extremely heterogeneous. If euthanasia were legalized, could those with dementia, anencephaly or AIDS become part of the modern "killing fields?" The recent genocidal disintegration of the Balkans or Rwanda offers a constant warning that the last thing the vulnerable and socioeconomically challenged need is to become more vulnerable. Already, in the Netherlands, for example, 0.8% of all deaths annually are associated with physicians prescribing, supplying or administering a drug with the explicit purpose of hastening the end of life without an explicit request by the patient. Only 43% of all euthanasia deaths had euthanasia recorded as the cause of death which means that non-requested euthanasia deaths may even be higher.

For me, it is the "slippery slope" argument that most persuades against legalizing euthanasia.

Trust in physicians by some groups, such as African Americans, is deservedly low based on historical occurrences. Should already suspicious patients have to wonder "when my doctor will kill me?" The first killing is hard; the more we undertake, the easier it is; and the sanctity of life will soon no longer be a societal belief.

Jane Kenyon in Let the Evening Come argued for the triumph of natural death:

"Let it come as it will and don't be afraid. God does not leave us comfortless, so let the evening come."

This is a modern echo of the 23rd Psalm:

"The Lord is my Shepherd
I shall not want

Though I walk through the
valley of the shadow of death

I shall fear no evil."

Conclusion

Aging presents us with multiple ethical conundrums. In most cases, the answers are not black or white. Our own ethical beliefs concerning elders are often shaped by our experiences and our age. To conclude, I would like to share with you an anonymous poem apocryphally found in a room of a nursing home resident after her death, which encapsulates not only the worth of the elder but also the difficulty younger persons have in seeing who "the elderly" really are:

What do you see nurses. What do you see.
Are you thinking, When you are looking at me?
A crabbit old woman, not very wise.
Uncertain of habit, faraway eyes.
Who dribbles her food, and makes no reply.
When you say in a loud voice, "I do wish you'd try."
Who seems not to notice, the things that you do.
And forever is losing, a stocking or shoe.
Who unresisting or not lets you do as you will.
When bathing and feeding, the long day to fill.
Is that what you are thinking, is that what you see?
Then open your eyes nurse, you are not looking at me.

I'll tell you who I am, as I sit here so still.
As I use at your bidding, as I eat at your will.
I'm a small child of ten, with a father and mother.
Brothers and sisters, who love one another.
A young girl of sixteen, with wings on her feet.
Dreaming that soon now a lover she'll meet.
A bride soon at twenty, my heart gives a leap.
Remembering the vows, that I promised to keep.
At twenty-five now, I have young of my own.
Who need me to build a secure happy home.
A woman of thirty, my young now grow fast.
Bound to each other, with ties that should last.
At forty my young sons now grow and will be gone.
But my man stays beside me to see, I don't mourn.
At fifty, once more babies play round my knee,
Again we know children, my loved ones and me.
Dark days are upon me, my husband is dead.
I look at the future, I shudder with dread.
For my young are all busy, rearing young of their own.
And I think of the years, and the Love that I've known.
I'm an old woman now, and nature is cruel.
It's her jest, to make old age look like a fool.
The body it crumbles, grace and vigor depart.
There is now a stone, where I once had a heart.
But inside this old carcass, a young girl still dwells.
And now and again, my battered heart swells,
I remember the joys I remember the pain.
And I'm loving and living, life all over again.
I think of the years, all too few--gone too fast,
And accept the stark fact, that nothing can last.
So open your eyes, nurses, open and see,
Not a crabbit old woman. Look closer -- see me.

Anonymous


Footnotes

1Teno JM, Licks S, Lynn J, Wenger N, Connors AF Jr, Phillips RS, O\'Connor MA, Murphy DP, Fulkerson WJ, Desbiens N, Knaus WA. Do advance directives provide instructions that direct care? J Am Geriatrics Soc. 45(4):508-12,1997 Apr.
2Morley JE. The strange case of an older woman who was cured by being allowed to refuse therapy [letter]. J. Am. Geriatrics Soc. 41(19):1012-3,1993 Sep.
3Pearlman RA, Uhlmann RF. Quality of life in chronic diseases: perceptions of elderly patients. J Gerontol. 43(2):M25-30,1988 Mar.