What should we do with the old people?

The world welcomed the 7^th billion baby this week leading to a furor that the earth is unlikely to be able to provide for this growth in population with its limited resources. Clearly the growth in babies is not being balanced with the departure of the old. With medical advances, the old are living longer and longer and the lowering of child mortality further accentuates the problem. And hanging above it all is the cost of medical support for the elderly leading many to proffer, very guardedly, that perhaps the time has come to limit these costs in the waning days of the old. The question is how do various cultures around the world deal with the problem of the aged?

When people grow old in many parts of the world, family and friends care for them at home until the end. In America, the elderly are more typically sent to an assisted living or a skilled nursing facility, a contrast that may appear selfish, uncaring and even callous.

Eastern cultures place enormous value on family and the elderly, often adhering to traditional age hierarchies. The Confucian doctrine of ‘filial piety’ continues to have a strong presence in Chinese and Asian culture. It simply means showing obedience, respect and deference to your elders. It’s considered a privilege to be in the enlightened company of an elder, and ancestral reverence remains vitally important today. In these and other cultures, it is considered utterly shameful not to take care of your aging parents.  

In stark contrast, Western culture encourages families to strike a balance between allegiance to the elderly and individual freedom. Values of Western cultures tend to celebrate youth, self-reliance and individualism. Routinely, seniors do not live with their children and it’s often considered a big hassle to take care of your parents, even if you really want to do so. The “cult of youth” and emphasis on the virtues of independence, individualism and self-reliance also make life hard on older people as they inevitably lose some of these traits. Then, there’s America’s Protestant work ethic, “which holds that if you’re no longer working, you’ve lost the main value that society places on you.” Retirement also means losing social relationships, which, coupled with America’s high mobility, leaves many old people hundreds or even thousands of miles away from longtime friends and family.

While modernization has brought many benefits to the elderly — most notably improved health and longer life spans — it has also led to a breakdown of traditions. Modern literacy and its ties to technology are also putting the elderly at a disadvantage. “Modern literacy means that we look up things in books or on the Internet — we don’t go ask an old person. And lightning-speed technological advances “mean that the things that old people do understand got technologically outdated.”

According to UCLA professor Jared Diamond, “The idea that it’s human nature for parents to make sacrifices for their children and, in turn, for their grown children to sacrifice for their aging parents — turns out to be a ‘naïve expectation,’ This assumption, he said, ignores undeniable conflicts of interest between generations.” From a common sense perspective, “Parents and children both want a comfortable life — there are limits to the sacrifices that they’ll make for each other.”

In a provocative article, sociologist Amitai Etzioni, argues that the Eskimo solution of “putting the old on an ice floe and left to float away into the sunset” is not the right solution. Of course, he would argue that – after all he is 83! But his reasons for dismissing this are cogent and logical.

According to a recent study, Dr. Alvin C. Kwok and his colleagues find that surgery is common in the last year, month and week of life. Eighty-year-olds had a 35% chance of going under the knife in the last year of their lives; nearly one out of five Medicare recipients had surgery in their last month and one in 10 in their last week. Nobody doubts that some of these surgeries were necessary. But major medical and ethical figures argue that they reflect our reluctance to accept death or let go, the surgeons' activist interventionist orientation and the way the incentives are aligned.

As the surgeon Atul Gawande put it in The New Yorker: "Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop."

Focusing on care for the elderly, some others warn that our present attitudes "doom most of us to an old age that will end badly: with our declining bodies falling apart as they always have but devilishly -- and expensively -- stretching out the suffering and decay." They hence call on us to abandon the "traditional open-ended model" (which assumes medical advances will continue unabated) in favor of more realistic priorities, namely reducing early death and improving the quality of life for everyone. They further advocate age-based prioritization, giving the highest to children and "the lowest to those over 80."

The journalist Beth Baker summed up this position: "After people have lived a reasonably full life of, say, 70 to 80 years, they should be offered high quality long-term care, home care, rehabilitation and income support, but not extraordinary and expensive medical procedures."

Etizioni argues that “once we set an age after which we shall provide mainly palliative care, economic pressures may well push us to ratchet down the age. If 80 was a good number a few years ago, given the huge deficit and the pressure to cut Medicare expenditures, there seems no obvious reason not to lower the cut-off age to, say, 70. And nations that have weaker economies, the logic would follow, should cut off interventionist care at an even younger age. Say, 50 for Guatemala?”

But if we do not use age as a criterion for abandoning serious surgical and costly medical interventions, what is the alternative?

Etizioni argues that the correct criterion is the capacity to recover and return to a meaningful. Thus, if a person is young but has a terminal disease, say, advanced pancreatic cancer, and physicians determine that he has but a few months, maybe weeks, to live (a determination doctors often make), he may be spared aggressive interventions and be provided with mainly palliative care. In contrast, an 80-year-old with, say, pneumonia -- who can return to his family and friends to be loved and give love, contribute to the community through his volunteering and enjoy his retirement he earned with decades of work -- should be given all the treatments needed to return him to his life.

The real moral is that we should learn to accept death more readily; we should stop aggressive interventions when there is little hope; we should provide dying people with palliative care to make their passing less painful and less traumatic. And finally we should learn from the Eskimos -- they long ago stopped abandoning their elderly just because they got "too" old.