tHURSDAY, MARCH 6, 2003Session 2: Beyond Therapy: Ageless Bodies
CHAIRMAN KASS: Thank you very much. Other comments before we move forward? Okay. The topic of this session is "Beyond Therapy: Ageless Bodies?". This is a piece of the "Beyond Therapy" project in which we are investigating those uses of biotechnology to intervene in the human body, in the mind, affecting the life span and the mode of generating new life. We are working toward writing this up, and I hope by the next meeting, before the next meeting, there will be things to read of a more coherent and unified sort. In the previous sessions when we touched these topics, we had invited outside experts to tell us where the science is, both now and prospectively. What we have in two sessions today is a return to these topics to look at the human and moral significance of acquiring these new powers, in this case, over the aging process. And the next case, over some aspect of human memory. And this is a much more difficult task, where we're engaged in forecasting the human significance of things which are not yet here, and in which the meaning of any one of these developments will be connected with many other things that may or may not happen, either in biology, or in society, or what have you. And part of the reason for tackling this project is to allow at least one aspect of that cumulative meaning to come forward; namely, what human life might look like if a variety of these powers arrived at once, or arrived in concert. In this session, we've put together reflections on what it would mean to intervene either in toto in the process of the human species, or in part, looking at the possibility of stronger and longer-lasting skeletal muscles through the intervention of various biotechnologies, in particular, genetic modification of muscles. You'll recall that we heard about this from Dr. Sweeney already last, I want to say July. The Staff has prepared two papers which are in the briefing books. I trust you've read them. In this session, rather than go in the usual form, sort of episodic comments, I would see if I could try to hold the reins a little more tightly and discuss some of the, what I think might be the critical issues. Let's stipulate that these techniques would be widely available, relatively inexpensive, and for the sake of the discussion, relatively safe. And that one would either be able to significantly extend the human life span through intervention in the aging process, or more modestly, that one would be able significantly to affect human musculature through interventions. And let's also, I think probably not as reasonably assume that these things would be equally available, so that we don't raise, at least for the moment, the question of unequal access, or the fact that these would be the gifts only to the rich or to the privileged, just so that we could look for the moment at the thing itself. And I guess the two staff papers have, in addition to reviewing the state of the science, listed a number of possible implications of this, both for individuals and for the society as a whole. But I thought I'd like to begin and see if we could discuss the question. Does it strike us as reasonable to regard biological aging on the model of a disease which would be at least addressed, if not remedied or alleviated, at least to some extent by medical intervention? The conceptual question now of how we sort of think about the process of aging, whether this is rightly to be thought of as on the model of disease begging for medical examination, intervention, and possible remedy? By the way, I should mention while you're pondering, and I'm going to stop in a second, the latest issues of Science magazine, 28 February, has "The Research on Aging: The End of the Beginning" is the theme of the issue, and it's linked to a website, "Science of Aging Knowledge Environment", SAGE KE, which has a whole series of articles which describes this really as the end of the beginning phase of this research. And in fact, talks about the conclusion of the editorial, quotes Charlie Chaplin, "That we are all amateurs. We don't live long enough to become anything else." It goes on to say, "If the aging process could be attenuated, humans would have additional healthy years to bring their personal goals to fruition. The challenge to society will be to ensure that those goals are compatible with the needs of humanity", whatever those might be. It seems that we -- our discussion has at least got the imprimatur of the latest issue of Science Magazine, so we're not too far ahead of the curve. Let's start with this question. Is it reasonable to think that the biological processes of aging are rightly regarded as analogous to a model of disease to be studied and modified? Elizabeth. PROF. BLACKBURN: I think the problem I'm having in reading the paper which didn't clarify it, and I think we should bring up now is, we're going to assume mortality at some point. Right? We're going to assume that that will happen. And I think the issue is the rate at which we approach that from some peak state. Right? And so, if we -- none of these discussions seemed to deal with the idea that we could imagine a scenario in which we had different kinetics of the various stages in life, and so you used in the paper the rubber band analogy where everything is stretched out. And I'd like to return to this, but the quick question is, if we assume that these sorts of ideas are based upon the idea of an extension of the say prime years of life as defined by, you know, whatever your prime favorite decade is, your 20s, or 30, or 40s, whatever, 50s, but then -- and then 60, of course, terrific decade. And then there would be a decline that would be say, to put it scientifically, a particular slope down to death. Right. Now you keep that slope the same, but now that slope would only begin at say 100 years old. Right? What you've done is simply extended the adult phase. Right. That would be saying that there is a phase which for the life, contour and so forth is, you know, a decline which everybody would have, but the delay before its onset would be different, and that's what I'm not clear about. You see what I'm saying? Or you could have mortality in two seconds, you know. Suddenly, you're going from prime to death, and I don't know if that's the thing that's being specifically discussed here, that there is no intervening period of what one has been calling senescence. Could you clarify, because I could see various trajectories. If you'll line them up, there's three. The rubber band, everything is equally stretched. Twenty-four months of gestation, three decades of teenagerhood. Great. I can see that's not going to work. Right? So let's say -- and I think developmentally that is incorrect, so I think we probably will mature at reasonable ages. Then the question is -- at reasonable speeds. Then we get to adulthood. Should there be an adulthood of 80 years of undeclined abilities and so forth. Right. And then a normal rate of decline, i.e., we decline at some normal rate as a species, and then there's mortality. Or the other extreme is that you have the extended decades of adulthood, and then a very rapid decline, because we're going to assume that there's death at the end. CHAIRMAN KASS: Right. PROF. BLACKBURN: Right. And it seems to me that is the part that is troubling these discussions, that there is not a normal rate of decline at some potentially delayed point in life. CHAIRMAN KASS: Yeah, I suppose, and I should be corrected on this, but I suppose it's not possible to know in advance of more work on the science and more work on what the particular interventions might produce as to which of those latter two models one is likely to be going for. PROF. BLACKBURN: I think it would be helpful if we -- CHAIRMAN KASS: So could we extrapolate -- PROF. BLACKBURN: I think we should discuss each one separately because they raise very different issues. There's the rapid decline issue. Right. CHAIRMAN KASS: Right. PROF. BLACKBURN: The preparedness for ultimate mortality which I think is, you know, the question being raised, but that may not be -- you know, that's one issue. And then another issue is what about the idea of having say, you know, 70 years of full prime adulthood. And I think that's another thing. And for the discussion, I was going to propose that maybe we separate them, because I think that would be helpful. As I was reading the paper, the very well prepared paper, I saw a certain sort of mixing in of many of those arguments. CHAIRMAN KASS: Okay. Charles. DR. KRAUTHAMMER: Could we not extrapolate from our experience in the last century where there was a dramatic increase in life expectancy, and I guess we might conclude from that that the opening trajectory, the early years are the same except for infant mortality, of course. And then you end up with extended adulthood, and probably a decline that would parallel -- I suspect senescence today is not that different from 500 years ago, except it's perhaps extended because of the -- we probably have longer periods of decline and illness than happened a millennium ago. PROF. BLACKBURN: Right. When infectious diseases would perhaps claim -- DR. KRAUTHAMMER: Right. So if anything, you'd have a slightly flatter curve at the end, rather than a steeper one. PROF. BLACKBURN: Yes. So I think you're saying we're already very experienced, you know, as a society in much of this. DR. KRAUTHAMMER: Yes. PROF. BLACKBURN: We've already done a lot of this already. DR. KRAUTHAMMER: Right. So I'm just saying in speculating about an answer to your question, I would say let's look at what happened when we've already had some life extension. I would suspect the trajectory at the end would be probably the same slope, and perhaps a little shallower. CHAIRMAN KASS: I'm not sure one could know, because the changes over the last century are none of them due to interventions and the basic process of aging. I mean, they're all either reductions of infant mortality or just reductions in specific lethal diseases, and much wouldn't you think on how the basic process of aging is in fact interfered with as to what the pattern would be. And we could pick and choose if one wants, and have a discussion stipulating one particular pattern. The other thing is it's true that we've had some experience with social changes over the last century that have changed the age demographics of the population, and you could either argue that on the one hand that's a laboratory for study, or you could argue that in some ways it's irrelevant because we haven't really touched the maximum. In other words, there are very few people living a lot longer than anybody ever lived before, and so the question of whether a five generational world or a six generational world can be somehow fully understood in terms of the changes that have taken place, where more and more people go to live to their three score and ten or four score. So I mean we have some things to go on that would help us think about this. We're not absolutely in the dark, though it's a long question, I think, whether the precedent is simply adequate. Let's see if we can specify the conditions of the discussion and then address the question. You know, my experience always is you ask a question of a bunch of professors and they're going to change the question on you, except for you, Charles. Shall we, for the sake of the discussion, say let's conceive something that would treat -- that would interfere with aging so as to simply expand a stretch of the good years, however you define them, without affecting terribly much the period of character of the decline, and let that be the basis of the discussion. And ask the question, is it reasonable to somehow think about the processes of aging that prevent us from going from instead of 20 to 65, going from 20 to 105 before entering into sans teeth, et cetera. Robby. PROF. GEORGE: Sorry not to address the question. CHAIRMAN KASS: I expect it. PROF. GEORGE: But just for clarification, when you use the term "aging" in setting the question, you said the biological processes of aging, so -- CHAIRMAN KASS: As discussed in -- PROF. GEORGE: In the paper, right. So I'm wondering about the distinction between the biological processes of aging and disease in order to evaluate whether we can conceive the biological processes of aging on a par with disease. What I have in mind is a sort of -- can be expressed in a kind of simple flat-footed way. WE go to grandma's house for Thanksgiving. She greets us at the door. How are you, grandma? Oh, I'm okay. What do you mean you're okay? Something is wrong? Oh, nothing. It's just old age. Right. Now when she's saying that, she's referring to some biological processes, but she probably has various things, various symptoms that are diseases, aren't they? Or things are breaking down, things aren't going right. It could be anything. It could be Gout, it could be -- well, all the things that happen to us as we get older. Now is there some distinction between the biological processes of aging and just that collection of things that grandma has in mind? PROF. SANDEL: Well, does anybody ever really die of old age? PROF. BLACKBURN: I think they do. I think there's a very real -- if we take, you know, reduce it to the humble nematode worm, you know, referred to by Steve Austad in a session where he presented, it's very clear that you see these worms that have absolutely everything supplied to them, and yet they will have a trajectory of decline which you can, as we heard, alter by very simple, sometimes single nucleotide changes in their genomes. And there's a clear process. Right. Now we don't like it and so we call it disease, but I think it's a very real process, and can be quite distinguished. And the fact that it manifests itself in a series of definable symptoms and definable tissue states, I think doesn't -- changes the real biology. I think that's what's being learned, that there is something real there. Now your question is, can you treat each of these tissue issues as a disease and treat them all, and that's, I think, a good question. PROF. GEORGE: Have we exhausted it? I mean, at that point, have we exhausted everything there is that counts as old age? I mean, I think we probably in every case if grandma listed them, we'd say oh, yeah, we want the doctor to take care of that. Yeah, we want you to go to the doctor for that. Don't sit around. Yeah, we want you to go to the doctor and have him take care of that, but then after we've exhausted all that would we then say but look, there's no point in going to the doctor just to fight old age. PROF. SANDEL: Could I just follow up on that? This is a dumb question but I think it's a really good one, and I don't know the answer. Most of the -- you talked about worms where we can see this, but most of the people I know who die of old age, almost all of them had something wrong with them. PROF. BLACKBURN: Was that because their intrinsic ability to fight off the disease, or their ability to control a particular tissue growth pattern? You know, in other words, something -- PROF. SANDEL: I don't know. I'm asking you what's the answer? PROF. BLACKBURN: I actually don't know whether -- Dan, you must know. I don't know. DR. FOSTER: Well, I think that Mike is right, that most of the time, you know, if you do an autopsy, we don't do too many autopsies any more, that there's almost always an association of some illness there from which they died. But from time to time, not too infrequently, a person dies and there's no cause of -- part of the difficulty is that most people who die a normal death at home don't get autopsied, so they may -- you know, there may be something. I think I mentioned once before, if you have a perfectly matched kidney, for example, that it lasts about -- and you transplant it, I mean a transplanted kidney perfectly matched, after about 30 or 32 years, it begins to fail. And when you biopsy it, there's no rejection by the body, there's no disease in it.It just appears that entropy has finally triumphed, and so we're getting ready to transplant, somebody has just done that. And Tom Starzl who started off the whole transplant thing, said they just die of old age. I mean, that's a phrase, you know, the kidney just dies of old age, so I don't know the answer to the question. It's complicated, because if you're in a hospital where most of the deaths, then you say yeah, this person died of cancer or coronary artery disease, but I don't know about the grandmother who dies at home peacefully in the sleep. I mean most people would say well, they had a run ventricular tachycardia or something and died quietly, so I don't know the answer to it for sure. DR. KRAUTHAMMER: I'd suggest that anybody who dies happy is somebody who died of old age. All the rest died of something else. DR. HURLBUT: Dan, do you mean that if you transplant a kidney from an older person, that that kidney is going to die in the life span of the older person, not in the younger recipient? DR. FOSTER: No. I don't even know what the, you know, most transplanted organs are from young people, you know, who -- unless using a living donor who -- so the kidneys are usually not from older people, so it's just -- you know, I'm talking mystically here. DR. HURLBUT: Well, say a parent to a child, to their child. DR. FOSTER: Well, I can't answer that question. You mean, would that kidney live longer, you mean, if it was genetically -- DR. HURLBUT: Would the kidney senesce along with the parent's life trajectory, or would the -- DR. FOSTER: Oh, yeah. I don't know the answer to that. That's not what I understood Starzl to say, that it was the life expectancy in the recipient, unrelated to the donor is what I understood him to say, but I don't know the answer to your question for sure. CHAIRMAN KASS: I'm going to -- DR. KRAUTHAMMER: Could I try to answer, Leon? CHAIRMAN KASS: Are you going to answer the question? DR. KRAUTHAMMER: Yeah. CHAIRMAN KASS: I want to read something. I want to read the -- look through the paper and then I'll let you -- just so we've got it. DR. KRAUTHAMMER: Sure. CHAIRMAN KASS: And this is the notion that the senescence researchers use. "Aging synonymously used in this paper with senescence denotes the gradual progressive loss of function over time, beginning in adulthood, leading to decreasing health and well-being, increasing vulnerability to diseases and increased likelihood of death", that there is some process of decline of function, gradual loss of function over time which at least the aging researchers distinguish from the particular diseases that go by. PROF. SANDEL: Could I ask you about that? That means that when -- to go back to the thing that Gil is always taxing me with. When I get less and less good at playing baseball, as I approach my 50s, what makes that happen is the same thing, the same process as what will kill me if I don't die of a disease, even though my lessened ability to play baseball isn't itself a disease. Is that what you're saying? CHAIRMAN KASS: Let's leave aside the question of whether anybody actually dies of old age. That seems to be a sidepoint. That there is some kind of process of gradual loss of function that is separate from specific diseases, everybody in this room ought to be able to give personal testimony to, that there is this kind of underlying process which wears us down. And the question is, should we come to regard that like a disease against which we should bring the powers of medicine to bear. Charles, are you going to take that one on or not? DR. KRAUTHAMMER: Well, I would just offer, to be as provocative as I can in answer and to provoke discussion from that, would be that disease implies some defect in biology, some error, some deviation from the normal trajectory. It was hard to see how philosophically you could call aging a disease if it is the 100 percent norm for all organisms, so from that perspective, a biological perspective, I would say that I find it hard to call it a disease, it being such an intrinsically natural, if you like, process. From the human psychological perspective, it's a disease in the sense that it creates problems which we want to fix, and that -- and we regard -- it sort of ranks psychologically as a disease in that sense, but I'm not so sure how much applying the word helps us in deciding what to do about it, but that's what I would offer as an answer to is it a disease? Biologically, philosophically, no. Psychologically, it feels like it; therefore, we treat it as one. CHAIRMAN KASS: Paul. DR. McHUGH: I want to continue to follow-up on this, and Michael's point. First of all, on the baseball story, we do know exactly how the aging process affects the batting averages of major league baseball players, and there was a wonderful article written demonstrating the difference in the batting average trajectory of decline in the ordinary 35, 36 year old baseball player and Lou Gehrig. And you could see how the onset of the disease, Amyotrophic Lateral Sclerosis, cut short and altered what was an already declining skill. I think the important point to note is that as we understand diseases better and better biologically, we stop talking about them as entities, and begin to talk about them as life under altered circumstances of some event, some genetic event, some invasive event, some neoplastic event, or something of that sort, and we attack those particular events as altered life circumstances available to us. As we do that, let us say with a disorder like Huntington's Disease, where we see -- or Alzheimer's Disease, the accumulation of particular proteins and particular losses of things. We are going to chip away at what is happening ordinarily in a slower form. We're going to find the cure for Alzheimer's. We're going to find a way to -- let's not necessarily cure it, postpone Alzheimer's Disease, Huntington's Disease, and in that process you're going to see the little things that accumulate in aging, and which represent a combination of several processes, some of which give us particular vulnerabilities. So my answer to the question is that I think we're going to redefine disease, and explain disease in ways that also ultimately explain aspects of senescence. CHAIRMAN KASS: Elizabeth, and then Gil. PROF. BLACKBURN: But that suggests -- again we have two issues on the table. One is, the postponement of this, should we postpone it but say inevitably it's going to happen at some rate that's normal. And I think Paul, and perhaps Charles are raising the possibility that once, you know -- there's a second thing. As each thing goes on, should it be treated individually, and make that curve more and more shallow? I see them as really two distinct kinds of issues, not only as issues, but also underlying basis for them. One is the postponement and one is the treat everything as it comes and make the curve shallower and shallower. CHAIRMAN KASS: Gil and then Michael. PROF. MEILAENDER: When you asked your original question, I thought I understood the question clearly, just wasn't sure what the answer was. I'm increasingly unclear about the question, and here's -- I think I can say why anyway. If you say should we regard -- is it reasonable to regard biological aging as disease?I mean, the reason we want to talk about that is to know whether -- I mean, presumably if it is, then nobody would object to trying to stop it, at least retard it, and slow it down, postpone it. But now the image isn't clear to me any longer. I mean, we have Elizabeth's several images, but if we're thinking about a period of time in which I'm -- what you call the good years. I'm if not at the very peak of my powers, at least really doing well. And then we think that at some point decline begins, and we want to know if somehow it's reasonable to think that we should think that something analogous to disease has happened when decline begins. I mean, I'm certainly not there yet, you know, but eventually we all get there. That's one question, but actually your definition suggests that I'm aging all along the way. And even while I'm at the peak of my powers, whenever exactly that was, it is no longer, I'm aging. If that's the case, then stretching it out doesn't seem to be postponing it at all. It stretches out the period of time over which it happens, but aging is happening all along, so you're not stopping aging from happening. So I don't think we're really -- I'm not sure we're talking about stopping aging as happening, or whether what we're really talking about is some moment in the lifelong process of aging when decline becomes pronounced, and we want to intervene. But there's a sense in which on the definition, you know, the 30 year old at the peak of his powers is aging, and I don't see that stretching out the period of time in which he feels that way is stopping aging in any technical sense, so I -- you know, it's confusing to me. The fact that this time in which precipitous decline has not happened is longer, is not retarding aging. DR. MAY: (Off mic.) PROF. MEILAENDER: Sure, I suppose that's right, but it's not retarding aging. Aging is happening the whole time, whether I age over 70 years or 100 years. PROF. BLACKBURN: You're slowing the physical properties down. You're aging in the sense you're accumulating experience throughout those -- let's say there's a period of comparative youthful physically adulthood. Right. You'll be accumulating mental experience in that time period, so you'll age in that sense chronologically, but by the -- you know, again the simple model systems where they look at the worms extending their life span six-fold, they really have a postponement for all the obvious physical onset of things, and then those take place with a fairly normal trajectory. PROF. MEILAENDER: But that is not a postponement of aging. PROF. BLACKBURN: It is a postponement of all the symptoms, physical symptoms of aging. PROF. MEILAENDER: Physical symptoms of what? They have -- as I understand the definition, they have been aging this entire time, whether you stretched it over a longer period of time or not. PROF. BLACKBURN: Well, no, they didn't stay very youthful. That's the difference. CHAIRMAN KASS: Let's take the -- here's the example from the muscle would be a useful particular in which you could see it. In those muscle experiments that Dr. Sweeney reported on, the injection of the gene for the insulin-like growth factor in the early life of these mice and rates prevented -- when they got to be two years of age or whatever, there was none of the normal decline of function that one ordinarily sees as a result simply of what, of these biological processes of use, whatever the mechanism is, so that the muscle remain vigorous, healthier, repaired themselves better, and showed no sign of decline of the sort that one normally saw in the life cycle. And the point of this question was not to introduce a kind of new set of language where you had to decide whether something was a disease or not. That might only make the thing more complicated. Here there is an underlying biological process of decline which makes us more susceptible to specific known diseases, and in fact, is increasingly vulnerable also to death. And the question is, should we regard this as the kind of thing, as the kind of badness in human life which, with the same kind of medical means that we attack disease, we should set about attacking this, and the attempt to slow it down, arrest it, postpone its onset. Michael. PROF. SANDEL: Well, could I do a shockingly unprofessorial thing, and try to answer your question? And to do it by way of responding to the arguments presented in the paper, the working paper. To answer the question subject to the reasonable qualification that Elizabeth introduced, they were talking about your postponement or extending the good years in Bill's sense, put aside the issue of disease. Extending the average life span such that we would have multiple generations on hand, more than we're used to. That's, I think, the assumption of the paper. And the arguments that the paper presents against doing this, or at least the cautionary considerations that it raises consists of the eight effects, five individual and three social effects, speculative effects of extending the average life span in a way that would extend the good years and produce multiple generations. And I'd like to question those worries, those effects. Sorry, not the effects, but I want to assume that the analysis is more or less correct. Assume for the sake of argument that these would be -- these speculative effects are accurate, that they would -- would that give us cause for worry about this project? That's really the issue this paper presents, as I understand it. And the claim that it would be a cause for worry if these effects really would follow in the wake of age retardation or extending the good years depends on two reasons, two reasons that are implicit in this list of effects. One of them points to disrupting effects. There would be things we would have to adjust to, and the adjustment might be difficult. And the other which carries the moral weight, are dehumanizing or possibly dehumanizing effects. Quite apart from whether we could adjust to these changes, the effects would be undesirable or dehumanizing, maybe indirectly, maybe directly because a longer life span would somehow change human self-understandings in a way that would possibly undermine the background conditions for the exercise of certain virtues or valuable activities. That's the worry that runs through this list of effects. And the question I have is again, that one could quarrel with whether these really are the right effects. But putting that aside, assuming that they are, the question that I came away with is -- goes back to a discussion we had about the moral weight of the given, and here it takes the following form. Are the background conditions in human self-understandings for the virtues just about right now at 78 years of the average life span, or such that they would be eroded and diminished if we extend it to 120 or 150, or 180. But that would be odd if they were just right now. Is it the suggestion that back when it was 48, rather than 78, a century ago, and here's where the retrospective suggestion of Charles kicks in, where the background conditions and self-understanding is sufficiently different, that the virtues we prize were on greater display or more available to us. And if so, would that be reason to aim for, or at least to wish for or long for a shorter life span, rather than a longer one? Now this question arises. You could take the eight [effects] point by point and ask about this. And the one, the individual ones, the five commitment and engagement, the worry is that without an acute sense of our relatively immediately mortality, say within 78 years, that we might have a life of lesser engagements and weakened commitments, but that worry suggests that it would be a bad thing to lighten up, or the postmodern lightness of being, less gravity is -- more detached, more irony is a bad thing. And maybe we've already gone down that path, but does that suggest it might even be better? Maybe it would cure the kind of ills that post modern lightness of being to aim or wish for a shorter life span if this really is an effect that sets the background conditions. Or would we want to say that actually this is also less - lightening up is less in fanaticism and dogmatism of a kind that on balance is a good thing. Or to take the second aspiration and agency, here the idea is that death prods us to achievement. Well, there is -- these days the problem is probably the opposite, that pressures for achievement are so ratcheted up, and we've talked about them in discussion at schools and drugs, that maybe that would be a good thing, or what is the degree? How much spur do we want to achieve, and how soon does death have to loom in order to provide it? If we really want -- if we feel we've become a species of slackers, then that might be a reason to think well, maybe it would be better at 48 or 58, rather than 78, so it can go in both directions. And as for children as the answer to mortality, longevity corresponds to declining birth rates. Well, why assume that the one we've got now is just right? Do we have just the right birth rate now, or do we want a greater or lesser spur to answering our mortality through the generation of more children. Likewise, in the case of the fear of death, that's number four. We don't want the fear of death to become a preoccupation. If people live to 150, the suggestion is, people would really -- it would be very, very risky to -- because you'd be giving up 125 years rather than maybe just, you know, 25 or 30 so people would become too cautious and preoccupied. Well, then there too do we have just the right degree now of preoccupation with death at 78, or -- and is that the right temperament in relation to the willingness to take on life risking activities? Or have we given up a more heroic age that's prompted by well, you're only going to live to 40 or 48 anyhow. Maybe that generates virtues that the heroic, that we should adjust in the other direction. Why assume that 78 is the right degree of heroic activity? And then just to jump to some of the social ones, the worry about there being a glut of the able, or slowing the pace of innovation in companies and in public institutions if they're clogged up with all of these older people, and young people can't get tenure, can't get jobs, there are no openings, that kind of objection. Well, there too, why assume that the one we happen to have at the moment is the right one? Those might be legitimate worries, but if we're really worried about innovation in the kind of highly technological society we have, maybe it would be better to have a quicker turning-over of the generations in military and in schools, and universities and scientific institutions, and in companies. So the general question is, can't we test all of these arguments by saying well, wouldn't we do even better to push it backwards? And the more general question that raises is, doesn't this accord undue moral weight to the given, unless there's some reason to think that with respect to all eight of these virtues we're at just the right point now. CHAIRMAN KASS: Does someone want to join Michael's comment, very interesting comment directly. DR. KRAUTHAMMER: Yes, I would. I had a similar impression. As always, Michael stated it rather eloquently. I think this is not a new question because we have just emerged from the greatest increase in life expectancy in the history of the species. It's been recent and rapid, and we've -- many of us, our parents have lived through it, and we can learn a lot about what might happen from what has happened. I think if we recast the whole issue, it becomes a little less problematic than the way Michael had posed it. If we don't pose the issue of ought we do something about it, or should we start worrying about it? But if we pose it as can we say something intelligent about how we, as society and individuals will change as this revolution accelerates, I think it becomes easier. Then I think what you have in the paper is rather interesting, rich, and contributes to a debate in thinking about it, rather than -- I mean, once we start thinking about regulation or pronouncements about whether this stuff is good or bad, we're going to get into all kinds of troubles. And I think Michael is right, if you look at it retroactively, you'd want to argue for a decrease in our life span. I think it's useful for us as a body to have a paper which will be a decade or two ahead of the curve, and say something like we're entering a revolution in life expectancy. We've lived through one which was, as you said, disease-specific, but now we're going to perhaps enter a threshold where we're going to increase life expectancy by actually attacking the process of aging itself, which may increase life expectancy by multiples. And here is what -- how it might affect society, and here we might want to think about these long-range effects. I think if we stray beyond that advisory or sort of analytic approach, we're going to run into the problems that Michael has identified. In fact, given the choice, if people have been asked the question we are asking 100 years ago, I think they would have said let's try to extend life expectancy and see how it develops. And I would say that on balance, it's been a pretty good experiment, and the species has done rather well. I would find it very hard to argue against -- it's beyond hard. I think it would be odd if we were to as a body begin to argue against or question the value of this enterprise. I think the best that we can do is to say here are the problems which might arise. Let's start thinking about them. CHAIRMAN KASS: Mary Ann. PROF. GLENDON: Well, we're distinguishing between prolonging life and alleviating the symptoms of decline. And as a practical matter, when we're trying to figure out what the consequences of one or the other will be for society, as a practical matter, this is a question for the medical people, isn't it the case that what is likely to happen in the foreseeable future is that we are much more likely, we are, in fact, in the process of prolonging longevity while not alleviating those processes, whether you call them -- whether they are the real diseases, or whether they are just the process of senescence itself. And isn't this the most immediate problem that we have to think about as a society, is prolongation of life, but life that will still be characterized by -- well, put it another way, prolonging that period of senescence. That's one observation. The other is that we sometimes start out our discussions with a literary piece that raises the issues, and I wonder if any of you have read the poem by Oliver Wendell Holmes, the elder, called "The Wonderful One-Horse Shay". He remembers that people went to school in New England all had to learn that poem. Now Oliver Wendell Holmes, the elder, was a medical doctor, a very distinguished medical doctor, as well as a literary man, and he wrote this poem that I think is a reflection on the very problem that we're discussing. He discusses this beautifully constructed carriage, horse-drawn carriage that's constructed in the previous century. And this carriage functioned well for 100 years, and then one day they opened the carriage house and there it was just all disassembled into its various pieces. Now what was Holmes thinking about? I think the poem is about a longing that all of us have. I mean, whether it's worthy, or noble or rational, most people would like to just live with all of faculties in tact until they fall into their various pieces. Now I know that's probably not the philosophic, it's not the "Meditation on the Life Worth Living", and all that, and it's not "Meditation on Preparing to Die", but I think, you know, most of us in our heart of hearts would say boy, that would be a good way to go so, Leon, I took your question to be, is that really what we should want is something like that? CHAIRMAN KASS: Let's see. Bill, and then Gil. DR. HURLBUT: Oliver Wendell Holmes also wrote a poem called, "The Chambered Nautilus", "Build ye more stately mansions oh, my soul as the swift seasons role, leave thy low vaulted past, that each new temple nobler than the last", and so forth, implying that there was a progression over life that somehow expanded our comprehension of existence and gave us a meaningful completion. And it seems to me that one of the fundamental questions is whether those increasingly large chambers somehow involve the kind of life experience that's implied by an aging and suffering individual, or whether -- and whether we could disrupt that. The image to me of life extension that comes to mind is like a symphony. It seems to me that if you play a symphony much slower than normal, it won't be very good any more, that there comes a point where you've lost the artistic coherence of the thing. But this raises a real interesting question, and Michael made a comment that bothered me the whole time I was reading the paper too, and not that I disagree at all with the sentiment of the paper, but I kept thinking where did we ever get this notion that life was supposed to be three score and ten? How come that's in the Bible when everybody on average was dying at 50? And the only thing I could think of was that well, maybe they observed that you can get the impression that somebody who dies at 80, died of old age. But somebody who died before that, died of an acute disease or prematurely. So then you think to yourself well, why do we feel like a good life ought to be three score and ten? Wouldn't you think that if there is a meaningful life, it ought to be the life that was woven in coherence with our physical process in the environment of evolutionary adaptation in which both our mind and our body would be coordinated. This strangely suggests that life was somehow created by a benevolent force that had in mind some improvement in which we would finally find our fullness, who knows, by technology or so forth. Now I don't want to get into the question of whether -- how the world was created, but the implication in the paper is that somehow or another we've arrived at this little point in technology where things are good, but if we keep going, we'll make them bad. But I want to point out something interesting in all this. At the same time that the life span has been increasing, the age of the onset of puberty, at least in young women over the last 200 years has declined, the so-called secular trend, so that actually life happens -- we've unbalanced the life span with our technology. In this case, it was just better food it seems, but it raises a really interesting question, because I think we sort of feel the disorder of that. I don't know. I mean, that's a hard call, but it does seem to me that children entering puberty earlier and earlier is a disruptive effect on life process in time as people live longer, which is a good process. That then suggests that maybe the advent of technology wasn't the whole solution to what was missing in the environment of evolutionary adaptation. You see the distinction I'm making? It's kind of a mysterious category because I remember very well when we went to see President Bush the first day of our meeting, our first meeting, and after his prepared comments, he kind of spoke extemporaneously, and he sort of leaned forward to us and he said, you know that there is a creator, and beneath it all, it seems to me that's a very profound comment, because how do we know what would make a good life, and who's behind all this? What is it that actually will draw us to that coherence which is meaningful? And anyway, why should we assume there is meaning in life that is present in one state and not in the other? That's a -- there's a cosmology under there, and I don't mean to over-stress that, that it has to be a theistic creator or notion like that, but somehow or another we do have this image of what makes a good and coherent, and meaningful life, and the worry that we might just walk ourselves out of it, write ourselves right out of our own story. CHAIRMAN KASS: Gil. PROF. MEILAENDER: Yes. Listening to Michael and Charles, and Mary Ann and Bill actually brings me back to Elizabeth's images at the start. And I'm still trying to sort out my puzzles from before. It seems to me that we really do need to distinguish two kinds of -- two different questions, because they call for different sorts of answers, or they might call for different sorts of answers anyway. One is the question, would a longer life span be problematic? And if somebody asked you to answer that question, Michael's cautions might be in order, or you might not be -- you might not think you could give, or necessarily even being asked to give a definitive answer, but simply to sort through a number of possible effects of such a longer life span. The other sort of question one might ask is, would it be better not to have a period of decline? And that's a different sort of question, because on the one hand, of course, you could also think through consequences and so forth with it, but also it's just asking a more straightforward question about kind of what would be a good life for a human being. And I think that those are somewhat different kinds of answers with the -- just, you know, would we better off with a longer life span? Well, it's complicated, you know, and kind of hard to sort out. There are some interesting things to speculate about, and they're worth speculating about. We should be ahead of the curve as Charles says, and so forth, but I'm not sure exactly how one says more than that. Would it be better not to have a period of decline? I don't know. That's a different sort of question, I think, that calls for a little different kind of answer, so it seems to me anyway. CHAIRMAN KASS: Having brought up the second question, do you want to put your toe in the water on it? PROF. MEILAENDER: I think it's what -- I think Mary Ann is right, that it's what -- I don't know about most, but many, many people want today. What people really want is to live at something -- they don't want not to age at all. I mean, they don't mind having grandchildren as long as they're still kind of peppy, that is to say, that the grandparent is still peppy and able to do whatever they want, and so what we'd like to do is kind of live at a really high level and then just drop off the map suddenly, your two seconds of mortality, Elizabeth. And I understand the appeal of that. I guess you probably understand the appeal more and more as the years go by in some ways, but I think that would be bad. It would lose something essential in the kind of trajectory of a biological organism, which we are in part, and which we need to come to terms with. And it would, in a sense, as you, yourself have argued in the past, Leon, make it kind of harder to acknowledge the reality of death. So my toe in the water says with the second question, no, it would be a bad thing not to have a period of decline, that some people suffer horribly in it, you know, and it's terrible I understand, but not to have it, that would be bad. CHAIRMAN KASS: Mary Ann. PROF. GLENDON: Well, again just thinking of literary examples. It was at one time thought the worst thing you could wish for your worst enemy was that the person would have a sudden death, which is exactly what many people wish for themselves. I mean, how many people have you heard say I hope I get my heart attack. PROF. BLACKBURN: But, Mary Ann, wasn't that mostly implying a premature death? I think it was the prematurity rather than -- PROF. GLENDON: No, a death without opportunity to come to terms with -- PROF. BLACKBURN:Without preparation. I see. Okay. CHAIRMAN KASS: Bill. DR. MAY: I think it was Kierkegaard in the 19th Century said it was the modern world that tends to associate a good death with a sudden one. He found that rather odd because, of course, the prayers and the Catholic tradition talked about an evil of sudden and unprovided for death, and so a time of warning. Now it is the case, of course, most deaths occurred rather rapidly earlier, and they didn't have the artificial prolongation of life that we've had possible to us recently. I worry in the discussion, the unspoken assumption that we're dealing with life in unilinear terms, from a beginning to an end, and then you stretch that line, or then you begin to discuss a fattening of the line, that's the good years. And then the line thins out when you enter into a decline. And there was a certain differing -- and then we associate, therefore, all of this with the medical problem, the physical problem, whether our physical life suffers a decline in resources that allow us to mount these fat years, these good years. And we'd merely be prolonging lean years, and nobody wants that. And what all this misses is something that in traditional society we're vividly aware of, that death is not simply the event at the end of life, but nor is it simply the event that relates to decline. But life suffers terrific interventions in the course of life, which are reminders of death, and of our mortality. And it's not the case that if we provided the physical base for an expanded life, that we have somehow eliminated the constricting experience and crisis of death in the course of life. And, of course, traditional society's puberty rite appropriately included the whipping, the tattooing or the pulling of a tooth or something to remind people that you're undergoing an alteration of identity from going from childhood to adult life. And it's -- the death experience relates to those experiences of alteration and identity in the course of life. It is not simply that that's a moment at the end of life, so I'm not sure it's the case in this discussion of extending life, that therefore, we have not prepared ourselves for the problem of death. That assumes it's only the death experience at the end of life. There are all sorts of ways in which people are going to have to come to terms with death, even if they enjoy relatively good health, good counts on blood pressure and all these other things that we take as indices of well-being and life. I don't think we're going to be removed from the problem of dealing with our finitude, our mortality simply by extending life, as this paper tends to suggest. CHAIRMAN KASS: Paul. DR. McHUGH: I'm just going to continue some of our literary associations. I'm with Mary Ann, and I go with the idea that "Twixt the stirrup and the ground, many have sought salvation found." It can come quick, and it can happen, and it'll be okay. And I also wish to see things that could be extended with a good life. Again, speaking in New England literary terms because I have "promises to keep and miles to go before I sleep." We've got a ways to go. We've got more promises, and we'd like to keep them. On the other hand, what's going to happen in my opinion, as I said before, is that we're tackling diseases, and in that process, finding out pathological mechanisms that in minor form are the essences of aging. They include oxidative injuries, and they include replicative injuries and exhaustions that Elizabeth could talk about far better than I have. And that ultimately, those kinds of slow injuries, the aging that Gil is saying are in fact going on all the time, it would be useful, I think, to be able to slow them a bit. I don't think you can eliminate them and be ultimately iron-rust. The one-horse shay falls apart. We are material, and this material is going to be afflicted, but could we extend it longer? Yes, I think we will. And in fact, when we do discover more about disease, those things will be available to us. Whether it will take the form like everybody else is popping Vitamin E or not, I think there will be things of that sort. And it will happen, and then just what Michael has predicted, we'll adjust to that. And by the way, I want to be on record to say that it would be a good thing to adjust to those problems. I'm ready. CHAIRMAN KASS: Robby. PROF. GEORGE: I suspect that the worry among people who do worry about the project that we're talking about here is that our apprehension and understanding, and our possibility of an accurate understanding of the meaning of life or its aspects is somehow connected to our understanding of the meaning of death. Is death a natural part of life, or ought we to conceive death as something other than a natural part of life? And I suspect that the worry is that if we conceive it as something other than a natural part of life, that that will effect broadly people's understanding of the meaning in life. Leon, you and Bill May, and Gil probably have at the tip of your tongues what I'm searching for here, but there are some passages in Plato where he talks about the importance of understanding your activities today, shaping your activities today in the shadow of your death. When you see the problems that you face today, and you make the decisions and choices that you make today, having in mind your death, you make better -- your understanding is better. You make better choices. You're more likely to act in a human and humane way. Now I think that those -- that that's considered, the worry about what death will mean to people, how people understand death, and then the impact on their understanding of the meaning of life, their capacity accurately to understand the aspects of the meaning of life, probably isn't reducible to the considerations that were adduced in the paper, and that could be addressed analytically, as Charles said. So although I'm not able certainly off the top of my head to articulate the alternative here very clearly, it doesn't seem to me that it really is addressed by Michael's critique of what is in the paper, these considerations about social effects, having to do with the laying of childbearing and so forth and so on. I think it's something else like how people will conceive death and the meaning of death, or the relation of death to life, or the role of death in life, and therefore, the impact on their understandings and choices today. Sorry I can't do better than that, but I think if we don't get something like that on the table, we may be really missing the core of the worry about this. CHAIRMAN KASS: Yeah. I mean, part of the reason that doesn't show up is that I think the Staff paper was not conceived of as being about the mortality project, which would have made that absolutely vivid, though there is a certain suggestion, I think, in one of the places where tacitly if you somehow say all decline is somehow regrettable, that ultimately you're really saying whether you know it or not, that the real name of the game is to prevent the ultimate decline and disappearance. PROF. SANDEL: But unless that claim is convincing, and so far I don't think it's been made convincing, there are two separate issues, as you say. Banishing immortality being one, prolonging life or retarding aging being the other. And the paper, to be fair to the paper, addresses not the banishment of immortality, but the prolongation of life. CHAIRMAN KASS: Indeed. Indeed. PROF. GEORGE: Well, I just want to flag that although the distinction is there, and I understand it, as a practical matter for purposes of the worry, I don't know if it can drawn all that sharply, because if it's true - I don't know whether it's true. I don't know how we would even go about trying to figure out whether it's true. If prolongation of a certain sort, a certain length or achieved in a certain way has the impact of, in effect, banishing death from the mind, or changing our attitude toward death in a way that has this putatively deleterious effect on our capacity to understand our actions in the shadow of death and, therefore, the meaning of life, then we've got the same problem, whether it's prolongation or banishment. PROF. SANDEL: Well, someone would have to try to flush out that case. I don't think anybody has done that, and Bill gives reasons to think that it's probably an implausible case, but someone could try. It would be interesting if someone were to try. So far that hasn't been produced. CHAIRMAN KASS: Yeah. Let me respond, Michael, to your comment which I'm not so sure I would have characterized as a critique of what's in the paper, as much as filling out of what was somehow implied by raising those kinds of questions. And your sort of deft way of saying well, wouldn't this kind of concern maybe lead us to wonder whether we should have a shorter life, reverse some of the things. And having done that, would it be an embarrassment to someone who complacently thought that the given was the best, that this was the best of all possible worlds. But having provoked the question, doesn't somehow that paralyze us before the necessity of addressing it? PROF. SANDEL: Oh, I agree. CHAIRMAN KASS: And in that sense, it does seem to me that -- would you not say that, maybe it's not an exhaustive list, but at least the paper does touch on certain aspects of our existence that might be affected, and might be affected for better, or might be affected for worse. And rather than say well, the precedent that we've gotten used to the world of modest longevity implies that we will get used to the world of super longevity and, therefore, it's cost-free or good, doesn't that in a way compel us -- PROF. SANDEL: That wasn't my claim. That's closer to the spirit of Charles and Paul. That's not what I was saying. I would say it's not a knockdown argument against this to say you open the question whether to push it back. I would say yes, so I'm agreeing that you could take it in both ways. CHAIRMAN KASS: Then let me try you on one particular piece of -- I mean, you spoke mostly about the -- I mean, you could have gone on, had you wanted to, I'm sure, to tackle some of the social aspects as much as the individual ones, but take the question of pursuit of our preservation, longevity and well-being, and its relation to the willingness to be devoted to those who will replace us. On balance, how do you think this plays out? PROF. SANDEL: Will we be less devoted to those who -- to successive generations, to our children and grandchildren if we live longer and see more generations, more great-grandchildren? Is that what -- CHAIRMAN KASS: Well, there was no procreation in the Garden of Eden, where the possibility of indefinite life was just a reach away. No one had any interest in it, not having discovered that death was bad. But the suggestion seems to be that the blessed pain-free, joyous life for one's self is perhaps at odds with the willingness to make way for and demote one's self to those who will replace one, especially if the replacement seems more and more optional. It's not meant to be an assert -- it's meant to be -- raise a serious question. Biology is quite interesting on this, because there seems to be some interesting connections between these things which sort of produce longevity and actually get in the way of fertility, and the connection with -- and there are lots of possible explanations of this. But we had some discussion when our experts were here, and was there some speculation on the connection between puberty and fertility on the one hand, and a switch that might, in fact, lead down the road to decline and disappearance? PROF. SANDEL: It's a good question. My intuition, if I knew I would live to 150 or expected to, would I be less likely to have kids, or would I have fewer kids? Intuitively no, I don't get it, but I don't know. What makes you think that I would? CHAIRMAN KASS: Well, I'm struck by just a number of things. The declining birth rate in places of prosperity and longevity is an interesting fact. And it's not obvious to me that those of us who have really prospered under the blessings of prosperity and good health for a long time see our place in the world as those who are somehow going to make a better life for our children, as much as we're going to see it as an opportunity to fulfill ourselves here and now. DR. MAY: It's an interesting issue on education. After all, at the end of World War II our expenditures for education and health care and defense for a while were roughly comparable, and now health care has zoomed over 14 percent, and education is still down there at 5 to 6 percent. That's not the issue that you raise in this paper. You raise it more in personal terms. The next generation would be less inclined to invest in the education of the young. I found it amusing to think, however, that in this paper that if I were to cut down my caloric intake down to 60 percent, it would not be a public spirited act on my part. I mean, living longer and soaking up resources and so forth, so obviously the paper does not lead in the direction of regulations, but it is a cautionary note. And the caution ought to impinge on such questions as how we invest our resources, and whether this becomes a top priority issue in the future, or whether we are already lopsidedly investing in health care, as compared with other kinds of investments we ought to be making for the welfare of future generations. DR. KRAUTHAMMER: But on that point, it might be a useful contribution to the question of how we distribute the resources within the amounts allocated for health care. In other words, it might make more sense to invest money on retarding the aging process than on going after Disease X, Y and Z, because in the end, your -- I mean, presumably if you went after aging, you'd be extending this period of health and vigor, rather than substituting one way of dying for another, which is what a lot of the disease-specific stuff is doing. Just an aside on that point. One other -- just as another aside, that the best verdict on what life expectancy does to how you lead your life I think came from Mickey Mantle, whom as you know, lead a rather wild and raucous life. When he died in his late 50s, he said if I had known I was going to live this long, I would have taken care of myself. And that's because he had a father, and uncle and a brother, all of whom died early of heart disease in their 40s. He expected he would too, so he didn't really take care of himself. CHAIRMAN KASS: Rebecca and Dan. DR. FOSTER: One quick comment about the health cost. A very large portion of the health costs in the country are at the end of life expenditures, where there's not, if you look at Medicare and so forth, I mean it -- so an economic problem is if you're going to continue to treat diseases, they have longer to develop and so forth, unless you can stop all that. I mean, the costs of prolonging life are very huge, because it's the highest cost that we have right now. CHAIRMAN KASS: Rebecca, and then I think we'll close. PROF. DRESSER: A bunch of disjointed comments. One is, I don't know -- your original question, is this a medical problem? If it's not a medical problem, if it's considered a social problem to deal with just the senescence process, I think it will get just as much attention from society, if not more. It will be like our impaired mobility. I mean, people will invent cars, you know, outside of the medical model, so in fact, it might get treated in a more sort of crass commercial way if it's not defined as a medical problem. I do think that this paper has an inherent tone of conservatism, and we live in the best of all possible worlds. And I notice that at the beginning you said the case in favor of living longer hardly needs to be made in detail, and so if we focus more on the drawbacks than the advantages, it's not because the advantages are not lacking. But I think that that's one thing that gives it this tone of well, let's -- what we have now is the best, and let's think about all the bad things that would happen if we changed it. So I mean, I think we should concede that -- just think of the opportunities for human flourishing that would expand. You could have different careers. I could go back and study the classics that I missed by being a social science major. I mean, there would be lots of positives, so I certainly agree that there are concerns, but I think it comes off as, you know, as I said essentially let's preserve the status quo. And I'm not sure that we want to -- I think we want to be more exploratory. For me, if we want to -- I thought Michael's statement was really great. For me to inject an evaluative note on whether what we have now is better than what we would have if this aging, if the healthy part of aging were extended. We have to look at something objective like constraints on natural resources and sustainability. To me, the social effects are the most concerning, and there does seem to be an element of selfishness in some of this, and so I wonder if tying some of these concerns to the Mother Earth and limited resources, maybe we'll go to other planets or whatever, but it does -- that, to me, seems to have -- gives some grounding that otherwise you say well, why don't we have shorter? Why don't we have longer? We don't have that grounding. And then finally, to quibble, I do think that this -- the effect of reduced fertility and people wouldn't want to have children as much, I really question that. And I guess the explanation I've heard for the decrease in the birth rate we've had is because when children live longer, people don't feel they have to have 10 children and hope that they'll end up with two. And then the other thing is the availability of contraceptives, and changing gender roles. I guess those are the things I've heard demographically that have explained a lot of the declining birth rate, with economic prosperity, so I would just be really cautious about explaining our increased life expectancy as one of the reasons that people are having fewer children. I don't know what those social science data are on that. CHAIRMAN KASS: Does someone want a last word? DR. MAY: A limited comment, innovation and change. It seems to me the argument that's given here is that you people will be in full vigor, and you won't be able to blast them out of their jobs. And then the big time institutions where they work will, therefore, not change as much. It's quite possible there would be another reading, people having the time after their jobs to be involved in so-called third-sector institutions, which have been very important to the vigor of this country, and a source of innovation and change. And as I recall back in Vatican Council II, my Catholic friends sometimes said the most conservative generation was the "fortress" generation, that was in charge, but those were in the earlier stages of life, and those in the later stages of life were most disposed to be more venturesome about what was happening, so I think one might give a different reading about some of those social impacts. CHAIRMAN KASS: Well, we are adjourned until 2:00. Please try to be prompt. We have Steven Pinker as a guest, and we'd like to start on time. Thank you. (Off the record 12:32 - 2:03 p.m.) |
