Mary Ann Glendon Otto von Bismarck never dreamed, when he established the world's
first social security system, that a large proportion of the populace
would live long enough to draw old-age pensions. With a tight grip
on the public purse, the Iron Chancellor set age 65 as an eligibility
threshold that few could be expected to cross. In the developed
countries at the time, including the U.S., the average life expectancy
was less than 50 years. When the American version of the welfare
state came into being in the New Deal period, the labor force was
relatively large in comparison to the population of those likely
to receive benefits, and death was seldom preceded by a long period
of disability. Today, with greatly increased longevity and low birth
rates, the United States is on the brink of a care-giving crisis
that will affect young and old alike. Thanks to medical advances, especially in the area of infectious
diseases, most Americans are living healthier, longer lives. In
2000, the average life expectancy for a man was 73 and for a woman
77. These dramatic advances in health and longevity have been accompanied,
however, by an equally striking development that presents our society
with novel problems: Nearly all elderly Americans will spend two
or more of their final years with chronic illness and in need of
assistance with routine daily activities. Treatment for this expanding dependent population is becoming
more expensive, straining our health-care system. The prospect
of lengthy disability due to physical illness or dementia affecting
large numbers of people poses an even more daunting challenge:
the country's supply of caretakers, paid and unpaid, is dwindling
just as the need for them for them is appearing on an unprecedented
scale. Both of these problems will become increasingly acute as
the baby boom generation approaches the traditional retirement age
of 65. The first wave of the nation's 77 million boomers will
reach that age in 2011, with the crest in 2015, and with significant
numbers still to come for six years after that. At present, all indications are that the United States is unprepared
to meet the needs of the large and expanding number of people facing
a lengthy period of disability before death. Yet, remarkably, there
has been relatively little public discussion of the dilemmas facing
an aging society. What discussion there is, moreover, has been
focused primarily on the economic consequences, e.g., the statement
of the Senate Special Committee on Aging in a 2002 report that,
without significant reform, "the United States could be on
the brink of a domestic financial crisis." Alan Greenspan
warned in a March 2004 interview that the country "will almost
surely be unable to meet the demands on resources that the retirement
of the baby boom generation will make." The coming economic crunch, however, is only one of the dilemmas
our society will soon have to confront. As the age structure changes,
so does the culture, and so do the meanings and values that people
attribute to aging and mortality, sex and procreation, marriage,
gender, parenthood, relations among the generations, and life itself.
Testimony on aging, dementia, and care-giving at the June meeting
of the President's Council on Bioethics suggested that important
medical, psychological, ethical, and social issues have been neglected
in discussions of these matters. The Council was undecided whether to further explore the dilemmas
presented by an aging population. The purpose of this memorandum
is to suggest that the Council could perform a valuable public service
by producing a report that would aid in the search for practices
and ideals adequate to a new society quite unlike anything we have
seen before. Even a short report could usefully heighten awareness
of the looming crisis and promote public deliberation of its human
and ethical, as well as economic, dimensions. The major questions to be faced are fairly clear: How will society
care for its dependent, aging members? How can the supply of caregivers
be increased? How can this new set of needs be accommodated without
compromising other important social goods such as the education
of the young and the stability of the economy? How can this new
set of needs be accommodated without compromising human dignity?
What are the implications of the new situation for the debate over
treatment for elderly persons whose life expectancy is drastically
limited by serious chronic illnesses? What do we as a community
owe to our most dependent members, young and old? The search for feasible and humane approaches to these dilemmas
is complicated by two other twentieth-century demographic developments:
the sharp decline in birth rates which has decreased the ratio between
the active labor force and the dependent population; and the steep
increase in women's labor force participation rates which has
limited the availability of family-based care-giving for the very
young and the frail elderly alike. When welfare states came into being, it would have been difficult
to anticipate the combination of increased longevity, low birth
rates, and changes in women's roles that would strain all the
networks and institutions that traditionally have provided care
and support for the very young, the frail elderly, the sick, and
the incapacitated. Declining birth rates plus improved longevity
mean that the dependent population now includes a much smaller proportion
of children and a much larger proportion of disabled and elderly
persons than ever before. The mass movement of women into the paid
labor force, the dispersal of family members through geographic
mobility and family breakdown, plus the declining proportion of
active workers to the dependent population have shaken the main
pillars of our society’s system for dealing with dependency: the
family, pensions, social assistance, and community services. Families are still the central pillar of our care-giving system,
but they are losing much of their capacity to care for their own
dependent members just at a time when government is becoming less
capable of fulfilling the roles it once took over from families.
Ironically, the ambition of welfare states to free individuals from
much of their dependence on families, and to relieve family members
of some of their most burdensome responsibilities, may have succeeded
just well enough to put dependents at heightened risk now that welfare
states are faltering. Less visible, but equally grave, are the likely effects of an
aging society on children and child-raising households. When welfare
states came into being, the dependent population was composed largely
of children, most of whom were cared for at home. Now, with declining
birth rates and greater longevity, the dependent population is predominantly
elderly. Yet, with increased divorce and single parenthood, the
poverty population is composed largely of women and children. Political
support for measures that address the needs of child-raising families
is already difficult to rally. That difficulty can be expected
to increase as the proportion of childless households grows. As
society becomes more adult-centered, the general level of concern
for the well-being of children may well decline. It is puzzling that the building pressure on economic and human
resources from both ends of the life cycle has elicited relatively
little public discussion and has received relatively little attention
from policy makers. That may be due at least in part to the complexity
of the problems and the fact that many of the novel dilemmas are
by-products of genuine advances in medicine and in opportunities
for women. But if measures to address the new situation are developed
solely within a framework based on the idea of competition for scarce
resources, the outlook for children and child-raising families is
troubling. Thus, no small part of the challenge facing an aging
society is that of avoiding divisive competition for resources.
Developments in the ambitious welfare states of northern Europe
provide an early warning of the type of inter-generational conflicts
that may lie ahead in the United States. There, the pinch is already
being felt because birth and immigration rates are lower than in
the United States. In places where the state once ambitiously
took over many roles that formerly belonged to the family, governments
are less and less capable of fulfilling their commitments, while
the family has lost much of its capacity to care for its own members.
Yet even quite modest proposals to cut back on pensions or to raise
the retirement age in France and Germany have met with strikes and
protests from the groups affected--the elderly who there as here
wield considerable political clout and their family members who
have become accustomed to relief from much of the economic burden
of caring for the elderly. At the same time, young Europeans are
complaining about the high cost of health care for the elderly.
(One German youth leader recently gained notoriety by suggesting
that old folks should use crutches rather than seeking expensive
hip replacements). Confronting the problems of an aging society will require searching
for ways to maximize the ability of individuals and families to
plan and provide for periods of dependency. Clear thinking about
dependency, however, may require re-examining some widely shared
ideas about autonomy. Paradoxically, the concepts of the human person that are currently
prominent in social science and social policy both over-emphasize
individual self-sufficiency and under-rate individual human agency.
The ideal of the autonomous individual exerts such a powerful attraction
in our culture that we tend to relegate obvious facts about human
dependency to the margins of consciousness. Nevertheless, human
beings still begin their lives in the longest period of dependency
of any mammal. It is still a fact that circumstances can catapult
anyone at least temporarily from a secure to a dependent position.
It is still a fact that almost all persons spend much of their lives
either as dependents, or caring for dependents, or financially responsible
for dependents. While contemporary social thought tends to emphasize
self-sufficiency, our approach to welfare tends to under-rate human
capacities by treating human beings as passive subjects. Surely
social policy and social science would benefit from closer attention
to the fact that human beings are both able and dependent,
with variations over one's life span. To adapt to the increasing strains on all our systems for dealing
with dependency will also require a certain tragic sensibility,
for there will be no solution that will not entail striking balances
among competing goods. However, if political deliberation proceeds
within a framework based solely on the idea of competition for scarce
resources, the outlook for dependents is grim. And to state the
obvious: If the outlook for dependents is grim, the outlook for
everyone is grim. The most ominous development, of course, is
the growing carelessness about respect for human life when the dependency
of some becomes burdensome to others. Should the Council attempt to raise the level of public discussion
of the dilemmas facing our aging society? In favor of the project
is the fact that hard decisions will soon have to be made by individuals,
families, health care providers, and governments. The only question
is whether these decisions will be taken in haste, in the midst
of crisis, or whether they will be preceded and informed by adequate
information, study, deliberation, and planning. There is still
time for purposeful planning, but time is running out fast. The
role of the Council would not be to undertake new research, but
rather to heighten the visibility of what is already known; not
to offer policy prescriptions, but rather to broaden the framework
for discussion. If the Council does not assume this task, it seems
likely that important ethical and human aspects of the coming challenges
will be ignored in the scramble to adjust to the pressures of the
new situation. |
