Aging, Death and Human Longevity: A Philosophical Inquiry (review)

The rising costs of providing medical services and the increasing ratio of the old to the young lead some to claim that current medical systems are unsustainable; therefore, new methods for allocating medical care are needed. Philosophers such as Callahan and Hardwig advocate age-based rationing. Hardwig goes so far as to claim that the aged have a duty to die at around eighty. Overall joins philosophers opposed to this approach to distributive justice.

She is a fierce opponent of apologism (age-based rationing) and an ardent advocate of prolongevitism (which promotes the extension of lives). Many of her conclusions are so moderate, indeed so commonsensical, as to seem almost anodyne compared to those of extremists in the debate. Overall writes in a clear, accessible style, although she takes over from the literature a plethora of rebarbative 'isms,' e.g., apologism and prolongevitism, as well as the usual suspects, sexism, racism, ageism, ableism. ... She personalizes the discussion with references to her own situation: her 'lifelong preoccupation with the inevitability of death and a sense of its injustice,' as well as references to the deaths of her father and grandmother. But she buttresses her case with arguments, reasons, and evidence - usually to good effect.

Much of the book is devoted to perennial philosophical questions that provide a background to the issues of distributive justice: (1) What constitutes a good life? (2) Is there a 'natural' limit to human life? (3) Is a long life better than a short one? (4) Given the assumption that there is no form of life after death, would an earthly form of immortality be desirable?

Briefly, her answers are: (1) A good life is constituted either by the activities of the 'career self' or the experiences of the 'seriatim self' that values, for instance, the sequenced experiences of quotidian life. (2) There is no obvious 'natural life span'; science might offer significant extensions, as it has in the past. (3) Other things being equal, a long life is better than a short one. (4) The desirability of mundane immortality is limited by the finite resources of our planet and the finite capacities of the human body.

On the social policy level, Overall, a feminist and social democrat, advocates 'affirmative prolongevitism': laudable proposals that would direct resources, research, and services towards boosting life expectancy, with a special emphasis on aiding disadvantaged groups and on intergenerational support for the elderly. However, as she says, she does not 'attempt to describe [these proposals] in detail,' for that 'would require a book of its own.' No doubt, but the devil is in the details for both sides of the debate.

It is one thing to deal with the problems of distributive justice wholesale with philosophical generalizations based on abstractions and thought experiments; it is another to deal with them retail in the face of constantly changing real-world exigencies. Is age irrelevant in choosing whether a twenty-year-old cystic fibrosis patient or a seventy-year-old emphysema patient gets the only available lung transplant? (Fair disclosure: this reviewer, a septuagenarian who volunteers at a hospice, would choose the younger person.) Should we completely eliminate the discounting for age prevalent in our social systems, e.g., in insurance awards, tort law, and benefit/cost studies (using 'Quality Adjusted Life Years') for evaluating legislation? Issues like these are not discussed.

Moreover, the debate has been framed in the context of (currently) affluent North America and does not really address just health distribution on a world scale. Even in North America there are great disparities in medical expenditures: in Purchasing Power Parity terms, according to the OECD, the USA spends $5267 per capita on health, Canada $2931, Mexico only $553. Furthermore, in 2000 there were 605 million people on earth over sixty, with 278 million in the developed world and 327 million in the developing world, the latter number projected to grow to 1.6 billion elders by 2050. How should they be cared for along...