The Existential Dimension to Aging
In their recent book Aging Thoughtfully: Conversations about Retirement, Romance, Wrinkles, and Regret (2017), Martha C. Nussbaum and Saul Levmore consider their subject from two different personal and professional perspectives (philosophy and law, respectively) through the lenses of eight different topics: domination and control; forced retirement; friendship; the human body as it ages, primarily in aesthetic terms; backward-looking emotions; love in the later stages of life; wealth inequities among those who are older; and legacies. Yet they overlook other parts of the aging process that can be approached "thoughtfully," most importantly what I have termed the existential parts of aging, such as senescence; the "medicalization" of life; the issue of where, how, and with whom one will live in one's later years; and the family dynamics that assist in and impinge on the aging process. I explore these existential dimensions through several other writings on aging, as well as through my own experience.
Idiscovered Martha C. Nussbaum and Saul Levmore's Aging Thoughtfully: Conversations about Retirement, Romance, Wrinkles, and Regret (2017) at the same time I was rereading the ancient Roman philosopher Cicero on living and dying well, a text I often used in teaching prior to my retirement. Nussbaum and Levmore's book addresses a series of concerns about aging, and these concerns are presented by the two authors as alternative personal and professional perspectives. [End Page 195] The authors acknowledge at the outset that their focus is not end-of-life matters, and they also concede that they are making their observations from a relatively privileged point of view. They both like their work, and personal health matters are not prominent in their thinking. The book is divided into eight topics, each explored by both authors. Both are academics (Nussbaum a philosopher, and Levmore a law professor) at the University of Chicago. I will give a brief overview, focusing on the parts of the book most interesting from a philosophical or public-policy perspective. My chief aim is to offer a critical perspective, highlighting important dimensions of "aging thoughtfully" that the book ignores.
The eight pairs of essays deal with the following topics: King Lear and matters of domination and control; mandatory retirement; friendship (with special reference to Cicero's On Aging and On Friendship); bodies in the aging process (cosmetic surgery, anti-aging procedures, and the like); backward-looking emotions (regret, grief, and anger); love in the later stages of life through the eyes of Richard Strauss, William Shakespeare, and film; wealth inequities among those in the older segment of the population; and legacies (what we leave to others upon our death and why). The authors are clear at the outset that this is a book about "living thoughtfully and certainly not about dying," about "choices" (1), and that it is intended to provoke meaningful discussions within families as well as to raise more "philosophical and public-policy issues" related to aging (2).
The book begins with an interesting discussion of King Lear by Nussbaum. Many recent performances of the play have interpreted it in terms of aging and dementia, whereas Nussbaum sees it as being about powerlessness and losing control, two developments that often come with aging. Levmore's contribution to this segment deals in general with the issue of the distribution of wealth and power and in particular the relation between love and inheritance. Included in this are a discussion of the politics of wills, annuities as serving the opposite function from life insurance policies, the importance of wanting to be remembered, and the relation between gratitude and moral character.
The second pair of essays includes Levmore's proposal for voluntary contracts for mandatory retirement, which would encourage an exit from the world of work at a specified time. Though he himself is not personally interested in this, he sees it as a viable policy option. Nussbaum, on the other hand, is critical of compulsory retirement, seeing work as important to health and happiness, particularly in a society such as our own that suffers from "youth worship." Though the quality of life in Finland may be good in terms of a number of metrics, Finland's mandatory retirement policy does not sit well with Nussbaum.
The third set of essays deals with the subject of friendship, something important in life and particularly as one ages. As Nussbaum reminds us, the death of one's friends can be connected with depression later in life. She draws on the Roman philosopher Cicero as her model of friendship and is critical of the Stoic view of friendship, a view that is less intimate and more self-protected. In my [End Page 196] own reflections about aging, I have found the wisdom of the ancient Greeks and Romans helpful in understanding things that I have had to address. Levmore's discussion of friendship ranges from Facebook friends to the distinction between friends and acquaintances to friendship among thieves. For Levmore, friendship requires more than just good will; it also requires good faith (trust). He discusses friendship in the language of an economist: friendship as a "medium-length insurance contract" (90). Although Cicero claims that friendship should not be an accounting system of keeping score, Levmore remarks that Cicero may be "missing the likelihood that a serious asymmetry is unlikely to be good for a friendship" (89). He ends his treatment of friendship thus: "But a good friend acts as if no one else will save the day. Friends solve collective action problems for one another" (92).
Love is the topic of the sixth pair of essays. Here, Nussbaum draws on Richard Strauss's Der Rosenkavalier, Shakespeare's Antony and Cleopatra and Romeo and Juliet, the movie The Graduate, and more recent movies highlighting "gap couples" (couples where there is a significant age disparity; Nussbaum particularly emphasizes couples where the man, in a heterosexual relationship, is younger). Like the friendship discussion earlier, this theme has a long history and has much to tell us. Levmore's contribution also discusses "gap couples," drawing on some famous individuals such as Benjamin Franklin and the various Trump pairings. He raises the more general issue of romance and rejection, which he views through the eyes of an optimistic economist, using economic language like "invest" and "mutual insurance policy" in considering friendship.
The seventh pair of essays deals with the issue of economic and social justice. The authors admit that, despite the images we may see in the media, there about 4 million of our elderly citizens who are poor. Both authors offer a response to this issue. Levmore advocates an expansion of Social Security in which the government would require forced savings (a "livable benefit") to lessen the economic hit that some people take as they age. Nussbaum appeals, as she does in some of her other writings, to the "capabilities approach" in matters of justice. The idea here is to enhance opportunities for agency and choice throughout life, but particularly, in this case, in later life. She has summarized this view nicely in her Creating Capabilities (2011), but she applies it here to the aging segment of the population.
The Missing Existential Dimension
What struck me about this volume is the fact that it reflects the standpoint of two very successful individuals who like their work, who are financially comfortable, and who apparently are in reasonably good health. Yet many older people have various medical conditions for which they see multiple physicians and take numerous medications, and this pattern will continue for the rest of their lives. For [End Page 197] many members of this population, their life has been "medicalized," a fact that plays a prominent role in their daily living. I am reminded here of Paul Ramsey's book The Patient as Person (1970), a very influential early classic in bioethics. I would alter the title a bit to characterize the predicament of many of those who are aging now and, in the process, becoming patients with very medicalized lives. Many of them have become prisoners of their medical conditions, of bodies that are in a general state of decline, of their physical environments, and, perhaps, even of those taking care of them, be they health-care professionals, family members, or others. Ramsey's book could be retitled for this group of medically dependent aged as "The Aging Patient as Prisoner."
Continuing the medicalization theme, I was also reminded of two papers by bioethicist Arthur Caplan (1992, 2017). In these two papers, Caplan views aging as a disease and sees the developments and changes associated with the aging process as "dysfunctional," in that there is a constant deterioration of cellular function. At the heart of this discussion is the notion of senescence, the process of the unraveling of cellular function over time, a process that happens whether or not one has succumbed to other diseases. It is noteworthy that Nussbaum and Levmore use terms like "retirement communities" (for the healthier aging), rather than more medicalized phrases such as "independent living," "assisted living," "skilled care," "memory care," and "rehabilitation." Because of this assumptive paradigm of healthy aging, Aging Thoughtfully provides little reference to caregivers (children or others) and the joys and tensions that can and do exist between those on each side of the care relationship. As one who oversaw the care of two parents with incurable conditions over extended periods of time (three and seven years, respectively), this is no small matter. My joys were many and my tensions few, but I don't think my experience is common, and for many the burdens far outweigh the joys.
In brief, Nussbaum and Levmore have provided us with a good read, but in a very qualified way. Like the authors, I too am an academic in my 60s (though retired) who has been lucky to have reasonably good health and in a financially sound position. Yet unlike the authors, I am keenly aware of the existential predicament of those who are aging. Many of the aging see the decline in their own bodies and minds, and—almost as bad—they see that same decline in the other people in their lives who are also aging. This often makes matters worse, as they see themselves (or future selves) when they look at these others. Conversations that were once about a variety of different things now often begin with reports of a doctor's appointment, a new prescription, a new diagnosis, a rehabilitation program, and other preoccupations related to health. The existential dimension is not the only part of aging, but for many it is an increasingly significant part. Many are becoming "patients" in the serious sense of that term, and insofar as they are, many are also becoming "prisoners," as they will often admit in reflective moments. [End Page 198]
For deeper insights into the existential side of aging, I would recommend a recent issue of the journal The Hedgehog Review, the theme of which is "The Evening of Life" (Fall 2018), and a recent Special Report from the Hastings Center, "What Makes A Good Life Late in Life: Citizenship and Justice in Aging Societies" (Berlinger, De Medeiros, and Solomon 2018). There is an important dimension to aging that comes between the matters that Nussbaum and Levmore discuss and end-of-life considerations. These are the existential parts of the process, the process of decline, that is notably absent in Nussbaum and Levmore's treatment of aging. I will say more about the different perspectives presented in these two publications later. First, however, I would like to expand the significance of this existential dimension of aging with two episodes from my own life.
Exploring the Existential Dimension
The caretaking and eventual deaths of my parents, and especially my father, John, highlight important features of this dimension. Both parents gave me consent to use the stories of their respective medical odysseys in any way I thought might help others in their medical journeys.
Around age 50, I started thinking seriously about the ups and downs of aging for the first time. My mother had just died after a three-year experience with myelodysplastic syndrome (MDS, also called "smoldering leukemia"), and I was reflecting on our family's experience with her during that time. We were extremely fortunate going through this, as she had adequate financial resources, Medicare, and a good supplementary insurance plan; good doctors; was in close proximity to all of her health-care providers and her hospital; and lived in a very accessible house, with family and friends close by. She also had what I would characterize as a "good death" in an in-house hospice facility, surrounded by some family members and a hospice volunteer. In thinking about our experience with her, I wondered how people could manage without these resources. It was clear to me that the health-care system had become bigger, more bureaucratized, and hence more confusing; the doctor-patient relationship more impersonal and businesslike; and that many patients and their families needed help navigating the health-care system.
Years later my father John, age 83, went to his primary care physician complaining of a pain in his hip. After some testing, it was determined that he had prostate cancer that had metastasized to his hip. In addition to this diagnosis, he was also being treated for other medical conditions: hypertension, atrial fibrillation, and severe spinal stenosis of his neck and upper spine. He would later be diagnosed with early stage Parkinson's. He was completely deaf in one ear (probably due to being a navigator in a B-24 bomber in World War II) and had a hearing aid for his other ear (which he used only to listen to classical music). Well before he was diagnosed with prostate cancer, he had cataract surgery in both [End Page 199] eyes, had a number of stress tests for heart/lung-related issues, and was diagnosed with an enlarged prostate (perhaps a prelude to the cancer that was to follow).
I was fortunate to live about 25 miles from him and to have a college professor's work schedule. I had also worked as a medical technician in the laboratory of a community hospital while I was a college student (at a time when one could do such things without official certification), and I had taught bioethics since the mid-1970s. The medical world, hence, was not unfamiliar to me, either firsthand or through my teaching, and I accompanied my father to virtually all of his physician appointments and appointments for medical procedures or testing. At first, it was simply by mutual understanding. Later, I had to take him, as he could no longer drive. I remember sitting with him once in the waiting room of his ophthalmologist's office for his check-up before the cataract surgery. He said something to the effect that "This is your future." The waiting room was packed, and most of the people were Medicare beneficiaries seeking treatment for cataracts, glaucoma, macular degeneration, or some other eye condition probably related to their age. My father's comment was not snide or snarky, just a matter-of-fact statement about the world into which I would soon be entering. It was said respectfully and honestly, and I have never forgotten it.
John's medical odyssey included regular visits to an internist, a cardiologist, a urologist (both before and after his cancer diagnosis), a pain specialist for the spinal stenosis, a neurologist for Parkinson's, an oncologist, and finally an orthopedic surgeon. Near the very end of his life, he had a fractured femur—a "pathological fracture" caused by the Zometa he was taking, ironically, to build bone, though his internist sent him to the orthopedic physician thinking that the pain in his leg was caused by "bursitis"! Thursdays turned out to be our day together, as most of his physicians had their office hours on Thursday afternoons and my class schedule was such that I could be off campus without any problem. We typically had one or two physician appointments on those afternoons, did his grocery shopping for the week, perhaps squeezed in a haircut, prepared dinner for that evening, and did some cleaning or some other work on the house.
After my father's cancer diagnosis, we went to well over 200 medical appointments of one kind or another. This included scheduled office visits, the Zometa treatments, which were delivered through an IV drip and scheduled at roughly three-month intervals, and later radiation therapy appointments. There were also probably about 15 emergency department visits over this period of time at various times of the day and night. A number of these were for slight to moderate dehydration, something I came to learn is common among older patients. Though he came to call me his "caregiver," I was really not in that role as it has come to be understood. I never dressed him, bathed him, nor helped him in the toilet. I was simply his son, and in some sense, his patient advocate. Fortunately, he lived in a small, three-bedroom ranch house with no stairs, a washer and dryer in the kitchen next to the sink, and good neighbors on both sides who looked out [End Page 200] after him. Every week, I brought him frozen meals that we had prepared, either leftovers from our own meals or the extra portions of our meals we made for him.
What I didn't mention about John is that he was a student in The College at the University of Chicago in the late 1940s on the GI Bill after World War II. He earned a B.Phil. and ended up working in the insurance industry in the area of property loss and fire protection. However, given his experience in the so-called "Hutchins College" (named after Robert Maynard Hutchins, the University President at that time), he developed a deep interest in and passion for the "Great Books" that were the hallmark of the Hutchins era. When he died, his personal library included over 1,800 books, though earlier in his life he had given away hundreds more to the library at the University of Chicago. John's main interests were in the history of Western philosophy, especially the ancient Greeks, political philosophy, and bioethics and health-care policy. Many of his intellectual interests overlapped with mine, though his knowledge of Plato and the other ancient philosophers greatly exceeded my own. His main interest in all of his reading was the question of the good life and the good society. Though not an academic in the professional sense of that term, in a very real sense his readings and life mirrored that of Nussbaum and Levmore's "aging thoughtfully" discussion. My father was thinking and talking about many of the issues which are at the heart of the discussion of aging by Nussbaum and Levmore, but he was doing so as a person whose life was becoming increasingly medicalized by new and worsening conditions, less energy, more frailty, Still, he was reading Plato as well as his 20th- and 21st-century commentators.
At one point, John asked if I thought that he should stay in the house that he had lived in for almost 60 years. Typically, when he sought my advice on something (medical or otherwise), I would respond by first asking him what he thought. This time, however, I simply said, "Yes." He had the things he loved most right in his living room, a room surrounded by books and hundreds of CDs of classical music. He was a very private person, not very outgoing or gregarious, kept to himself and asked very little of others, liked his own routines, and would have perceived himself as a prisoner had he been "institutionalized" in an "independent living" arrangement. Were he to have lived in one of these so-called "independent" communities, he would have lived in a more sterile environment with people his own age—some a bit younger, some a bit older—and few, if any, who would likely be able to sit and discuss the books and the music that were at the core of his life. His life would be controlled by various presumably well-intentioned individuals. But by the very fact that he would be surrounded pretty much only by people in the later stages of life, he would be forced to constantly interpret his life and his declining conditions in comparison with those with whom he was living. So-and-so now uses a cane. That person now uses a walker or a rollator. So-and-so had a stroke, surgery for prostate cancer, spine surgery, or any one of a number of maladies that come with the aging process. By contrast, [End Page 201] in his own home my father was in a neighborhood with a range of people, most of them younger than him, including a number of children of different ages. He wasn't as free as he might have liked: he had given up driving about the time of the diagnosis of the cancer, due to the severe, debilitating spinal stenosis in his neck and not being able to rely on his neck to check traffic before making a right turn on a red light.
One of my concerns about so-called "independent living" is a concern about the mental health and well-being of those who live in such environments. Having talked to a number of friends and family members who live in such communities, one of the things that they have to work at seriously and continuously is fighting the potential depression and anxiety that people can succumb to living in such environments. In my own reading and my own firsthand experiences, I have come to believe that one's mental health in the aging process is just as important as one's physical health. Depression, anxiety, suicidal ideation and actual suicide, binge-drinking, and excessive drug use and abuse can be part of the mix in getting old. When one thinks about this, it shouldn't be surprising. In addition to being topics for television reporting on aging and articles in the popular press, these mental health concerns can be found regularly in medical and gerontology journals. How could an older person not be prone to depression, anxiety, or other mental health concerns? Many of the people they have known in their lives are no longer alive, including parents, perhaps some or all of their siblings, grandparents, aunts, uncles, cousins, friends from various stages of life, former teachers, current or former co-workers and, perhaps, others. This can represent quite a substantial set of losses, resulting in the narrowing of a number of dimensions to life, dimensions that were, in a previous time, probably at or near the center of one's life. In light of these changes, it would be very difficult not to be depressed, even for one who is the least bit self-reflective. The future doesn't bode well either: the people who have died are not coming back, and many of the medical conditions that afflict one when one ages can at best be treated and managed. Few, if any, can be cured.
Others have brought to light this existential dimension to aging thoughtfully. Two books written by physicians—Nuland's The Art of Aging (2007) and Atul Gawande's Being Mortal (2014)—come to mind, as well as the recent issue of the Hedgehog Review noted earlier, which includes six articles by authors from different disciplinary perspectives, two of which deal with the decline of a parent, a mother in one case and a father in the other (McClay 2018; Ruden 2018). A recent issue of Perspectives in Biology and Medicine was devoted to the "Varieties of Aging" and contained articles covering these matters as well (Gillick 2017). Families can and do play an important role in the aging process. Children with elderly [End Page 202] parents, depending on geographic proximity and other time commitments, can accompany their elderly parents to physician appointments, prepare meals, grocery shop, do laundry, fix things around the residence, and help with financial obligations. Even those who live at a distance can participate in this process.
Ethical issues emanating from the relationship between aging parents whose life is becoming more medicalized and their families have been addressed by Hilde and James Lindemann Nelson (1995), but their concern is not simply older people with medical and health needs. Family dynamics are often complicated. Events in the past that have led to divides in families may carry over into the present. Some of these can be patched up, others not so much. Despite all of the talk about the place and importance of so-called "family values" in our society, many family situations are less than ideal. People may not be talking because of a grudge or may simply have nothing to do with one another. There may be concerns about the estate of an elderly parent or parents (which Levmore discusses), with children chomping at the bit to get at least their "fair share," if not more. Serving on the ethics committee of a local hospice in the Chicago area, my eyes have been opened to these more pernicious forms of family dynamics. Many nurses and medical social workers have told stories of family members refusing them entry to a residence to provide hospice care for one of their family members, or children stealing money and even painkilling drugs from a parent who is terminally ill. "Family values" in care of the elderly is often less than ideal, sometimes sinister, and always a complex part of the larger existential context for aging. It is regrettable that Nussbaum and Levmore have passed over these matters for a more idealized version of aging.
In the fall of 2018, the Hastings Center published a special report on aging (Berlinger, De Medeiros, and Solomon 2018). The intellectual motivation behind this volume was to look at possible connections between bioethics and the discussions and experiences of aging, primarily in the United States. The concern was that it is time for some "fresh thinking" and that bioethics should shift its concern to social justice and "good citizenship," to societal issues and not only health-care issues. The authors writing in this report come from a variety of areas, and the document is genuinely interdisciplinary. The papers provide different theoretical frameworks from which to view aging; embedded in these various frameworks are alternative ways to understand the process of aging as well as specific policy recommendations that have an ethical dimension to them. Among the frameworks presented are gerontology (including social gerontology and critical gerontology); philosophy of disability and disability studies, a framework grounded in the notion of precarity; the capabilities approach advocated by Nussbaum, Amartya Sen and others; systems theory; critical geography; architecture and design; not to mention bioethics. Of all of the frameworks presented, the ones I found most interesting were those related to questions of housing and community. Three of the papers dealt specifically with these issues: "age-friendly [End Page 203] initiatives," emphasizing spatial justice and how place plays a role in social inequalities among older people (Greenfield 2018), "co-creating environments" where elders help create the environments in which they will live (Kiyota 2018), and the idea that older adults will need a range of options in terms of housing in order to be able to pursue their conceptions of "the good life" (Molinsky and Forsyth 2018). I found this volume to be a nice blend of theory and practical implications on a number of fronts, including a paper on advance directives for people with dementia, and a reflective piece by the late Daniel Callahan (2018). Although not all of the papers in the volume emphasized the existential dimension to aging, some did so directly, others more indirectly. It seems to me that one's environment in the broadest sense of that term—from the particular place where one lives to the community in which one lives, where one experiences and lives one's life day-to-day—is a key element of "thoughtful aging," both for those who are actually living their life as an older person but also for those who are thinking about that life, personally or professionally.
In emphasizing the existential dimension of aging, I do not mean to imply that aging is simply a disease (and I don't think Caplan would subscribe to that, either); I do not mean to say that there is some "essence" to aging; nor do I think there is some set of necessary and sufficient conditions that categorize aging as a process. In fact, there are probably as many aspects to aging as there are to any other period in life: medical/health, psychological, social, financial, familial, sexual, and so forth. Still I would claim that the existential dimension is interwoven with each of these aspects, and in ways that I may have failed to appreciate when I was younger.
For many years, I taught Aristotle's ethics in my introductory ethics class. In his discussion of virtue, Aristotle remarks that one can only judge whether one is virtuous and has lived a virtuous life later in life, when one has lived more and has had more challenges and experiences. I taught this discussion of virtue many times in the classroom. It was only toward the end of my time teaching and now that I am retired that I have much more appreciation for what Aristotle was saying. I now have to look at my life and ask whether it has been lived as a virtuous person should live it. The same is true with respect to teaching bioethics (what was called "medical ethics" when I started teaching). Topics such as ethical issues at the end of life, the nature and place of palliative care and hospice, the notion of the age-based rationing of health-care resources, were, at first, topics that were primarily of intellectual interest to me. As time went on, that intellectual interest was informed more and more by reality, as increasing numbers of the people I knew were encountering medical episodes of one kind or another. As I have aged, this reality has become ever more omnipresent, particularly as I see the lives of more and more people in my inner circle becoming "medicalized." [End Page 204]
One thing that needs to be kept in mind in the entire discussion of aging thoughtfully is that aging is a process: it occurs and develops over a period of time. One of the things that would irritate my father as he aged was seeing AARP commercials on television. Though a member himself and a supporter of many of the things that the AARP does, he would cringe every time he saw one of their commercials. They always portrayed the young, healthy, active, vibrant segment of the older population which, from John's perspective, was not an even remotely accurate portrayal of his own life or the lives of anyone that he knew. These commercials were a constant reminder of how far away from this healthy, active group he was. If I look at my circle of family, friends, and acquaintances, many of whom range in age from their early 60s to almost 90, they are recipients of a number of unwanted medical conditions: hip replacements, knee replacements, bladder cancer, breast cancer, lung cancer (and, later acute respiratory distress syndrome), adult late-onset asthma, osteoporosis, stenosis of the upper spine and neck, type-2 diabetes, hypertension, high cholesterol, dental implants, loss of hearing, loss of balance, cataracts, and the list goes on. Many of the conditions which have afflicted my circle most likely would not have occurred before the age of 50, and none of these people would be candidates for a young, vibrant AARP commercial. Fortunately, no one in my circle is experiencing dementia in general or Alzheimer's in particular, but if this were so, this essay would require another separate, lengthy discussion, given the enormity of these conditions and their implications.
I, myself, am in the process of a series of medical maladies, including an implant of a new molar to replace a necrotic one and cataract surgery sometime in 2020. In my college days, I was struck by a line in a song by Bob Dylan, "It's Alright, Ma (I'm Only Bleeding)." It caught my attention then, and it still resonates with me, though its existential impact is much different and much harsher: "He not busy being born is busy dying."