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REFERENCES

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ARNOLD, R. M., YOUNGNER, S. J., SCHAPIRO, R., and SPICER, C. M. (eds.) (1995), Procuring Organs for Transplant: The Debate Over Non-Heart-Beating Cadaver Protocols

(Baltimore: JHUP).

BARTLETT, E. T. (1995), ‘Differences Between Death and Dying’, Journal of Medical Ethics, 21: 270 – 6.

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BERNAT, J. L. (1998), ‘A Defense of the Whole-Brain Concept of Death’, Hastings Center Report, 28/2: 14 – 23.

CULVER, C. M., and GERT, B. (1981), ‘On the Definition and Criterion of Death’,

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CAMPBELL, C. S. (1999), ‘Fundamentals of Life and Death: Christian Fundamentalism and Medical Science’, in S. Youngner, R. Arnold, and R. Schapiro (eds.), The Definition of Death: Contemporary Controversies (Baltimore: JHUP), 194 – 209.

COLE, D. J. (1993), ‘Statutory Definitions of Death and the Management of Terminally Ill Patients Who May Become Organ Donors After Death’, Kennedy Institute of Ethics Journal, 3: 145 – 55.

GERVAIS, K. G. (1986), Redefining Death (New Haven: Yale University Press).

LAMB, D. (1992), ‘Reversibility and Death: A Reply to David J. Cole’, Journal of Medical Ethics, 18: 31 – 3.

LOCK, M. (2002), Twice Dead: Organ Transplants and the Reinvention of Death (Berkeley: University of California Press).

LYNN, J., and CRANFORD, R. (1999), ‘The Persisting Perplexities in the Determination of Death’, in S. Youngner, R. Arnold, and R. Schapiro (eds.), The Definition of Death: Contemporary Controversies (Baltimore: JHUP), 101 – 14.

MAYO, D., and WIKLER, D. (1979), ‘Euthanasia and the Transition from Life to Death’, in W. L. Robinson and M. S. Pritchard (eds.), Medical Responsibility: Paternalism, Informed Consent, and Euthanasia (Clifton, NJ: Humana Press), 195 – 211.

PRESIDENT’S COMMISSION FOR THE STUDY OF ETHICAL PROBLEMS IN MEDICINE AND BIOMEDICAL AND BEHAVIORAL RESEARCH (1981) Defining Death (Washington, DC: US Government Printing Office).

RIX, B. A. (1999), ‘Brain Death, Ethics, and Politics in Denmark’, in S. Youngner, R. Arnold, and R. Schapiro (eds.), The Definition of Death: Contemporary Controversies (Baltimore: JHUP), 227 – 38.

SCHONE¨ -SEIFERT, B. (1999), ‘Defining Death in Germany: Brain Death and Its Discontents’, in S. Youngner, R. Arnold, and R. Schapiro (eds.), The Definition of Death: Contemporary Controversies (Baltimore: JHUP), 257 – 71.

SHEWMON, A. (2004), ‘The Dead Donor Rule: Lessons from Linguistics’, Kennedy Institute of Ethics Journal, 14: 277 – 300.

SIMINOFF, L., BURANT, C., and YOUNGNER, S. J. (2004), ‘Death and Organ Procurement: Public Beliefs and Attitudes’, Social Science in Medicine, 59: 2325 – 34.

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TOMLINSON, R. (1993), ‘The Irreversibility of Death: Reply to Cole’, Kennedy Institute of Ethics Journal, 3: 157 – 65.

YOUNGNER, S. J., LANDEFELD, C. S., COULTON, C. J., et al. (1989), ‘Brain Death and Organ Retrieval: A Cross-Sectional Survey of Knowledge and Concepts Among Health Professionals’, JAMA 261: 2205 – 10.

ARNOLD, R. M., and DEVITA, M. A. (1999), ‘When Is Dead?’, Hastings Center Report, 29: 14 – 21.

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S T E P H E N G . P O S T

OF the many topics worthy of discussion regarding older adults and bioethics, two seem to provide an especially pointed opportunity for reflection on our aging society. First, is aging itself something that biomedical researchers should focus on as a deficit to be overcome through eventual anti-aging treatments? While aging may not fall neatly into the disease category, it is clearly the primary susceptibility factor for the innumerable diseases of older adults, and therefore its potential deceleration consistent with the compression of morbidity might constitute a salutary biomedical goal. The aging society is no panacea to those who suffer from a host of chronic illnesses and feel overwhelmed by the burden of years. Perhaps we must now take scientific steps that may allow an escape from widespread frailty and senility, or such costly demographics will drive us toward inordinate filial,

economic, and social responsibilities. Such thoughts raise broad questions about endeavors to modify human nature along ‘posthumanist’ lines. Second, we must concentrate on the most challenging problematic of our current aging society, assuming that anti-aging technologies will only become available in future decades. One immense problem is the harsh reality of irreversible progressive dementia, which will serve here as an example of the rise of chronic illness, for which age itself is the primary risk factor. While this second focus overlooks the many older adults who age well and are functional until their final days, these examples of ‘successful aging’ pose no unique issues worthy of special bioethical consideration. And so this chapter is framed around the more unfortunate realities of an aging society, and the related question of whether we ought to strive to ameliorate these realities by developing anti-aging interventions.

DECELERATE D AGI NG AND

T HE AME LI ORAT I ON OF AGE-RE L ATE D

DIS EASE

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The possibility for significant deceleration of human aging can be ethically assessed in a variety of frameworks. The outcome of this assessment is a direct result of the ethical theory and assumptions that disparate camps bring to the debate. Two theories that currently shape a rather acrimonious discussion are natural law and equalitarianism, each of which presents a deeply critical perspective on the goal of prolongevity. Yet despite valid natural law cautions that human goods are violated by anti-aging goals, and meaningful equalitarian concerns that anti-aging treatments would create immense class disparities, there is one extremely powerful ethical argument that may outweigh such criticisms: i.e. the principle of beneficence, which supports the deceleration of aging so long as this significantly diminishes the onset of the many chronic diseases for which aging is the primary risk factor. This assumes that the deceleration of aging will achieve this purpose, rather than the harmful protraction of decrepitude.

Ethical theories do have consequences. A resurgence of natural law ethics, which asserts the goodness of human nature and aging as we know it, has of late given rise to a significant set of criticisms of the goal of prolongevity, in particular through the work of Leon R. Kass and the President’s Council on Bioethics, for which he serves as chair. The equalitarians, on the other hand, do not engage in the moralization of human nature as we know it, but nevertheless cannot support the goal of prolongevity until the vast inequalities that currently plague the world — including access to basic healthcare — are corrected. These are both important frameworks for critique of decelerated aging, should this ever become possible.

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At first glance, however, it is difficult to see why the deceleration of human aging presents a major ethical concern. There are four reasons for this.

1.Aging may not be a ‘disease’ by most definitions, but it is the major risk factor for innumerable diseases of old age, and is therefore so closely associated with disease that it is not completely implausible to think of it as such.

2.While the concept of ‘aging as disease’ might be thought to reinforce existing stereotypes of older adults, and so contribute to ‘ageism’, there is no logical connection between ‘anti-aging’ research and prejudice. The goal of prolongevity through deceleration of aging has the more obvious inclusive aspect of making old age more enjoyable and acceptable by mitigating the frailties and infirmities that make the increase of years unwelcome.

3.The goal of decelerated aging and prolongevity does not obviously violate the ethical principle of nonmaleficence. Unlike abortion, infanticide, suicide, and euthanasia, the goal of prolongevity does not violate respect for, or sanctity of, life. It is difficult to see how the addition of healthy years to old age could be anything but ‘pro-life’. While moral criticism of therapeutic stem cell cloning is based on the unavoidable destruction of embryos in the process of procuring stem cell lines, there is no such destruction associated with prolongevity.

4.The goal of longer and healthier lives is hardly new and we have been acculturated to it. Life expectancy has risen dramatically over the past two centuries and has been embraced as progress. Public health, sanitation, reduction of infant mortality, antibiotics, and many other factors have contributed to our current level of prolongevity, which some might have deemed an ‘unnatural’ goal a century or more ago. In other words, the genie is in many respects already out of the bottle. This progress in life expectancy might be hampered by sedentary lifestyles, fast foods, obesity, and related diabetes, all of which are viewed as public health problems to be overcome.

And yet deeply thoughtful bioethicists are concerned with the implications of anti-aging research and related prolongevity. Kass prepared a discussion paper for members of the Council on Bioethics prior to their meeting on 16 – 17 January 2003. Entitled ‘Beyond Therapy: Biotechnology and the Pursuit of Human Development’, it established the Council’s future agenda (Kass 2003).

Biogerontologists, one of whom is with the National Institute on Aging, can embrace the ideas of ‘The Serious Search for an Anti-Aging Pill’ that would mimic the effects of caloric restriction as an approach to the eradication of disease (Lane et al. 2002). Aging is the prominent risk factor for so many diseases, and the best way to prevent such debilitation is to alleviate aging. The removal of this risk is not obviously contrary to human dignity. In fact, we would all agree that removing the major risk factor for diseases such as Alzheimer’s or osteoporosis would do quite a bit for the preservation of human dignity, for the control of health care costs,

and for the alleviation of sometimes overwhelming adult filial duties. Still, Kass’s natural law ethics are to be taken seriously, a topic to which attention now turns.

Natural Law Criticisms

Natural law places moral value on human nature as we know it, and represents a necessary reaction to post-humanism. One reason why natural law, a form of anti-posthumanism, has an immediate appeal is because many of the major defenders of posthumanism are rather cavalier (see e.g. www.betterhumans.com; www.transhumanism.org; www.foresight.org). Websites reflect the enthusiasm of the young convert to some new image of the human future that is liberated from biological constraints but lacking in wisdom. More reverence for human nature and aging itself as the product of millions of years of evolutionary selection would be the necessary corrective, and this is just what natural law theorists offer.

The posthumanist embraces decelerated and even arrested aging, but only as a small part of a larger vision to re-engineer human nature, and thereby to create biologically and technologically superior human beings (Hayles 1999). Posthumans are the much more advanced models that we humans today will design for tomorrow, not unlike new models of automobiles. Genetics, nanotechnology, cybernetics, and computer technologies are all part of the posthuman vision, including the downloading of synaptic connections in the brain to form a computerized human mind freed of mortal flesh, and thereby immortalized. Posthumanists do not take biology to be destiny, and see human nature as an obstacle to be overcome (Hook 2004). They see the next great step in evolution as our own re-creation by human ingenuity.

The posthumanist may be irreverent of human nature, but within the boundaries of the technology of the day, humans have been reinventing themselves anyway for millennia. And what is natural and what is unnatural, when the human condition has already been so deeply impacted by technological innovation? Where do we draw lines? As Freeman Dyson writes, ‘the artificial improvement of human beings will come, one way or another, whether we like it or not’, as scientific understanding increases, for after all, such improvement has always been viewed as a ‘liberation from past constraints’ (1997: 12). After all, the idea of human flight was once deemed heretical hubris in the light of eternity and nature. So it is that Gregory Stock writes a book entitled Redesigning Humans: Our Inevitable Genetic Future, in which he introduces the idea of ‘superbiology’ as we take full control of our own biology in turning toward perfectibility (2002).

Thus did George Bernard Shaw, in his remarkable Back to Methuselah (1921), take up the variations in lifespans between species such as parrots and dogs, or turtles and wasps, and ask that science rise to the redemptive occasion by vastly increasing human longevity. Indeed, Francis Bacon, a founder of the scientific

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method four centuries ago, in his essay The New Atlantis (1996), set in motion a biological mandate for boldness that included both the making of new species, or ‘chimeras’, organ replacement, and the ‘Water of Paradise’ that would allow the possibility to ‘indeed live very long’. Three centuries before Francis Bacon the English theologian Roger Bacon argued that in the future the 900-year-long lives of the antediluvian patriarchs would be restored alchemically. Like many Western religious thinkers, both Bacons saw death as the unnatural result of Adamic fall into sin. These Western dreams of embodied near-immortality could only emerge against a theological background that more or less endorses them.

The modern goals of anti-aging research and technology are historically emergent from a pre-modern religious drama of hope and salvation. Longings for immortality within a religious context are understandable in light of existential anxiety over finitude and mortality, and the goal of prolongevity may be — at least historically — shaped by such passions. Renaissance science transferred the task of achieving immortality from heaven to earth in the spirit of millennial hopes. The economy of salvation presented by Dante was replaced by the here and now. There is a vibrant millennialist optimism in the responsible biogerontologists, for they have proclaimed aging itself to be surmountable to degrees through human ingenuity.

At the end of The New Atlantis, Bacon lists more specifically among the goals of science ‘the retardation of age’, which is taken with great seriousness by today’s biogerontologists who create scientific breakthroughs with fruit flies, roundworms, rodents, and monkeys, but with an eye toward the alleviation of senility in an already aging society plagued by chronic age-related diseases.

But the natural law theorists attempt to stem such rash tides. One of the wiser minds of the last century, Hans Jonas (d. 1993), an intellectual inspiration for today’s natural law anti-posthumanists, first articulated deep questions about the prolongevity agenda. How desirable would this power to slow or arrest aging be for the individual and for the species? Do we want to tamper with the delicate biological balance of death and procreation, and preempt the place of youth? Would the species gain or lose? Jonas, by merely raising these questions, meant to cast significant doubt on the anti-aging enterprise. His later essays raising many of these same questions were published posthumously (1996).

Many of these questions are echoed in the writings of Kass, who for the most part accepts biotechnological progress within a therapeutic mode; his issue is with efforts to enhance and improve upon the givens of human nature.

There is arguably a tone of solipsism in grasping at extended life rather than accepting old age and celebrating youth in the lives of our offspring. Responsibility to future generations precludes a clinging to our own youthfulness. There is wisdom in simply accepting the fact that we evolved for reproductive success rather than for long-lived lives. Without such wisdom will we lose sight of our deepest creative

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aging societies is that, factoring out infant mortality, people can expect to live into their eighties. Many will experience chronic illness for which old age is the dominant risk factor, ranging from Alzheimer’s and Parkinson’s to osteoporosis and vascular disease. Our demographic transition to greatly increased life expectancy through means that do not involve the deceleration of aging has resulted in a scenario that is clearly not idyllic, and the solution may rest with advances in the basic science of aging that would achieve even greater prolongevity but without the perils of massive debilitation. In other words, to resolve the problems of senility and dementia, brought on chiefly by enhanced life expectancy absent anti-aging interventions, we must now develop those interventions or suffer the immense negative consequences.

Among those consequences are future generations of young people extremely burdened with the direct and indirect support of tens of millions of citizens who require demanding, complex, constant, and expensive care.

When one considers the goal of decelerated aging in this context, it begins to appear more rational, salutary, and necessary. No longer the bizarre dream of superficial technology zealots, decelerated aging appears to be a more reasonable aspiration. Indeed, the biogerontologists hard at work in serious research are much less the children of posthumanism than they are of a will to benefit a common humanity regrettably caught between the old world of relatively short and ‘natural’ life expectancy and the future world of the nonfrail and nonsenile.

So, the individual confronted with the possibility of decelerating his or her aging process may not ask the question of the dignity of human nature as we know it, or of whether we humans are wise enough to control our future development, or of equalitarian justice. Instead, he or she may reflect on loved ones who have struggled with a syndrome that strips away memory and self-identity, such as dementia, and quickly declare that his or her true dignity lies in decelerated aging consistent with the retention of cognitive temporal glue between past, present, and future.

It may well be that the only real progress we will see in ridding the world of such debilitating diseases as Alzheimer’s is through slowing the process of aging because old age is by far the most significant risk factor. Currently there is no reason for strong optimism about scientific breakthroughs to cure this disease, or to stabilize symptoms in the long term, although there are some compounds in use to ameliorate some symptoms for a limited period. Thus, basic scientific advances in the area of aging itself could, if successful, significantly reduce the incidence of diseases associated with old age that are too complex to be solved on their own terms. It is, then, unfair to responsible anti-aging researchers to suggest that they are engaged in an effort that will only radically protract the lives of the most deeply forgetful. Maybe greatly enhanced prolongevity is not all bad if a number of conditions can be met regarding preserved memory and other dimensions of health and rigor. It might also be that, given the realities of the old age boom, anti-aging research will prove curative where all else has failed.

Will anti-aging researchers provide the solution? Two respected researchers from the University of London conclude in Nature that ultimately we will find the human lifespan to be quite plastic, and scientific progress in this area ‘may allow us to reduce the impact of ageing-related diseases as the limits on the human lifespan recede’ (Partridge and Gems 2002: 921).

While I share natural law concerns over the unleashed powers of biotechnology to influence what increasingly appears to be a somewhat malleable human nature, and while I too cringe at immature millennialist enthusiasm over the remaking of the species, I nevertheless can appreciate the goal of eradicating our modern epidemic of chronic illness, which grows more extensive and costly with every elevation in average life expectancy.

Indeed, it is because of the potential positive health consequences of anti-aging treatments that they will probably not be easily restrained in the name of natural law or equalitarianism. It may well be that, in the process of decelerating aging with the intent of ameliorating chronic diseases, the human lifespan will be extended. We do not have much choice but to move forward. The goal of prolongevity is rooted in the reality of the 80-year-old who has struggled with hip replacements, a diagnosis of dementia, retinopathy, and related depression. Perhaps Kass is correct that under conditions of prolongevity many of us would lose interest and engagement in life, seriousness and aspiration, and virtue and moral excellence centered on a generative relationship with the young. Yet more surely, a potential solution to the widespread problem of the death of the mind before the death of the body may rest with the anti-aging technologies of the future, and we must at least seriously grapple with this important and very real problem.

A number of scientists convened in 1999, under the auspices of the National Institute on Aging, for a conference entitled Caloric Restriction’s Effects on Aging: Opportunities for Research on Human Implications, where they charted a bold new therapeutic research agenda focused on slowing or ‘retarding’ the aging process, which implies the extension of the lifespan (Masoro 2001). The driving motivations expressed, however, were focused on slowing aging in order to prevent the many diseases for which old age puts people at risk. This scholarly meeting sparked no significant public debate, although few things could be more deserving of critical reflection on human aspirations than this. A principal topic was the research to develop a treatment to prolong life and youthful vigor through imitating the remarkable effects of caloric restriction, which for more than sixty years has been documented for its dramatic ability to slow aging in nonhuman mammals and significantly extend their lifespans.

More research on the basic science of aging will hopefully give rise to the ability to decelerate this natural process. People will be attracted to this technology because they know how burdensome are the diseases to which old age makes us all susceptible. Should they wish to select this medical option, as a way of insuring a better quality of life for themselves and for those loved ones who would otherwise