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ALZHEIMER’S DISEASE ASSOCIATION (2001), Ethical Issues in Alzheimer’s Disease (Chicago: Alzheimer Disease Association).

BACON, F. (1996), The New Atlantis, in Francis Bacon: A Critical Edition of the Major Works, ed. B. Vickers (Oxford: Oxford University Press), 457 – 89.

DYSON, F. J. (1997), Imagined Worlds (Cambridge, Mass.: Harvard University Press). FINUCANE, T. E., CHRISTMAS, C., and TRAVIS, K. (1999), ‘Tube Feeding in Patients with

Advanced Dementia: A Review of the Evidence’, JAMA 282: 1365 – 70. FIRLIK, A. D. (1991), ‘Margo’s Logo’, JAMA 265: 201.

GAUDERER, M. (1999), ‘Twenty Years of Percutaneous Endoscopic Gastrostomy: Origin and Evolution of a Concept and Its Expanded Applications’, Gastrointestinal Endoscopy, 50: 879 – 82.

and PONSKY, J. L. (1981), ‘A Simplified Technique for Constructing a Tube Feeding Gastrostomy’, Surgery in Gynecology and Obstetrics, 152: 83 – 5.

GILLICK, M. R. (2000), ‘Rethinking the Role of Tube Feeding in Patients with Advanced Dementia’, New England Journal of Medicine, 342/3: 206 – 10.

GJERDINGEN, D. K., NEFF, J. A., WANG, M., and CHALONER, K. (1999), ‘Older Persons’ Opinions About Life-Sustaining Procedures in the Face of Dementia’, Archives of Family Medicine, 8: 421 – 5.

HAYLES, N. K. (1999), How We Become Posthuman: Virtual Bodies in Cybernetics, Literature and Informatics (Chicago: University of Chicago Press).

HOOK, C. C. (2004), ‘Transhumanism and Posthumanism’, in S. G. Post (ed.), The Encyclopedia of Bioethics, 3rd edn., 5 vols. (New York: Macmillan Reference).

JONAS, H. (1985), The Imperative of Responsibility: In Search of an Ethics for the Technological Age (Chicago: University of Chicago Press).

(1996), Mortality and Morality: A Search for the Good After Auschwitz (Evanston, Ill.: Northwestern University Press).

JUENGST, E. T., BINSTOCK, R. H., MEHLMAN, M., and POST, S. G. (2003), ‘The Social Implications of Genuine Anti-Aging Interventions: The Need for Public Dialogue’, Science, 299: 1323.

KASS, L. R. (2003), ‘Beyond Therapy: Biotechnology and the Pursuit of Human Development’, <http://www.bioethics.gov/material/kasspaper.html 2003>, accessed 12 Mar. 2003.

KITWOOD, T. (1997), Dementia Reconsidered: The Person Comes First (Buckingham: Open University Press).

LANE, M. A., INGRAM, D. K., and ROTH, G. S. (2002), ‘The Serious Search for an Anti-Aging Pill’, Scientific American, 287: 36 – 41.

MACINTYRE, A. (1999), Dependent Rational Animals: Why Human Beings Need the Virtues

(Chicago: Open Court).

MASORO, E. J. (2001), Caloric Restriction’s Effects on Aging: Opportunities for Research on Human Implications, Journal of Gerontology, ser. a, 56a, special issue 1.

NIEBUHR, R. (1956), An Interpretation of Christian Ethics (New York: Meridian).

PARTRIDGE, L., and GEMS, D. (2002), ‘A Lethal Side-Effect’, Nature, 418: 921.

POST, S. G. (2000), The Moral Challenge of Alzheimer Disease: Ethical Issues from Diagnosis to Dying, 2nd edn. (Baltimore: Johns Hopkins University Press).

(2001), ‘Tube-Feeding and Advanced Progressive Dementia’, Hastings Center Report, 31/1: 36 – 42.

et al. (1997), ‘The Clinical Introduction of Genetic Testing for Alzheimer Disease: An Ethical Perspective’, JAMA 277/10: 832 – 6.

RUDMAN, S. (1997), Concepts of Persons and Christian Ethics (Cambridge: Cambridge University Press).

SABAT, S. R. (2001), The Experience of Alzheimer’s Disease: Life Through a Tangled Veil

(Oxford: Blackwell).

SINGER, P. (1993), Practical Ethics (Cambridge: Cambridge University Press).

STOCK, G. (2002), Redesigning Humans: Our Inevitable Genetic Future (Boston: Houghton Mifflin).

US GENERAL ACCOUNTING OFfiCE (1998), Alzheimer’s Disease: Estimates of Prevalence in the U.S., HEHS-98 – 16 (Washington, DC: GAO, 28 Jan.).

VOLICER, L., and HURLEY, A. (eds.) (1998), Hospice Care for Patients with Advanced Progressive Dementia (New York: Springer).

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My hospice room is rose and blue.

The blue is like the sky.

They think that if you’re happy here,

You’ll be content to die.

They proffer comfort, warmth, and peace,

All shining like the sun.

They strive to meet your every need.

They meet all needs but one.

So now I have another scheme,

I thank James Dreier, Sara Ann Ketchum, Christine Overall, and Bonnie Steinbock for extremely helpful discussions; James Dreier, David Estlund, and Bonnie Steinbock for extremely useful advice about background reading; Antonio Ramirez for extremely adept research assistance; and Zelda Sondack Ackerman, soon to embark on her second century, for extremely sharp-eyed proofreading.

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My object all sublime.

I’ve gotten on a transplant list, And so I bide my time.

(Ackerman 2005b)1

GRADUATE students in my department run a weblog that has solicited suggestions for ‘the worst philosophical position ever’ (Ichikawa 2004). When I suggested the position that ‘illness and mortality are good things [and] it is bad to do research on extending the human life span’,2 Jonathan Ichikawa wrote, ‘Do philosophers really hold [that view]? I find that so absurd that I have a hard time imagining anyone seriously thinking otherwise.’ I replied by citing the most powerful bioethicist in America, Leon Kass, then head of the President’s Council on Bioethics, whom the New York Times Book Review described as ‘among the most respected authorities in the field’ (Nuland 2002: 49).3 Kass has said that ‘the finitude of human life is a blessing for every human individual, whether he knows it or not’ (Kass 2002: 264). He also opposes attempts to extend the maximum human lifespan, i.e. ‘the outer limit of human longevity’ (Overall 2003: 7), which ‘has remained more or less fixed at about 120’ (Overall 2003: 10). This chapter will argue that Ichikawa’s common-sense intuition is basically right. The achievement of greatly extended human life and even (or especially) immortality would be like the discovery of electricity. It would bring many problems and dislocations and would even do some people more harm than good, but overall it would be an enormous boon to humanity.

Like other secular philosophers who write on this topic, I will assume there is no afterlife and hence that death is ‘the unequivocal and permanent end of our existence’ (Nagel 1979: 1). Except where indicated, I use ‘immortality’ to mean earthly immortality rather than immortality in a religious sense. This assumption accords with what I believe, but my reason for making it here is to delimit the scope of this chapter. It is hardly surprising that, after seeing ‘a part of the adventures of the [Holy Grail]’, Sir Galahad ‘fell in his prayer long time to Our Lord, that at what time he asked, that he should pass out of this world’, because of the ‘great

I dedicate this chapter to my mother, Zelda Sondack Ackerman (b. 1912), in anticipation of a time when nonagenarians will have most of their lives ahead of them.

The chapter title comes from the following letter of mine in the Arts and Leisure Section of the New York Times (Ackerman 2002). ‘William Hurt, a star of the film ‘‘Tuck Everlasting’’, is quoted as saying, ‘‘Most people think of life as the story of life and death. Death is a bookend. If you take that bookend away, what have you got?’’ This is typical of attempts to sugar-coat death. Here’s an alternative metaphor: Death is a punch in the jaw. Take away the punch and what have you got? An [unpunched] jaw.’

1 Also see ‘Flourish Your Heart in This World’ (Ackerman 1998b) and n. 10 below. ( This poem first appeared in Ragged Edge Online and is reprinted by permission.)

2 I actually wrote ‘so’ rather than ‘and’, but that was a poor formulation.

3 Many assessments of Kass are more critical, however. For example, see Mooney (2001) and McGee (2003). Even Nuland’s largely admiring review expresses reservations, acknowledging that ‘most [readers] will . . . recognize the need for [more] flexibility’ (Nuland 2002: 49) than Kass offers.

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the morbid phase of our lives’ (Gems 2003a: 34) should be assessed in light of the fact that many seriously ill people find the ‘morbid phase’ of their lives well worth prolonging. ‘Study after study has concluded that many healthy people often say they would never want to die in an intensive care unit, but may change their minds when they are very sick’ (Kolata 1997). One study found that ‘The majority of [a group of 244 patients with various serious illnesses] wanted to receive a life-sustaining treatment if it would prolong life for any length of time’ (Danis et al. 1996: 1813). Another study, emphasizing the disparity of values between the healthy and the ill, found that ‘Patients with cancer are much more likely to opt for radical treatment [a grueling course of chemotherapy] with minimal chance of [cure or if it offers as little as three months of life-prolongation] than people who do not have cancer, including medical and nursing professionals’ and also including healthy controls matched with patients for ‘age and sex, as well as for occupation and hence educational and social class’ (Slevin et al. 1990: 1458, 1460), i.e. a control group selected to represent the attitudes of the patients before they had cancer. And a study of patients with end-stage kidney disease concluded that ‘chronically ill people cherish their lives, despite the appearance [to outsiders] of inadequate quality’ (Gutman 1988: 899).

Here it is crucial to recognize that expertise lies with the patients. They have first-hand knowledge of what it is like to be seriously ill. So their desire to extend the ‘morbid phase’ of their lives seems prima facie rational. This point will resurface in my discussion of resource allocation. For the present, note that even Overall — who perceptively warns against assuming that ‘life with chronic health problems or disabilities is not worth living’, and stresses that decisions about ‘the minimum conditions of quality of life that make existence worth sustaining’ should be made by competent patients, ‘not their families and not their health-care providers’ — says, ‘If the available medical, social, and material resources are so limited that one’s extra stretch of time is lived in misery, then that is a problem, and no prolongevist advocates the extension of human life if it can be lived only in poverty, pain, and ill health’ (2003: 188, 191, 192, 41; italics added).7 She is mistaken. I advocate this (for people who desire it). Of course, I believe that wealth, comfort, and good health are better than poverty, pain, and ill health. But the blanket presumption that the latter states bring ‘misery’ that is worse than death is disrespectful to those who, having experienced them, disagree. (Perhaps they disagree because they have found that these states, far from entailing living in misery, do not preclude such pleasures as love, friendship, television, music, reading, and thinking.) Thus, the popular phrase ‘compression of morbidity’, i.e. ‘reduction of . . . the end-of-life morbidity characteristic of old age’

7 Elsewhere in her book she offers the more moderate formulation ‘Prolongevists . . . advocate the extension of life only if it will not involve the severe illness, unrelieved pain, or disablement that undermine an individual’s capacity to pursue his or her life’s projects’ (Overall 2003: 65 – 6; italics added). This formulation is more respectful of individual differences in values. Also see Overall (2003: 96).

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(Battin 1987: 328), glosses over the difference between curing a sick person and denying him treatment that would extend his ‘morbid’ life.8 And Overall’s claim that ‘medical treatments that . . . extend an end-state of suffering, extreme dementia, or relentless deterioration must be recognized as pointless or even, at worst, as harmful’ (2003: 190; italics added) conflicts with her above-quoted views about patient self-determination, given that some competent people choose ‘relentless deterioration’ over death.

This consideration is particularly important in view of some ideas behind the conventional wisdom about when life is worth prolonging. Thus, M. Pabst Battin identifies ‘increasing debility, dependence . . . loss of communication and affection . . . isolation’ as part of an ‘unfortunately realistic picture of old age’ constituting ‘human degradation’ that can lead to a sick old person’s ‘increasingly poor self-image’ and desire to die (1980: 274). By contrast, other philosophers, such as Susan Wendell, question independence as an ideal, pointing out that no one is completely independent and that ‘ ‘‘independence’’ . . . is defined according to a society’s expectations about what people ‘‘normally’’ do for themselves and how they do it’ (Wendell 1996: 145). Overall says, ‘There are varying patterns of dependence throughout the life span’ and ‘to the extent that [old people] are dependent, their dependence should not be interpreted as evidence that increased longevity is bad’ (2003: 188). Such views are more logical as well as more humane than the view that ‘dependence’ is characteristic of only some people’s lives or is inherently degrading.

Three more points are worth noting here. First, the ‘increasingly poor self-image’ of the old, ill, and disabled, like the poor self-image some blacks may have in a racist society, arises ‘from the low value . . . society places on people of a certain sort, rather than from anything inherent in the person’s condition’ (Ackerman 1998a: 151 – 2). Second, present-day society over a quarter-century after Battin’s article appeared, offers the old, ill, and disabled a new opportunity to bypass ageism and ableism and to overcome isolation ‘in a better world, where there is neither young nor old, healthy nor crippled . . . On the Internet’ (Ackerman 2005c: 43)9 or in online relationships with people who have chosen to identify themselves online as old, ill, and/or disabled. Third, I am not claiming that all sick people want to extend their lives even if they cannot be cured, just that many bioethicists have shortchanged those who do.

Overgeneralization is hardly rare in discussions of whether greatly extended life would benefit the person living it. For example, Kass, whose opposition to attempts to extend the maximum human lifespan rests partly on his ad hominem ‘For most of us . . . the desire to prolong the lifespan (even modestly) must be seen as expressing a desire never to grow old and die’,10 suggests the following ‘virtues of mortality’:

8 See the discussion in Battin (1987: 328 – 36).

9 This reference is to a short story about a crippled old woman who does just that.

10 See also President’s Council on Bioethics (2003a: 162, 186). For a dissenting view, see Blackburn and Rowley (2004: 0420). (Of course, I also reject Kass’s view that there is something wrong with a

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A world of immortals, though, would be scientifically advanced way beyond our present level. Why couldn’t we imagine such continued human development?16

Overall further objects that in such a scenario we would have godlike abilities and hence not be living a ‘recognizably human life’ (2003: 173). And Kass holds that ‘to argue that human life would be better without death is . . . to argue that human life would be better being something other than human’ (2002: 265). This makes me wonder what people in the time of Sir Thomas Malory (the fifteenth century) would have said about beings who went to the moon, received new hearts, talked with others thousands of miles away, and held it to be self-evident that all men are created equal. Progress means change.17 Why shouldn’t scientific progress cause people to have characteristics previously deemed beyond human possibility? Why should we be ‘defining humans in terms of our limitations rather than by our ability to supersede our limitations’ (Kurzweil 2005: 67)? Consider also Nagel’s apt observation ‘A man’s sense of his own experience . . . does not embody [an] idea of a natural limit. His existence defines for him an essentially open-ended possible future’ (1979: 9 – 10).

Two further points are important here. First, since I am assuming that immortality would be optional and reversible, people who found their greatly extended lives unsatisfactory would be as free to commit suicide as are people in our world. Although some who long for death might have scruples against suicide just as some do in our world, there could be an equivalent of ‘passive euthanasia’, where immortality would be maintained by a substance that people could simply choose to stop taking.18 Second, even in cases where Kass is right that eternal life brings diminishing returns, the real question is not whether this extra life is as fulfilling as the early part, but whether it is better than nothing. If boredom is taken to be a reason against immortality, see how high the bar for acceptable quality of life has been raised. ‘Bored to death’ is a figure of speech. How many people deem boredom a fate literally worse than death?19 Overall considers the possibility that the boredom could be so extreme as to make ‘the experience of immortality . . . analogous to the experience of severe insomnia, in which, having been awake for seemingly endless hours without respite, one feels tired of being awake and exhausted by being oneself and wants only the nothingness of unconsciousness that is afforded, temporarily, by deep sleep’ (2003: 145). This certainly does not correspond to my own experience of severe insomnia, which has led me to long for sleep not as a temporary escape from consciousness but as a means to an improved state of consciousness upon awakening. Moreover, the unpleasant state of intense physical exhaustion, which frequently accompanies severe insomnia, seems less characteristic of boredom.

Kass’s other ‘virtues of mortality’ are equally problematic. He asks, ‘Could life be serious or meaningful without the limit of mortality?’ and cites the Greek gods as living ‘shallow and rather frivolous lives’ (Kass 2002: 266). But he himself admits