oxford handbook of bioethics

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Another potential problem involves overpopulation. Here it is important to distinguish greatly extended but finite longevity from immortality. I will consider the former case first. Peter Singer suggests that if an anti-aging drug doubled the human lifespan in a world unable to support an increased population, an increase could be avoided ‘by persuading people to have fewer children, and that one of the means of achieving this is by persuading them to start their families later — say, only when they reach about 50, rather than when they reach about 25, as they do now’ (Singer 1991: 138). He adds that, in the scenario he is envisioning, the drug will make this biologically possible. Note that although population increase can be avoided if people have fewer children, it can also be avoided if people have the same number of children but have them later in life, thereby preventing increased longevity from increasing overlap between generations. This point is especially important if instead of considering Singer’s hypothetical doubled human lifespan, we consider a finite lifespan that is multiplied tenfold or more. People who live to be 800 can, without risking overpopulation, have as many children as we do — provided that their reproductive period occurs no farther from the end of their lives than our reproductive period occurs from the end of our lives.

Would this harm society or the human species? Obviously, much depends on what these long-lived people would be like. Singer, asking ‘how . . . to quantify the benefits of the freshness of youth as against the benefits of the wisdom of accumulated experience’, reasonably replies that ‘we do not know’ (1991: 138). I also doubt we know that the ‘freshness of youth’ and ‘wisdom of accumulated experience’ are actualities rather than simplistic cultural stereotypes on a par with women’s altruism or blacks’ sense of rhythm.

One of Singer’s main concerns is that in his scenario fewer people would come to exist over the course of, say, a century. He rejects the intuitively plausible objection that we should take no account of the interests of ‘those who might have existed, if we had not opted for the anti-aging drug’ (Singer 1991: 144). His reason for this rejection involves imagining our adopting the following strategy in response to the moral imperative of not condemning future generations to a life unsustainable by our planet’s remaining resources. Suppose we all decide to avert ecological disaster for future generations by ensuring there will be no future generations; i.e. suppose we all decide to refrain from reproducing and to enjoy a fling as the last generation on earth. Singer comments, ‘Those who refuse to take into account the interests of merely possible people seem committed to saying that this would be right’ (1991: 144). This seems mistaken. Holding that the end of human life and human civilization would be catastrophic does not entail locating the catastrophe in the violation of the interests of merely possible people. Consider the following three scenarios: (1) the ‘last generation’ scenario Singer envisions; (2) a scenario where members of that generation reproduce at the average rate of one replacement per person; (3) Scenario 2 with the following changes: first, in the generation under consideration, the average replacement rate is two people per person; second,

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the world’s resources are adequate to sustain this population increase. It seems incontrovertible that the difference in desirability between Scenarios 1 and 2 is much greater than that between Scenarios 2 and 3. But anyone accepting this intuition must find the source of this discrepancy in something other than the interests of merely possible people.26

At this point it may be tempting to suggest that a society scientifically advanced enough to achieve greatly increased longevity might find a way to sustain a greatly increased population. Perhaps this could occur, as Overall suggests in her discussion of immortality, through migration ‘to other planets, perhaps planets in other solar systems’ (Overall 2003: 140).27 For the sake of argument, however, I have been accepting Singer’s background assumption that available resources would be inadequate to support a population with increased longevity that continued our present pattern of reproduction. This problem intensifies once we consider immortality rather than greatly extended but finite longevity, at least if we assume that problematically many people will opt for immortality. Overall discusses various ways of dealing with this problem. One is to confine the opportunity for immortality ‘to a select few’ (Overall 2003: 139). Her objections here — the moral problem of unfairness and the practical problem of resentment — might be obviated if the ‘few’ were selected by lottery.28

Another approach is John Harris’s suggestion that we might ‘offer people lifeprolonging therapies only on condition that they did not reproduce, except perhaps posthumously, or that they agreed if they did reproduce to forfeit their right to subsequent therapies’ (Harris 2000: 59). Overall objects that ‘it is hard to see that making pregnancy a capital offense could be justifiable’ (Overall 2003: 137). But this approach, which allows each person to choose what he or she values most, seems preferable to more coercive alternatives, such as either outlawing pregnancy altogether or setting ‘some definite upper limit on the duration of one’s right to live’ (Woods 1978: 128). Suppose everyone, given the choice, opted for immortality over reproduction. Overall maintains that if reproduction were to cease, ‘the culture as a whole . . . would suffer a staggering loss of relationships and interactions with babies and children and the invigoration and renewal provided by the presence of young people’ (2003: 137). Although elsewhere expressing skepticism of cliched´ claims about the ‘freshness of youth’ (Overall 2003: 44), here she seems to take it for granted that those who are no longer young would be inadequate to provide ‘invigoration and renewal’. Harris, who identifies ‘fresh ideas’ with ‘new human

26For further discussion of the moral status of merely possible people, see Woods (1978: 128) and Overall (2003: 137 – 9).

27See also Sawyer (2005: 88 – 9).

28Then, again, they might not be. In discussion, Sara Ann Ketchum has pointed out that many

people consider the ‘natural lottery’ unfair in its distribution of beauty, talents, etc. and might resent the outcome of a socially engineered lottery as well. But I doubt that many who find immortality desirable would prefer no chance at immortality to a lottery for it. (For a more optimistic view of the population problem, see Kurzweil 2005: 65 – 6.)

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individuals’ (Harris 2000: 59), rather than with youth, escapes this objection. Once again, however, we should keep in mind that a society capable of achieving human immortality will be scientifically advanced beyond ours in other ways as well. Perhaps, as already suggested, these ways will enable the same people to keep generating new ideas from their vast experience. This is not to deny that cessation of reproduction would be a significant loss. People who choose immortality over reproduction, however, are indicating that they find loss of their own lives even more significant.29

To better appreciate this, imagine a society of non-reproducing immortals who know no other sort of existence but are suddenly told they must die in order to make way for new people. Would their outrage be surprising? Or unjustified?30 Although John Stuart Mill’s ‘Everything which is usual appears natural’ (Mill 1970: 4) is an obvious exaggeration, we often feel outraged at the prospect of losing the good things we have taken for granted. Overall recognizes that ‘it is probably too much to expect that immortals would freely choose to abandon their immortality’, that it is unclear ‘why the right to reproduce [should] trump the right to go on living’, and that ‘it is hard to see that . . . limiting the amount of time that people are permitted to live, is justified’ (Overall 2003: 139, 138). Why should the onus of keeping the population down fall on the old? As John Woods says, ‘None of us . . . need feel obliged to pay with our lives for the consequences of an out-of control population’ (1978: 130).31 Furthermore, Gems points out that ‘advances in

29 There is an intriguing parallel here to the claim that the loss of Jews to assimilation and intermarriage amounts to a ‘silent Holocaust’, as if the decline of Judaism through lack of interest could in any way be equated with the decline of Judaism through the murder of Jews. See the discussion in Buchwald (n.d.). In this case, as in the case of the end of human reproduction, the distinction between an end that comes about through individual choice and an end that comes about despite it will seem crucial only to those who give individual choice high priority.

30Upon reading a draft of this chapter, Bonnie Steinbock mentioned her ‘son’s comment (age 2 1/2): ‘‘I don’t want to die; I want the new people to die’’ ’.

31Note the relevance of this point to the common view that even though compulsory retirement is

now illegal for professors in America, elderly professors should retire in order to free up space for ‘new blood’. Remaining unanswered is the question of why the onus should fall on the elderly. Why not instead have it fall on professors who are too experienced to count as ‘new blood’ but are still young enough to train for other careers without running great danger of age discrimination, or on married professors who could afford to live on the income of their spouses while taking extended sabbaticals to devote their energies to child-rearing? It is noteworthy that those urging retirement on elderly faculty overlook the contribution elderly professors make to the goal, much trumpeted in America, of ‘diversity’. Of course, there is no perfect correlation between attitudes and age, just as there is no perfect correlation between attitudes and dimensions on which American colleges and universities prize diversity, such as race or gender. But, as a bioethicist, I have attended conferences where no one (except me) favored high-tech life-extending care for the old and ill — and no one appeared to be much (if at all) over 70. (Full disclosure: At the time of this writing, I am only (?) 58.) What would we say about a conference of white men who assured one another of the wrongness of affirmative action? Note also that, as Ketchum has pointed out in discussion, different generations may provide diversity of perspective through having lived through different historical events, such as the Cold War. Note further that Kubler¨-Ross justifies compulsory retirement on the grounds that it benefits the young

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medicine along with improved nutrition and hygiene have greatly reduced infant mortality during the last century. This has led to dramatic increases in population, but no one has called reducing infant mortality undesirable’ (Gems 2003a: 34).32

Kass also emphasizes the tension between immortality and reproduction. He says that ‘in all higher animals, reproduction as such implies both the acceptance of the death of self and participation in its transcendence’ (Kass 2002: 271).33 But it is far from obvious that having children automatically makes people more willing to die. Overall reasonably suggests just the opposite, saying that her children are among ‘the best possible reasons for me to want to live a very long life’ (2003, p. xi). Kass’s claim that ‘to covet a prolonged lifespan for ourselves is both a sign and a cause of our failure to open ourselves to procreation and to any higher purpose’ (2002: 271) overlooks the fact that people can have high purposes for prolonging their own lives and thus their opportunities to do good in the world. And his pronouncement ‘The salmon, willingly swimming upstream to spawn and die, makes vivid [the] universal truth’ (2002: 271) that to accept reproduction is to accept death, invites two questions. First, what does the word ‘willingly’ mean in this context? Second, are we humans supposed to model ourselves on salmon?

A final set of objections involves inequality. Easiest to deal with is the concern of Eric Juengst and his co-authors that ‘if slower aging extended the years available for productive work, vigorous and expert older workers may become more desirable, [leading to] unfair discrimination against the less experienced young’ ( Juengst et al. 2003: 27). Why suppose this would be worse than the present-day workplace discrimination against those no longer young? As with all workplace discrimination, the solution lies in well-enforced anti-discrimination laws if the target group’s qualifications are acceptable. If young and less experienced workers are genuinely inferior, it would hardly be unfair for employers to favor more experienced workers. Extended apprenticeships to help the young get their skills up to par are a more humane solution than condemning the elderly to deterioration and death in order to keep them from ‘encroaching on [the] careers’ of the young (Nuland 1994: 87). The latter words are Sherwin B. Nuland’s, as he excoriates what he calls the ‘useless vanity’ of ‘Those who would live beyond their nature-given span’ (Nuland 1994: 87).34 But the charge of vanity seems more applicable to young people who expect their careers to have priority over the lives and health of the elderly.35 Moreover,

(Kubler¨-Ross 1974: 150). This suggests she has little to offer old people who are more interested in achieving equal opportunities in life than in learning to accept death.

32See also Overall (2003: 52 ff.) and Naam (2005, ch. 6).

33See also President’s Council on Bioethics (2003a: 188 – 9).

34See also President’s Council on Bioethics (2003a: 193 – 7, 297, 302).

35I made this criticism in my review of Nuland’s book. See Ackerman (1995). On 2 October 2005,

when Nuland was interviewed on C-Span’s In Depth call-in program, I called in and repeated the criticism. Nuland replied on the air that he had no objection to 90-year-olds who wanted to live to be 100; his opposition was directed at attempts to extend greatly the maximum human lifespan. He suggested that I was taking something out of context, misinterpreting him, or being a kind person and

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such young people would be short-sighted to overlook the fact that they themselves would eventually reap the benefit of greatly extended life.

A more serious equity problem is that of access to life-extension. What if not everyone has equal opportunity to opt for greatly extended life? This is one question I consider in my final section.

SH O U L D RE S O U RCES BE AL LO C ATE D TO

AT TEMP TS TO EXTEND GREAT LY T HE

MAXIMUM HUMAN LIFESPAN?

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As Harris points out, ‘Most people fear death, and the prospect of personal extended life-span is likely to be welcomed’ (Harris 2000: 59). Harris’s observation provides prima facie reason for supporting attempts to extend greatly the maximum human lifespan, although it obviously leaves open the issue of where this should rank among other priorities. Rather than attempting to settle this extraordinarily complex issue, I will focus on rebutting some recent objections to allocating significant resources in this direction at all. Overall mentions that ‘most of the modern philosophical discussion . . . along with a great deal of . . . extra-academic cultural commentary, seems weighted against the prolongation of human life’ (2003: 15 – 16). I have already considered various reasons for this, but surely some of the most important have to do with expense and inequity. For example, Ronald Dworkin says,

Science . . . promises — or threatens — new medical and surgical techniques of increasing life expectancy, in some accounts to expand it to biblical magnitudes, but at such enormous cost that developing and testing these technologies, let alone making them available to more than a tiny minority, would drain away the resources needed to make people’s lives good as well as long. (Dworkin 1994: 240)

Overall says that ‘the main emphasis in longevity programs ought to be placed on those who have been disadvantaged rather than on expensive and risky36 technologies available only to those who already enjoy life-expectancy advantages’ (2003: 200).

These claims cry out for critical examination. More than one type of inequality is at issue here. There are two distinct ways in which life-extension technology

introducing some controversy. Since I was criticizing his opposition to attempts to extend greatly the human lifespan, his reply is surprising. Also surprising is his mention of his age — 74 — as a defense against the charge of ageism, unless Phyllis Schlafly’s gender would likewise count as a defense against the charge that she is sexist.

36 A discussion of the biological risks of such technology and how they might be minimized or regulated is beyond the scope of this chapter. But see President’s Council on Bioethics (2003a: 279 – 80, 287); Garreau (2005); Kurzweil (2005: 66 – 7); Naam (2005).

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is open to the objection that it would favor the privileged. First is the obvious objection that only the rich may be able to afford it. In principle entirely distinct is the objection that long-lived people are privileged in virtue of their longevity; so it is more egalitarian to direct resources toward bringing short-lived people’s longevity up to par than toward extending the lives of the old. In practice, of course, economic inequality is relevant to the second objection, as many causes of early death are related to poverty.

I will consider the second objection first. Battin, drawing upon work of Norman Daniels (1983; see also Daniels 1982, 1988), has endorsed an approach to health care allocation that could also apply to allocation of resources for medical research. This approach relies on the view that rational self-interest maximizers behind a veil of ignorance37 that made them ‘unable to know their own medical conditions, genetic predispositions, physical susceptibilities, environmental situations, health maintenance habits, or ages’ (Battin 1987: 322) would, in a condition of scarcity, choose ‘to ration health care to the elderly (in order to enhance health care available to younger . . . people and, thus, maximize the possibility of each person’s reaching a normal life span at all)’ (Battin 1987: 324).38 More recently, she has embraced a global perspective relying on an idealized hypothesis that ‘The savings from our earlier deaths . . . in the first world [could be directly] translated into resources in the third world’ (Battin 2000: 16). After all, behind the stipulated veil of ignorance, people also would not know whether they are Japanese, with a life expectancy (as of 2000) of nearly 80, or Burundian, with a life expectancy (as of 2000) of under 45. Note that the view that rational self-interest maximizers behind the stipulated veil of ignorance would seek to maximize the possibility of each person’s reaching a normal lifespan is already a departure from the Rawlsian position of maximizing the minimum, i.e. making the worst outcome as good as can be. If (as on Battin’s approach) we think in terms of people’s complete lives, a maximin rule, on the above idealized hypothesis, would not only ration health care to the elderly, but would deny a 45-year-old in the developed world antibiotics for pneumonia until Burundians’ life expectancies had been brought up to par. In fact, such a rule might not allocate any medical resources to adults (except to maintain the minimum number of adults necessary to keep society functioning) until every child who could be saved from death had been. Battin repeatedly refers to deaths in the developed world as occurring ‘a little’ earlier on her veil-of-ignorance approach (Battin 2000: 12, 13, 16). This would quite likely be a great understatement on a maximin rule.39

37The idea of a veil of ignorance is adapted from Rawls (1991).

38Battin mentions another consideration: rational self-interest maximizers would know, behind

the stipulated veil, that ‘by and large, a unit of medical care consumed late in life will [be much less efficient] than a unit of medical care consumed at a younger age’ (Battin 1987: 324). For a related consideration, see Daniels (1988: 88 – 91).

39 Daniels (1988: 88 – 91) discusses his reason for not using a maximin rule for allocation of health care resources. Also see Daniels (2002). Note also that the question of who is worst off is relative to

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Overall has offered objections to Battin’s approach. One is that ‘the first cohort of midlife and elderly people would literally sacrifice a portion of their lives for the sake of this reallotment, without profiting personally from it. [They] would be too old to have benefited from the redistribution of savings to younger people’ (Overall 2003: 212).40 Overall further criticizes Battin on the grounds that ‘selfinterest ordinarily has a wider purview than merely one’s own survival . . . even from a Rawlsian veil-of-ignorance perspective, it would be unreasonable to assume that there are no elderly people or potential elderly people who might play key roles in our life’ (Overall 2003: 212). But would self-interest incline us to trade our own survival for the survival of these people? That would be expecting quite a lot.

Battin’s approach faces other problems. She says that decisions behind the stipulated veil of ignorance parallel those of people who are actually considering health care policy in our ordinary life, because ‘ordinary persons who have not yet reached old age or death’, i.e. ‘those of us who are considering this issue — who would be prepared to develop policy requirements on the basis of these considerations and who would be governed by whatever policies might be devised — are effectively behind the ‘‘veil of ignorance’’ with respect to the specific events of our own aging and death’ (Battin 1987: 324, 323). Here she overlooks her own stipulation that rational self-interest maximizers behind the veil would not know their ages (and hence would not know that they have not yet reached old age). She also disenfranchises the actual elderly as policy-makers in the real world and disregards their status as people who will be governed by ‘whatever policies might be devised’.

This raises the question of just what is meant by the stipulation that behind the veil of ignorance people would not know their ages. The most natural interpretation seems to be that these people would have particular ages that they realized they simply did not know. But this would threaten the claim that rational self-interest maximizers behind the veil would choose to skew resources toward the young and ‘not to underwrite treatment which would prolong life beyond its normal span’, where the ‘ ‘‘normal life span’’ [has] to do with the rough boundary between middle and old age or between early old age and late old age’ (Battin 1987: 322, 326 n. 29). After all, the rational self-interest maximizer would realize that, for all he knows behind the veil, he might in fact be old at the very time he is making the decision that is about to go into effect. If we accept Battin’s supposition that rational self-interest maximization here involves a highly conservative risk-reduction strategy, wouldn’t it be more rational for a self-interest maximizer to maximize his chances of staying

whether the comparison is made in terms of people’s complete lives or in terms of current stages of people’s lives. See the discussion in Ch. 8, by McKerlie, in this volume. (I thank Ketchum for help formulating the paragraph leading up to this note.)

40 Battin (1987: 334; 2000: 6) acknowledges this problem. For a response, see Daniels (1982: 535; 1983: 516; 1988: 129 – 30).

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alive, whatever age he actually is, ‘even’ if, unknown to him, he is presently at or beyond the end of a normal lifespan?41

Another interpretation, suggested by Battin’s remark that rational self-interest maximizers behind the veil ‘must decide in advance on a spending plan, budgeting a fixed amount of medical care across their whole lives’ (Battin 1987: 322; italics added), is that behind the veil people are allocating resources from the standpoint of someone who envisions his entire life stretching before him, yet to be lived and unknown in its medical specifics. But although Daniels repeatedly insists that age-ignorance prevents biasing the choices in favor of the interests of a particular age group (for example, see Daniels 1988: 64 n. 8, 75), this construal yields a standpoint biased in favor of the young, as it is the standpoint of someone so ‘young’ that his life has not yet even begun.

A related objection applies to Dworkin’s claim that ‘The choices Americans of average income make about their employee insurance package in wage negotiations . . . can offer some guidance’ about appropriate priorities for health coverage (Dworkin 2000: 217). The problem arises from his view that

we should aim to make collective, social decisions about the quantity and distribution of health care so as to match, as closely as possible, the decisions that people in the community would make for themselves, one by one, in the appropriate circumstances, if they were looking from youth down the course of their lives and trying to decide what risks were worth running in return for not running other kinds of risks. (Dworkin 2000: 208 – 9; italics added)

This openly biases priorities in favor of the interests of the young.42 Looking at choices people actually make about their employee insurance packages also biases priorities in favor of the interests of people healthy enough to be employed.

A third interpretation of Battin’s age-ignorance stipulation, suggested by James Dreier in conversation, is as follows. Rational self-interest maximizers behind this veil of ignorance have an atemporal perspective in the sense of having no ages but just comparing different lives atemporally, rather than having ages they realize they do not know. To the extent that I understand this interpretation, it does not seem to be the natural interpretation of the stipulation that decision-makers behind the veil do not know their ages. Moreover, it is clearly out of line with Battin’s parallel between these decision-makers and ordinary persons who are aware that they have not yet reached old age.

A further objection to Battin’s approach is independent of which, if any, of these interpretations is used. This objection, arising from a basic problem with the

41Battin stipulates that rational self-interest maximizers behind the veil of ignorance have some general information about health and health care in their society, including the knowledge, cited in n. 38, above, that medical care is much less efficient in old age. But this hardly seems adequate to lead a rational and risk-averse self-interest maximizer to deny all life-prolonging care for people beyond an age he realizes that, for all he knows, he may already have reached.

42Overall recognizes this sort of problem; see Overall (2003: 238 n. 13).