Ethics of healthy longevity

Civis Mundi Digitaal #20

door Maartje Schermer

Ethics of healthy longevity

Maartje Schermer

NCHA congress Adding healthy years to the human lifespan, 7-8 february 2013, The Hague

You probably all know this picture. It is a painting by the German Renaissance painter Lucas Cranach the Elder, depicting the fountain of youth. You can see how old people go in at this end, and they come out revitalized and restored to youth at the other end.

The fountain of youth is something that many have sought for; it figures prominently in many stories, myths, and works of art. We might even say that the search for biomedical interventions for healthy aging is the present day equivalent of this quest for the fountain of youth.

What I did not know, however, before I started to prepare this talk, is that the fountain of Youth has actually already been found.     The sixteenth century Spanish explorer Ponce de Leon has discovered it in 1513, in what is now St Augustine, Florida.  The Fountain can still be visited there today, in the Fountain of Youth Archeological Park.  So this may be an explanation of why so many retired people move to Florida.

In my contribution I want to concentrate on two ethical issues that have to do with our modern day quest for the fountain of youth, the quest to combat and eradicate the diseases of old age, and to attain healthy aging.

The first issue is: what does the ‘healthy aging enterprise’ aim at exactly? What is the ‘good’ we are after? I will argue that the ultimate goal is, or should be, to contribute to good aging, that is: to a good over-all quality of life in older age.

The second issue is: who is responsible for healthy aging? To what extent can aging people themselves be held responsible for their health, for example for following a healthy lifestyle? And what are the responsibilities of researchers, healthcare providers and the state?

I. Goals of the healthy aging enterprise

The first question I want to address is: what is the ultimate goal of the healthy aging enterprise? What do we aim at? What should we aim at? Are we looking for eternal youth? For eternal life? Do we wish to significantly extend our human lifespan?

Although the media and the general public may be fascinated and triggered most by the idea of immortality, or ‘finding a cure for aging’, this is not primarily what healthy aging is about. Healthy aging is not primarily about the prolongation of life, about extending the human lifespan (although this may be a side-effect).

It is obvious for anyone who gives the issue a moment’s thought, that the goal cannot merely be to live longer lives; however much we value life, we value it because it enables us to do things, to enjoy things, experience things, be engaged in activities we find meaningful, to participate in social relationships and communities et cetera. Mere biological life, ‘being alive’, is not what it is all about; what it is ultimately about is leading a full human life.  Life in a biological sense is only valuable and worthwhile if it enables us to do just that.

Therefore, it is clear that the goal should not just be to add years to life, but, as the title of this conference aptly says: to add healthy years to life.

But what do we mean by ‘health’? And how does health relate to leading a good, happy, fulfilling human life? Is healthy aging the same as good aging?

One way to define health is to say that it equals the absence of disease. Being healthy means not being ill.

A more ambitious definition is the well known WHO definition: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"

This definition has rightly received a lot of criticism for being overly ambitious - if this is health, that probably none of us is ever healthy.

Recently a new conceptual framework for understanding health has been proposed, that aims to be better attuned to our aging societies in which chronic illnesses have become the norm rather than the exception.

The core idea here is that "Health is the ability to adapt and self manage in the face of social, physical and emotional challenges". Note that this definition does not exclude disease: one can have one or more chronic conditions and still be healthy in this sense.

Health should not be seen as a static condition, but as a dynamic capacity to cope, to adapt to new circumstances and to maintain and restore one’s integrity and sense of well-being. Chronic illness and impaired functioning need not affect one’s perceived quality of life in a negative way, if one is able to employ successful coping strategies. Disease and physical impairments need not diminish one’s well-being, if one is able to manage them successfully. Health is not necessarily the absence of disease or impairment, but the ability to cope with disease or impairment.  So, terms like: adaptation, resilience, self management and coping are very important for this new dynamic concept of health.

This new framework for understanding health is especially suitable for understanding healthy aging. It shows us that healthy aging is not necessarily understood as aging without illness. On the contrary, it shows that even if aging inevitably comes with some impairments and diseases, one may still have a good and satisfying life at older age. Moreover, it shows that healthy aging is not only a matter of better medication or better medical treatments, and physical health, but also a matter of the attitude and abilities of elderly people themselves.

An example of such adaptive abilities can be found in what gerontologists Paul and Margaret Baltes have called the strategy of Selective Optimization with Compensation (SOC). This entails that when confronted with an impairment due to aging a person can do three things:  First, select a different priority in goals, of choose new goals; second, Optimization: realizing ones goals by optimal and intensive efforts to enhance the use of ones means and resources. And Compensation: putting other skills and resources in efforts to compensate for lost abilities.

A fine example of this adaptation strategy is given by the famous concert pianist Arthur Rubinstein. When he was 80-years old, and still giving piano recitals, Arthur Rubinstein was asked in an interview how he managed to maintain such a high level of performance. He explained that he did so by playing fewer different pieces by concentrating on Chopin (Selection); secondly, he practiced these pieces more often than he used to (optimization) and finally, he counteracted his loss in speed, by playing more slowly before fast segments, to make the latter appear faster (compensation). 

As I have said I think that healthy aging is important because it closely related to quality of life and to well-being. Healthy aging is not so much a goal in itself, but should ultimately contribute to good aging, in the broadest sense of the word. Good aging means having a fulfilling human life while adapting to changing circumstances. It means living independently as much as possible, according to one’s own convictions and commitments, having autonomy, maintaining social relationships, participating in society and being valued by society, and enjoying meaningful activities.

So the question we need to keep asking is how can research and development in healthy aging contribute to this ultimate goal of good aging, of adding quality to later life?

II Healthy lifestyle/aging: whose responsibility?

The second issue I want to address is the issue of responsibility for healthy aging.

There are a number of important ethical and societal questions here. To what extent are people personally responsible for their own health? How much effort can we expect of people to age healthily? Can we blame them or make them pay if they don’t? How far can or must the state go in enforcing a healthy lifestyle?

To start answering these questions, I want to distinguish between two forms of responsibility: prospective responsibility and retrospective responsibility or accountability.

First, prospective responsibility is, as the name says, forward looking. It is about what people are supposed to look after, to take care of.  "Prospective responsibility is about what people should care about and what they should do. It is an action guide". In this sense, parents are responsible for their children; doctors are responsible for providing good care to their patients. And in this sense, one might say that every person is to some degree responsible for his own health.

Retrospective responsibility is backward looking. It is about holding people responsible, in the sense of accountable, for what they have done, and for mistakes they have made, or damage they have caused. It is about accountability. I’ll come back to accountability later on, but will first discuss prospective responsibility: what can we expect of people and what of the state?

In general, we can say that people have a responsibility for their own health; people should care about their health and try to maintain or improve it, and not damage it. We can see this as a kind of moral duty towards oneself, to take good care of yourself. This means you are responsible for refraining from things that are clearly unhealthy, such as smoking, and that you should adopt a healthy lifestyle with enough exercise, healthy food et cetera. It also means you should comply with medical treatment and for example take your medication.

It is clear, however, that this responsibility has its limits, and that it can clash with other duties or interests a person may have. People cannot be expected to only live for their health - there is more to life than that.

Moreover,  people have a right to make their own choices regarding what they find important in their lives. Some may choose the fountain of bacon over the fountain of youth.

Now what prospective responsibility does the government or the state have with regard to healthy aging and healthy lifestyle?  The government has at least two responsibilities: first, towards the health and well-being of its individual citizens. The state has responsibility to provide good healthcare and to enable people to live healthy lives.

Second, the state has a responsibility towards society as a whole. It should promote the interests that society has in healthy aging, such as an enhanced labor force, a reduction in the cost of healthcare and the promotion of public health.

But how far may the state go - or how far must the state go - to attain this? Can the state interfere with people’s lifestyle choices? How far may the state go in promoting, stimulating or perhaps even enforcing healthy lifestyle choices?

A first important consideration is of course peoples autonomy. People have a right to make choices regarding their own lifestyle. We all find it important that we have this right to make such choices for ourselves. Therefore enforcing a healthy lifestyle goes too far. It would be an extreme form of state-paternalism if the government were to decide that we should all eat fish twice a week, and 200 grammes of vegetables and two pieces of fruit each day and that we should avoid smoking, work-stress and dangerous sports. A law that would require each of us to do physical exercises for 20 minutes a day would not only be impracticable but would also seriously infringe on our right to make our own lifestyle choices. 

The state has no right to enforce a lifestyle upon people for their own good.

However, the state does have a responsibility to enable and empower citizens to make healthy choices for themselves.  Providing people with accurate and understandable information about healthy food, healthy exercise or the dangers of smoking empowers people to make their own choices. Measures that stimulate a healthy lifestyle, like information campaigns, or like subsidizing exercise programs for the elderly do not infringe upon people’s right to make their own choices, but do stimulate health.

There is one ethical concern that I believe is extremely important in this context and that is equality. When we speak about healthy aging, I think it is important to realize that there is a huge difference between lower and higher socio-economic groups with regards to both quantitative and qualitative aspects of aging. People in lower socio-economic groups do not only have an 8-10 years lower life expectancy than people in higher socio-economic groups, but they also have a shockingly shorter healthy life expectancy , around 15 years less.

An important part of this difference in healthy life expectancy and in healthy aging can be explained by lifestyle factors. In part, it may be that people with lower socio-economic backgrounds genuinely hold other values than people from higher socio-economic groups. They may have different priorities and really prefer a shorter life with cigarettes and lots of fatty foods over a longer life without them.

However, for an important part, these lifestyle choices are not so conscious and purposeful. People may simply not know enough about the dangers of smoking, or obesity. They may lack knowledge with regard to healthy food choices. Also, they may not have the financial and social resources to adopt a healthier lifestyle. Healthy food and organized forms of exercise are expensive, and if everyone in your environment smokes, it may be more difficult to quit.

When interventions aimed at healthy aging mainly reach the higher socio-economic groups, or are mainly taken up by them, the existing inequality in healthy life expectancy between lower and higher socio-economic groups may further increase. Chances are that knowledge and interventions aimed at healthy aging will reach the higher socio-economic groups better and easier than the lower socio-economic groups.

For example, in the Netherlands a Prevention Consultation has been introduced. This is a consultation by General Practitioners aimed at people of 45 and over, in which individual risk factors for cardiovascular disease, diabetes and the like are assessed and personalized advice is given about how deal with these I order to prevent disease.  At the moment, this Prevention Consultation is not included in the basic healthcare insurance. This implies wealthy people will be able to afford it out-of-pocket, whereas poor people - the ones who may need it the most! - will not be able or willing to pay for it. I think the government has a responsibility here to make sure that opportunities for healthy aging are equally accessible for all citizens.

Likewise, researchers and healthcare providers have a responsibility to make sure the interventions they develop to support and improve healthy aging, are accessible for patients from all layers of the population. We should aim at developing interventions that are practicable and feasible for people with less money, or with less formal education, or from different ethnic backgrounds. Information should be made available in ways that people who have low literacy can also understand, for example. New ICT based self-management support systems must be tailored to use by people who are perhaps not very familiar with computers and smart-phones.

These are just a few examples, but the point is that in developing interventions to promote healthy aging, it is very important to keep in mind we should aim at reducing socio-economic differences in health. We should aim at truly equal opportunities for all to attain a healthy old age.

I have been talking about prospective responsibility - about what we can rightfully expect of people themselves, of the state and of research and healthcare to promote healthy aging.  Now for the remaining few minutes I will turn to retrospective responsibility and the question: can we hold people accountable if they do not age healthily?

If people do not follow a healthy lifestyle, or do not comply with doctors orders all that well, or if they just do not take very good care of their own health, should we blame them for that? Are they responsible for the healthcare costs this may cause?

Retrospective responsibility means holding people accountable for the consequences of their choices and actions. We might say, for example, that people who smoke, or who are obese, or who do not take enough physical exercise should pay extra insurance premiums. Or we could argue that they should pay an extra amount out-of-pocket if they need healthcare because of their own unhealthy behavior. Proposals like this are made regularly by politicians and others.

I will briefly rehearse the arguments in favor and against this type of measures.

First, measures like this may stimulate healthy behavior and thus healthy aging.

Second, it may decrease healthcare cost, because of the healthier behavior and because of the extra insurance incomes. However, health economists are not in agreement whether this would be an over-all benefit. If people do actually live healthier and age healthier, they may still make a similar amount of healthcare costs, only later in life. Most costs are made in the last year of life, regardless of whether this is at age 70 or age 90.

Third, from an ethical point of view, one may say that measures like this rightly hold people accountable for their own behavior. This argument assumes, however, that people have knowingly and willfully engaged in unhealthy behavior, and as I argued before, that is not always the case.

We can also list some argument against this type of measures.

First, it is not always clear that people are really to blame for their unhealthy lifestyle; as said, socio-economic factors, education, or social circumstances can all influence health behavior. Moreover, for many diseases it is not only lifestyle factors that matter, but also genetic or environmental factors. For some people it may be much more difficult than for other to keep a healthy weight, for example. So, one might say that having people pay for an unhealthy lifestyle is actually blaming the victim.

A second argument is that such measures would be practically unfeasible, at least if we want to avoid a health-police. Checking whether people smoke, what they eat or how much they drink would be difficult in practice and would be very privacy sensitive.

And thirdly: it would be unfair to have people pay for certain types of unhealthy behavior but not others.  Why should people pay if they smoke, but not if they work too hard and get all kinds of stress related diseases?

I want to end with a final remark. However good the intentions are, if we put too much emphasis on individual responsibility for healthy aging, we may inadvertently but wrongly raise the suggestion that a healthy old age lies completely within our own control. I need not tell you this is an illusion. Regardless of what medical science can do nowadays, we will still have to face that not everything is malleable.  We will still have to deal with back luck and misfortune and diseases that we can’t prevent. Sometimes people just fall ill.

Therefore, people should not be made to feel guilty if they do not manage to age healthily; and they should not be blamed by others. And as I argued at the beginning of my talk, the way in which one deals with impairments and diseases, with bad luck, and with the twists of fate, is also part of good aging. Exercising the ability to adapt and self manage in the face of the social, physical and emotional challenges is that come with aging, is also an important part of what it means to age healthily.