In the January 2006 edition of Commentary, bioethicists Eric Cohen and Leon R. Kass offer a compelling essay on the challenge represented by millions of the aged among us. In “Cast Me Not Off in Old Age,” they warn that we are now witnessing the development of a “mass geriatric society” which will present this country with massive economic, social, medical, political, and ethical challenges.
Recognizing that, many Americans argue that there must be some better way to confront these challenges, and all too many appear willing to redefine human dignity in terms of quality of life, autonomous choice, and the competing interests of generations.
Indeed, some are ready to argue for a “duty to die” that assumes a responsibility for the elderly to get out of the way. Far more are ready to assume that the death of the elderly is at least preferable to long-term debility and decline. Both of these assumptions run into direct conflict with the Christian worldview and the Bible’s teachings regarding reverence for life and respect for the aged. Confronting these assumptions will require Christian courage as well as keen Christian thinking. This challenge will not wait.
In light of these challenges, Cohen and Kass suggest two false “solutions” that may appeal today to Americans who take opposing sides on these issues.
First, the authors dismiss the argument that the problems of old age can simply be solved by medical technology. They cite Dr. Mark B. McClellan, the top official at the Centers for Medicare and Medicaid Services, who claimed last July that “Medicare can do so much more than give you dignity in old age.” Dr. McClellan claimed that Medicare can actually extend life, improve health, and save money by preventing and curing the diseases of old age.
Cohen and Kass dismiss this as “the medical gospel of healthy aging.” While accepting that persons can do much to make themselves healthier and to extend active and vigorous life, Cohen and Kass understand that life itself, even with medical treatments, involves limitations. It is foolish, they suggest, “to act and speak as if medical progress (whether in prevention or in cure) will liberate us from the realities of decline, debility, and death or from the unavoidable duties of caregiving at the end of life.” The authors insist that the paradox in modern aging is this: we are vigorous longer and we are incapacitated longer.
Most tellingly, Cohen and Kass criticize much of the propaganda about old age now commonly advertised in our society. “Finally,” they note, “there is something weird about treating old age as a time of life when things should always be ‘getting better.’ While aging affords some people new possibilities for learning and ‘growth,’ it also means–eventually and inevitably–the loss of one’s vital powers. Some people may ride horses or climb mountains into their seventies and eighties, just like in the commercials for anti-arthritis medication, but such idealized images offer a partial and misleading picture of the realities of senescence, that series of small dyings on the way to death.”
The second “solution” Cohen and Kass rightly dismiss is the “legal gospel of the living will.” Returning to the case of Terri Schiavo, Cohen and Kass lament the fact that the significance of this tragedy for so many Americans was, as so many in the media insisted, the moral lesson that one should always have a written living will or “advance directive” to guide medical decisions once one is no longer in a capacity to speak for oneself.
With keen insight, Cohen and Kass point to the worldview of individual autonomy as the driving force behind the development of living wills and the current confidence in these documents as the “solution” to difficult issues at the end of life.
In the first place, Cohen and Kass recognize that living wills simply do not live up to their reputation. The documents are often legally unsustainable, and medical personnel are often unaware of such documents or unable to make decisions that are in any sense clearly based upon the desires of the patient who framed the document. They cite a study that indicated that decisions made by surrogates using living wills “were no more likely to reflect the patient’s prior wishes than decisions made by family members judging on their own.”
Most important, Cohen and Kass understand that the inevitable bottom-line issue is the dignity of human life. While our society holds a general consensus concerning equal human worth when it comes to the healthy, Cohen and Kass argue that “this general agreement regarding equal human worth can disappear in some cases.” Specifically, “Although many continue to believe that every human life, regardless of debility, possesses equal dignity, others now argue openly that equal treatment for all is best advanced by not diverting precious resources to the severely disabled. Still others believe that the indignities of old age–especially dementia–belie all sanctimonious talk of ‘equal worth.'”
In the end, Cohen and Kass argue for Americans to understand that there are better and worse ways to understand the challenge of aging. The worldview of personal autonomy corrupts the question by placing moral confidence in the real or perceived intentions of the patient, generally without regard to the larger moral context or to enduring moral principles.
As they argue, “The better way begins in thinking of ourselves less as wholly autonomous individuals than as members of families; in relinquishing our mistaken belief that medicine can miraculously liberate our loved ones or ourselves from debility and decline, and instead taking up our role as caregivers; and in abjuring the fantasy that we can control the manner and the hour of our dying, learning instead to accept death in its proper season as mortal beings are replaced and renewed by the generations that followed.”
This is a statement of moral insight that is deeply based in a biblical worldview and in an understanding of human dignity that is rooted in something larger than individual autonomy. The Christian worldview adds the absolute affirmation of human dignity at all stages of life, and in all conditions of life, whether young or old. Furthermore, the Christian worldview insists upon the respect due the aged as honored members of the family and of the larger society.
Without doubt, the rise of the “mass geriatric society” described by Cohen and Kass will present all Americans with a dramatic series of challenges. The church faces an even greater challenge–to develop a theology of aging that is deeply rooted in the riches of Scripture and is directly relevant to the real-life challenges of growing old. Inevitably, a genuinely Christian vision of aging and the aged will represent a counter-thrust against the spirit of the age.
R. Albert Mohler Jr.
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