ON TURNING 70 : Will I practice what I preach?

I have long been interested in the relationship between our moral theories, values, and convictions, and our actual experience of the world. I have had more than the usual interest lately. I recently turned seventy, an age that makes one sit up and take notice, especially someone like myself who--maybe surprisingly--never gave much thought to the passing of the years. Not for me was there a crisis at thirty, forty, fifty, or even sixty.

But seventy was different. There can't be many years left, for one thing; and, for another, I can hardly fail to notice that the downhill pace of aging seems to pick up considerably about this time. There is also another reason, which many have pointed out to me.

During the mid-1980s, I wrote a book, Setting Limits: Medical Goals in an Aging Society, that brought me much attention and even more criticism. Looking down the road I foresaw an eventual clash of two great forces, the growing number and proportion of elderly people and the increasingly successful, but expensive, ways of providing medical care for them. The long-term projections for incredibly large Medicare deficits were fearsome. The only solution I could envision, when the conflict became overwhelming, would be to set an age limit on high technology, even life-extending technology.

If this became necessary, I argued, it could only be done with the democratic consent of the elderly themselves; and, moreover, good long-term and home care, and basic primary medical care, would never be denied. While the young have obligations to provide good health care for the old, the old in turn have an obligation not to make excessive demands on the young (who, after all, actually pay through their taxes the Medicare costs of the old). Just what would be the cutoff age? I proposed the "late seventies or early eighties" but added--not winningly, maybe--that by sixty-five most people had lived a full life, and that while there was more they could do with their lives, death in old age was a sad, but not tragic, event. Compare the funeral of a child with that of someone who has died in his eighties, and note the difference in mood.

An age limit was not then, nor would it be now, a popular suggestion--even though no one then or now has offered a better way of dealing with what will one of these days be an intractable problem. I was attacked as agist, murderous, and--most tellingly--lacking insight in what it would be like to be old, sick, and denied Medicare reimbursement to save my life. "How old are you anyway?" I was constantly asked. When I said I was fifty-seven (the year the book was published), a common response was, "well, no wonder; wait until you are really old and know what you are talking about."

So here I am at seventy, getting there. I haven't really changed my views, mainly because most of the alternative--and of course painless--solutions depend upon astonishingly large acts of scientific or economic faith. Research, some say, will eventually avert the problem, finding cures for all those deadly and expensive diseases. The Genome Project will lead to a discovery of the genetic basis of all disease, which can then be eliminated. "Death," the CEO of a major biotechnology company recently said, "is nothing but a series of preventable diseases." A savings account system, more market choice, or greater efficiency, say others, will avert a crisis. Efficiency, one of the great gods in the American pantheon of secular deities, is almost as good as research in getting rid of what ails us.

I don't believe it and, in any case, what will I say when I get critically ill and the expenses mount? I see that happening to many of my friends. And I can't but notice how many of them--who had said for years that they did not want expensive and useless treatment at the end of their lives--often do in fact want treatment that offers only the faintest hope of doing much good. They clutch at straws, defer to their families' wishes, or are seduced by well-meaning physicians who say "it's too early to give up hope; let's try one more round of chemotherapy."

Since that happens to people who are tougher and of better character than I am, I have no reason to believe I would be any more resistant to the lure of expensive technological rescues than they are. Should I, therefore, change my theoretical views, bringing them more in line with nasty old reality, in this case my self-interest in staying alive (an attitude hardly anyone in our society would now call selfish), which will no doubt show its hand at some point?

No, I hope I won't do that. I see the situation as one where, much like Ulysses, we need to bind ourselves to the mast to avoid temptation. If, and only if, we reach a point in this country when the health-care costs of the elderly become insupportable--by which I mean they are clearly depriving younger people of what they need to live decent lives and to have a chance of becoming old--then I would support an age limit on expensive medicine. I would vote for such a limit with trepidation, knowing that I (and others like me) could be deprived of that which would give them a few more years of life.

Becoming seventy has not persuaded me that my death from here on in would be a social tragedy, even if it is not something I look forward to. The world has many problems--war, poverty, violence, racism, exploitation of others--but I have never heard anyone make a plausible case that one of the great evils to be put on that list is the fact that elderly people get sick and die. In the end, then, I can tolerate the idea of an age limit because I take aging and death to be a part of human life, and not a wholly evil part. There are far worse things that happen in this world.