Implications of longevity research

Questions we will address today

1. How long can we live?

2. Is there a “right” time to die?

3. Should we use age to set limits on utilization of health resources?

4. What do the young owe to the old?

Increase in numbers of older adults: 1900-2050

Changes in life expectancy from ancient to modern times

Limiting premises

1. The human life span is increasing.

2. Death is the result of disease.

3. Disease is best treated by medication.

4. Aging is controlled by the brain and the genes.

These “limiting premises” are in keeping with which world view?

Rectangularization of the survival curve A more “domesticated”

environment leads to

a increasingly “rectangular” survival curve.

What is meant by “domesticated”?

What is the significance of the “rectangular” shape of the survival curve?

Life expectancy vs. life span

Rectangularization of the survival curve (cont’d.)

What kinds of changes prompt rectangularization?

How much has the life expectancy of a 70 yr. old increased in the past 50 years?

How much has the life span of a 70 yr. old increased in the past 50 years?

Rectangularization of the survival curve (cont’d)

The “flip-side” of survival is mortality and morbidity.

Why is this thought to be the “ideal” mortality curve?

Fries (1984): New Syllogism

1. The human life span is fixed.

2. The age of first infirmity will increase.

3. Duration of infirmity will decrease.

Can we develop a treatment that extends the life span in the same way as caloric restriction in mice?

Can we extend the life span by developing anti-aging medicine?

Will there ever be a “fountain of youth” in pill format? http://www.youtube.com/watch?v=RDaIjm0p6Fo

Fries (1984) – Age and the decline in reserve capacity

At age 85, homestasis is at risk due to declines in reserve capacity. Why? Isn’t there plenty of reserve capacity left?

In figures A, B, and C from Arking’s (2006) Drosophila research, which findings demonstrate increases in life expectancy, life span, or both?

La, 2La selected for long-life

PQR selected

RaHx selected for heat resistance

Rectangularization (cont’d): Life expectancy and life span

Can we stop aging? Reverse aging?How limited is the human life span?

Hayflick/Fries (very limited)Olshansky/Carnes (pretty much limited)Arking/Wilmoth (perhaps not so limited)

Significant factors in longevity:

Gender Diet (e.g., cholesterol,

toxins) Caloric restriction Stress Genes (e.g., in Drosophila)

Implications of rectangularization

Fries (1984) “Compression of morbidity” Olshansky (1991) “Expansion of morbidity” Miller (2001) “Relatively fixed period of

morbidity” Arking, (2006), De Grey (2010) “Delayed/

eliminated morbidity”

Based on your analysis of the survival data (e.g., Fries vs. Miller vs. Olshansky vs. Arking vs. De Grey), is there a “right” or “good” time to die?

Implications of rectangularization (cont’d)

Which of the scenarios is in keeping with:

Hayflick?

Arking?

Olshansky’s theory?

Fries’ theory?

De Grey?

Should age be used to set limits on allocation of health care resources?

A skillful, medically trained geneticist, Lenz headed the Racial Hygiene Bureau at the Kaiser Wilhelm Institute in Berlin which endorsed Nazi eugenic laws. As early as 1917, Lenz had envisioned Germany’s future in expanded eastern territories. Viewing Slavs as an undesirable, racial element that threatened to “overrun the superior [German] Volk,” Lenz advised the SS in 1940: “The resettlement of the eastern zone is… the most consequential task of racial policy. It will determine the racial character of the population living there for centuries to come.” After the war, Lenz was Professor of Human Genetics at Göttingen University. He died in 1976.

Biography drawn from the U.S. Holocaust Museum, Washington, D.C.

From: “Medical Science under Dictatorship". New England Journal of Medicine 241: 39-47. 

Recent attempts to ration or alternatives to rationing

1960’s – Seattle hospital’s committees and access to kidney dialysis machines

1989 – The Oregon Plan 1990’s to present – Waiting lines in Canada’s

national health care system. Ongoing rationing in managed care and hospital

settings (see WSJ article) Ongoing debate over euthanasia and assisted

suicide

Callahan’s proposal for age rationing

Setting Limits (1987)What Kind of Life? (1990)

Starts with a simple question:

Can there be a “tolerable death”?

Callahan’s three principles guiding government age rationing of health care resources1. Government has a duty, based on our

collective social obligation to help people live out a natural life span, but not actively to help extend life medically beyond that point. By life extending treatment I mean any medical intervention, technology, procedure, or medication whose ordinary effect is to forestall the moment of death, whether or no the treatment affects the underlying life-threatening disease or biological process.

Callahan’s three principles guiding government age rationing of health care resources (cont’d)

2. Government is obliged to develop, employ, and pay for only that kind and degree of life-extending technology necessary for medicine to achieve an serve the end of the natural life span; the question is not whether a technology is available that can save a life, but whether there is an obligation to use the technology.

Callahan’s three principles guiding government age rationing of health care resources (cont’d)

3. Beyond the point of a natural life span, government should provide only the means necessary for the relief of suffering, not life-extending technology.

Defining “tolerable death”

a) the individual’s life possibilities have on the whole been acomplished;

b) the individual’s moral obligations to those for whom one has had the responsibility, has been discharged;

c) the individual’s death will not seem to others an offense to sense or sensibility, or tempt others to despair and rage at the finitude of human existence.

Defining “natural life span”

When one’s life possibilities have on the whole been achieved and after which death may be understood as sad, but acceptable.

Setting limits on two levels:Public policy and clinical practicePublic policy:

1. Find antidote to high-tech medicine.

2. Provide security to poor elders and other subgroups not receiving care: women, minorities.

3. Reset priorities to preventive medicine, treatment of chronic disease, and long-term care, and in general to allowing people to live out a natural life span.

Setting limits on two levels:Public policy and clinical practice (cont’d)Clinical practice:

1. After a person has lived out a natural life-span, medical care should no longer be oriented to resisting death.

2. Provision of medical care for those who have lived out a natural life-span will be limited to relief of suffering.

3. The existence of medical technologies capable of extending the lives of the elderly who have lived out a natural life-span creates no presumption whatever that the technologies must be used for that purpose.

Callahan’s criteria for withholding or withdrawing treatment.

1. Inability to relieve pain and suffering.

2. Disproportionate burden of treatment.

3. Inability to restore or maintain quality of life.

Should doctors ever assist in death?

What role should government play here?

The case of Teri Schiavo.

I will be the first to object to any effort to deny life extending care before the other reforms [the three policy initiatives] are well under way and assured of success.

Daniel CallahanSetting Limits, p. 148.

…a sanctioning of mercy killing and assisted suicide for the elderly would offer them little practical help and would serve as a threatening symbol of devaluation of old age…I want to be clear about my argument here…I oppose it.

Daniel CallahanSetting Limits, p 194.

Rationing by age is not desirable in many respects, but it is far more desirable than any other solution that has been offered.

Daniel CallahanSetting Limits, p. 200.

Medicare politics is now transparently a battle of ideas about the role of markets and government in public policy. This is, in many respects, the same debate held in the 1950’s and 1960’s before Medicare’s enactment, replete with the same sharp partisan cleavages, high visibility politics that reach into national elections, a broad scope of conflict, and an engaged public. The new politics of Medicare is an echo of the past. As a consequence, after 37 years of policy innovations, political upheaval, changing economic circumstances, and a radically altered health care system, Medicare politics is back to where it started.

Jonathan Oberlander (2003)The Political History of Medicare

http://content.nejm.org/cgi/content/full/360/4/e5/DC1

Costs: Age vs. TD model

Taxes: Age vs. TD model

From Miller, T. (2001). Increasing longevity and medicare expenditures.