III. SOCIETAL AGING

A society is said to age when its number of older members increases relative to its number of younger members. The societies of the United States and of many other industrialized nations have been aging since at least 1800. In 1800 the demographic makeup of developed countries was similar to that of many Third World countries in the early 1990s, with roughly half the population under the age of sixteen and very few people living beyond age sixty. Since that time, increases in life expectancy, combined with declines in fertility rates, have dramatically increased the proportion of older persons in developed nations. By contrast, the age profile in many Third World countries is still heavily weighted toward younger age groups, even though the increase in actual numbers of old people is even greater in many developing countries than it is in the developed world. What future societies will regard as distinct about population aging in the twentieth and twenty-first centuries is the rapid pace at which it is occurring. Since 1900 the percentage of Americans sixty-five and over has become eleven times more numerous (from 3.1 million in 1900 to 35.0 million in 2000). The fastest growth has occurred among the oldest old. Thus, in 2000, the group aged sixty-five to eighty-four (18.4 million) was eight times larger than in 1900, but the seventy-five to eighty-four age group (12.4 million) was sixteen times larger, and those over the age of eight-five (4.2 million) were thirty-four times larger (Administration on Aging).

During the last century or more that population records have been kept, women's life expectancy has always exceeded men's (Cassel and Neugarten). Although at younger ages there are more men than women, by old age women far outnumber men (Cassel and Neugarten). In 2000 there were 143 women for every 100 men sixty-five and over. Sexbased disparities increase with age. The ratio of older women to older men ranges from a low of 117 to 100 for persons sixty-five to sixty-nine, to a high of 245 to 100 for those eighty-five and older (Administration on Aging). Although demographic predictions have sometimes been proven wrong by subsequent facts, demographers in the early twenty-first century predict this sex differential will increase until the year 2050, at which time it will level off; but before it does, there will be only 38.8 men per 100 women aged eighty-five and over.

Ethical Implications

The rapid increase in the number of older persons relative to younger ones carries important implications for society. In the area of healthcare, societal aging will increase costs and exert greater pressure to ration services. It will thus bring to the fore questions regarding a just distribution of healthcare between young and old. The population's aging will also alter the nature of health services by increasing the number of patients who have chronic and disabling conditions that are not life threatening. This, in turn, will change the face of bioethical debate, from a focus on acute life-and-death medical decisions made at a particular instant in time, to an emphasis on ongoing and often relatively mundane problems spanning many years. Finally, societal aging portends changes for family life. Already, the imbalance between young and old is placing strains on offspring who undertake care-giving responsibilities and is prompting questions about the scope and limits of filial duties. To the extent that family members play an increasing role in elder care, their role in healthcare decision making is a significant and vigorously debated question.

HEALTHCARE RATIONING. The aging of society will increase healthcare expenditures simply because persons over the age of sixty-five consume far more healthcare than other age groups do. In the United States, persons sixty-five and over account for roughly 12 percent of the population but utilize one-third of the country's total personal healthcare expenditures (exclusive of research costs). In an era of fiscal constraints, this makes the elderly an obvious target for healthcare rationing. The financial savings that would accrue if the elderly were disfranchised from various forms of healthcare is disproportionately high, because the elderly are more frequent utilizers of healthcare. According to one estimate, if those over the age of fifty-five were excluded from treatment for renal disease in the United States, 45 percent of the costs of the renal-disease program would be saved. In many other areas a large financial saving could be achieved through excluding elderly persons.

Arguments supporting age-based rationing and the shifting of scarce resources from old to young groups have been advanced by Daniel Callahan, Norman Daniels, Richard Lamm, and Samuel Preston, among others. Callahan, for example, proposes rationing publicly funded life-extending care based on old age. Such a proposal might be implemented once society comes to accept the idea that "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 beyond that point" (Callahan, p. 137). Both Lamm and Preston favor directing fewer resources to older age groups and more to younger persons as a necessary condition of meeting duties to younger and future generations. They maintain that unless society limits healthcare expenditures for the old, it will eventually impoverish health services and other social goods for the young. Finally, Daniels urges one to think about justice between the young and old from a first-person point of view. According to him, when we succeed in viewing our lives as a whole, rather than from a particular point in time, it will sometimes be prudent for us to prefer a healthcare plan that distributes fewer services to our old age in exchange for more services earlier in life.

Critics of age-based rationing object, for example, to the implications of age-based rationing for women (Jecker, 1991); to the violation that age-based rationing implies of the moral thrust of both Judaism and Christianity (Post); and to the message that age-based rationing conveys about the meaning and worth of the lives of aged persons (Murray). Finally, critics cast doubt on the prediction that agebased rationing would yield large financial savings in healthcare expenditures. They point out that the amount of money that would be saved by old age-based rationing would be negligible if these dollars were simply spent elsewhere in the healthcare system.

LONG-TERM CARE. In addition to increasing healthcare expenditures, societal aging will increase the number of disabled persons and the need for long-term care, including adult day care, in-home services, and care in resident facilities, convalescent homes, and intermediate and skilled nursing facilities. Several factors will contribute to a greater need for long-term care. First, the ratio of older women to older men is expected to increase, and older women experience a greater incidence of morbidity and disability than older men. Second, the population over age eighty-five constitutes the fastest-growing age group in the population, and this group is also the heaviest users of long-term care. More than 70 percent of those eighty-five and over require some kind of assistance with one or more activities of daily living. Finally, fewer offspring will be available to serve as informal caregivers for future generations of elderly persons. This is because individuals are having fewer children than previous generations did, and greater numbers of women are joining the paid labor force.

The growing need for long-term care raises social and policy questions concerning the just allocation of funds between acute hospital care and low technology supportive services for chronic disabling conditions. In addition, it alters the nature of clinical ethical cases by changing the sorts of decisions faced and the age, gender, and health profile of the affected population. According to Harry R. Moody, bioethical analysis has tended to emphasize a principle of individual autonomy and respect for persons' self-determination. Yet this principle begins to break down as the patient population becomes increasingly geriatric, increasingly dependent, and increasingly disabled. In this environment, it is argued, the ideals of human dignity and self-respect, ideals that are intimately linked to human relationship and community, will assume greater significance. Yet others suggest, to the contrary, that the values of autonomy and privacy must retain their central importance because such values are inextricably linked to assuring a good quality of life in old age.

FAMILY RELATIONSHIPS. The rapid aging of society will reshape relationships within the family as parent-child relationships extend over many more years and pose new challenges in later life. Although most agree that parents undertake special duties toward offspring, there are different opinions as to whether grown children have corresponding duties toward aging parents. For example, Jane English denies that adult offspring owe their parents anything by virtue of being their offspring. Instead, she defends the idea that "the duties of grown children are those of friends, and result from love between them and their parent, rather than being things owed in repayment for the parents' earlier sacrifices" (English, p. 147). Others object to special duties of any form, whether founded on friendship, filial status, citizenship, or other bases. The favoritism implied by special duties is sometimes considered logically or psychologically at odds with the ethical requirements of impartiality and equal respect for persons. Still others object, on justice grounds, to the disproportionate share of caregiving borne by women.

On the other side of this debate are those who defend special duties. Various underpinnings for adult children's responsibilities toward aging parents have been offered, including gratitude, reciprocity, and duties to the vulnerable.

Historical and Cultural Perspectives

An aging society, defined as a society in which the population of older individuals is increasing relative to the population of younger individuals, presupposes that individuals can be separated into meaningful categories of old and young. Although contemporary Western society tends to conceive of youth, adolescence, middle age, and old age as unique life stages with distinct sets of problems, this perspective is hardly universal. Indeed, present conceptions of the life course are a relatively recent phenomenon. Thomas Cole traces the metaphor of life's stages to the cities of northern Europe in the sixteenth and seventeenth centuries, where the current life-stage metaphor first emerged. Picturing life as a series of ordered stages represents the life course as in conformity with the order of the universe and makes it possible for every individual to "step outside of his own life experiences and view it as a whole" (Cole, p. 25).

Just as society's recognition of aging reflects historical and cultural traditions, so society's beliefs about the meaning and value of old age bespeak historical and cultural heritage. The social rank of elderly persons varies during different historical and culture periods, depending upon the perceived cost of supporting older age groups and the contribution they are thought to make (Amoss and Harrell). For example, the Akamba people of Africa believe that "the older a person becomes, the more intricately interwoven that person becomes in the lives of others, and the greater the damage done if that person is removed. At the same time, the older person has wisdom—a perspective on life that comes only with age—which is considered to be a particularly important social resource" (Kilner, p. 19). By contrast, U.S. society has traditionally valued "pragmatism, action, power, and the vigor of youth over contemplation, reflection, experience and the wisdom of age" (Butler, p. 243); hence, ageism (age discrimination) is especially evident in U.S. society.

Despite different cultural conceptions of aged persons and their role in society, anthropologists identify common biological and cultural features of aging. Thus, every known society has "a named category of people who are old—chronologically, physiologically, or generationally. In every case these people have different rights, duties, privileges, and burdens from those enjoyed or suffered by their juniors" (Amoss and Harrell, p. 3). This suggests that people in culturally distinct societies may face similar ethical questions concerning relationships among people of different ages.

nancy s. jecker (1995)

revised by author

SEE ALSO: Chronic Illness and Chronic Care; Future Generations, Reproductive Technologies and Obligations to; Healthcare Resources, Allocation of; Human Dignity; International Health; Justice; Life, Quality of; Long-Term Care; Natural Law; Population Ethics; Right to Die, Policy and Law; Women, Historical and Cross-Cultural Perspectives; and other Aging and the Aged subentries

BIBLIOGRAPHY

Administration on Aging. 2001. A Profile of Older Americans: 2001: The Older Population. Washington, D.C.: U.S. Department of Health and Human Services.

Amoss, Pamela T., and Harrell, Stevan, eds. 1981. Other Ways of Growing Old: Anthropological Perspectives. Stanford, CA: Stanford University Press.

Butler, Robert N. 1969. "Age-Ism: Another Form of Bigotry." Gerontologist 9(3): 243–246.

Callahan, Daniel. 1987. Setting Limits. New York: Simon and Schuster.

Cassel, Christine K., and Neugarten, Bernice L. 1988. "A Forecast of Women's Health and Longevity: Implications for an Aging America." Western Journal of Medicine 149(6): 712–717.

Cole, Thomas R. 1992. The Journey of Life: A Cultural History of Aging in America. New York: Cambridge University Press.

Daniels, Norman. 1988. Am I My Parents' Keeper? An Essay on Justice between the Young and the Old. New York: Oxford University Press.

English, Jane. 1991. "What Do Grown Children Owe Their Parents?" In Aging and Ethics: Philosophical Problems in Gerontology, ed. Nancy S. Jecker. Clifton, NJ: Humana.

Foner, Nancy. 1984. Ages in Conflict: A Cross-Cultural Perspective on Inequality between Old and Young. New York: Columbia University Press.

Jecker, Nancy S. 1991. "Age-Based Rationing and Women." Journal of the American Medical Association 266(25): 3012–3015.

Jecker, Nancy S. 2002. "Taking Care of One's Own: Justice and Family Caregiving." Theoretical Medicine 23: 117–133.

Kane, Rosalie A., and Caplan, Arthur L., eds. 1990. Everyday Ethics: Resolving Dilemmas in Nursing Home Life. New York: Springer.

Kilner, John F. 1984. "Who Shall Be Saved? An African Answer." Hastings Center Report 14(3): 18–22.

Lamm, Richard D. 1987. "Ethical Care for the Elderly: Are We Cheating Our Children?" In Should Medical Care Be Rationed by Age?, ed. Timothy M. Smeeding, Margaret P. Battin, Leslie P. Francis, et al. Totowa, NJ: Rowman & Littlefield.

Meyers, Diana T.; Kipnis, Kenneth; and Murphy, Cornelius F., eds. 1993. Kindred Matters: Rethinking the Philosophy of the Family. Ithaca, NY: Cornell University Press.

Moody, Harry R. 1992. Ethics in an Aging Society. Baltimore, MD: Johns Hopkins University Press.

Murray, Thomas. 1991. "Meaning, Aging, and Public Policy." In Too Old for Health Care? Controversies in Medicine, Law, Economics, and Ethics, ed. Robert H. Binstock and Stephen G. Post. Baltimore, MD: Johns Hopkins University Press.

Post, Stephen. 1991. "Justice for Elderly People in Jewish and Christian Thought." In Too Old for Health Care?, ed. Robert H. Binstock and Stephen G. Post. Baltimore, MD: Johns Hopkins University Press.

Preston, Samuel H. 1984. "Children and the Elderly in the U.S." Scientific American 251(6): 44–57.

Smeeding, Timothy M.; Bettin, Margaret P.; Francis, Leslie P.; et al., eds. 1987. Should Medical Care Be Rationed by Age? Totowa, NJ: Rowman & Littlefield.