My father passed away on 28th March 2008, having crossed his 90th birthday milestone a few months previously. In the weeks before and after his demise, I used this fact as a consolation. Not that it is a very effective palliative: the loss of a parent, at any age, has a huge impact on everyone. But this ties in with the bromide,” He lived a full and long life”. The counter-question,” Why not longer?” is answered by pointing to the infirmities of extreme age: the loss of teeth, strength, memory, mobility, almost everything – to various degrees. There are remarkably few individuals who manage to hang on to their abilities till their dying day. In fact, with the increasing incidence of Alzheimer’s disease (one in three?) amongst the very old, the loss of memory practically translates to a horrifying loss of identity. In his last years, my father could recognize his wife of 50 years standing only intermittently. In his last three years, he stopped reading, and he spoke very seldom, with great difficulty, and whether he knew who he was at the end, would be difficult to ascertain. There are incidents of people who have been in coma recovering miraculously after even longer than a decade. Even people with Alzheimer’s can remember who they are, in intervals of lucidity. Memory remains a mystery, and the essence of our individuality is deeply entangled with our ability to remember.
At this point, a caveat is in order. Why should one assume that a long life is better than a short one? Because more is better? We mourn those who die young, because we feel that they could have experienced and achieved so much more, had they lived. But a long life may just as well have been a fruitless quotidian passage from womb to tomb. In the words of the Beatles, a ‘nowhere man’ who lives long would impact nothing and nobody, and his passing on would not be missed or even noted. There are many who have achieved glories in their youth, and nothing whatsoever later. On the other hand, it would be narrow-minded and immoral to deny a long life to someone merely because they did not do anything of import. What goes on in the private universe of any person, whether ‘normal’ or mad, gifted or retarded, is inaccessible. We cannot evaluate what we cannot know – but we cannot, on those grounds alone, dismiss them. If one accepts this argument, then one must strive to lengthen any life as much as possible.
Under what conditions would we stop this effort? The arguments for and against euthanasia are complex and fraught. If the person concerned is in immense pain and wants to end such a burden, most of us would accept it as a just demand. But if the person is unconscious or not capable of communication, what does one do? Such a judgment is enormously difficult and painful. On the other hand, should one resort to such extreme measures as connecting a dying person to a heart-and-lung machine? One can keep somebody ‘alive’ almost indefinitely…like Ariel Sharon, for example. The argument against ‘unnatural means’ is not a strong one, since all medical interventions could be described as ‘artificial’. However, the consensus seems to be that such interventions are justified – if there is a reasonable chance of recovery after the ventilator is (at some point) disconnected. For very old people who are already into multi-organ failure (as my father was) it may not make sense – although, admittedly, a tough decision is involved even here.
For a believer in religion, accepting death is easier than for the agnostic, and the position of the atheist is the worst. The ideas of a supernatural entity and an immortal soul have tremendous appeal and resonance. As an agnostic, I am denied the comfort of knowing that my father lives on somewhere, somehow. I have to rescue his soul by arguing that we live on in the memories of others, albeit in a scattered kind of way: in gestures, words, beliefs, dreams that are passed on from one generation to the next. But this is paltry comfort, straws that we clutch in desperation, in comparison with the deluded (?) certainties of the religious believer.
Nevertheless, one should not underestimate the power of memories. A few years ago, I was walking with my father in the park, and I remember that he said that we should walk carefully to avoid killing ants on the path. I replied that this was impractical, since one could not even see the small ants. Often when I go for a walk in the park, I remember my father’s lesson in nonviolence, and try not to step on the ants that I can see…
To return to my starting point: that my father just made it to the exclusive club of nonagenarians. Like any scientist, I find my comfort in numbers. In this case, the numbers say that about 0.6% of Indians cross 80 years [1], and about 0.25% of India’s population makes it past 90 years. This compares with about 2.9% octogenarians in the US. Worldwide about 1.1% of the population is categorized as ‘the oldest old’ (more than 80 years of age), of whom 88.8% are octogenarians, 11% are nonagenarians and 0.2% are centenarians [1]. So my father was a lucky man. Particularly, it is well known that women live longer on an average than men (the weaker sex!) by roughly 7-10 years (provided that adequate access to health- care prevents their dying during child-birth). Consequently there are more women than men among nonagenarians by a factor of about 3:1. The number of centenarians is extremely low (e.g. about 250 per million in Japan today, around 140 per million in the US and about 75 per million worldwide) [2]. This ties in with the observation that, past the age of 30, the probability of dying doubles (roughly) every 8 years. A recent definition is that you are young as long as your probability of dying is less than 1% per year; middle-aged as long your probability is less than 3%; and old when your probability crosses 3%. After you cross 90 years – which is in itself difficult – with every passing year the probability of dying increases. The number of super-centenarians (those who cross 110 years of age) is extremely low: not more than 450 worldwide; only one in a thousand centenarians becomes a super-centenarian. And the gender gap only increases with age: women centenarians outnumber men by a ratio of about 9:1.
The actuarial tables are pretty accurate for all but the oldest old. One of the interesting laws is the Makeham-Gompertz law of mortality: the term attributed to Makeham is age-independent, while the Gompertz term is age-dependent. Gompertz studied the mortality of animals and observed that the logarithm of the age-specific death rate increases linearly with time: ln[- (1/N)(dN/dt)] = C + Bt [3]. For man the age-specific mortality rate doubles every eight years. This explains why there are so few centenarians, and orders of magnitude less super-centenarians. Some biologists attribute the Gompertz law to the specifics of damage to cells, growth of tumors, etc.
Scientists have observed that typically men die of their diseases (heart attacks, stroke, cancer etc), while women live with theirs (arthritis, osteoporosis, diabetes etc)[4]. About 25% of the causes of death are genetic [5] based on studies of identical twins, the rest are lifestyle-related. The gender gap seems to be narrowing, with more women taking up highly stressful work lives – in addition to their housekeeping, child-bearing and rearing roles. Whether the average person drinks, smokes, exercises, or eats her vegetables adds or subtracts five to ten years to or from her life (according to Thomas Perls of Harvard Med School & Ruth Fretts of Boston Beth Israel), while the extra 30 years needed to become a centenarian require special genes to avoid heart disease, cancer, strokes, Alzheimer’s, etc. – that mostly reside with women. So gerontologists perforce study women! It also seems to help to live in some special ‘hotspots’ like Okinawa (more than 400 centenarians per million!), Barbados, Costa Rica, etc that have a healthier environment than the rest of the ‘developed’ world. The medical community has made a lot of noise about the advantages of taking vitamin supplements and antioxidants, but recent studies (that need to be replicated) suggest that supplements of Vitamins A, E and beta carotene either confer no advantage or increase mortality by ~10% [6].
My mother is eighty – and she is highly skeptical of the advantages of a long life. She feels that the deterioration that sets in after about 70 is far too much to justify ‘carrying on’. Bryan Adams dreams of being ‘eighteen till I die’ but such a vision is far from being attained, if at all it is possible. Theories of aging range from the ‘error theory’ to the idea that it is all down to ‘inflammation’[7,8], but it is likely that there is no single magic bullet that will make us all into Methuselahs. And a good thing it is too, since the world is already overpopulated! Nevertheless, people will continue to imagine that a longer life would allow them to fulfill their dreams. Some scientists [9,10,11] predict that the day is not far off when we will be able to upload our memories onto computers, clone ourselves, and download our selves onto our clones, thereby achieving ‘immortality’ (or, at least, as close to immortality as is theoretically possible). Of course, the process is not likely to be glitch-free and is, in any case, reasonably far in the future (our children may benefit from these technologies). At present, we will just have to manage our memories as best as we can.
A somewhat different perspective can be seen in Sogyal Rinpoche’s, “The Tibetan Book of Living and Dying”. I have not read it yet (although I bought it years ago), but I just read a review in today’s Hindu by E.S.Krishnamoorthy and Niranjana Bennett (1st June 2008). Rinpoche’s Buddhist perspective is deeply spiritual, and rests upon ideas of rebirth (which I find difficult to believe), but he discusses our avoidance of the idea of death, and a need to accept death, and emphasize the dignity of the individual, in an atmosphere of meditation. I wish to read this book, but I have doubts about the value of meditation in patients with Alzheimer’s or the possibility of meditation when the person is in pain. Still, the compassion that one associates with the Buddhist ethos inspires a feeling of respect, and it would be unwise to comment without a sincere effort to understand.
1) http://www.un.org/NewLinks/older/99/older.htm
3) http://en.wikipedia.org/wiki/Benjamin_Gompertz
4) http://www.hno.harvard.edu/gazette/1998/10.01/WhyWomenLiveLon.html
5) http://www.brighamandwomens.org/Pressreleases/PressRelease.aspx?PageID=341
6) http://www.cbc.ca/health/story/2008/04/16/antioxidants-study.html
7) http://longevity.about.com/od/longevity101/a/why_we_age.htm
8) http://www.oprah.com/presents/2005/young/life/life_aging.jhtml
10) http://home.earthlink.net/~davidlperry/clone.htm
11) http://www.wie.org/j30/kurzweil.asp
From Ref.4:
The researchers estimate that a 70-year-old man who did not smoke and had normal blood pressure and weight, no diabetes and exercised two to four times per week had a 54 percent probability of living to age 90. However, if he had adverse factors, his probability of living to age 90 was reduced to the following amount:
- Sedentary lifestyle, 44 percent
- Hypertension (high blood pressure), 36 percent
- Obesity, 26 percent
- Smoking, 22 percent
- Three factors, such as sedentary lifestyle, obesity and diabetes, 14 percent
- Five factors, 4 percent
