The Greenwall Foundation
The 2000 Oscar M Ruebhausen Essay Award Winner
Distributing the Gift of Life
by Lawrence Malkin
New York City
This
year, to my consternation, I attained the Biblical age of
threescore and ten, when my life is supposed to be rounded
off forever. Science now hints that in another twenty years,
when I reach 90, the age at which my mother died after a catching
a cold and drifting peacefully off to sleep, it may be able
to offer me double or quits. Even if I am promised relief
from the gouty miseries of age, will I have the energy and
desire to survive almost two hundred years of life? Selfishness
is the Darwinian law of survival of the species. The community
would have to support me far beyond its actuarial and social
expectations. How high a price is it willing to pay for believing
that life itself is an absolute value? The great religions
hold human life precious and inalienable except in the most
dire circumstances. In doing so they unwittingly join hands
with the life sciences, which are edging toward the belief
that death is a disease and not a defining condition of life.
Science
is once again promising to extend life and improve its quality,
but on a scale once imagined only as fantasy. Presuming to
alter the vital instructions sent by the human body's genes
to its cells would surpass the accomplishments of the great
public health scientists who purified milk, water, and food;
sterilized medical instruments, and isolated animal diseases.
Surely many more years have been added to life, and at lower
cost, by sanitation and vaccination than by all the high-technology
cancer cures and radio-imaging of the past half-century. The
one possible exception is antibiotics, now losing
their potency by indiscriminate use.
These
low-tech accomplishments also far surpass the way my sight
was saved in middle age through a cauterizing beam of light
focused on a tom retina by a laser, a true product of scientific
invention that was only fiction when I was a child. My most
terrible pains, those of a tiny, sharp, piece of calcium oxylate
gravel scraping its way along the thin tube leading from my
kidney, have been alleviated by chemical combinations that
were unimagined almost half a millennium ago by a fellow sufferer
named Montaigne. His reflections on these tortures of the
body gave rise to the literary form of self-discovery I am
employing here to consider my own mortality, just as he did
his. He concluded: " [Y]ou do not die of being sick;
you die of being alive." So did Shakespeare, that other
molder of modem personality, who wrote, "We owe God a
death."
Science now is not so sure of that debt. Dr. Michael Rose of the
University of California has extended the life span of fruit flies
from 80 days to six months by selective breeding of long-lived specimens.
"I am now working on immortality. It is an Einsteinian revolution
compared with what we used to do," he told Wired magazine, and he is far
from the only researcher to make such boasts. Six months of life for a fruit
fly is equivalent to 700 years for humans, but to test Dr. Rose's
techniques on humans would take 1,500 years. There is a methodological
flaw here somewhere, and perhaps something worse. Dr. Rose spoke as the
mapping of the human genome was opening the way to the substitution of
malfunctioning genes, or if the discredited concepts of eugenics are
revived, genes that are viewed as merely substandard. A sure sign of i
mminent but socially indigestible medical advance is the appearance of
quacks. Surf the internet and you will stumble on offers. Here is one
plucked at random from my e-mail spam: "Aging can now be reversed!!!
Turn back your body's biological clock 10-20 years."
Immortality,
if there is such a thing, lies in the gene, the transmitter
of the species, the software, as we would think of it today,
that is embedded in the hardware of individual bodies. Or
it lies in the ideas we leave behind, the operating systems
of civilization, the classical sense of moderation and limits,
the ideas of human rights, the objective methods of science.
Democracy means that society moves only at the speed it wants
to go, although utopian experts often think they know better.
We
now have at most a generation to decide whether to follow
the experts in the life sciences or to lead them. That is
an arbitrary but not unreasonable timetable. The history of
science records an ever-shortening gap between its theory
and application. More than three centuries elapsed between
Fibonacci's arrival in Italy with Arabic numbers and Galileo's
measurements of gravity and planetary motion. It took only
about 150 years for Newton's codification of the laws of motion
to help create an industrial revolution, and less than half
a century for Einstein's equation of matter and energy to
become a bomb that turned pure theory into destructive technology.
Sure enough, about the same amount of time elapsed between
Crick and Watson's discovery of the double helix inside living
cells and the detailed chemical analysis of that beautiful
pattern of life. And just as Einstein himself was in the forefront
of an awesome technological development--building an atomic
bomb in wartime was a matter of life and death--here is James
Watson fighting to ensure that the life-preserving aspects
of his great discovery are maintained for the widest possible
public good. So far, he has had only middling success.
Dr.
Watson acts as he does because there is no doubt that medicine
will be revolutionized by therapies modifying the chemical
structure of genes. I am thinking mainly about humans, not
com and cotton, or even livestock. The projected medical therapies
have no public mediating mechanisms equal to the food and
drug, truth-in-packaging, or environmental laws, however imperfect
these may be. Even the market itself can render adverse verdicts
on products that have been modified by the insertion of alien
genes. This lesson was learned by Monsanto, which was punished
for resisting attacks on its genetically modified seeds by
losing its independence as a company.
Privacy
laws can also be strengthened to prevent prying into human
genetic histories, and the litigious nature of American society
can restrain zealous researchers. At the University of Pennsylvania,
where an I8-year-old patient with a rare liver disorder died
in 1999 after experimental gene therapy, not only were the
academic and commercial researchers named in a civil suit,
but, uniquely, so was the university ethicist who advised
them; coincidentally he was also organizing a conference of
doctors and divines entitled, "Extended Life, Eternal
Life."
Demands
for the extension of human life regardless of cost pose a
more insidious problem than its creation; for many years more
than half of Medicare's resources have been spent during the
last six months of patients' lives with little study or public
debate. By contrast, the mere journalistic mention of cloning
babies for childless couples has provoked heated debate. Finally,
the enormity of cloning humans for slavery or their transplantable
organs (not domestic animals, which mankind has been breeding
for thousands of years), was so quickly recognized by governments
and scientists that it is as likely to become a reality as
a second Nazi state. That would imply a moral upheaval far
more generalized than anything emerging from a laboratory.
No,
the principal moral problems facing the life sciences today
are more subtle. They pose profound spiritual questions about
the nature of human life and our priorities for preserving
the humanity we already have before we reach out selfishly
for more of it, especially a favored few. Many problems arise
from ideologies with either no sense of the public good, or
those simply confused by the distinction between private and
public. In America, even the right-to-life movement has turned
its own arguments on their head by preventing all publicly
financed experiments with stem cells, thus abrogating public
surveillance of the raw material from unformed embryos that
may prolong life by developing into replacement cells for
failing body parts. In the American tradition, private business
has rushed in to fill
the vacuum in public policy with the reigning ideology
of the day, individual enterprise and the pursuit of profit.
Patents have replaced charity in the Pauline meaning of the
word, or at least its modem equivalent, the social solidarity
that once ensured care on the wards for the indigent sick.
A
national obsession with the individual has pushed America
so far from the idea of community that we refuse to spend
enough money to help poor children escape stunted lives when
this could be accomplished by the early application of the
simplest medical procedures and more careful nutrition. Public
priorities are essential because, as a free market British
health minister, Enoch Powell, once bemoaned when he insisted
on setting them, "The demand for health care is infinite."
In Europe the arc of life is considered to have a beginning,
a middle, and an end, like all tragedies. In America we spend
huge sums through publicly funded research programs to extend
the lives of less productive individuals like myself and bestow
great honor on people who perform miracles of medical science
as if they were witch doctors intent on enhancing their magical
aura.
This, to my mind, reverses the order of nature, but I have
heard few scientists protesting these priorities and can only
think back with anger at the activities of the nation's premier
organization of physicians during most of my lifetime.*
Under extreme pressure, the American Medical Association is
gradually changing its views on caring for those least able
to afford its services, but the moral challenge to the healing
professions remains largely unmet. Doctors take an oath to
Hippocrates, not Adam Smith. The principal problem of American
medicine is that they have tried to serve both. In the apt
phrase of the sociologist Paul Starr, doctors have squandered
"the cultural authority of medicine" by their inability
or outright refusal to organize their affairs for public purposes.
Consider where this is leading. Who would any longer concede
to committees of doctors the sole decision on which patients
are physically and psychologically resilient to be worthy
of heart transplants? Instead, hospitals now compete for the
business. The allocation of scarce medical resources has been
abdicated to the marketplace in America, and corporate medicine
has moved in quickly.
(*)
Saving the sight of my right eye cost my insurance company
only $200 in France, where I happened to be living, and about
ten times that to save my left eye when I returned home several
years later--and not because of any government subsidy in
France, but because of the more efficient organization of
medical resources. While no self-respecting hospital in America
is without a $100,000 laser on which it must make a profit,
the French medical system has half a dozen strategically placed
laser centers, operated full time by staff ophthalmologists.
American doctors fought to be paid for each zap of the laser
at the same rate as the far more complex eye surgery it replaced.
The Medicare administrators, whose services are the price
leaders in the field because laser surgery is performed principally
on older people, confided to me that they collapsed under
the political pressure of the medical lobby. When I wrote
an article about this, half a dozen readers wrote approving
letters, while about the same number of doctors wrote saying
that I didn't understand the system. I felt I understood it
all too well.
Imagine
the merger of a national health maintenance organization with
a major pharmaceutical company, formally tying up marketing
arrangements that probably exist already in practice. The
pharmaceutical company will have long since organized its
genetic medicine subsidiary to exploit the map of the genome
posted free on the Internet There are no prizes for guessing
which brands of medicine will be favored by the doctors contracted
to the HMO, or what kind of gene treatment their scientific
colleagues will be devising.
The
corporation, let's call it HealthPreservation Inc., consumes
research money at a ferocious rate searching for elusive human
versions of genes known as Silent Information Regulators,
or sir2,3, and 4, that supposedly control aging in
yeast. The company runs short of capital to develop new markets
and merges with a life insurance company whose motto once
was "The light that never fails." The new conglomerate,
offering standardized treatment, its own branded pharmaceuticals,
and a huge cushion of capital to crush smaller competitors,
changes its name to LifePreserver and adopts the appropriate
corporate logo. A
huge white circle shines arrogantly over Manhattan from its
skyscraper headquarters.
LifePreserver
offers a unique sign-up bonus: an analysis leading to replacement
therapy of the gene that regulates the liverâs secretion of
the protein ApoE. By
controlling cholesterol levels, this protein can help guard
against heart and circulatory diseases, and according to recent
research also seems to offer protection against Alzheimerâs,
diseases with an already known genetic predisposition. There
are several versions of this gene, and the best one is e2.
(Scientists know this from studying centenarians in France.)
But this lucky number is found only in ten per cent or less
of the population. Far more people carry e3 and e4.
These imperfect genes have little chance of being weeded
out by natural selection because their effects show up only
late in life, long after they have been passed on to their
descendants.
I
must confess that although my cholesterol is occasionally
high in my annual medical checkup, I get around it by not
eating butter the week before the test or breakfast on the
day. Let chance pick the date of my death; it did so when
I served as a soldier in combat. But LifeMaster will take
such matters far more seriously. Will it develop and patent
e3 and e4 replacement therapy for huge license revenues? Or will it concentrate resources on the corporate holy
grail of the sir genes to retard aging. These could
eventually make life insurance policies irrelevant, but not
before proving themselves over many years while the customers
dutifully pay premiums.
Thus
would cash flow almost comically help conceal some of the
fundamental problems corporate medicine raises about how society
will deal with longevity. The rising cost of health care, and the scandal of
those without a guarantee of it, is an old story in American
medicine. But in trying to stop human beings from wearing
out, scientific medicine is approaching its ultimate moral
test by literally putting a price on many additional years
of life. Even if cancer were eliminated, average human life
would be extended only two years, according to the biologist
Steven N. Anstad, and the end of heart disease would add only
three to five years. But think of doubling the span of life
by reversing the natural decline in the ability of living
cells to replace themselves. Not only would it challenge the Biblical wisdom that
there is a time to be born and a time to die, but it would
overturn the foundation of modem biology itself. For if Casanova
instinctively understood the link between sex and death, Darwinâs
theories proved it.
Two
sexes insert the excitement of chance. But when change becomes
the law of life, so does death, which, by the way, means that
cloning is actually a step backward from genetic modification
to genetic standstill. This may be a heavy dose of paradox
to swallow, but not after the purpose of sex is understood.
Sex inevitably means that life has no meaning without death.
What is the significance of a bacterium that replicates itself
by dividing into two equal halves? Not much beyond mere quantity:
the millions of bacteria that subsist--I will not use the
word live--in my mouth or armpits are not individuals. The
best that can be said about such beings is that, more than
an influenza virus but less than a spider. Two sexes permit
the combination of two different sets of genetic instructions,
and with mutations, perhaps one out of a million becomes new
and more advantageous for survival.
When
life depends on such serendipitous combinations, which some
believe are not determined by chance but by divine will, the
old and less advantageous members of the species are pushed
out of the way. I would argue that a soul is a unique sum of
experience and heredity, and as long as one's life cannot be
separated from one's inheritance, it is necessary to take account
of the rules of evolution. They include renewal, selection,
and the necessity of death at some point after the reproductive
mechanisms have done their work. Cell decay usually begins when
reproduction ceases, and almost all sexed species die when their
reproductive lives are complete, usually before. Human beings
are almost the sole exception.
To
replace the finality of death with the uncertainty of an extendable
life would cut away the foundations of our civilization, which
above all is based not on the immutability of ideas but on
their gradual change and increasing subtlety, often the result
of individuals contemplating their necessary end. What would
happen, for example, to the simple idea of equality if some
people were able to purchase the huge advantage of a doubled
life span?
The
extension of the human life span to, let's say, 150 or 200
years would turn all social calculations and even unspoken
intergenerational arrangements on their heads, from the actuarial
calculations of the Western world's social insurance programs
to the increasingly tense relationships between rich and poor
nations. Do I have the unlimited right to extend my life when
I know that others less fortunate will pay part of the cost
and probably not have the same choice? What is the responsibility
of the medical scientist who offers me that choice, heedless
of the cost to society? In the unprecedented scientific advances
of the past two centuries, one technological advance has always
managed to bailout another. Just when Malthus was predicting
that natural limits to food production would produce demographic
catastrophe, quite unbeknownst to him industrial productivity
in England was increasing tenfold or more, earning the country
money to import food. When the 19th Century microbe hunters
were lengthening lives, millions of broad backs were urgently
needed to farm grain and build the railroads which opened
the new lands of the American west and Argentina. In the second
half of the 20th Century, the green revolution helped feed
the unchecked numbers arising from advances in public health
and medicine.
All
this has brought the planet to the edge of habitability, with
a much closer margin for error than before. Researchers mesmerized
by the idea of extending life cannot assume that surplus populations
will be exported to Mars and Venus as easily as they once
were to the Dakotas and the pampas. More likely, population
densities in the advanced world will climb to the order of
those in India, Mexico, and the Han areas of China. The most
urgent scientific needs will be the delivery of simple care
to limit families and guarantee that young people can expect
a reasonable life span--not complex genetic substitutions
to ameliorate or even prevent civilized ailments like my kidneys'
imperfect metabolism of the waste products of rich food and
delicious wine.
Introduced
in a measured way, longer life spans enhance the order of
nature, but science has always moved faster than society.
Doubling the length of individual lives without careful social
preparation would stretch nature even more than it already
has in the past century of a hugely increased life span. Tremendous
stresses have already been placed on the planet's resources
by birth patterns that continued to accord with a short life
during which a child represented cheap labor for his parents
and security in their old age.
Evolution
gives each species, from slime to sponges to spiders, the
capacity to exploit a niche in nature. It cannot be seen in
one generation, only in ten or twenty or a hundred. Only a
few centuries ago, death at 40 was the normal, so it is likely
the human menopause is an attribute not yet overtaken by evolution.
It is easy to see why the older generation must eventually get out
of the way or be pushed. Assimilating new knowledge without
radical changes in outlook and behavior is rare for mature
people at any age. Grandmas have a certain utility in teaching
and nurturing the young, yet even they tyrannize their daughters
and especially daughters-in-law. But grandpas have less. Their
minds are usually focused in the past, which can serve as
a useful anchor to a society in a storm, but an anchor nevertheless.
Elders
in authority can frustrate the intellectual exploration of
the young, which includes the freedom to be wrong but also
to upset the ossifying theories upon which reputations rest.
Consider the conservatism of faculty chairmen, protected by
a perverse application of the age discrimination laws, who
refuse at 70 or beyond to step down from committees that often
refuse preferment to the inventive and questioning young.
Or the autocrats who run their own companies into the ground
by refusing to step aside as the world changes around them.
In a family, consider a 150-year-old great-great-great-great
grandparent with all faculties engaged, sitting on a sizable
accumulation of wealth and authority and dominating a clan
of intelligent and restless descendants who are as distant
from him as, say William McKinley is from us. A more timely death would be better for everyone, and
surely for the species and society as a whole.
The
individual knowledge that there is an end to life colors and
defines every act because everyone knows there are physical
limits to the time of childbearing, to muscular strength,
to the number of times anything can be tried again. The very
fact that we grow older implies fewer chances to do things
over. Each attempt counts more heavily because we know that
one of them will be the last. Infinite possibility is no possibility;
infinite chances at the wheel mean that at some point, it
is bound to turn your way. Life without a foreseeable end
is not life as we know it.
I
have an unscientific proposal for those constructing this
latest population time bomb. Let the rule be that with every
life-giving advance they discover, no patent will be granted
without an accompanying arrangement to ensure that the benefits
are equitably distributed, which is hard enough, and that
the community also agrees to finance the additional life it
has created. Otherwise let the beneficiary himself pay the
full social cost. Those whose lives are extended first will
of course be the richest, and therefore able to underwrite
their extra years. That is the market principle by which our
society works. But
once death is defined as a disease, how man sufferers
will demand at least a temporary cure, and then come back
for more? Will doctors get rich by charging by the additional
year, as they now charge by the hour? Or will the secret eventually
be wrested from their grasp and given to everyone, with unimagined
social consequences?
This
is not a Luddite appeal to halt the exciting scientific quests
now underway. Given their therapeutic potential, it is unnecessary
and in any case would be impossible. But creation is bliss
for lovers, artists, and for scientists as well, and I am
merely making a suggestion to the researchers to pause and
think about unintended consequences. Engineering teams now
must submit their designs to cost-benefit analysis as well
as traditional stress tests; why not genetic engineers? Otherwise
creators can become destroyers.
When
I reach 90, I am certainly not thinking of throwing myself
on the funeral pyre in a kind of suttee to the younger generation,
to whom I have already given my share in educating my children.
Nor am I thinking of sacrificing myself to the greater glory
of the race. But I do hope to avoid the arrogance of considering
immortality and to embrace the natural order of things. In
a secular age, we no longer owe God a death. We owe it to
ourselves.
Endnotes:
"[Y]ou do not die of being sick..." "Of Experience," Michel de Montaigne.
Selected Essays, trans. by Donald M. Frame, D. Van Nostrand Co. Princeton, 1943
Suit against the University of Pennsylvania. "Ethicist Included in Suit Over Fatal Gene Test,"
Washington Post article in the International Herald Tribune, Sept. 20, 2000. Conference on
"Extended Life, Eternal Life." "Whose Right to Extend a Life?" The Philadelphia Inquirer,
March 6, 2000
Dr. Michael Rose. "Don't Die, Stay Pretty," by Brian Alexander, Wired Magazine,
January, 2000. Dr. Rose is also one of several scientists cited in "The Clock of Ages," by
Dr. John J. Medina (Cambridge University Press, New York 1996, p. 312-13) asserting that
the principal limitations to much longer life now are essentially technological.
Stem cells. "The Recycled Generation," by Sacha Waldman, New York Times Magazine,
Jan. 30, 2000.
"Published an article..." (footnote). "A Tale of Two Eyes: My Controlled Experiment in Health
Care Costs" by Lawrence Malkin, The New Republic, Sept. 4, 1989.
"The cultural authority of medicine." By far the most comprehensive history of the selfishness
of the medical establishment may be found in "The Social Transformation of American
Medicine," by Paul Starr, Basic Books, New York , 1982, which was justly awarded a
Pulitzer Prize.
Silent Information Regulator genes. "Searching for Genes That Control Aging," New York Times
article in the International Herald Tribune, Sept. 28, 2000.
ApoE gene. "How We Age," by
Steven N. Austad, John Wiley, New York, 1997, p. 101-2.
Cancer and heart disease eliminated. Austad, p. 14. Faculty refusing to retire. "Death in
Tenure," by James Shapiro, University of Chicago Magazine (reprinted from the Chronicle
of Higher Education), Summer, 2000.
Honorable Mentions
Peter D Baird, Phoenix, Arizona
Sven Birkerts, Arlington, Massachusetts
Anne Finger, Oakland, California
Judges
Roger Rosenblatt (Chair)
Andrew Delbanco
Martin Marty
Gayle Pemberton
Robert Wright
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