Ed i to r ia l

Death is not the major problem – it is ageing and disability

There is one thing that is certain in life – it is that

we will all eventually die. Although we constantly

strive to put it off far as long as possible, the end

will always arrive one way or another. Great effort

and large sums of money are spent in trying to

prolong life by the use of multiple medications and

technology but all of these have consequences. In

many instances, there is now no longer a clear

distinction between living and dying. Different

parts of the body and mind die at different times

and as the ability to ‘resuscitate’ brain function

comes within our grasp, this will become even

more of a problem. It then raises clear moral and

ethical issues with regard to the definition of life or

death and how one distinguishes between these

two states. Also it increases the level of responsi-

bility on those who have to make that decision for

individuals in their care.

In May of this year there is going to be a major

symposium involving neurologists and philoso-

phers who are going to try and produce a definition

of death. As we all know, there are medical devices

that can keep our lungs breathing and our hearts

beating even if the brain has suffered extensive

damage. This raises the real issue as to whether we

should be considered as dead if our brain is dead.

It could be argued that destruction of the frontal

part of the brain and essentially the ‘personality’ is

enough to declare that someone is dead, even if

there is enough brain function to retain function of

the heart and lungs. Unfortunately another group

suggest that the heart must stop before someone

can be considered dead. At present the law revolves

around the fact that a person can only be declared

dead if almost all the brain is irreversibly destroyed

or non-functioning. This also raises the issue

regarding organ donation as they can only be

removed when someone is declared dead. The

present regimen is such that a person is supported

on ventilators while the organs are removed, but if

the second definition is adapted, serious problems

arise regarding the viability of the donated organs.

Recent studies have shown a greater understanding

of the self repair mechanisms of the brain and the

potential to induce this process by various drug

therapies or by transplanting of regenerated neural

tissue into the damaged areas. However, it has even

been suggested by researchers in this field that

these individuals may not in fact be the same per-

son as they were before due to potential differences

in personality brought about by the ‘new’ brain

tissue and regenerated pathways. Finally, it has

been suggested that individuals should be able to

define their own definition of death but this would

present enormous difficulties to those who would

be the final arbiters of life.

It was once believed that humans had a defined

lifespan beyond which we could not go even with

the help of medical science and technology. How-

ever, that does not appear to have occurred and the

average life span has increased by over 2 years per

decade over the last century. This presents enor-

mous problems for society with the latest forecasts

suggesting that there will be one million people

over 100 years old by 2074. This is something that

seems almost too great to grasp or to understand

the consequences for the lifestyle of the 21st cen-

tury. The key issue, which has been discussed on

many occasions by individuals working in this field,

is that although life expectancy has increased,

healthy life expectancy has lagged behind signifi-

cantly. This results from people surviving chronic

diseases but not being able to slow the ageing

process. Nearly 30 years ago, researchers in Stan-

ford University School of Medicine predicted that

the diseases and disabilities of ageing would be

compressed into a short period before death, as

average lifespan approached maximum lifespan but

this has so far proved not to be the case. In fact,

most of the evidence would seem to suggest that

the reverse is true. There has been a significant

increase in degenerative diseases such as cancer,

cardiovascular and neurological diseases and

chronic diseases such as osteoporosis, diabetes and

arthritis as well as being deaf, blind and having

limited mobility. The latest estimates suggest that

the number of people with Alzheimer’s disease in

the US will rise to 12.5 million by 2050, 74% of

those over 80 will have a disability and a quarter of

those over 85 will be depressed. Many medical

colleagues suggest that all they have in fact done

with the progress in medicine is to turn many of

the disease processes from acute to chronic rather

than actually curing them. So instead of previously

dying, individuals survive but with every chance of

living with a poorer quality of life. Recent evidence

from research in Manchester, UK has indicated that

brains infected with the herpes simplex virus, HSV-

1 saw a rise in a protein linked to Alzheimer’s

disease and this supports previous work which

established that the virus was found in up to 70%

of these patients. It has also been found to be linked

� 2008 The Author

Journal compilation � 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25: 1–2 1

to those who carried a mutant gene, ApoE4, which

is involved in the breakdown of fats in the body.

Another line of research in the same field has

found that the injection of etanercept into the spine

at the level of the neck seemed to deliver almost

immediate effects in relieving symptoms. However,

the fact remains that with current progress, most

people are likely to live to 100 years but could

stand up to a 50% chance of suffering with

dementia before they die. The consequences of

such a situation have not been considered by

society as a whole but a key factor must involve

research into the ageing process itself and the

diseases of ageing not merely attempting to pro-

longing life. Closer to home, there have been some

new projections of population demographics in

Scotland. These show that over the next 25 years

the number of people over 75 will increase by

81% but in some areas this could be as much as

156%, presenting very significant problems to local

communities.

Longer life spans will present society with major

moral dilemmas. It could be suggested that two

possible situations could develop: one where

people live longer but with chronic disease and

disability or ageing research allows people to sig-

nificantly expand their functioning well-being to

much later in life. The greatest likelihood is that a

composite of both will be the norm, but that does

change the issues. In the former, serious decisions

will need to be taken regarding societies ability to

support these individuals and to maintain their

quality of life and more importantly to give them

the choice as whether to continue living or not.

Some European countries have already crossed that

final barrier. Questions will arise as to whether

the global situation will be sustainable and this

discussion is already exercising scientists and

politicians. Philosophers have pointed out that we

already debate contraception, abortion, cloning and

embryonic stem cell use on the one side and

euthanasia, withholding life support, electing not

to resuscitate, and post-operative quality of life on

the other. In an attempt to control its population,

China decided to restrict the number of children

that couples could have, but this has lead to the

situation where there are 39 boys for every girl at

primary school. Unfortunately, many compromises

have been made but few decisions have been taken;

perhaps because our own lives are intimately

bound up with survival at all costs. We seem to

have drifted into a mind set possibly supported by

the developments in science and medicine that we

are not meant to die, let alone merely slow down.

One question that has often stretched the minds

of scientists and philosophers is how it feels like to

die. Nobody really knows the answer but we now

have a better understanding of what goes on in

those last few moments. Ultimately, it is usually the

lack of oxygen to the brain whether as a result of

suffocation, heart attack or drowning. When the

oxygen stops, it takes about 10 seconds to lose

consciousness but probably the final moment of

death may take substantially longer. Large studies

of people who have suffered a cardiac arrest show

that the first 4 minutes is critical and 50% may

survive. After about 15 minutes, many of our cells

go into self destruct mode and only about 1%

would be lucky to survive. However, the key factor

would revolve around that level of survival and the

person’s quality of life as a result.

One day, my father said that I would not need to visit him

the next day as he was about to die….. Later, his breathing

began to slow. Then he took a long final deep breath and I

knew it was his last. He looked so peaceful.

Personal communication, 1997

James P Newton

Editor

� 2008 The Author

Journal compilation� 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25: 1–2

2 Editorial