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