The search for a treatment for ageing
Bioethics Briefing Note
Ethical and social issues raised by ageing research
The discovery of safe and effective treatments that delay ageing and reduce the risk of ageing-related diseases could have consequences for health, society, and the economy.
Effects on health
Compressing the period of poor health experienced by many in old age could have a transformative effect on the lives of older people and is widely considered to be the primary goal of geroscience research. It is not known, however, whether biomedical ageing interventions will simply put off the period of ill health, or if this period will be extended, with people living longer in poor health. Other kinds of medical and social interventions have led to improved health and functioning in older people alongside increases in lifespan, but it is not clear whether this trend will continue.* Questions also remain about whether ageing interventions will need to be taken while people are still in good health; whether they will be able to reverse diseases that have already started to develop; how often they will need to be taken; and the seriousness of any side effects.
*Baltes PB and Mayer KU (2001) The Berlin aging study: aging from 70 to 100; Mor V (2005) The compression of morbidity hypothesis: a review of research and prospects for the future J Am Geriatr Soc 53: S308-S9.
Extending life span
Biomedical interventions, along with environmental, social and lifestyle modifications, have already contributed to the extension of human lifespan. Depending on other factors that could affect lifespan, ageing interventions could lead to a further delaying of death. Some suggest that a realistic target of geroscience research is to delay all ageing-related disorders by about seven years. Other commentators believe that scientific advances will lead to much more radical effects on ageing and human lifespan in the near future. There are differences of opinion about the value and morality of extending lifespan, even moderately (see also Williams B (1973) The Makropulos case: reflections on the tedium of immortality). Some philosophers believe that we think of our lives as having a certain shape, which underpins how long we think people should work and how long it is appropriate to be old. Increased longevity therefore might threaten the shape we envisage for our lives and our sense of personal identity.* The benefits of experiencing the pleasures of life over a longer time period are used by some to justify life extension;** others argue it is quality not quantity of years that matters. Some equate extending life with saving lives, and suggest there is a strong moral imperative to pursue treatment for disease, even if the side effect is an increase in lifespan.***
*Bavidge M (2006) Ageing and human nature in Dementia: mind, meaning and the person Hughes JC, Louw SJ, and Sabat SR, eds.; Lesser AH (2006) Dementia and personal identity in Dementia: mind, meaning and the person Hughes JC, Louw SJ, and Sabat SR, eds; Wareham C (2016) The transhumanist prospect: developing technology to extend the human lifespan in The Palgrave handbook of the philosophy of aging Scarre G, ed.
**Horrobin S (2006) The value of life and the value of life extension Ann N Y Acad Sci 1067: 94-105; Overall C (2003) Ageing, death and human longevity. A philosophical inquiry.
***Harris J (2007) Enhancing evolution; Gems D (2011) Tragedy and delight: the ethics of decelerated ageing Philos T Roy Soc B 366: 108-12.
A common concern of lifespan extension is that it would accelerate population growth, and that this would have a range of adverse consequences, particularly for the environment. However, one study suggests that population changes would be surprisingly slow in response to even a dramatic extension of lifespan and would not necessarily lead to overpopulation. It has also been argued that using finite resources in a non-sustainable manner is a problem that needs to be solved independently of how long people live.
Estimations of the impact of increasing health span on the economy are generally positive. For example, one analysis suggests increasing human health span would reduce healthcare spending and lead to significant economic savings. Another suggests that delayed ageing could mean increases in social benefit and public healthcare costs, but that these would be far outweighed by economic gains as a result of a healthier workforce who remain employed for longer and are given more time to save for retirement. These effects would depend on the relative increases in health span and lifespan that could be achieved by ageing interventions, which currently are highly uncertain.
The social and cultural impact of increased health and lifespan could be far reaching. Even without the availability of ageing treatments, it is expected that people will have to keep working for longer in future, which could change workplace practices and opportunities. If ageing interventions became available, people’s experiences and expectations of old age could change further. Enabling older adults to be more active and live longer could have many benefits for individuals, families, and communities. This might also result in changing demands for old age care, with implications for state-funded care, the role of adult children in caring for their parents, and intergenerational living.
Ageing interventions are likely to be available only through the private sector initially. As with any paid for therapy, it is probable that access to ageing interventions will be unequal, leading to an exacerbation of existing health inequalities according to income, socioeconomic status, and geography. In addition, personal choices about uptake of ageing interventions could have implications for entitlement to state care and health insurance. There are calls for government policies to ensure unequal access to ageing interventions is avoided. Global health inequalities present particular challenges in this context, given that the citizens of some countries still have low life expectancies owing to poor sanitation, nutrition, and healthcare provision. The duties of developed countries to put efforts into addressing these problems, in relation to the efforts put into research on ageing interventions, require consideration.
Medicalisation of ageing
Some argue that the focus on finding medical treatments for ageing is unhelpful, in that it suggests ageing is a problem that requires fixing and reinforces negative views of ageing.* There are parallels with how the medical community view frailty. Frailty is commonly regarded as a state of overall poor health, weakness and vulnerability, but diagnosing people with frailty may serve to marginalise them from society and unfairly label people as being destined to decline. There is also concern that other important elements of successful ageing, such as personal relationships, social position, physical environment and independence, are side-lined by geroscientists. The World Health Organization recommends that a holistic policy framework for healthy ageing should include a combination of public health measures, capacity building strategies, and the creation of an age-friendly world.
*See, for example, Vincent JA (2008) The cultural construction old age as a biological phenomenon: science and antiageing technologies J Aging Stud 22: 331-9; Hadler NM (2011) Rethinking aging. Growing old and living well in an overtreated society.
The fact that there are no proven treatments for delaying or reversing ageing has not curtailed the anti-ageing product market. Despite strict regulations on nutritional supplement health claims, resveratrol and TA-65 are widely touted as having anti-ageing properties. A three month supply of TA-65 can be purchased for around £400. Unproven and potentially harmful stem cell therapies that promise anti-ageing and rejuvenating effects are offered by clinics around the world at great cost. The US Food and Drug Administration recently announced it will increase regulatory enforcement of unlicensed stem cell therapies and has taken action against a number of clinics in the US. As research in this field progresses, reducing harm to consumers from the use of unscrupulous clinics and retailers will become an increasing challenge. Similar challenges exist within the cosmetic procedures industry, which the Nuffield Council on Bioethics has recommended should be subject to tighter regulation.
An important question for geroscience research is whether potential interventions should be tested in younger people, before biological ageing has started, or in older adults already experiencing symptoms of ageing. In the past, involving older adults in research was thought to be difficult and of no benefit to them. This view has broadly changed. The challenges of research have been found to be much the same whatever the age of the participant, and medical interventions in people aged over 80 can have beneficial effects on their health. In addition, ‘older adults’ are a diverse group and generalisations about people’s ability and willingness to take part in research should be avoided. More tangible barriers exist to testing ageing interventions in healthy people, whatever their age. In the US, the state-funded healthcare system will only cover clinical trial costs for people with diagnosed disease.* In addition, measuring the effects of ageing interventions presents major challenges, given humans have a long life span and show great heterogeneity in ageing.** Participants at a recent Nuffield Council on Bioethics workshop called for an ethical framework for geroscience research to be developed to help guide researchers, policy makers and consumers.
* Medicare policy states: “Trials of therapeutic interventions must enroll patients with diagnosed disease rather than healthy volunteers”. See: Medicare (2000) Medicare coverage clinical trials: final national coverage decision. See also: Moffitt TE et al. (2017) The longitudinal study of aging in human young adults: knowledge gaps and research agenda J Gerontol A Biol Sci Med Sci 72: 210-5.
**Belsky DW et al. (2015) Quantification of biological aging in young adults Proc Natl Acas Sci USA 112: E4104-E10; Belsky DW et al. (2017) Impact of early personal-history characteristics on the pace of aging: implications for clinical trials of therapies to slow aging and extend healthspan Aging Cell 16: 644-51; Belsky D et al. (2017) Telomere, epigenetic clock, and biomarker-composite quantifications of biological ageing: do they measure the same thing? Ame J Epidemiol (in print); Kirkland JL et al. (2017) The clinical potential of senolytic drugs J Am Geriatr Soc 65: 2297-301.