On Getting Older In America

THE OPEN MIND
Host: Richard D. Heffner
Guest: Robert N. Butler
Title: On Getting Older In America
Recorded: 11/17/98

I’m Richard Heffner, your host on The Open Mind. And my guest today is a much-honored physician, gerontologist and psychiatrist whose Pulitzer Prize winning book on being old in America begins this way: “Old age in America is often a tragedy. Few of us like to consider it because it reminds us of our own mortality … we are so preoccupied with defending ourselves from the reality of death that we ignore the fact that human beings are alive until they are actually dead. At best, the living old are treated as if they were already half dead. And, because we primarily associate old age with dying, we have not yet emotionally absorbed the fact that medical and public-health advances now make it possible for millions of older people to be reasonably healthy”.

And that’s what I want to talk about today with Dr. Robert N. Butler, who founded and chaired the Department of Geriatrics at New York’s Mt. Sinai Medical Center and who now heads the International Longevity Center.

Now I know from his books and articles that Dr. Butler feels strongly that how we talk about aging, particularly about supposedly unaffordable dollars being “wasted” on life-extending/life-enhancing medical procedures, impacts quite negatively upon the quality of life in our later years.

So let me ask my guest to elaborate on that theme.

BUTLER: Well, you know it’s interesting in the nearly twenty-five years since that book was written, we’ve had a fifty percent reduction in deaths from heart disease or stroke. We’ve had significant drops in disability rates so that happily, despite the mass production of old age, despite the fact that Centenarians are the most rapidly growing age group, we have a more vigorous, healthy, less disabled group of wonderful older people, who are contributing. And since they’re contributing we really do have to think through these casual statements about “how unaffordable they are”.

HEFFNER: Now, it’s interesting to me that you say “casual”, because it seems to me that they’re far from casual, that they’re part of an approach to aging that is very determinedly set to minimize the cost.
BUTLER: Well, you’re absolutely right. But it is, you know, you often hear it in casual conservation, but it’s also in the minds of policy makers. “Can we afford older people?”. I’ve traveled now in some fifty countries in relationship to the International Longevity Center and before both as an official traveler and unofficial. Can we afford older people, people ask. Will there be a stagnation of the economy as a consequence of older people? Will we have inter-generational conflicts? Will there be a gerontocracy, too much power in the hands of older people? They’re all answerable questions, but it does indicate what you said. It’s extraordinarily serious this attack, really, upon the reality of survivorship.

HEFFNER: What happens in other countries? Is there the same substitute of economics for ethics as I think about it when my friend and your friend, Dan Callahan, comes here and argues his point. He argues very, very well, but it does seem to me he comes as an economist rather than an ethicist.

BUTLER: I couldn’t agree with you more. I agree. No I don’t want to think that we’re the only country that thinks this way. But we do have in Europe still the vast social protections. We have in Japan, which really newly emerged in terms of a semi-welfare state. Right now, despite their economic problems, the introduction of the Gold Plan, which is an endeavor to create first rate long-term care for older people in Japan despite what’s happening to them economically. We’re not doing that. We still depend upon Medicaid, where people have to humiliate themselves, spend down their income and assets in order to have access … access to decent long-term care.

HEFFNER: How do you explain this, particularly in terms of whatever power there is to this notion of older people voting, older people calling the shots, younger people getting less of the social pie.

BUTLER: Well, of course, that’s not true. It’s true if you only look at the Federal dollars … that Social Security and Medicare are a large part of the Federal budget. But if you put everything on the table, State money, private money, public money at the community level, it’s not the case. For example our wise Founding Fathers decided that public education should not be under central domination, it should be local controlled. So if you add up all those dollars and compare it to the Federal dollars for older people, of children and older people, it’s about the same. Literally about the same.

HEFFNER: And where do we go from here?

BUTLER: Where do we go from here is to always be concerned about a fair allocation of resources. But I think psychologically and humanistically we have to keep in mind that today’s children will one day be older people and today’s older people were once children. There’s a unity and a continuity to life which we must bear in mind. And when we negative towards old age we slashing our own tires. This is really our own future we talking about.

HEFFNER: Dr. Butler, what do you mean by a “fair distribution”? How could there be anything fair about saying “well, fifty percent perhaps goes here and fifty percent goes there” if neither one is enough?

BUTLER: Well we’d always depend on productivity of the society. If we don’t have prosperity, if we don’t have productivity, the pie gets tight, then it’s of course very difficult. But so long as we have certain resources, then we have to distribute them in a way that probably comes about as a result of the general will of that body of people, that society. If you look at families, individually, we know in America the family protects its older members. It is not true that American families abandon older people. That they do not respond to them when they’re ill or impaired. We do. So if we were to write large what we do on a family basis for the community as a whole, I think we’d have a reasonably fair allocation of resources.

HEFFNER; Well, I … forgive me for pushing the notion of the question of, of fairness. Doesn’t that imply that there is just a limited pie, or that there is a pie that has to be sliced in such a way that there is a limited portion for the very young and the very old.

BUTLER: Well, you know, the pie really isn’t limited. All we need to do is to look at what it was like in 1898 when we had no idea about lasers and forty hour weeks and computers and airplanes. There’s always been, happily, a growth of our gross national product and our productivity over time. But what we do see today is a gross inequality of wealth and income across the spectrum in American life which is going to ultimately be extremely harmful not just to older people, it’s already also very harmful to children.

HEFFNER: How much can a democracy tolerate that increasing dichotomization?

BUTLER: Well, you know, there are those that think that part of the reason we had the great economic depression in the 1930’s was because people had so little money they could not buy things. And that’s one of the beauties of Henry Ford’s introduction of the Tin Lizzie, way back when, was the idea of getting market share by creating an automobile that was cheap enough for everyday folks to buy. But if we make that impossible, then we are going to wind up again with a deflation or a depression consequent, following upon this inequality of wealth and income.

HEFFNER: Now, given the … whatever inequality there is now, and it is growing …

BUTLER: Massively.

HEFFNER: … what do you see as what is going to happen in terms of the medical progress that you attribute to the past quarter century?

BUTLER; Well, we’re already seeing it happen. You know in many community hospitals, the public city hospitals, people are not getting the care that those of us who are more fortunate are getting. We have subtle, covert rationing already. We have, in my judgment, a kind of passive euthanasia already occurring in which people die simply because they do not have the resources available to them. We see it in prisons, we see it out of prisons, in the Black community, and in a variety of other settings in the United States.

HEFFNER: You think that is acceptable to us … on a conscious level?

BUTLER: Not to me.

HEFFNER: No, not to you, of course. Do you think we’re aware enough of it?

BUTLER: No, it’s always amazing to me … for example, the press today speaks of a Social Security crisis … an overused word which I think has been mobilized largely by Wall Street, because in fact we don’t even begin to have a problem until 2032. And even at that point, we’d be able to pay people 70% of their Social Security if there did need to be a cut-back, and we only need to have about 2.1% increase in either payroll tax or some other arrangement that could solve that problem. But the press buys it as “a crisis” and we are facing a very serious crisis in Medicare, which has to be addressed. And again, in terms of what we can do. I think we have to point out that it’s women that are particularly affected by any cuts that might be forthcoming with regard to Social Security and Medicare since they’re the survivors. The mothers of our country, our older sisters.
HEFFNER: Are you waving a flag?

BUTLER: Yes.

HEFFNER: Because you think that will be most effective?

BUTLER: Well, I’ve always been surprised that the Woman’s Movement has been so disinterested in the issues of their older sisters. I find it quite amazing. Women live nearly seven years longer than men, they are the ones that are most affected … literally the most affected by any perspective reductions in coverage for Medicare, Medicaid, or Social Security. Why aren’t they screaming?

HEFFNER: Why aren’t they?

BUTLER: Why aren’t we men screaming, since we presumably love our women.

HEFFNER: Well, we love ourselves and we seem not effectively to be screaming about our own lot. How do you explain that?

BUTLER: I think we get caught up in kind of what’s immediately in front of our own nose, our own immediate survival, our day by day activities, and we really find it very hard to look far ahead. I guess I’d have to say that since 1955, I think that’s about 43 years that I’ve been in the field of aging, the single biggest enemy has been denial. The fact that people do find it hard to face it, to really look it straight in the eye, to recognize their own mortality, to recognize the possibilities of dependency, of poverty. People don’t want to look at it, it’s not very pleasant.

HEFFNER: But we look around today and we see on every side of us the survivors who aren’t doing that well.

BUTLER: We numb ourselves, I think. It’s like television, watching the body sacks of Vietnam, or whatever … the body counts we get so used to it that we somehow don’t really let it fully register.

HEFFNER: As a psychiatrist you feel that that’s …

BUTLER: I do … I think …

HEFFNER: … a partial explanation?
BUTLER: … I think denial is a very powerful, very powerful psychological problem in human society.

HEFFNER: And what signs are there now that there may be, with the leadership of people like yourself less denial, more action.

BUTLER: Well, do think … I’m not as pessimistic as I maybe sounding because I actually do think that over the last 40 years since I’ve been in this, we now do have Medicare, we didn’t have before. We do have the National Institute on Aging, which we didn’t have before. We have at least two Departments of Geriatrics, which we did not have before. So there has been progress, it’s just not enough. And when you consider the huge number of Baby Boomers, 76 million strong, they’re on their way to Golden Pond. We’re not really prepared for them. And they’re not prepared. So when we get to 2011 when the first Baby Boomer turns 65 and then when we get to 2020 to 2030, when one out of every five Americans will be over 65 and they’ll be Baby Boomers. We’re simply not prepared.

HEFFNER: But that, of course, is the same statistic that Dan Callahan and people who believe the way he does … same statistic they use. Why do you have a different approach to the meaning of the statistic.

BUTLER: Well, his statistic is based on a arbitrary age. That is to say that after 75 or 80 we should not provide any longer the type of resources … medical resources. I respond to that in terms of function. And preference by people. But it should not be arbitrary on the basis of a specific age.

HEFFNER: What do you mean “preference”?

BUTLER: Some people quite … have decided … because they have, let’s say, cancer and they don’t want to have the treatment and they don’t … and shouldn’t be forced to take the treatment if they don’t want to have it. There should be rights to a dignified end to one’s life. That’s certainly something that we’re much interested in our Project On Death In America, is to see … we provide thoughtfully and humanely with adequate care for people … pain, discomforts and also the deeper aspects of the end of life.

HEFFNER: You have said, and I know that the Project makes the point, too. You have written that if we pay more attention to the suffering at the end of life, that exists and alleviate it, there will be less of a problem with this question of physician aided suicide.
BUTLER: I think so. I mean there may always be, you know, the most tragic of situations. Some one that has what some call a “locked-in” syndrome, where they have no control over their body whatsoever, but they’re fully conscious. And they may give signals as best they can through eye movements that they would wish their life were ended. And I can imagine with amyotrophic lateral scoliosis, popularly called “Lou Gerhrig’s Disease”, that at certain points people feel they want to end their lives. And I can understand and respect that. But for the vast majority, probably as much as 98% of people, if we could assure them that they would get decent resolution of pain and other physical discomforts and some sense of appreciation of their inner life, I think people could accept that and they would not be interested in physician assisted suicide.

HEFFNER: What indication do you have that that is the fact?

BUTLER: Well, as a physician, seeing people who’ve died. Seeing those that did have a reasonably decent death, who had a chance to deal with the kind of life they’ve led, and to try to come to terms with it, perhaps to deal with alienated relationships which they are then able to undertake reconciliation, or to atone even for things they may have regretted and to feel free enough from the pain and discomfort to be able to deal with these very important personal issues. And then I’ve seen others who have not had the opportunity and who have suffered and I can understand the clear distinction between the one and the other.

HEFFNER: Of course, you write and not twenty five years ago …

BUTLER: Yes.

HEFFNER: … in “Why Survive”, but you say very recently that you have seen so many residents, so many doctors in training who have not the faintest idea of how to relieve pain.

BUTLER: That’s right. And it’s not me alone that says that. It’s the … the Project On Death In America has come to appreciate the frequently, not for want of desire on behalf of young doctors to be and residents, but they just haven’t had the training, even in terms of appropriate use of morphine and other opiates. And in the techniques of dealing with immediate pain. I had occasion in our own family in which the resident simply did not understand … and had this thought that if he gave too much morphine the patient would die. A patient who was right near the end of death, and was in great pain and great anxiety, and was suffering from what we call “air hunger”, which was in part an expression of anxiety, and part seeking to get some breath at the end of life. There was no calm capability with basic knowledge on the part of that physician to respond. I don’t fault him, it’s our educational system. We don’t have a well developed palliative medicine educational program in the United States.

HEFFNER: Are we developing one?

BUTLER: Well, the Project On Death In America, which is part of the Open Society Institute, which is headed beautifully by Dr. Kathleen Foley, has been trying to see that our 126 medical schools begin to have curriculum reform, we’ve created scholars who have … in a sense, invaded a number of these campuses to see if we can get teaching inaugurated and inculcated within the students and residents, to acquaint them. A variety of conferences have been held. Writings are beginning to appear in the literature to deal with this very, very serious problem.

HEFFNER: When Dr. Foley was here on The Open Mind she made this point and I wondered whether in the two years or so since she was here whether any substantial changes have taken place?

BUTLER: You know, I think so. It’s very hard to document. You know, we don’t, and can’t claim we’ve had a thermometer or Geiger counter that’s picked all of it up. But you get a sense of a growing awareness among the medical community and also among wonderful health care workers in general … nurses and social workers … greater appreciation of this topic. This topic of end of life care, this topic of how we each may die and our desire to see that we put that into some kind of decent focus and decent program of care.

HEFFNER: And you feel that if that feeling is extended, if it becomes more widespread, then there will be less of a desire to look for …

BUTLER: I think so.

HEFFNER: … end of life measures such as suicide.

BUTLER: What is so amazing, often is when you work with patients, even those who have extraordinary impairments … cling on to life. Life is very precious, people are not ready to give it away. As long as they have some sense of some potential quality of life. Now that quality of life will vary individual by individual. Perhaps you want to see a granddaughter who you helped finance through college graduate that June. Or be at their wedding. So those extra days or extra months that might get you there through some life extending technology becomes very important. For someone else they may not have that particular end point.

HEFFNER: And then what do we do with our friend Dan Callahan? Who is my friend and I needle him at times when he, when he comes here and I say, “well …”, I haven’t said it recently, but “Dan, I’m now 73 and I get hit by a truck on the corner … because I’m over 70 are you going to say ‘Leave old Heffner alone there?’”.

BUTLER: But Dan says something more … if you’ve got the money, go ahead and pay for it. He just doesn’t want public dollars to be spent for that. Well to me that’s even less ethical. That you could imagine that we would have a system in which those of us who are better off, could pay our own way, when confronted with death, and those of us who cannot and are dependent upon public dollars, cannot have that same care.

HEFFNER: But, of course, Dan also says something more profound and very, very interesting. In a sense he’s saying that we will never learn to accept the fact of death if we keep chasing life-everlasting. And it’s a pursuit that we can never achieve.

BUTLER: I think … you know, I feel uncomfortable criticizing a fellow who’s not here. My own sense is that if we were to have had that attitude in 1850 we would not have developed as we have since. Antibiotics, a variety of vaccines, a whole host of medicines that have dramatically reduced death. I think it is foolish to imagine the total conquest of death, to imagine immortality, but to pursue diseases, to pursue means of bringing quality of life … I stand by that as being one of the noble achievements of the twentieth century.

HEFFNER: Do you feel yourself as a physician that there is an end point, chronologically speaking?

BUTLER: Well we know from a variety of studies in aging that all species have a particular genetically determined life span. A mouse maybe 36 months, a mayfly a day, and a human being probably 120 years. There are, of course, those who would like to intervene in human destiny and alter the whole evolutionary pattern and have people live even longer. And there are data that suggest that between two and a half million years ago and a hundred thousand years ago, there was a doubling of the size of the brain and actually a doubling of the life expectancy. This is based upon studies of fossil remains from various hominid species as they moved through time. So there have been biologically evolutionary advances in longevity and there are those who hope that will happen again. But realistically my sense is that what we’re interested in is reducing disease, reducing disability, and advancing quality of life within what has been given to us.

HEFFNER: Talk about reducing disease. You’re really, aren’t you really talking about reducing discomfort? On every level?

BUTLER: Absolutely. Absolutely. And quality of life, the absence of discomfort are in many ways equivalent, although I guess I think of quality of life of even being something more. One of the things we discovered in our studies at the National Institute of Health many years ago, was those who had a sense of purpose lived longer. I was surprised at that. I was 28 years old at the time we were doing those studies. And they also had a happier quality of life. Just by virtue of a sense of real purpose. It didn’t have to be a grandiose purpose, but something that gave meaning to their every day life.

HEFFNER: The question that that I want you to address in the few minutes that we have left is what is going to happen, in your estimation now, in terms of the monies that we’re willing at this moment to appropriate for making life happier, more pleasant, more livable at the end.

BUTLER: I think there’s going to be a surprising turn around as the Baby Boomers approach Golden Pond. I think they are going to want things for themselves. I think suddenly the youth market will become the mature market. I think suddenly people will appreciate that this health industry is one-seventh of the nation’s economy, has ten million workers, is not a bad deal. That we waste a lot of money on many other things, and while we should reform it and make it better and probably ratchet down some of our own salaries, and I speak as a physician, nonetheless I think health is something people very much want.

HEFFNER: Yes, but what …

BUTLER: And they’re going to pay for it.

HEFFNER: … but we seem to be identifying the problem as the dollars that go to health right now. The percentage of our national income that goes to health matters.

BUTLER: But there are many economists, Joe Newhouse for example, and others who feel we’re not spending enough on health care. That we still don’t cover 41 million Americans, for example. That there are many goods and services people can buy, and these provide jobs. That one person’s cost is another person’s asset, income, job. And we may turn this whole thing around. That doesn’t mean we’re going to be foolish with resources. We shouldn’t be, but we may change the questions and may look at health care in a very different way.

HEFFNER: Do you at all believe in rationing?

BUTLER: No.

HEFFNER: Not at all?

BUTLER: No. I do not.

HEFFNER: And around the world?

BUTLER: Any more than we should ration cars or food or anything else, perhaps.

HEFFNER: You mean it’s a free enterprise notion?

BUTLER: No. No, I think it may require, quite the contrary, I think it may require the kind of regulatory or convening, or … what should I say … keeping a level field setting that perhaps is the appropriate role of government and it has a mix of free market, but at the same time some humane guidance to lead us in a reasonable manner.

HEFFNER: So you foresee, by definition, a larger and larger role of government.

BUTLER: No, not necessarily. I think we’ll see a new movement toward something that some call the welfare society rather than the welfare state. Where the non-governmental sector, which is wonderful in this country, as Tocqueville defined it many years ago, with the individual, the family and business, all five of those pillars … government, business, the family, the community, the non-profit sector, playing a vital role in the support of a more benevolent society. That’s my optimism.

HEFFNER: And the leadership coming from where?

BUTLER: All sectors. All sectors in a much more thoughtful, coordinated manner than we’ve presently seen.

HEFFNER: Do you see any of that now?

BUTLER: Yes. I think so. I think we see some of it already in Sweden, for example. I think we see it in some communities in the Untied States. You see it in some unique situations where academe and the private sector may work together.

HEFFNER: Hmmmph. I “hmmmmph” only because it’s an optimism that I hope is well founded.

BUTLER: Well, after beginning what sounded like I was so pessimistic, I have to end with an optimistic note, because I really am optimistic that the human condition is such that will alter it, and especially as we see this growing, marvelously growing, vital new stage of life.

HEFFNER: We must talk sometime about your concept of the welfare society, not the welfare state, necessarily. Dr. Butler, thank you so much for joining me today.

BUTLER: My pleasure.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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