Book Review

The Journey of Life: A Cultural History of Aging in America

N Engl J Med 1993; 329:2043-2044December 30, 1993

Article

The Journey of Life: A Cultural History of Aging in America
By Thomas R. Cole. 260 pp., illustrated. New York, Cambridge University Press, 1993. $34.95. ISBN: 0-521-41020-7

A leading Broadway composer, 88 years old, is undergoing renal hemodialysis while preparing for the upcoming opening of his new show, The New York Times recently reported. I suspect that most of us would see such aggressive medical treatment as appropriate in this instance, but I wonder what we would think about an 88-year-old resident of a nursing home with advanced Alzheimer's disease and renal failure. Should this person receive dialysis? Why one and not the other?

In his fine new work, The Journey of Life, Thomas R. Cole surveys changing attitudes toward aging over the course of our nation's history but does not explicitly address such questions. He argues, however, that this sort of historical inquiry is a prerequisite if we are to clarify our values and reach a consensus about these painful ethical dilemmas.

Cole, the director of the graduate program of the Institute for Medical Humanities at the University of Texas, believes that in our culture old age is viewed primarily as a problem that can be solved through modern technological expertise rather than as an experience shared with societies throughout the ages. He sees the elderly as pushed to the sidelines and deprived of a meaningful role in a society devoted to youthfulness and the pursuit of health and wealth. Rather than confront these underlying cultural and economic values, we continue to focus on the scientific management of aging -- “lengthening life while draining it of its substance.”

Cole begins by summarizing the perspectives on aging in antiquity and the Middle Ages. These consisted of a classical view and a complementary biblical view: the first outlined the stages of life and stressed the physical causes of aging, and the second saw life as a spiritual journey from birth to death.

Cole then shifts to Puritan America, but the heart of his study is a fascinating discussion of changes in Protestant theology in 19th-century America, based on a close reading of the sermons of selected Protestant ministers. In general, according to Cole, early American attitudes toward old age bore the imprint of Calvinism. The elderly were venerated by the Calvinists, at least in theory, and aging was seen as a sacred pilgrimage to an inscrutable and omnipotent God. Long life and old age were seen as God's precious and mysterious gifts, not as rewards for proper behavior. To expect a long life was considered unwise.

By the early 19th century, the appeal of this harsh Calvinist view had begun to wane. (Cole touches only briefly on the reasons for this change.) The Victorians saw God as compassionate and benevolent. The second “Great Awakening,” an evangelical movement that swept the nation in the 1840s, was based on the concept that obedience to the laws of God and nature would make people happy.

This new theological perspective had far-reaching implications, according to Cole. Although the Calvinists “held an integrated view of aging, acknowledging both inevitable loss and hope of redemption,” the evangelicals “created a dualist vision that split sin, decay, and dependence from virtue, self-reliance, and health.” An aging body and death were now seen as punishments for sin, and old age was considered “an embarrassment to the new morality of self-control.”

This perspective became the basis for a mid-century popular health movement. Hygienists such as Sylvester Graham (inventor of the graham cracker) claimed that the “true principles of virtue and religion are inseparable.” Prolongation of human life, no longer simply a desirable goal but now a moral one, became the central aim of the movement. Ironically, writes Cole, this quest for perfect health, which is still with us, has “saddled many middle class Americans with feelings of failure and shame in the face of physical decline.”

Cole sees 20th-century medical science as the secular heir to Victorian evangelicalism, since science has shared with the evangelicals the assumption that aging can be controlled. The Nobel prize-winning Elie Metchnikoff sought the source of bodily aging in the byproducts of intestinal microbes and identified lactic bacilli as the antidote, sparking a sour-milk craze. Public discussions about aging that focused on scientific assessments of efficiency and productivity led William Osler to argue for the comparative uselessness of men above the age of 40 and their absolute uselessness over 60. The emerging field of geriatrics, while rejecting such extreme views, came to see aging in an analogous light. Geriatrics, according to Cole, has envisioned aging as an issue of health and disease and thus as a scientific or technical problem. Rather than accept the aging process as part of a continuum, Cole argues, geriatrics has split old age into a “good old age” characterized by health and independence and a “bad old age” characterized by illness and infirmity.

Cole's analysis of medical science is certain to be provocative, but he should not be interpreted as advocating the abandonment of science or a return to “old-time religion.” Cole writes as one intimately associated with modern medicine, in a tone at once sympathetic and critical. He suggests only that we acknowledge the realistic limits of scientific technology and restore the balance between the scientific and the ethical and spiritual dimensions of medical practice. This approach need not be seen as defeatist. If we are unable to face squarely the inevitable losses that aging brings, Cole argues, if we persist in seeing the potential debilities of old age as failures and in treating old age as a problem rather than as a life experience, we relinquish the hope of finding a meaningful place in our world for the elderly.

Alan Astrow, M.D.
St. Vincent's Hospital, New York, NY 10011