Toward a Philosophy of Aging for Public Health: Presented as the Luther Terry Lecture at the 17th Annual Meeting of the Commissioned
Officers Association of the USPHS [United States Public Health Service], Orlando, Florida
As life-expectancy in the United States increased while the birth rate decreased, Koop sought to make the aging of the American
population and the provision of health services to the elderly a major concern of public health officials, both to anticipate
the mounting cost of caring for an aging population and to change notions of the elderly as feeble, passive, and unproductive.
Number of Image Pages:
20 (1,262,333 Bytes)
1982-10-20 (October 20, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Religion and Medicine
Reproduction and Family Health
"Toward a Philosophy of Aging for Public Health: Presented as the Luther Terry Lecture at the 17th Annual Meeting of the
Commissioned Officers Association of the USPHS [United States Public Health Service], Orlando, Florida" [Reminiscence]
Letter from Luther L. Terry to C. Everett Koop (November 23, 1982)
Surgeon General and Deputy Assistant Secretary for Health
Presented as the Luther Terry Lecture at the 17th Annual Meeting of the Commissioned Officers Association of the USPHS
October 20, 1982
(Greetings to hosts, guests)
I am honored to join you today to get the Luther Terry Lecture. I sincerely appreciate the opportunity to speak on the topic
of my own choosing -- a rare enough opportunity, I might say -- and, at the same time, to mark once again the leadership of
Dr. Terry, with whom I have had a relationship in what are the three stages of my life: my academic career, my confirmation
struggle, and my life as the Surgeon General.
A dozen Surgeons General preceded me. Each man made his particular contribution to the enhancement of the health of the American
people and each man added something to the legacy of the office of Surgeon General. Dr. Terry has passed on to us a legacy
of courage and a regard for good science. I'm sure each of his successors has had his moment or two of trial and doubt.
And I'm equally sure that his example helped me through those moments. It certainly helped me. So this is a particularly
pleasant assignment for me . . . doing honor to a person who added much luster to the title I am now privileged to hold.
When Dr. Hurlburt first broached the idea of my giving the Terry Lecture, I was in the process of reviewing public health
policies toward the aging. I had the pleasure at that time of several long and valuable conversations with Dr. Robert Butler,
then Director of the National Institute on Aging. The NIA is an outstanding institution with an excellent record for innovative
intramural and extramural research in the field of the aging.
I visited with other Institute directors, with the people at the Alcohol, Drug Abuse, and Mental Health Administration, who
also have concerns related to the elderly, and I also talked with a number of people elsewhere in the Department of Health
and Human Services -- people who work in legislation, in planning and evaluation, and in social services. Two things struck
First, just about everyone I talked with who worked in some aspect of the field of the aging was genuinely concerned for the
welfare of America's elderly population. And . . .
Second, just about everyone I talked with came the subject of aging from a different perspective, with different value-laden
data, and with a different concept of what they hope to see government achieve.
The people I talked with earlier this year -- and we're all still talking, by the way -- were very forthcoming and generous
with their time and their ideas. And I must say that their commitment to their work was infectious. The experience led me
to want to attempt a contribution of my own to the field of the aging. With all these thoughts in mind, I told Dr. Hurlburt
that, yes, I would be honored to deliver the Terry Lecture and that the occasion might be just the stimulus I needed to put
together a few notes "Toward a Philosophy of Aging for Public Health."
Drawing upon those conversations and upon my own reading, I would like to suggest some common ground for people who work in
the aging field. I certainly do not mean to be prescriptive. Provocative . . . yes. Prescriptive . . . no. I do hope, however,
that this may be not the last word on a commonly accepted philosophy of aging, rather one of the first words contributed to
the building of that philosophy in -- and for -- the public health profession.
Of course, I don't mean to suggest that people are now serving the aged without a scrap of philosophy to give them some
direction. No, in fact what we do have is the profession of health care applying its fundamental notions of compassion, of
public service, and human decency to the problems of the aged. And we ought to be rather proud of that.
However, I think the problem arises in the fact that, although the aging process begins in youth, the end stages of aging
provide the ultimate, terminal human experience. Therefore, I would say that the approaches we employ elsewhere in public
health -- that is, our methodologies, insights, or corporate responses -- are not completely appropriate. Our usual methods
don't translate well, since they usually lead to something else. We are trained to identify opportunities for "linkage"
and "follow-through" and "follow-up" and "cost-effective this" and "technology-intensive that."
But the aging experience leads to a known endpoint . . . namely, death. Any follow-up would be purely presumptive and would
depend on one's theological understanding. For the most part, we have to admit that very little that's done for the
aged is really "cost-effective" in terms of the conventional P&E wisdom. With the aged, we bury our successes
as well as our failures.
If you look at the aging experience as a terminal but unknown length of time, you can then possibly make some judgments about
the nature of that time. I think if I went back to my friends who work in the aging field and asked them to categorize that
time period, they would probably all say they hoped it would be "good" time . . . that is, it would be marked as a
time in which the dying person might enjoy . . .
Reasonably good health . . .
Enough nourishment prepared and presented with at least a touch of interest . . .
A degree of comfort as far as clothing and shelter are concerned . . .
And they might also enjoy, at long last, a period of peaceful human relationships.
In our American culture, the age of 65 is considered to be a turning-point. Somehow or other it became the pinnacle of an
individual's life. After 65 he or she is "over the hill." The road of life from then on is all downhill: the only
variable among people is the steepness of the decline.
Part of that time, then, may not be so "good." This is the time in which the person is in a real and accelerated decline.
Health deteriorates . . . nourishment is reduced to just that, lacking any reason for interest . . . discomfort becomes a
round-the-clock norm . . . and the human relationship that absorbs most of the dying person's attention is the relationship
with one's self.
I think it's clear that good medical and health care seeks to ensure to the fullest extent the "good" qualities
of that terminal time in the aging process and to compress the downhill slide into a short a time as possible. The shorter
the time, the steeper the slope. The preferred goal would seem to be to keep the pinnacle of that magic age 65 as a plateau
-- to make it all "good" time -- for as long a period as possible. This is the aspect of a philosophy of aging that
appeals to me most. But how do we prolong that good time and how might we attempt to control the onset of the period of decline?
That question actually presents us with two problems:
First, if we recognize aging as being a "good" time followed by a difficult time, that we may begin to perceive the
aging process as a series of self-fulfilling prophecies, and that's certainly a problem for anyone in health care.
Second, if we recognize that there may be two qualitatively different periods of time, it's only natural that we would
want to manipulate them in some way beneficial to the patient, as I have suggested, so as to prolong a person's "good"
time and shorten the time of decline. The period of decline might be his or her "dying time," as it were, except that
the two types of time are not neatly defined and separated for us.
Let's look again at that first problem, the problem of self-fulfilling prophecies. The aging process is most often described
as a chain of successive and anticipated events. A physician or counselor will say, "You know, your father is getting
on in years. You can expect this to happen. Then that will happen. And you should prepare your family for this other thing
to happen." And superficially this sequence of events may indeed occur as much as it is described.
We tend to accept those predictions -- they are orderly and, therefore, comforting -- although we know from our own personal,
hard experience that life really doesn't unfold that neatly. Events tumble in one upon the other . . . cause-and-effect
is very often a shrewd guess at best . . . and other people and the environment itself will trigger some events to occur early
and delay or prevent others from occurring at all.
When an aged person lives normally -- that is, the aged person moves and is moved by events in a rather random fashion --
we may become confused and even fearful. We conclude that "Something is wrong with Dad. This is happening way ahead of
schedule and that shows no sign of ever happening at all." In other words, deviation from the anticipated norm -- even
if it is healthful behavior -- may be a cause for some concern.
The aged person can actually be the victim of this kind of response. If we expect deterioration to take place, we might feed
and medicate the aging person as if deterioration were in fact taking place. As a result, the person may become malnourished
and then deteriorate, fulfilling the prophecy. Over-medication is another is dangerous outcome of this kind of behavior toward
the elderly: we anticipate the aging person will require certain drugs and medicines, we go ahead and administer them too
soon, and that we witness the very decline we thought would take place, right on schedule. The whole problem of the aged persons
being erroneously judged "senile" is yet another aspect of the aging process seen as a sequence of anticipated events
in the eyes of the forewarned younger beholder.
The second problem, however, is more delicate and complex. That's the problem of our lack of any neat definitions for
these periods of time. Modern medical technology does make possible certain measures that can prolong life, at least for a
time. When these measures are available to extend what I have called the "good" period within that terminal time of
aging, I think we all agree they should be carefully considered and most probably used. I think a pacemaker implants, colostomies,
coronary bypass surgery, or motorized equipment for stroke victims.
But what about that period of decline? This is the time when the public tends to speak of anything the physician does as the
"taking of heroic measures" to save the patient's life. If we accept the philosophical principle that we should
work to make that true "dying" period as brief but as comfortable as possible, that we are able to commit ourselves
to a rational, compassionate course lying between "heroic measures" on the one hand and, on the other, the callous
mindset expressed in that inaccurate and dreadful term, "pulling the plug."
Let me interject right here and say I never use the terms "extraordinary" and "heroic." What was "extraordinary"
yesterday is "ordinary" today. What is "extraordinary" today will be "ordinary" tomorrow? I don't
know how to define "heroic" in this context. Nevertheless, each of us does have some intuitive and operational understanding
of these gradations of meaning and it helps us deal openly and candidly with patients.
When we counsel with the patient and with the patient's immediate family about a developing crisis during this time of
dying, we need to clarify what our medical alternatives will accomplish:
Will this or that procedure enable the patient to enjoy some additional "good" time, or will it only prolong the period
Will doing nothing effectively shorten the period of dying? Does the patient consider that to be a desirable alternative?
This is the time we should not confuse the terms "cure" and "care." We may seldom cure chronic disease in
the elderly. But we are never relieved of the obligation of caring for them.
I hope I am not misunderstood or misinterpreted. I am committed to giving a patient all the life to which he or she is entitled.
Yet, I am equally committed not to prolong the act of dying.
It's at this point that we have to deal with all three aspects of the human experience: the state of the body, the state
of the mind, and the strength of the patient's spirit. Physicians and other health professionals want to steer clear of
this triangle. They profess not to have the training to deal with matters of spirit , for example. And, of course, that's
probably true. But they still need to recognize that such matters are a profound concern of the patient and need to be addressed
I would suggest that the way all three aspects are handled -- physical health, mental health, and spiritual health -- will
probably determine the nature of the medical care given to the elderly patient in the final stage of approaching death. Here
again, we cannot even attempt to be prescriptive in defining our philosophical base. Instead, we may need to simply accept
that, as a part of our treatment philosophy relative to the aged, we will give substantial attention to patient's spiritual
health during the final phase of this terminal period of life.
This is not very revolutionary talk, I might add. It is the kind of thinking that underlies the hospice movement. We know
that, at some point during their final period of decline, many patients are more concerned about the spiritual quality of
their remaining time than about any further repair work on their bodies or minds. Above all they want peaceful human relationships.
They want dignity. Some act of heroism -- either by their physicians or by themselves -- just may not be very impressive or
useful anymore. Hospice care is organized to provide that kind of experience, whether in an institution or in the dying person's
I don't want to dwell unnecessarily on the period of decline and the event of death. I think many of us -- possibly most
of us in this room -- have dealt with it already and so I will assume we have some common, understood points of reference
that don't need further elaboration. For my purposes now, let's just think about the end of the aging process as being
a finite period that has some "good" time, but then closes with a time of decline -- we would want it as brief as
possible -- that ends in death.
But how does it begin? When does it begin? Let me return to that magic number of 65.
As I mentioned earlier, our culture has more or less determined that the beginning point of the aging process follows one's
65th birthday. At that point, you are "retired" . . . you are literally "withdrawn" from the world you've
known for six and a half decades. You are paid off in some way -- a pension or Social Security or some other means to help
you negotiate this last period of time.
The Social Security Retirement System had said that men could begin receiving their full benefit 65, but women could at age
62. The law has since been changed so that both men and women can claim at age 62, but from that point on they will only receive
80 percent of their benefit. If they wait until they're both 65, they can then claim their full retirement benefit. So
we have some acknowledgment that the aging process may begin a few years early for some people.
The law also says you can receive your benefit if you earn more than a certain amount of money each year from other sources
while you're collecting your Social Security benefit. However, if you are still alive at your 72nd birthday, you can thereafter
receive your full Social Security benefit and also earn all the money you want with no penalty. But even that is changing.
As of January 2, 1983, you can collect 100 percent of your Social Security benefit and also earn all the money you want if
you've only passed your 70th birthday.
So there seem to be two interpretations of when the "good" time in the aging process may begin -- at age 65 and at
age 70. These are, of course, economic interpretations and there are many more of these than just the two from the Social
Security Retirement System. A number of companies want to "withdraw" their managers when they reach 55. Others have
a productive role for senior managers between age 60 and age 70. The military will allow you to retire at 50 percent of your
pay after 20 years of service. So if you join at age 18 and stay for two decades, you can return to civilian life at age 38
and receive half the salary received when last you were in uniform. If you stay 30 years, you receive 75 percent of your pay.
Generals and admirals are retired when they reached the mandatory retirement age of 62. Only presidential appointment can
keep them in uniform. As you know, the office of Surgeon General of the US Public Health Service carries the flag rank of
Admiral of the Navy and the incumbent is also a Presidential Appointee. Those of you who followed my torturous process of
appointment and confirmation last year will appreciate the fact that I now know something about all this -- though not necessarily
by free choice. At any rate, at age 66 I am Surgeon General and in uniform four years after most other admirals have retired.
And I must confess that I thoroughly enjoy it.
Some orthopedists tell patients that the aging process begins around age 30, when their shoulders and their back begin to
stiffen and some signs of arthritis become common. Some psychiatrists believe that the aging process begins when you first
cry out in the delivery room and become an air-breather. Unfortunately for us, there is more poetry in all this then there
is in good science. I mentioned the National Institute on Aging earlier in this lecture. One of the questions they keep returning
to is this: "When does the aging process really begin -- biomedically . . . biobehaviorally . . . neurophysiologically
. . . cardiorespiratorially . . . or musculoskeletally?" I'm afraid we are some distance from a scientific answer.
But that very lack of precision may be the most important thing for us to know about right now. It means we have to take into
account a great deal of behavioral and biomedical information because we don't dare leave anything out. And that's
good. It throws the public health professional in among many other disciplines for dealing with the aging process:
We work with electronic engineers . . . metallurgists . . . architects . . . interior decorators . . . lawyers . . . educators
. . . labor leaders . . . economist, and others.
Ultimately, our philosophy of aging for public health will be congruent with the philosophies of these other professions and
vocations as well -- if they are also thinking about developing one.
If we can indeed arrive, as a profession, at some consensus as to what our philosophy of aging ought to be, what would be
its significance . . . its real impact upon the people we serve?
I firmly believe that, with the help of a coherent philosophy, we will be better able to provide care to all older people
-- including those who are in that final period of decline. I also think it will itself stimulate clear thinking about the
aging process among those very people we serve. With the help of some philosophic approach, we can gain the mastery of that
basic information about aging that would help us -- and through us, help others -- make informed decisions . . .
About our own aging . . .
About the aging of our friends and members of our family . . .
And about the aging process in society itself.
I think we need such a philosophy not only for our own work in public health but also as our contribution to society's
understanding of aging in general. Before very long, young people in American society will have to make some difficult decisions
about the role of older people in American life -- decisions that could affect public policies toward pensions and retirement,
job seniority and security, homeownership, insurance coverage, medical benefits, and so on.
- They should be making those decisions, comfortable with the idea that, whatever their youthful age, they may already be
part of the "aging process."
- They need to understand and accept -- if at all possible -- eventually terminal nature of the aging process . . . of life
-They need to evaluate the nature of the "good" time for an elderly person.
- And they need to participate in or somehow influence the decisions made during that very difficult period of final decline.
At the turn-of-the-century, United States is slated to have some 50 million persons over the age of 65, or about 20 percent
of the American population. That's twice the number of people over age 65 in the country right now. The impact upon all
our services -- but especially public health services -- is going to be considerable magnitude.
Today's "middle-aged" persons are already ambivalent about the effects of this evolving demography: they know
that decisions about care for the aged that are made and ratified today may determine how they themselves are cared for not
too many years hence. Yet, they are not keen on putting forward any position, however reasonable, that might nevertheless
raise the hackles of their juniors.
This has already happened in organized labor, for example. Older workers have wanted certain basic retirement and pension
guarantees written into new contracts and have been willing to discuss larger payroll deductions or employer-employee contributions.
But younger workers have often voted that down. Without a good basis of common understanding between young people and middle-aged
people, our society might face several more decades of deep division over the issue of aging and the position of the aged.
Certainly we should look to philosophy as a way of healing divisions and overcoming barriers, real or imagined. At least,
that is my intent in pursuing this idea of a philosophy of aging for public health. Nor do I see any conflict in the very
idea of bundling a word like "philosophy" together with a phrase like "public health." I am reminded of the
lesson taught by the late James Bryant Conant, who wrote that "any attempt to draw a sharp line between common-sense ideas
and scientific concepts is not only impossible but unwise." I hope that, in these few minutes together, we may have made
some progress seeking the unity of common-sense with science, possibly gaining that sense of unity with the help of a touch
of philosophy. If so, then I hope it might count as another small victory for older people in our society.