When should I die? - life prolongation and medical innovations - Brief Article

Whole Earth, Summer, 2000 by Pw

When should I die?

"Sometimes I get so mad, I feel like just up and diluting his anti-gerasone," said Em.

"That'd be against Nature, Em," said Lou, "it'd be murder. Besides, if he caught us tinkering with his anti-gerasone, not only would he disinherit us, he'd bust my neck. Just because he's one hundred and seventy-two doesn't mean Gramps isn't strong as a bull." "Against Nature," said Em. "Who knows what Nature's like anymore? Ohhhhh--I don't guess I could ever bring myself to dilute his anti-gerasone or anything like that, but, gosh, Lou, a body can't help thinking Gramps is never going to leave if somebody doesn't help him along a little.

Golly--we're so crowded a person can hardly turn around, and Verna's dying for a baby, and Melissa's gone thirty years without one." She stamped her feet. "I get so sick of seeing his wrinkled old face, watching him take the only private room and the best chair and the best food, and getting to pick out what to watch on TV, and running everybody's life by changing his will all the time.

--Kurt Vonnegut, Welcome to the Monkey House (1968)

Kurt Vonnegut was, of course, the first to depict a totalitarian gerontocracy. What will happen when we are able to ask: When should I die? Will doctors be reborn as postmodern shamans and tell us how to choose between living long and living well? What is the new path of the soul?

In the odd ways of the world, as birth control has become a fact of life, death control has begun to emerge as a futuristic option for population management. Over the next fifty years, as birth rates subside, there may be a tidal wave of elders--some approaching 120 to 160 years in age. With increasing life spans, can we make the transition from birth control to death control? If not, what is the meaning of population control? Will Kevorkian euthanasia become as common as birth-control pills?

The techno-materialist view insists that longer and healthier lives are unquestionable "assets"--death is the enemy, and should be resisted with every last resource. A budding ecological /Hippocratic service-oriented movement wonders about society's willingness to spend so lavishly to extend the lives of some, while being apparently unwilling to focus public spending to improve the quality of the majority's shorter lives. Do the poor, always marginalized, die sooner from lack of funds?

--PW

LIFE IS INHERENTLY IMMORTAL

A Report by Steve Weber from NextMed2

Eugenia Wang reminded us that life span extension, in principle, is a familiar thing in the twentieth century. The average human life span in 1900 was around 54 years; it is now around 78 years in industrialized countries. Even without revolutionary breakthroughs in technology, incremental improvements in knowledge about genetic risk factors and environmental elements will continue this trend. After all, there is already a substantial population of centenarians in the world.

But there will almost certainly be some revolutionary breakthroughs which will change the parameters of how long we can live. Consider chronic heart failure, a common endpoint of many different diseases, which frequently brings an end to life in the developed world. Heart failure costs the US upwards of $18 billion a year. For the most part, today's medicine offers little more than palliative treatment.

In the near future, some combination of (1) stem cell biology, (2) drug intervention, (3) gene therapy, and (4) material sciences will change that. Heart repair is on the way, but probably not through the artificial-heart approach that was favored twenty years ago. In fact, biological approaches are eclipsing engineering approaches. Xenotransplantation (the use of organs grown in other animals) is a promising interim approach, but it will be probably be eclipsed by the increasing use of human cells through myocyte proliferation (finding ways to stimulate heart cells to divide), transdifferentiation (converting other kinds of cells into myocyte heart cells), and stem cell transplants. After all, skeletal muscles repair themselves and often get stronger in the process (think of weightlifters). The trick is to control the proliferation, differentiation, and most importantly, the structural and architectural arrangement of heart muscle cells. The biology to do all three is in reach.

In some sense, all of medicine is about extending and improving the life span, but some approaches are more direct and dramatic than others. Recent work on telomeres is the most dramatic. For instance, discreet sequences at the ends of the chromosomes, called telomeres, degrade over time as the cell goes through cycles of cell division. Stop this process of degradation, as we can now do easily with an enzyme called telomerase, and you stop the genetic key to the aging of cells. Introduce the telomerase gene into normal human cells, and they become immortal, but not cancerous.

When I was in medical school this achievement was thought to be the unattainable Holy Grail of cell biology. It is now done. The company Advanced Cell Technology is currently preparing telomerase virus vectors, and anticipates moving to clinical trials in perhaps three years. These trials will tell us if cells in living animals can actually be brought back from old age to youth.