To change the meaning of “being useful” for the elderly

regarding D.Callahan’s idea　of 　

“life-sustaining treatment” and “euthanasia” 

Cold Spring Station, a suburb of NYC

The idea of Communication 

and 

The idea of Generation

Elucidating two pillows of Re-ageing Gerontology

(A Philosophy of Aging)

Naoki Morishita

President of Center for Re-ageing Gerontology

Morishita, the author of this article, had obtained oral consent from D. Callahan at the time of shooting, 2010, and got written permission from the Hastings Center at this time regarding the use of the following photos. In addition, Morishita’s writings mentioned in this article is posted on the homepage (in Japanese site, one of them in English site) of the Center for Re-ageing Gerontology.

Introduction

Clarify the vision of Re-ageing gerontology that I advocate as a new philosophy of aging. The Beginning of Re-ageing gerontology (Japanese), which I started writing from that point of view, has already counted eight times, but it seems that the search for it has come to an end. This is because I was finally able to grasp the ideas that should be the two pillars of Re-ageing gerontology. That is the idea of ​​”communication” and the idea of ​​”generation” developed from it.

The former is explained in detail in my book System Ethical Thinking, and the latter is also explained in the Beginning of Re-ageing Gerontology VIII from the perspective of transcending ideological conflicts. However, their significance to the Re-ageing gerontology has not yet been fully explained.

So, this time, I take up D. Callahan’s Setting Limits: Medical Goals in an Aging Society, which advocated the limitation of life-prolonging treatment for the elderly, and also my book Who are beings of unworthy life? (Japanese edition). Based on them, through seeking a point of view against the thought of Uselessness that naturally takes for granted that there are useless people, I would like to explain the significance of the two ideas as clearly as possible.

Here, “the thought of Uselessness” is my coined word, and refers to the general view of ability discrimination, including “ageism,” which regards old people as useless. The honorific titles of those mentioned in the theory will be omitted.

1.  Elderly problems and life-prolonging treatment

In March 2010, I visited The Hastings Center for Bioethics in Cold Spring, a suburb of New York City. There, I had the opportunity to talk to one of the founders of this Center, Daniel Callahan, who is renowned at Bioethics. He was 80 at the time. He had already retired from his honorary position, but he turned a small room beside the front door into an office, where he politely answered the questions of young researchers. An old dog was lying at his feet.

Twenty-three years ago, this gentle-eyed Scottish old man wrote “Medical Care for Aging ” (Japanese, translated by Atsushi Yamazaki,1990. Daniel Callahan, Setting Limits: Medical Goals in an Aging Society, 1987.) and boldly advocated that geriatric medicine should be restricted. He died in 2019 at the age of 89. As an introduction to this discussion, let’s review the significance and problems of his claim while arranging the outline of his claim. The numbers in the text are the number of pages in the Japanese translation.

The emergence of a new “elderly problem”

As pointed out in The Beginning of Re-aging Gerontology VII, the “elderly problem” was discovered in the 1960s and early 1970s. The background to this is the trends common to industrialized countries, such as postwar economic growth, aging population composition, longevity due to advances in medical technology, and political movements of liberalism.

 At that time, three masterpieces were published on this problem and the “ageism (discrimination against the elderly)” that created it. In France, S. de Beauvoire‘s “La vieillesse” (1970), in Japan, Sawako Ariyoshi‘s “Kohkotsu no Hito” (1972), and in the United States, R. Butler‘s “Why survive: Being old in America” (1975). The contents of these three books are introduced in detail in “Re-aging Gerontology Materials”, and their significance and problems are examined from the viewpoint of Re-aging Gerontology.

Well, what happened after that? Since the 1970s, as the anti-ageism movement has spread, political eyes have finally begun to reach the dire situation of the elderly, and the situation of welfare for the elderly has gradually improved. It was medicine and medical care at that time that strongly supported this trend. Life-saving medical care has made great strides, intensive care units have been put in place, and dialysis machines have become widespread. As a result, the desire for health has grown endlessly, depending on life-prolonging technology, and health has become one of human rights. Furthermore, the realization of health and longevity has fundamentally changed the outlook on life. The short and miserable old age turned into a frontier full of possibilities (pp. 20-21).

Since then, to this day in the early 2020s, medical technology has become more sophisticated, health has been regarded as the highest value, and a healthy, active and long-lived life has become commonplace. However, as of the latter half of the 1980s, another “elderly problem” had already sprung up. The super-aging population, the endless increase in medical costs, and the loss of meaning to live with longevity with chronic illness (p. 26). Today, the new “elderly problem” is getting a lot of attention, but at that time it was hidden behind the anti-ageism movement and the spectacular success of medical care. Callahan was the first to pay attention to it and tackle it head-on.

Medical Care for Aging

(Japanese, translated by Atsushi Yamazaki,1990. Daniel Callahan, Setting Limits: Medical Goals in an Aging Society, 1987.)

Community based perspective

Callahan focused on the deeper ethical issues of society, rather than the reforms of the social security system required from a financial perspective. Why and how much should the family take care of the old parents? Why and to what extent should society support families who collapse together in long-term care? How can the old and young generations form a bond without division? The answer to these questions depends on how the community positions old age and death (pp. 27-30).

However, the anti-ageism movement does not look directly at old age and death. Of the two pillars of exercise, death means defeat in medical care aimed at health and immortality (p. 31). Butler’s gerontology (Callahan calls it the modernization theory of the elderly), on the other hand, values ​​being productive and ignores aging and death (pp. 33-39). Callahan points out that behind that trend lies American individualism (pp. 40-44, 276). There it is avoided to speak publicly about the goodness of life, and it is considered solely as a matter of personal belief or religion. A good society is a pluralist society that respects individual beliefs (pp. 73-75).

Callahan, on the other hand, thinks that public debate about aging and death is needed (pp. 77-78). He is a “communitarian” who emphasizes public tradition, as opposed to a “libertarian” who puts freedom as the supreme principle and a “libertarian” who prioritizes the value of justice (pp. 45, 276-279). So, he sympathizes with Edmund Burke’s “Reflections on the French Revolution”, citing the phrase “the state (or society) is a partnership between the dead and the living and the unborn” (p. 60).

Meaning and role of aging, goals of society and medicine

Callahan looks at Erikson’s “life cycle” to narrow down the meaning of aging (pp. 50-52). This does not see life as a straight line, but as a periodic “unit”. The aging period on the life cycle is at the stage of completion. In order to grasp this substance, Callahan goes to consider time consciousness.

Beauvoir is a pioneer when it comes to aging time consciousness. She analyzed aging time phenomenologically and defined it as “an uneasy present in which one cannot feel oneself between a condensed past and a limited future” (for this, introduced in “Re-aging Gerontology Research Materials” and “Beginning of Re-aging Gerontology VII”). However, her theory of time is limited to the linear consciousness of time of existence (individual), and lacks the viewpoint of the time of the community that surrounds the individual. Given the time of the community, the past is not condensed and the future is not closed. The past and the future are connected in the urgency of the present (p. 55).

If old age is in a position to connect the past, the present and the future, and the elderly can imagine the future by learning from the past, what will happen to the role of the elderly in the present? Many elderly people have usually given up on their potential and have already fulfilled their responsibilities to their families. Callahan says that the remaining role, on the one hand, is to contribute beyond family service, that is, to support the younger generation, and on the other hand, to face the declining self and prepare for death (pp. 60-63).

Following the meaning of aging and its social role, the next question is goals of society and medicine. The crucial point here is how to set the basis for deriving the goal. Callahan focuses on “acceptable death” rather than “premature death.” It consists of the following three conditions (pp.84-85).

⑴ Realizing the potentials of life

⑵ Fulfilling the obligation to the person who should be responsible

⑶ It is the end that does not go against common sense and does not invite the negative emotions of the people around

The core of the above conditions is the “potentials of life.” As Joan M. Erikson says in this regard, some will be lost at the age of 90, but others may be gained (E. H. Erikson & J. M. Erikson, Life Cycle, Its Completion, Japanese version, 2001).  However, Callahan thinks that most elderly people will accept it “generally” with resignation.

“Natural lifespan” is derived from “acceptable death” (p. 85). This concept is an extension of the perspective of an individual organism, “health as a standard of life,” throughout life, where “nature” is not a life science nature, but a common pattern throughout human culture (pp. 81-82). The average life expectancy in the United States at that time was about 71 years for men and 78 years for women, and based on this, Callahan defines “natural lifespan” as being in the late 70s to early 80s (p. 188). It can be considered to be almost 80 years old.

Assuming “natural lifespan”, the goal of society is “everyone can live a natural lifespan”. In other words, a good society for Callahan is not a pluralist society, but a “society where everyone can live a natural life” (p. 198). On the other hand, regarding goals of medicine, medical care supports  (1) health by using high-tech medical technology to prevent premature death and achieve a natural lifespan, but (2) the elderly social contributions through elimination of pain after the natural lifespan, and ⑶ ding with peace of mind at the end (pp. 98-99, 172).

Geriatric medicine principles and practices

Restrictions on geriatric care are required to prevent unilateral self-sacrifice on young people (children’s generation). However, the elderly cannot be cut off. So, medical restrictions must be compatible with respect for the elderly (pp. 148-149). The logic of Callahan that makes this compatibility is summarized in my own way (pp. 150-151).

(1) Everyone should have a natural lifespan. Therefore, no generation should be unilaterally sacrificed by another generation.

⑵ An elderly one who has reached the end of one’s natural life has almost realized one’s life potential. Moreover, the elderly one is about to leave this life.

(3) Therefore, the elderly generation should hand over high tech medical resources to the young generation after the natural life span has passed.

Based on the above, the principles of age-based public policy are established (pp.217-219). Life-prolonging medical care includes emergency life-saving treatment (level 1: cardiopulmonary resuscitation), intensive care (level 2: ventilator, dialysis), general medical care (level 3: antibiotics, surgery, cancer chemotherapy, artificial water / nutrition), and general care (level 4: painkillers, cleaning, hydration / nutrition, comfort) (p.229). After the natural lifespan, Level 2 is not applied and it is switched to Level 3 or 4 to eliminate pain, supporting contributions to younger generation and helping to die with peace of mind until the end. 

However, the application of the principles of public policy (medical system for the elderly) is discretionary in clinical practice. This is because it must be decided not only on the age basis but also on individual medical needs (p. 233).

For example, let’s say you have an elderly (85 years old) who has passed his or her natural lifespan. Callahan says that any level of treatment may be given if the elderly is extremely healthy, but should be stopped at level 3 if he has severe dementia. The application to the former, of course, deviates from the age base. However, such exceptions are unavoidable until a policy can be made through public dialogue on the meaning of aging and medical goals, or even if it can be done, considering humanity (p. 250). 

In addition, since water and nutrition supplementation has a symbolic meaning, level 3 artificial methods should be withheld along with antibiotics, but level 4 should be maintained until the end (pp. 243-244). 

Callahan’s proposal summarized above received a large chorus of opposition, as he expected (p.12). There are various reasons for the opposite. Main opinions are the followings:

The sophistication of medical technology is good, and the accompanying increase in medical costs is unavoidable; Health and longevity are good, and society should not intervene in individual beliefs about life; dividing medical care by age in the first place is the ultimate ageism; life value is absolute and artificial addition is not allowed; and above all, it violates the principle of medical ethics that considers only the medical needs of individuals (p.212) .

However, if the increase in medical expenses is left as it is, it will drive the social security system into bankruptcy and leave areas and fields other than medical care and health in a poor state. In addition, problems such as curbing medical expenses and allocating medical resources cannot be solved by the tactics of small hands. Anyway, a drastic reform is needed, but in the United States and Japan, people don’t try to see it, and they don’t think about it.

According to Callahan, the allocation of medical costs and medical resources is not the only issue. Even more important is the issue of ethics. The collapse of caregivers, the division of society due to intergenerational struggles, and the loss of motivation to live due to longevity are occurring everywhere, and weigh more and more on us. Behind the lighted health and longevity, there is widespread view that aging and death leaking from it are useless. Bedridden and dementia in particular further accentuate the misery of aging. Against this background, the number of people who support euthanasia has increased over generations, but Callahan opposes euthanasia because it does not lead to respect for the elderly (p. 245).

2. Callahan in ideological conflict

Daniel Callahan, Hastings Center, 2010

I’m not always convinced of the details of Callahan’s proposal to limit geriatric medicine, but I basically agree with the perspective that underpins the overall proposal. As he says, the issue of aging and death should be publicly discussed in order to share the meaning and role of aging. After confirming that point, I would like to take a look at Callahan’s claim from the perspective of ideology before stepping into the euthanasia issue.

Callahan and Butler

Callahan refers to Robert Butler at the conclusion of this book (pp.255-256). Butler quoted Pindar’s maxim “Don’t wish for immortality, but push the limits of your possibilities” at the beginning of the conclusion of “Why survive”, and emphasized “proceed without such limits”. 

Callahan sees the contradiction of the aging-modernist Butler there. It is an attitude that constantly pushes it forward, even though it presupposes a limit. However, that important passage is not translated in the Japanese version for some reason. I myself knew the fact only after being pointed out by Callahan.

Butler, on the other hand, emphasized in the first edition of the original book (1975) that the meaning of an elderly’s longevity is to change without fixing his/her identity,  and chanted “life as artistic work” (Chapter 14). However, in the “Foreword to the Japanese Version” (1991), he suddenly mentions “inheritance of generations” as the meaning of longevity (ⅷ). This can be interpreted as a response to criticism from Callahan.

Communist position and responsibility theory

Moving Callahan’s criticism of Butler to the dimension of political thought puts him in the position of a communitarian who prioritizes the public tradition of the community over the “individualism” of libertarians and libertarians. Butler’s theory of aging modernization and modern medicine are both based on individualism. The conflict between libertarians/libertarians and communitarians is central to modern political thought.

Conflict of thought is inevitable, but it may be possible to alleviate or fluidize the conflict. With that in mind, I advocated “balanced thinking” based on the four-dimensional correlation, which is the basic structure of the human meaning world, in “System Ethical Thinking”. (This point is also explained in “On ‘Bias’ in the World without” Correct Answers” in our homepage). 

However, balanced thinking is a conceptual framework, and it is difficult to imagine it by itself, and it is also difficult to use it as a tool. Intuition is also needed to guide practical policies. Therefore, the “generation” was called from the warehouse of the idea of ​​mankind. Because the idea of generation incorporates the four types of ideas of individual body, commune, integrative body, and transcendental noting as elements, which is explained in “The Beginning of Re-ageing Gerontology VIII”.

From the ethical point of view, Callahan takes responsibility approach against rights approach. Speaking of responsibility, Hans Jonas is famous in the context of bioethics (“The Principle of Responsibility”, translated by editor Hisatake Kato, Japanese version, 2000). Callahan also mentions Jonas in his acknowledgments, but there are differences. 

The origin of Jonas’s theory of responsibility is the unconditional care of parents for innocent and vulnerable babies. However, Callahan is skeptical about his attitude of unconditional service to the vulnerable (p.141). Also, Jonas’s theory of responsibility lies within the nation issues that lead Heidegger to Hannah Arendt. The theory of responsibility regarding nation and war bears the mark peculiar to the 20th century when nationalism collided. In the super-aging society of the 21st century, the theory of responsibility will be required for non- individuals and non-national groups. Callahan presents “mutual responsibility of each generation” (p. 259). “Generation” appears here as well.

Lifespan between a human being and a living thing

The premise of Callahan’s proposal is “natural lifespan.” At the heart of this concept is the situation of “realizing the potentials of life” or “living enough until then.” In other words, “natural lifespan” is not “lifespan as a living thing” but “lifespan as a human being”. Callahan gives three points about how to perceive human beings, reason, emotion, and relationship with others (pp. 20-21). It is a common view of person theory in bioethics. However, it seems to be too poor for grasping human life?

In Chapter 7 of System Ethical Thinking, I analyze the concept of QOL and reconstruct “conceptual framework” consisting of three layers of life , survival as animal behavior,  human activity as mutual communication, and life as time consciousness, and two quality, objective and subjective. Based on this framework,  it will be possible to grasp the “potentials of life” as a four-dimensional correlation from multiple perspectives. Therefore, the beginning of “reduction of mutual communication” can be regarded as the end of “life as a human being”.

The death period comes before the end of “life as a human being”, but the “death period” of human beings should be regarded as the final stage of “mutual communication”, not the end of “life as a living thing”. The final communication suitable for humans is neither high-tech life-prolonging treatment nor euthanasia (assisted suicide), but lies between the two extremes. At that time, the problem is how to supply water and nutrients.

Social security system and poverty policy

Finally, since Callahan’s gaze is on ethics deep in society, he has not taken steps to improve the social security system. If he goes into that, he will be asked the basic idea of ​​how to build a comprehensive policy of poverty and what is the basis for that. In the case of Japanese society, we must start with a rational reconstruction of the de facto standard for receiving welfare expenses. The above is mentioned in “Old Age Bankruptcy” of My Bookshelf No. 6, even though it is a rudimentary one.

3. Euthanasia and Thought of Useless

Who are beings of unworthy life?

In September 2020, I co-authored with M. Sano The new version of  “Who are beings of unworthy life?” This is a two-part structure, consisting of a complete Japanese translation of “Die Freigabe der Vernichtung lebensunwerten Lebens. Ihr Maß und ihre Form, Binding, K. und Hoche, A. (Felix Meiner, Leipzig, 1920, 62S)”, which theorizes the acceptance of euthanasia in medical treatment, and critical considerations of the two translators. 

Actually, I published the old version 20 years ago, but I wrote about the circumstances during that time in this book, so I will not repeat it. Only the important issues are mentioned here. Why 20 years? That’s because there are more positive opinions about euthanasia. Looking around, many elderly people find hope in euthanasia in the daily life of a super-aging society. It’s like this.

If I have incontinence or swallowing problems and am bedridden with diapers, I don’t want to live. If I don’t understand the people around me or myself, I can’t help living. So please let me die. If possible, I want to be euthanized before that happens. (vii, 153, 213-4)

However, it is not only elderly people, but also young people who think so. In my experience, euthanasia affirmatives and negatives antagonized students 10 years ago. Before that, the number of affirmatives was small, but now it is the overwhelming majority. If this trend continues, euthanasia will be legalized in Japan in the not too distant future.

Regarding voluntary euthanasia (including assisted suicide), I have no intention of choosing it, and I loosely think that natural death is preferable for about two weeks immediately before death, but as a society, I thought that euthanasia could be accepted as an option. 

But, while preparing this book, I came to the conviction that euthanasia should not be legally accepted as an alternative in the face of the unexpected spread of euthanasia desires. The reason is that euthanasia presupposes the useless common sense that “some people are useless” and instead encourages it. 

Below, I would like to explain my point of view while comparing the logic of “Die Freigabe”, which was also taken up in our “Who are beings of unworthy life?”, with the mentality of the two Japanese people 100 years later.

The logic of “Die Freigabe” 100 years ago

In Europe, there were two long-controversial themes between law and medicine. One of them is “suicide” based on the person’s free will. This has been a sin in Christianity. The other is “pure euthanasia” in which the person’s will is absent. This has been at the discretion of the doctor at the end of a patient’s life. 

If you confirm here, “euthanasia” means “murder by others”. “Suicide” is also a murder by another person, as long as one considers that the life given by God is to be disposed of arbitrarily.

By the way, “Die Freigabe” allows the “murder by others” that has been prohibited until then by combining the following two viewpoints. One of them is to regard “a state that is unlikely to be saved” as an “incurable disease.” The other is the viewpoint of “a burden on the person himself/herself and a burden on the caring people and society around him/her.” Combining these two viewpoints, we can conclude that “a condition that is unlikely to be saved as an incurable disease” is a “burden” for everyone. 

From the above point of view, one suicide is limited to “incurable disease”, and it is regarded as euthanasia in medical treatment because it is a burden to the person. On the other hand, the target of “pure euthanasia” has been expanded to “incurable disease” from the end of life, and patients with dementia, intellectual disability, and mental disorder are burdened on themselves, those around them, and society. Euthanasia becomes the responsibility of the medical practitioner.

“Die Freigabe” occupies a special position in the history of thought about euthanasia. There are two types of euthanasia, voluntary euthanasia and involuntary euthanasia, which have traditionally been viewed in different contexts. This book reconsiders suicide and pure euthanasia, which had been at the extremes until then, as the same euthanasia from a “clever” point of view, and incorporates it into general medical care to uniformly euthanize the severely ill and the elderly and disabled people. It paved the way for the target. In that sense, “Die Freigabe” is a comprehensive general theory of euthanasia, which includes all the elements of euthanasia, including humanism, economy and war, etc.

However, the “state unlikely to be saved”, which has been reconsidered as an “incurable disease” in daily clinical practice, is extremely ambiguous in terms of its criteria and scope. Also, when it comes to “a burden on the person, the people around him/her, and society,” the meaning of the burden is different for each, and it must be said that it is an outrage to put it together as a burden for everyone. In short, the view that “a state unlikely to be saved is equal to a burden for everyone” is a grotesque emphasis on the “useless thought” that naturally takes into account that there are “useless people” in social groups. 

In addition, why was “Die Freigabe” published in 1920? If you recall the social situation at that time, you can see the background of the times. First, there was a social movement for the right to die that had continued since the latter half of the 19th century. There were also theoretical works related to this. Next, there was the poverty of the people of the defeated Germany, and the left and right political radicalism was growing in power over the solution. At this time, Hitler’s Nazi predecessor party was also born. And finally, the epidemic of the Spanish flu (pandemic). It has been going on for several years and is estimated to have killed about 50 million people worldwide. The above is what happened 100 years ago, but it overlaps with today, 100 years later.

Mentality of two Japanese women

Next, we asked two Japanese women to appear almost 100 years after that book was lifted. One of them is Sugako Hashida, who published “Please let me die by euthanasia” (Bunshu Shinsho) at the age of 92. She enrolled in a Swiss organization hoping for her euthanasia (assisted suicide), but she died in a Japanese hospital in March 2021. She was 95 years old.

Hashida is a well-known TV screenwriter and has made her life worthwhile in her screenplay work. She also lived hard before and after the war, not to bother anyone. But for years, no script requests have come, her time has passed, she thought she had finished her role and was no longer needed. She already has no goal to live because she is useless to the world. She is not motivated to live and has no fun. When she is bedridden, she must bother the hands of young careers around her, which her pride does not allow. So she imagined and wanted to be euthanized for years.

Another, Mina Kojima (51 years old), is the first Japanese to publish her euthanasia on television. Hashida had already done well in her life, but in the case of young Kojima, she had a regret that she was frustrated in the middle of the road (Yohichi Miyashita, “Japanese who euthanized” Shogakukan, 2019).

Kojima has lived in her belief that she is an independent woman. She was diagnosed with multiple system atrophy when she was 48 years old. This is an intractable neurological disease similar to ALS. She gradually loses her leg. Numbness and pain run throughout her body. She sedates this with medicine. She gradually gets stuck in her tongue and she gets hard to talk. She imagined her own future. “I become more and more unlike myself every day. Eventually, I’m going to be bedridden, and every day of changing diapers is waiting. I can’t say “thank you” to her family. I no longer feel the joy of living in such a future, and I don’t want to live”. She thought so and she repeated suicide attempts several times. She was inspired by reading Hashida’s book, persuaded her sisters which have took care of her, registered with a Swiss organization and actually euthanized there.

In the case of the two, there is a common belief in the choice of euthanasia. You decide how to die yourself. In comparison, intimate relationships with family members are not a top priority. If you don’t want to live, choose euthanasia yourself. It’s not like you to live until you’re bedridden or have dementia. You can’t do it like you used to, and you don’t have a goal to stay alive. Also, living up to that point will cause trouble for others, which your pride does not allow.

If you expand the mentality of both, it will be like this. “What I can’t do” brings you the consciousness of “I can’t do anything” and the consciousness of “I cause trouble for others “. And when these two are combined, the consciousness of “useless self” arises. From there, he is evaluated as “not worth living” and “euthanasia” is chosen as the least painful method. A logic similar to this pierced “Die Freigabe”. “A state unlikely to be saved equal to incurable disease” is considered “a burden on the person, a burden on the people around him/her and society”, and is evaluated as “unworthy life” because it is “useless” and euthanasia was chosen.

Thought of Uselessness

Let’s call the view that “some people are useful and some people are useless” in the world as “thought of Uselessness”. This is a far deeper social common sense than just an idea. The major premise of social groups is survival. And it is the energy involved in survival and the ideology that gives justification that underpins this possibility of survival. And what was created as ideology is ethics in a broad sense, which includes rules, laws, morals, and ideals. In this ethics, the work (function) of the members who help the survival of the social group is good, and their ability (what they can do) is evaluated positively. That point does not change in any social group.

Various ability discriminations arise from the common sense of useful/useless. There is an inherent distinction of ability among people belonging to social groups. Abilities are multidimensional and diverse in the first place. Distinction turns into discrimination when valuing it on a single scale. 

However, as long as a person is present in a particular situation, it may be more appropriate to have various discrimination from the beginning rather than just a distinction (difference) at the beginning. In this article, discrimination other than ability discrimination is not discussed as a subject.

There are two types of ability discrimination. Relative discrimination discriminates against people only on a particular measure of focus (this includes the placement of the right person in the right place). In absolute discrimination, people are fixedly discriminated against by attributes that are difficult for individuals to do, such as gender, ethnicity, or race. In this case, it may proceed to the selection of life.

Discrimination in ability is rooted in the thought of ​​Useless and will not disappear as long as the social group survives. Whether it is a modern civil society, a capitalist society, an industrialist society, or a managementist society, the essence of discrimination does not change even if the phenomenon of discrimination is different.

 If so, all we can do is recognize the mentality and logic that shifts from distinction to discrimination and from relative discrimination to absolute discrimination, and encourage it to constantly flow backwards. But in reality, even that is difficult, and that alone is too weak. Is there an idea that can be countered more strongly?

4. Change of meaning of “being useful” (1)

I seek the basis for countering the thought of ​​uselessness in the idea of ​​”communication” and of “​​generation” that develops from it. “Useless self” was caused by two elements, “the self who can’t do anything” and “the self who causes trouble for others”. First, let’s take up “I can’t do anything” and confront it with the idea of ​​communication.

Recapture of “the self who is unable do anything”

When people get stuck and can’t do something like they used to, people worry about what they can’t do, think they can’t do anything, get confused, angry, and eventually despair. At that time, what is working behind their mind is the idea of ​​Uselessness (that is, the general social common sense of ability discrimination). There have been at least three types of discourse to counter this thought.

The first is to regard “being unable to do” as “weakness” or “vulnerability”. From there, it is often said that “it doesn’t have to be able”, “it doesn’t have to do anything”, and “it just needs to be there”. However, everyone hold more or less weaknesses, all of which are concrete and multidimensional. Nevertheless, if we abstractly and absolutely emphasize “being able to do equal to weakness”, as Callahan points out (p.141), the other party can only worship before that “justice”. It raises the person into an absolutely passive being, making it impossible to take concrete supports based on what the person can do.

The second is to regard “being unable to do” as “individuality” rather than “weakness”. The slogan “Disability is individuality”, which was set out in the disable people movement, is typical. However, “disability” is a multidimensional fact and is different from individuality. Because the individuality of the person is formed by adapting well to what cannot be done and devising something else that can be done. The abstract “being unable to do equal to individuality” does not lead to concrete ingenuity, even if it encourages the person.

The third is to grasp “being unable to  do” as a viewpoint to overturn the value system ​​that consist of “being able to do”. Just as when a person becomes ill, the conventional view of a healthy person collapses, and when something cannot be done, the conventional values ​​of the world collapse. However, a change in perspective does not immediately overturn a world that can be done and create a world that cannot be done. For that purpose, daily steady practice is indispensable. As pointed out in “The Beginning of Re-aging Gerontology II”, the discourse “Overturn of value system” can be seen in Kiyokazu Washida’s “Cultural Blank of Aging”, but it is an abstract anti-order thinking on the premise of established order.

In my opinion, above discourses cannot counter the common sense of Uselessness. A more specific and positive base is required. It probably goes beyond the fixed binary oppositions of “can / cannot”, “do / do not”, “do / exist”, “weakness / strength”, “individuality / non-individuality”, or “order / anti-order”. And It would be an idea to loosen them and fluidize them. One of the candidates is the idea of “​​communication” that was set out in my book “System Ethical Thinking”.

System Ethical Thinking

The idea of Communication

The relationship of everything is communication. “Communication” is derived from the Latin word co+munus, and its original meaning is “interaction of something”. If you think that something is not a word or action, but an electron, a biomolecule, or a symbol, it can be between elementary particles, between pine and wind, between cells, between flowers and butterflies, that is, Communication will be established between all things. 

If there is a relationship there as long as the exchange is taking place, and if there is an exchange there as long as there is a relationship, then the relationship of everything is communication. So, what is being exchanged in human communication?

For example, suppose someone is raising their hand. You can see a series of acts (a behavior) of “raising one’s hand”, but unless you can identify the “intention” of raising one’s hand, you cannot decide what kind of action it is. It may be a manifestation of opposition, or it may be stopping a taxi. Or someone could be signaling you or doing gymnastics alone. 

When the visible action is regarded as an expression (information), the meaning of the expression is the intention to decide what the action is. In the actual situation, the intention is not always clear, and the person may not be aware of it. Even so, communication does not proceed without narrowing down the ambiguous intention (meaning) of information to one and deciding a specific action. The work of narrowing down to this one is called “interpretation”.

Based on the above, what is exchanged in human communication is the interpretation of the ambiguous meaning of information. At that time, the interpretation by the receiver is sent back as information to the other party (first sender) through words or actions (expression), and the receiver confirms his or her own intention by interpreting the information, adds a new meaning and sends it back again to the other party. In this way, it is the interpretation (acceptance) of the receiver, not the sender, that holds the initiative of communication and influences the direction of communication. Of course, the sender and receiver usually alternate.

The role of spoken side in partnership

Chapter 1 of “System Ethical Thinking” focuses on the communication process that occurs in the minds of both sides, assuming that the side that receives and interprets meaning as information takes the initiative in communication. Found that it periodically follows the four steps of ⑴information acceptance,  ⑵intention interpretation, ⑶interpretation comparison, and⑷ comprehensive evaluation. Then, from there, we took out the “logic of four-dimensional correlation” regarding communication in general, and in the following chapters 3 and 4, we made full use of it to grasp the world of human meaning as the world of a wide variety of communication systems. 

However, let’s return to the starting point that the receiver of communication takes the initiative.

In normal communication, both sides can talk, and it is assumed that the receiver and the sender alternate. However, there are cases where one person does not speak or cannot speak. Will communication hold even in this case? The answer is yes. As long as the receiver’s interpretation holds the initiative for communication, communication will continue even if the other person does not speak or cannot speak.

Communication is established as long as one side who can speak takes the initiative and continues to speak, even with the other side who does not speak or cannot speak. But is this a rare situation? It is not. If you look over time and space, communication with someone can’t talk about or talk about is far more comprehensive than communication between both can talk to. It includes not only dementia and bedridden old people, but also dead and unborn things, animals and plants, AI robots, symbols, and even materials.

Let’s focus on the role (part) here. In normal communication, there are roles of sender and receiver. In that it has a role, it is the same in communication that includes things that don’t say or cannot say. There is not only the role of the person who speaks, but also the role of the person who is spoken. Thinking in this way, at least in human-speaking communication, everything becomes a partnership. This viewpoint of “role to be spoken to” is as important as the conceptual framework of four-dimensional correlation, which is drawn from the idea of ​​communication.

5. Change of meaning of “being useful” (2)

Next, let’s move on to reconsidering another element of “useless self”, “the self that causes trouble for others”. Opposed here is the “idea of ​​generation”. This originally comes from childcare and elderly care. The essence of both is care that connects generations, and this is the origin of the type of mutual help communication. In that sense, the idea of ​​generation becomes the development of the idea of ​​communication.

Recapture of “the self that causes trouble for others”

As an introduction, let’s take Susumu Nishibe, a well-known critic. He entered the Tama River in 2018 at the age of 78 and “suicided”. Nishibe always wanted to end his life on his own, but he didn’t want to bother his family. The following is abbreviated from Wikipedia.

By the time he was 55, Nishibe was roughly ready for suicide, and he became even more determined after his wife died in 2014. […] In terms of health, Nishibe has a chronic illness on the back and may suffer from severe pain, suffering from dermatitis and neuralgia, and suffering from severe cervical spondylotic myelopathy. So, he couldn’t hold anything, which made writing activities difficult. […] In the years leading up to his suicide, he told his close younger friends that he wanted to die. He always said that he would also end his life so as not to bother his daughter or son. […] He said, “I can’t stand being seen without knowing my intentions,” and “it’s about to reach its limit.” In his books, “The reality of what is called natural death is nothing more than “hospital death”, “I don’t want to be ordered or tampered with by others at the end of my life”, “Death is the final finishing touch to my life.” He stated that he had the intention of “suicide” to kill himself.

Yoichi Miyashita, a journalist on the issue of euthanasia who accompanied Kojima to euthanasia, expressed discomfort with the trend of praising suicide of Nishibe (PRESIDENT Online, 2018.2.10). According to him, in Switzerland and the Netherlands, for example, persons who were euthanized by cancer at the age of 65 or older invited friends to hold a farewell party, but it is a personal point of view. The main character in one’s life is one’s self. Compared to that, Nishibe, who also expresses individualism but does not want to bother him, seems to be incomplete.

But should the dying person not be considerate of their surroundings? If there is a problem there, it may be in the way that is constrained by the negative view of causing inconvenience. In the case of Nishibe, it certainly didn’t bother the children directly, but with the help of two younger followers, they were arrested and punished for aiding suicide. It is rather that point that is incomplete. Isn’t it possible to take the idea of ​​”I don’t want to bother you” rather positively and reconsider how to care for the surroundings from that perspective?

What I remember here is the novel “Narayama Bushiko” (1956) written by Shichiro Fukazawa. This is based on the legend of abandoned private sector, and was made into a movie in 1958 (directed by Keisuke Kinoshita) and 1983 (directed by Shohei Imamura). Especially in the latter, which won the Grand Prix at the Cannes Film Festival, the figure of the heroin who actively accepts the succession of generations in the harsh but easy-going activities of nature is depicted as a matter of course.

Of course, this novel positively accepts consideration for the surroundings as a responsibility for inheritance of generations, but modern medical and cultural standards do not allow the abandonment of elderly people. Rather, we should look for help for the elderly to die with peace of mind while contributing to the younger.

The idea of Generation

Now, instead of the negative view of “I don’t want to bother others” regarding consideration for the surroundings, there is a direction line that actively tries to reconsider it as a responsibility to inherit generations. However, the concept of generation is still ambiguous, and it is necessary to reconstruct the concept of generation including age. Consider a 75-year-old man as an example (of course, the same can be said for a 40-year-old woman with appropriate changes).

75 years old is a living thing, but he is not just a living thing. He belongs to a social group. First, he has a family. His ancestors were definitely there. He may have descendants. This kind of genealogical continuity between parents and children is the first meaning of “generation.” Second, he was born in 1945. He spent his childhood in the 1950s and his youth in the 1960s as a member of the same age group. “They” share the “atmosphere” of the period of high economic miracle and have different values ​​from age groups such as prewar parents. The contemporaneousness of this same age group is the second meaning of “generation.” And finally, the 75-year-old, who has a family and belongs to the same age group (called the “post war baby boomer generation”), is in old stage on the life cycle. This means he is an old man.

As mentioned above, from the viewpoint of generation including age, human beings are not just individuals, but can be grasped from the four dimensions of (1) biological age of living things, (2) continuous genealogy of parents and children, (3) contemporaneousness of same age groups, (4) periodicity in the life cycle (completeness in the case of the elderly).

Combining the four dimensions, the concept of “generation” is reconstructed as the same age group who is responsible for communication between timeless the same age groups, in which the preceding same age group and the following same age group exchange values ​​and culture (lifestyle). If we take this as an idea, we can see that “people of each generation have a responsibility to inherit the values ​​and culture of the previous generation and pass it on to the next generation through criticism, sophistication, and synthesis.” The core of this perspective is generational responsibility.

Social and historical roles

As I wrote in “The Beginning of Re-ageing Gerontology VIII”, in the context of ideological confrontation, the ideology of generation is an intuition of the conceptual framework of four-dimensional correlation, so that It is an idea that becomes a comprehensive platform that makes it possible to loosen and shift the conflict between the ideological principles of individuals, communities, public bodies, and transcendental nothing.

It also makes it possible to derive the setting of “practical goals” that are the cornerstone of the method of system ethics, as long as it is an intuitional and imageable idea. However, the significance of the idea of generation is not limited to that. It has decisive significance in the context of roles, but this point has not yet been fully elucidated.

As mentioned earlier, at the heart of the idea of ​​communication is the perspective of partnership, where everyone has a “role”, even if they cannot or do not speak. On the other hand, the core of the idea of ​​generation is the perspective of “responsibility as a generation” in timeless communication among the same age groups.

Combining these two perspectives, the “role” is positioned in the timeless communication among the same age groups. The idea of generation, together with the idea of communication, teach us that there is a social and historical role that transcends individuals and families.

The idea of generation also provides a concrete image of the community, as well as a recapture of roles.As pointed out in Chapter 4 of “System Ethical Thinking”, there are three dimensions of the community. 

Community 1 is a group of communication networks. This is the most common level. 

Community 2 is a group that comprehensively handles multifunctional systems as opposed to a single-function system group (namely, society). This is a formal classification concept. 

Community 3 is the “Gemeinschaft” against the “Geselschaft” since German sociologist Toennies, which is in a historical context and refers to a traditional mutual help community to modern functional societies.

Community 4 is a timeless communication among generations who exchange values ​​and culture. Callahan is self-evident of the “community”, but I didn’t have a concrete image. The idea of generation make up for it.

The role of the old generation

One generation is roughly divided into four age stages: childhood stage, adolescence stage, middle age and elderly age. The role of each age stage in the community is different. The role of children is to accept and absorb existing values. The role of adolescents is to criticize and dismantle existing values, the role of middle-aged people is to refine and establish new values, and the role of the elderly people integrate both old and new values and transmit them to the next generation. 

The elderly is at the stage of completion on the life cycle. Focusing on this old age, it is divided into the following four sub stages.

⑴ Stage to maintain activities

⑵ Stage to reduce activities

⑶ Stage to be taken care of

⑷ The final stage of dying

Here, human activity is multidimensional mutual communication including work and volunteering, for examples. The role of the elderly is the same at each stage. While supporting the next generation, especially the younger generation, by integrating values, let them learn how to live based on their life experiences, and at the end, show human death as the end of life.

There are various ways to show responsibility as a generation. You can show it with or without words. Whether you are bedridden or have severe dementia, you can show your aging and death to subsequent generations. By having them see it, the younger can learn what life is for themselves, and the elderly can feel the other side of sight to be seen.

However, euthanasia is not included in the various forms at any stage. The vague reason and time of euthanasia mean that there is a risk of expanded interpretation. But fundamentally, even if the choice of euthanasia is applied only to the elderly themselves, by admitting that they are “useless”, they accept the useless idea that “there is a useless person” and have the ability discrimination more and more fixed.

What is of interest to the elderly is how to die in (4). This final stage of life also has roles. One of the roles to be played is to decide the policy of life-prolonging treatment before it becomes impossible to express the intention. Callahan suggests that high-tech life-prolonging treatment should not be given after the age of 80, but I personally think that the policy should be applied approximately one month or two weeks before the imminent death. The guideline is whether one can’t eat on one’s own. At that time, the problem is the supply of water and nutrition. Callahan says that if it’s not artificial, it should basically continue.

When I read Shuichi Sae’s “Yellow Fall” (1996), an old mother whose death was imminent squeezed her mouth and silently showed her willingness to refuse her supply. Traditional dying practices include fasting and entering the water. It’s different from Nishibe and the heroin in “Narayama Bushi Koh”, but it will be helpful as a way to reach the end when one can’t eat on one’s own.

Callahan’s office

6. Vision of Re-ageing Gerontology

In order to publicly discuss life-prolonging treatment and especially euthanasia, which is an extension of the way of life of the elderly, the meaning and role of aging, and goals of society and medical care must be shared in the community including the dead, the living and the unborn. I basically agree with this Callahan proposal. However, in Japanese situation where even the view of “community” is controversial, what should we start and where should we proceed?

Re-ageing Gerontology approach

The answers I have prepared are the ideas of ​​#communication” and of “generation”. In this discussion, we have clarified the significance of the two ideas as a basis for countering the thought of “uselessness” while taking the subject of medical restrictions on geriatrics and euthanasia. To summarize it again, it becomes like this.

First, two meanings are drawn from the idea of ​​communication. One of them is the conceptual framework of four-dimensional correlation that has been emphasized for some time. This makes it possible to grasp the human meaning world as a communication system. And the other is the viewpoint of “partnership” that I emphasized for the first time this time. From this point of view, communication continues even if the conversation is one-sided, and the side that is spoken unilaterally also has a role to play.

Next, two meanings are drawn from the idea of generation. One of them is a comprehensive idea that intuitions the conceptual framework of four-dimensional correlation. In this way, the conflict of ideology can be eased and fluidized, and the “practical goals” that are the key to the method of system ethics can be derived. The other is the new perspective of “responsibility of generation.” This gives the role of partnership social, cultural and historical significance, and fills the concept of community with a concrete image.

This both ideas of “communication” and of “generation” are crucial for public debate. This is because, to emphasize repeatedly, by relying on them, a new role concept that opposes the “social common sense of Uselessness” including “ageism” is presented, and the concept of “community” will come to be concretely imaged. Only on the basis of this familiar and imaginable community will public debate begin over the meaning and role of aging and the goals of society and medical care.

Public debate in the community

To highlight the Re-ageing Gerontology approach above, let’s contrast it with the self-sacrificing approach in emergencies.

With each wave of new corona infections, the number of critically ill patients increased, resulting in a shortage of beds in the intensive care unit at the host hospital. Staff and equipment are attached to the bed. Old people and young people were carried there at the same time. Which is the priority for the remaining one bed? This is triage. There are some agreements in each country and region, but in Japan, even if it becomes a hot topic, there are no official rules.

In April 2020, a Japanese doctor who took the situation seriously devised a “card to give up”. It states that the advanced life-prolonging device will be handed over to younger people, similar to the declaration of intention card for organ transplantation. The inventor was Fuminobu Ishikura (64 years old), a cardiologist. 

I read the article on line and immediately recognized its significance, but the response after that seemed to be negative. There are many voices among the elderly and medical professionals who disagree with the idea of ​​giving up because they are old people, saying that it is a “selection of life.” On the contrary, the opinion that agrees does not appear on the surface due to the nature of the net.

But what was the problem with the self-sacrificing proposal? I personally think that the intent of the inventor is not bad, but rather wonderful. However, unfortunately, the order of putting out is wrong. A society that encourages heroic actions from the beginning is by no means a favorable society. Looking back on human modern history, in such a society, people’s candid opinions are refracted, and the true intention and the formal statements(“Tatemae”) are significantly different.

The first thing we should work on is to set triage as a public policy. This point is also the case with Callahan’s proposal. And to do so, people must share a certain direction through public debate about the meaning of aging and social and medical goals. Callahan emphasized this point (p. 256), and my gerontology also aimed at it. However, the difference between Callahan and me is that I refined two ideas and drew the concept of community concretely from them.

Therefore, the order is as follows. The first is to build up a policy (social security system) through discussions in public forum about the way of life and medical care for the elderly, centering on countering “social common sense of uselessness”. Next, discuss the policies of the clinical setting within the framework of the policies and social security system decided in this way. In this regard, ACP (advance care planning) introduced in clinical practice should be utilized effectively. Only with the above efforts will the heroic actions of the elderly occur voluntarily in an emergency.

Closing remarks

So far, we have clarified the meaning of ideas of ​​”communication” and of ​​”generation”. These are the two pillars of Re-ageing Gerontology. I think this elucidation may have made the vision of Re-ageing Gerontology little clearer. 

Finally, I think Daniel Callahan is a personal model of the elderly in the 21st century for Re-ageing Gerontology. This article was written to remember a good encounter with him.