Healthcare Across the Lifespan

Part II draws on the philosophical framework set forth in Part I to tackle practical and policy concerns. Chapter 6 demonstrates the tendency toward midlife bias in both geriatric and pediatric bioethics and counters it with techniques that use life stage sensitive values. The chapter puts forth a 3-step dignity-guided method for addressing paradigmatic geriatric cases, such as dementia, where central capabilities are at-risk. The chapter also interrogates Joel Feinberg’s influential view that stresses children’s future autonomy. It argues that this approach overlooks children’s life stage–related capabilities and the value of nurturing care during early childhood. Chapters 7 and 8 turn to long-term care and assess 3 options for meeting the needs of care-dependent older adults: family caregiving, migrant caregiving, and robotic caregiving. It highlights the dignity of family and migrant caregivers as well as their elderly care recipients. It cautions against midlife bias in designing and deploying robotic caregivers and underscores the importance of sociable robots that offer companionship for older end users. Chapter 9 turns to ageism and its appearance in polices ranging from selecting subjects for clinical research to allocating scarce healthcare resources and mandating retirement. Chapter 10 applies a dignity analysis to the end of life, exploring respect for dignity of dying, newly dead, and long-gone human beings. Using narrative analysis, the chapter invites thinking about the end of life and the period following as the winding down of a story, which does not necessarily occur in a linear fashion or simultaneous with human biological death. The closing chapters spotlight the future of population aging (Chapter 11) and make a pitch for life stage sensitive moral theory (Chapter 12).

Future People

Chapter 11 explores the future of population aging, asking if aged societies will become a permanent fixture or are fleeting and unique to our time. It approaches this question by looking at the effects of controlling fertility rates by means of reproductive policies designed to balance ratios between young and old age groups. Using historical examples of China’s one-child policy and Romania’s Decree 770, the chapter argues that both pro- and antinatalist policies produce population aging and can exact a heavy toll on individuals’ capabilities to be healthy, have bodily integrity, and determine a plan of life. The chapter examines future societies with aged, super-aged, and extremely aged populations and gives guidance for intergenerational justice that is dignity-based. It considers the objection that reproductive choices do not make future persons worse off because they change the identities of future persons (the nonidentity problem). We counter this objection by drawing on the dignity framework developed throughout the book. After examining evidence of the effects of pro- and antinatalist reproductive policies, the chapters conclude that the longer-term effects on population aging must temper any assessment of the putative shorter-term good of raising or lowering fertility rates.

What Cares?

Chapter 8 imagines future challenges of designing and deploying carebots for eldercare and related artificial intelligence (AI) applications. We examine the objection that sociable robots cannot function adequately as caregivers because they do not care about care recipients. We show that what matters most is that care gets expressed, and we defend a version of care ethics which holds that the form care takes varies, depending on the capacities, contexts, and needs of those who give and receive care. While robotics literature stresses using machines to extend autonomy, we stress extending care and supporting not only autonomy but a range of human capabilities. We evaluate the goal of aligning machine behavior with human values (values alignment) and argue that this leads to algorithmic biases. We consider whether sophisticated AI should be trusted, since it operates as a black box, and address concerns about the ethics of robot deception.

The Preferred Account of Human Capabilities

Chapter 3 translates the idea of dignity as species integrity into the more grounded idea of respecting central human capabilities. Fleshing out human capabilities yields a preferred capability list, which is balanced, life stage sensitive, and provisional. This conception of human dignity carries the advantage of avoiding speciesism, the view that members of one’s own species are morally superior. It leaves open the possibility that members of nonhuman species possess their own kind of dignity, based on central capabilities for their species. Dignity as species integrity carries the advantage of avoiding ableism. In contrast to Kantian conceptions, which regard highly developed cognitive functioning as necessary for dignity, Chapter 3 equates dignity with possessing at least one central human capability. Infants and people with disabilities who can affiliate, express emotion, or exercise senses and imagination possess a human dignity that demands respect, even if they lack specific cognitive capabilities.

The Coming of Age of Old Age

Chapter 12 takes stock of the book’s central arguments and findings about the life stage relativity of values; midlife bias; human dignity; age group justice principles of capability sufficiency, relational equality, and reparations; narrative identity values of integrity, fairness, and prudence; geriatric and pediatric bioethics; ageism; fair subject selection; age-based rationing of life-saving medical care; mandatory retirement; duties to the dying, newly dead, and long gone; rational suicide; meeting the need for long-term care through family caregiving, migrant caregivers, and robotic caregivers (carebots); designing AI and sociable robots for older adults; duties to future people; and the prospects for future population aging. To remain relevant in aged societies, moral philosophers must tackle these concerns, end midlife bias, and contribute an account of the moral life that makes sense to people at each stage of life.

The Dying, the Newly Dead, and the Long Gone

Chapter 10 takes a careful look at duties to the dying, the newly dead, and the long gone. Care of the dying and newly dead are urgent matters for aged societies, because older people die at higher rates than other age group. The chapter unpacks the slogan “Death with dignity” and asks what duties to respect the dignity of people near the end of life is required. It examines debates over physician-assisted death and rational suicide for healthy older people. It evaluates definitions of death, noting global variation, and proposes duties owed to the newly dead and long gone. Key concepts, such as narrative identity, help flesh out the idea of a “good death.” Borrowing from ethics and archeology literature, Chapter 10 introduces a systematic way to think about duties to the long gone, including human fossils with archeological significance and ancestors in native burial grounds.

Ageism

Chapter 9 explores how ageism and midlife bias find expression in allocating life-saving medical care, selecting subjects for clinical trials, and mandating retirement. Subtle expressions of ageism and midlife bias include epistemic justice, internalized ageism, and elderspeak. Around the globe, ageism is not always directed to older people. We review and rebut the chief arguments for old age-based discrimination, including fair innings, cost-benefit analysis, and complete lives egalitarianism. We raise concerns about using age as a proxy, which can foster ageist attitudes. We show that a common form ageism takes is facially neutral policies that systematically disadvantage older adults. The chapter examines “the puzzle of age discrimination,” which is the tendency to oppose race and sex discrimination more strongly than age discrimination and argues that this tendency is unjustified. We rebut age discrimination by appealing to justice between generations, fair subject selection, and respect for dignity.

Who Cares?

Chapter 7 asks who will meet the growing demand for long-term care services as the proportion of care-dependent older adults increases. It explores meeting demand by relying on family caregivers and migrant workers and raises justice concerns with each related to respect for caregiver dignity. Dignity violations arise for family caregivers in both Confucian-influenced societies, which stress filial piety, and Western societies, which emphasize individual autonomy. Chapter 7 argues that families are subject to justice principles and defends feminist views on families, which regard just family structures as necessary for a just state. Hiring low-wage migrant workers from poor nations to support family caregiving also raises justice concerns. When care moves across borders, forging global care chains between nations, the conditions in which migrant caregivers live and work often fail to uphold dignity. Without safeguards to avoid bait-and-switch tactics and protect fundamental human dignities, migrant work violates justice principles.

Justice between Old and Young

Chapter 5 shifts from asking which values matter for individuals to asking which matter for groups of people at different ages. It addresses age group justice by proposing principles of relational equality, capability sufficiency, and reparations. It defends these principles by appealing to human dignity and central human capabilities. The chapter asks how to deploy justice principles over time; it argues for honoring capability sufficiency at each moment of a person’s life, while permitting inequalities at time slices that even out over the course of a person’s life. The chapter interrogates fair-innings arguments that discount later life and exposes values inherent in viewing life as a rule-governed game. It juxtaposes the metaphors of life as a game with life as a narrative, and argues for a narrative approach.

Values Across the Lifespan

Chapter 1 introduces the chief claim and main argument of the book, which we call the life stage relativity of values. This is the claim that different values matter more at different stages of our lives. During early life, caring, trust, and nurturing ought to figure prominently, due to the vulnerabilities and needs that characterize infancy and childhood. By young adulthood, the capacity to develop greater physical and emotional independence makes autonomy a focal value. During later life, we face heightened risk for chronic disease and disability, which makes maintaining capabilities central, and, in the face of loss, keeping dignity intact. Chapter 1 raises the concern that moral theories reflect life stage bias, in particular, midlife bias. Midlife bias consists of applying the values central during midlife to all life stages. Countering it requires addressing empirical, conceptual, and psychological naïveté and situating values within the context of life stages.