Fate vs. Choice

Dare to Be 100
by Walter M. Bortz II, M.D.

(Page 2 of 3)

Smarts — The What

Marie Garibaldi is the chief justice of the New Jersey Supreme Court. In 1987 she wrote an opinion in the matter of Kathleen Farrell. The case involved the issue of whether life support efforts could or should be withdrawn from Farrell, a 37-year-old competent, terminally ill patient suffering from ALS, commonly known as Lou Gehrig's disease. Her life was being artifically sustained in the intensive care unit by means of major medical technology. Justice Garibaldi wrote, "Matters of fate have become matters of choice." In this simple sentence she captured the essence of the illuminating moment in mankind's history. Until recently, death was random and virtually immutable. Fate ruled, and what happened was not ours to anticipate or challenge. Even twenty years ago, Kathleen Farrell would not, could not, have lived. Of course, recent knowledge and technology have changed that.

The shift of human destiny from fate to choice is enabled by one thing, and that is knowledge. For the first time we have enough smarts to propose a coherent whole view of what life can look like. We know how long it can be (the when) and, significantly, the nature and course of those conditions that threater, its quality as well as extent. We don't enter the future; we create it.

Along the same lines, almost everything in the medical textbooks about aging is wrong, inadvertently confusing one disease or condition with one another, and often returning to the presumption that aging by itself is the villain. The hackneyed joke concerns the old fellow with the sore leg visiting the doctor's office. The doctor, after a cursory exam, attributes the sore leg to aging. The patient's challenge — "But, Doc, the other leg is just as old and it's fine" — is haunting. Sure, aging and the passage of time play a role, but not nearly to the extent that have been presumed until now. This is great news. For conditions of old people not to be due to the passage of time gives hope that counterstrategies can be derived to prevent or reverse at least a major part of them. As we develop a conceptual framework of what aging truly is, we become newly able to reformulate the whole of the conditions that affect our lives.

Fate vs. Choice

Conditions as diverse as tuberculosis, hardening of the arteries, and Alzheimer's disease have in the past fatefully been conceded by practitioners to be due to aging. The error in this miscategorization is now clear, but as recently as forty-five years ago, stiff and clogged arteries were thought by all to be a reflection of "God's will." It is now evident that this fatalism was wrong. The facts that young people have some arteriosclerosis, that some old people don't, and that it is reversible proves that the condition is not due to aging. What this tells us is that it is susceptible to control.

By putting the correct label of disease on arteriosclerosis, fate is replaced by the choices of prevention or treatment. Medicine, like politics, is based on the art of the possible. If an illness is acknowledged to be due to something that is either obscure or beyond one's control, then little effort is likely to be expended. But what if the illness is not inscrutable, and a curing moment is lost because of the application of the wrong tag?

The correct diagnosis has been the cornerstone of the practice of medicine. When the cause of a condition is accurately known, the precision of treatment is made possible. Medicine has labored long and hard to make diagnosis and the rational categorization of disease a science. In my grandparents' day, thousands of people died of "acute indigestion." Thousands die today of "myocardial infarction," the same condition, but under the correct explanation.

Much confusion streams from the lack of a lifetime perspective. Illnesses are still viewed as static episodic events. This snapshot approach is driven, too, by the "quick fix" urgency of high medical costs. The acute moment of the illness obscures the evidence of earlier excess spending. In other words, only when the check bounces does an overdraw and sick notice arrive. Additionally, too much faith in the power of technology to cure has seduced us into unsound health practices.

Aging, too, has lacked a conceptual framework. By and large it has been neglected as a legitimate target for scientific study, or worse, it has been slotted as a traditional disease like scarlet fever, thereby susceptible to a curative approach. Where does aging come in? Does it deserve a subheading under all other headings, is it a disease, a process, a behavior, a symptom? What exactly is aging? Most texts don't even try to define it. Many describe symptoms that are commonly found in old persons, but almost none make an effort to provide a conceptual framework into which aging fits.

This is one of the intellectual gifts given to medicine by new research with old people. Conditions can be placed in the right slots.

This new formulation proposes that all human ailments fall into four separate and distinct types. Not only do these types have different causations, but their causations also lead to specific approaches, and even further to specific and appropriate public policy responses. These four types are (I) blueprint error, (II) lightning, (III) dissonance, and (IV) time. In more technical language, they are conditions of genetic defect, extrinsic agency, intrinsic agency, and aging.

Blueprint Error

If I, and you, have heard it once, we have heard it a thousand times. "If you want to live to a ripe old age, be sure to choose old grandparents." Cute, but wrong. Heredity has little to do with how long you live. Many scientific studies, including those which study longevity records of twins, conclude that inheritance has only 15 to 20 percent to do with how long you will live. In other words, "It's not the cards you're dealt that matter most, it's how you play your hand."

Certainly there are conditions due to a bad blueprint. These are known as the genetic diseases, such as sickle-cell anemia and cystic fibrosis, which clearly are the result of mismatched or defective genes and chromosomes. Fortunately, most bad seeds are expelled in utero, yet some do survive. Most mismatches that make it to the world are problems of early life, encountered largely by pediatricians. Once you make it to midlife, the medical conditions are basically not those due to defective design, but to conditions over which you can exercise a high degree of personal control.

The reason this is so important to emphasize is that until now people have, fatalistically, more or less programmed their health as an issue presided over largely by one's grandparents, and if a problem arose, the doctor would rush right in to restore order. It's not that simple.

Lightning

Until the present era, nearly all deaths were caused by lightning conditions — meaning conditions in which the person afflicted had little or no role to play in their occurrence. Such conditions are infections, malignancies, injuries, poisonings, and war. At the start of this century, eight of the top killers were lightning conditions — pneumonia, meningitis, tuberculosis, and so on. Virtually the entire current medical establishment has been dedicated to addressing lightning conditions, antibiotics and surgery being the two principal areas developed to offset them, exemplified by removal of a tumor or the administration of penicillin for a strep throat. Most medical technology and efforts of the pharmaceutical industry are directed to curative approaches to these events.

Importantly, lightning conditions often lend themselves to a curative effort. Time usually has played no role in the event, and the afflicted person can, by a direct and specifically targeted therapy, be restored to the original state of health. Much great good has occurred as a result of our new understanding and treatment of lightning conditions. Unfortunately, however, new villains have rushed upon the stage, and it is these conditions, which are due to dissonance, that now crowd doctors' offices and hospitals.

Dissonance

Unlike lightning conditions, in which the individual has little or no personal role to play in the ailment, dissonance conditions are the direct result of the inappropriate relationship of the person with his or her environment. Further, their onset is insidious, they take years to develop, and once encountered do not lend themselves easily to cure. This is not to say that heroic amounts of energy and money aren't spent in the effort, but like Humpty Dumpty, once the cracks are made, cure is impossible. Heart attacks, strokes, arthritis, emphysema, and cirrhosis are common examples of medical conditions due to dissonance, or imbalance.

Dissonance comes in two varieties: too much and too little. Too much contact between the environment and the individual is known as stress; too little as disuse. Stress is an epidemic condition in which a person suffers a broad array of physical problems as the result of what Stanford physicist William Tiller calls the "high event density of life" — constant bombardment by a tremendous assortment of often unpleasant and noxious stimuli. Ulcers, high blood pressure, diabetes, kidney damage, and skeletal and emotional problems result from living in a world that often seems simply to be spinning too fast. Disuse, on the other hand, leads to a long list of problems, including cardiovascular vulnerability and musculoskeletal fragility, as the direct byproduct of insufficient stimulation of our bodies by physical inactivity. What I, and other doctors, see in our offices is usually a result of a mixture of these two kinds of dissonance. Our brains are frizzed by too much energy, while our bodies shrivel because of too little stimulation and exercise.

Sixty years ago, famed Harvard professor Walter Cannon coined the useful term "homeostasis" to indicate the wonderful ability the body exhibits to maintain its equilibrium when buffeted by too many or too few influences. Our homeostatic mechanisms allow us to function in the heat and cold, dark and light, fed and starved, at rest and under heavy workloads. Dissonance conditions occur when these stabilizing devices are tested beyond their ability to compensate.

Time

Finally, we come to aging. We have until recently lacked a good definition of aging, and as a result we have assigned too much mischief to it. It is not an exaggeration to assert that almost everything we have been taught about aging has been wrong. Casually and wrongly, we have catalogued almost everything that happened to an older person as due to the passage of time. The truth is that until recently we haven't lived long enough to die of aging. Virtually everything that has been consigned to aging is due instead to the accumulation of changes due to lightning and dissonance.

This recognition is absolutely critical. Aging, in my definition, is the effect of an energy flow on matter over time. It is inevitable and nonpreventable. The march of time leads to the gradual accumulation in all our selves of debris, trash, the result of the generation by our metabolism of free radicals. But as we will learn in the next chapter, aging proceeds at a more stately pace than has originally been thought.

Four possible survival curves of a hundred coffee mugs in the dishwasher are represented in figure 2 on page 32. They conform to the four categories just described. In scenario A nearly all cups break the first day, because they just weren't made to last in the hubbub of the dishwasher. In scenario B all cups break randomly, one each day by accident. The graph looks like the human survival curve of 1900. In scenario C the cups don't break until after fifty days, when assorted minor nicks and cracks accumulated over the first weeks add up and breakage appears. This curve represents the survival curve symbolic of human lifespans. Finally, in scenario D, all cups break on the last day because they simply wore out. This is what engineers call systems death. The first three scenarios represent death from component failure, one or another isolated breakdown leading to death, while the rest of the organism is still okay. Very few of us have lived long enough to get to scenario D. But we will.

This new formulation of the four types of agencies that affect not just the length of our lives but also their quality is made possible by the identification of the power of time in human affairs. If life is viewed as nothing more than a series of unconnected snapshots, then this reconceptualization is impossible. But when we understand life as a long set of tightly connected and interdependent processes, this new comprehension is made possible.

From this definition it is possible to create effective therapies. Blueprint error and time are fate, agencies beyond easy approach. But both lightning and dissonance are phenomena that lend themselves powerfully to preventive and corrective strategies: choice. This differentiation is made possible by the proper redefinition of aging.

Copyright © 1996 by Walter M. Bortz II, M.D.

About the Author

Walter M. Bortz II, M.D., the author of We Live Too Short and Die Too Long and more than 100 scientific articles, is a member of the teaching faculty at Stanford University Medical School and a practicing physician at the Palo Alto Medical Foundation. Past president of the American Geriatric Society, former co-chair of the AMA-ANA Task Force on Aging, and participant in one marathon yearly, he also serves on the editorial board of Runner's World magazine.