by Emma Barrie
Is ageing a disease? What may seem like a straightforward question becomes more complex upon further reflection. It is a question that is plaguing the field of biogerontology, the study of the biological processes of ageing and age-related diseases. Since Galen in ancient Greece, the dominant narrative across history has been that ageing is a natural process. However, recent advancements within genomics, as well as the new classifications related to ageing in the recent edition of the International Classification of Diseases (ICD), have re-spurred debates about ageing as a disease. This is because in genomics, interventions can either be classed as a therapy or an enhancement. By defining ageing as a natural process, any interventions would be seen as enhancements, which are ethically problematic. Thus, the ageing debate has resurged with researchers such as Richard A. Faragher arguing that ageing should be considered a disease. However, I argue that this debate requires proper philosophical examination as there are several problematic implications of classifying ageing as a disease, particularly because of the ramifications potential “cures” pose to society and the environment. Thus, ageing should remain to be considered a natural process, with the appropriate checks and balances set up within biogerontology research.
The ancient Greeks, in particular the physician Claudius Galen, formulated theories of ageing that have affected how we think about ageing today. Within Galen’s philosophy was a strong emphasis on teleology in nature, built upon the motto “nature does nothing in vain.”[i] According to Galen, nature always acts in the best interest. While considering the question of ageing as a disease, Galen would reply that it is not a disease because ageing is not contrary to nature.[ii] This argument will be explained in more depth later in this essay. Of course, medicine and biology advanced exponentially between the 17th and 20th century, and much of Galen’s work has become outdated. New theories of ageing meant that there were new attempts to prolong human life, particularly towards the end of the 19th century. Nonetheless, Galen’s work remained influential for medical thinkers such as Aldred Warthin—“the father of cancer genetics”—and even within the field of gerontology with Vladimir Korenchevsky.[iii] During the establishment of biogerontology as a scientific discipline in the mid-20th century, it has been connected with anti-ageing research and the “forbidden” knowledge it strives to uncover due to interference with the “natural” process of ageing.[iv] This hesitance persisted despite biogerontology’s recognition by large funding agencies and other organisations as a reputable and cutting-edge area of research.[v] Consequently, several prominent scientists in biogerontology undertook “boundary work” to enhance their legitimacy and credibility which involved aligning the discipline with genetic research from other biomedical disciplines and distancing themselves from anti-ageing practitioners.[vi] Prominent biogerontologist Leonard Hayflick argued that “[a]ging is not a disease, so the concept of seeking a cure for it is tantamount to seeking a cure for embryogenesis or child or adult development.”[vii] Nonetheless, some ageing researchers have invoked anti-ageing rhetoric to describe the potential implications of their research.[viii] Before investigating the anti-ageing arguments used by some researchers, I will first discuss what biogerontology research involves to demonstrate the implications of therapeutic intervention and enhancement.
Within the biogerontological community, there are different pathways within ageing research. Four outcomes in particular have been outlined: “prolonged senescence”; “compressed morbidity”; “decelerated ageing”; and “arrested ageing.”[ix] Prolonged senescence occurs when the lives of the aged are prolonged without addressing the debilitations of the ageing process, a failed scenario within the biogerontological community.[x] Compressed morbidity is where the health-span of humans is increased, and the ageing process is compressed towards the end of the life (thus increasing the quality of life for people).[xi] Decelerated ageing is also known as “slowing the aging process” which is where the ageing process occurs at a slower rate.[xii] Finally, arrested ageing is the most futuristic, aiming for complete control of the biological processes of ageing.[xiii] This philosophical pluralism of ageing research creates confusion and tension within biogerontology. There are several lines of ageing research including stem cell treatment and hormone research. However, from my cursory investigation, the gene editing research focuses on targeting the trigger of the ageing processes and seems to be a promising avenue scientifically, but more problematic philosophically. Genome editing is currently being used to investigate treating age-related disorders such as Alzheimer’s Disease, Parkinson’s Disease and Amyotrophic Lateral Sclerosis.[xiv] However, some scientists believe that the key to curing age-related pathologies is to cure ageing itself. Recent studies have connected ageing with our genetic makeup. Studies have found “polymorphisms in genes that are associated with long life including APOE and FOXOA3.”[xv] Consequently, “ageing is probably a highly polygenic trait” which means that ageing is associated with several or more genes.[xvi] With the various types of interventions, it seems that there is not one ageing process but multiple ageing processes. But with the advancements in gene editing, the concept of “enhancement” has become central to many discussions, not just within biogerontology but within the larger field of biomedical research.
Discussion of enhancement within biomedical research flags “a significant set of moral concerns that are raised by the use of biomedicine to attempt to improve upon human form and function.”[xvii] First, I will define the boundaries between gene therapy and genetic enhancement. To define “gene therapy,” we can look to Norman Daniels’ formulation of the standard medical model in which therapy “is an intervention designed to maintain or restore bodily organization and functioning to states that are typical for one’s species, age, and sex.”[xviii] On the other hand, enhancement can be defined as an “alteration to improve upon normal organization, appearance, health, and functioning.”[xix] This is a particularly important distinction because therapy treatments have more chance of being available to people regardless of their socio-economic circumstance; whereas, enhancements do not satisfy the therapeutic goals of medicine and will not be a reimbursable service.[xx] As such, genetic enhancement is subject to several philosophical concerns. As evident in the above scenario, enhancements would only be available to those who can afford it, thus exacerbating class disparity and social injustice which raises questions regarding distributive justice. Furthermore, there are several arguments from an ethical perspective detailing the issues with genetic enhancements such as “‘playing God’, the appeal to intuition or emotion, human dignity, and the connection to eugenics,” which are detailed in the book The Ethics of Human Enhancement: Understanding the Debate (2016).[xxi] Each argument has their various strengths and limitations but nonetheless demonstrate that scientists can never fully predict the potential consequences of genetic engineering, particularly on future generations. Thus, we shall examine why some scientists justify ageing research by classifying it as a disease.
The argument for the classification of ageing as a disease has become of particular concern as the latest edition of the ICD, published by the World Health Organisation (WHO), has classified ageing as a major disease risk factor. In the previous edition of the ICD, there was a code for “age-related physical disability,” but in the latest edition there is now a code for “old age” which implies that old age is a health problem in and of itself.[xxii] The major change, however, is an extension code for “diseases related to ageing” which encourages potential investment in the development of pharmacological interventions into the biological processes of ageing.[xxiii] While this development was met with criticism from several organisations, this trajectory towards treating ageing as a disease has gained staunch advocates over the past decade. In particular, this essay will focus on the biogerontologist Richard G. A. Faragher’s argument. To validate ageing as a disease, Faragher attempts to break down Galen’s justification for ageing as a natural process, arguing that the justification contains philosophical error. He summarises Galen’s argument as follows:
(1) Disease is defined as a disordered or abnormal function.
(2) Ageing is universal. Everyone “catches it.”
(3) That which is universal cannot be abnormal.
(4) Therefore, ageing is not a disease. It is a “natural process.”[xxiv]
Faragher argues that the conceptual distinction between ageing as “natural” and disease as “unnatural” is “ripe with the potential for fundamental philosophical error and ‘moral concern’.”[xxv]
Faragher explains that the philosophical error in Galen’s argument is the naturalistic fallacy. Faragher provides the thought experiment where there is an island where everyone has scurvy which therefore—via Galen’s logic—is considered by the population to be a “natural condition,” before a cure is discovered.[xxvi] Faragher believes that when people argue that ageing is natural, they are conflating the natural with the “good” and the unnatural with the converse.[xxvii] Faragher’s thought experiment has a flaw: it is entirely human-centric. Animals have an ageing process as well, one that is often studied to understand how the human ageing process works. With plants, it is more complex as with the right conditions, plants can live for hundreds of years but still undergo an ageing process. In Faragher’s thought experiment, he looks purely at humans. Perhaps this is what Galen was noting when he argued that ageing is universal: it extends beyond humans. It is also highlighted that “considering aging as a disease that happens to everybody is an oxymoron.”[xxviii] Furthermore, while Galen’s philosophy revolved around the belief that nature acts for the best, I do not think that means everything nature does is good, just happenstance. Consequently, this does not mean that Galen conflates “unnatural” with the converse, to which I believe Faragher is implying that “unnatural” means bad.
So, why do scientists and scientific organisations continue to try and justify the classification of ageing as a disease? Juengst et al. argue that “pathologising ageing is a seductive way to increase public support for ageing research, and an effective way to argue that the mission of this research is not aimed at ‘enhancement’.”[xxix] To me, the justification of ageing as a disease feels like an excuse to pursue this line of scientific inquiry without having to thoroughly investigate the potential consequences of scientists slowing the ageing process. Those who are looking at slowing the ageing process have a “responsibility to contemplate the implications of their success.”[xxx] This means that they need to engage in an interdisciplinary study of social and environmental impacts. Post and Binstock note that criticisms against conquering ageing come in two forms: “predictions of bad social consequences and complaints about distributive justice.”[xxxi] How will living longer affect jobs, retirement, cultural attitudes and beliefs? Most examinations suggest that living longer will create highly disruptive and undesirable conditions that leave people worse off.[xxxii] This can be seen through the ecological/economic theory of the tragedy of the commons. The tragedy of the commons follows the theory that in a shared-resource situation, individual users who act in their own self-interest will spoil the common good through their collective action. If there was a “cure” to ageing, then in a self-centred pursuit of maximum longevity there could be ramifications of ageism, classicism, intolerance of diversity and intergenerational conflict.[xxxiii] Pursuing longevity could also result in a maldistribution of justice and resources.[xxxiv] Furthermore, there is also the worry that the “treatment” to ageing would be expensive and only available to those who can afford it. This concern is similar to the concern of genetic enhancement which strengthens the argument for classifying human longevity as an enhancement, not a treatment. Overall, these are just some of the potential consequences of humans living longer and it is clear that there needs to be a focus on forethought, not hindsight.
The quest for human longevity is a problematic endeavour and is not one to be glorified. The justification for treating ageing as a disease seems to be a ploy to make such a quest seem more desirable. Human longevity runs into the problems of being an enhancement as it is a natural process. The argument promoted by Galen was dominant for a reason, in that something that is as universal as ageing is clearly not a disease. Richard Faragher’s critique of Galen’s argument contains flaws, and other scientists have clearly defined the ageing process as one that is natural and inevitable. By trying to justify ageing as a disease, these scientists do not seem to fully address the ramifications of human longevity and what that would mean for society and the environment.
Emma Barrie is currently completing her undergraduate degree in Arts and Social Science, majoring in philosophy and health and society. She is interested in how the humanities intersects with science, and thus is passionate about philosophy of science, logic and ethics.
ENDNOTES
[i] Gerald J. Gruman, “A History of Ideas about the Prolongation of Life: The Evolution of Prolongevity Hypotheses to 1800,” Transactions of the American Philosophical Society 56, no. 9 (1966): 16, https://doi.org/10.2307/1006096.
[ii] Gruman, “A History of Ideas about the Prolongation of Life,” 16.
[iii] Richard G. A. Faragher, “Should We Treat Aging as a Disease? The Consequences and Dangers of Miscategorisation,” Frontiers in Genetics 6 (2015), 3, https://doi.org/10.3389/fgene.2015.00171.
[iv] Jennifer R. Fishman, Robert H. Binstock, and Marcie A. Lambrix, “Anti-Aging Science: The Emergence, Maintenance, and Enhancement of a Discipline,” Journal of Aging Studies 22, no. 4 (December 1, 2008): 2.
[v] Fishman, Binstock, and Lambrix, “Anti-Aging Science,” 2.
[vi] Fishman, Binstock, and Lambrix, “Anti-Aging Science,” 2.
[vii] Eric T. Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” The Hastings Center Report 33, no. 4 (2003): 22, https://doi.org/10.2307/3528377.
[viii] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 22.
[ix] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 24.
[x] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 24.
[xi] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 25.
[xii] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 27.
[xiii] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 27.
[xiv] Allen Caobi et al., “The Impact of CRISPR-Cas9 on Age-Related Disorders: From Pathology to Therapy,” Aging and Disease 11, no. 4 (October 11, 2019): 6, https://doi.org/10.14336/AD.2019.0927.
[xv] Heather E. Wheeler and Stuart K. Kim, “Genetics and Genomics of Human Ageing,” Philosophical Transactions of the Royal Society B: Biological Sciences 366, no. 1561 (January 12, 2011): 43–50, https://doi.org/10.1098/rstb.2010.0259.
[xvi] Wheeler and Kim, “Genetics and Genomics of Human Ageing.”
[xvii] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 21.
[xviii] Faith Lagay, “Gene Therapy or Genetic Enhancement: Does It Make a Difference?,” AMA Journal of Ethics 3, no. 2 (February 1, 2001): 37, https://doi.org/10.1001/virtualmentor.2001.3.2.gnth1-0102.
[xix] Lagay, “Gene Therapy or Gene Enhancement,” 37.
[xx] Lagay, “Gene Therapy or Gene Enhancement,” 37.
[xxi] Alberto Giubilini and Sagar Sanyal, “Challenging Human Enhancement,” in The Ethics of Human Enhancement (Oxford: Oxford University Press, 2016), 1, https://doi.org/10.1093/acprof:oso/9780198754855.003.0001.
[xxii] Emily Schuler, “ICD-11 and an Argument about ‘Old Age,’” Oxford Institute of Population Ageing (blog), June 30, 2021, https://www.ageing.ox.ac.uk/blog/ICD-11-and-an-argument-about-old age.
[xxiii] Schuler, “ICD-11 and an Argument about ‘Old Age’.”
[xxiv] Faragher, “Should We Treat Aging as a Disease?,” 2.
[xxv] Faragher, “Should We Treat Aging as a Disease?,” 3.
[xxvi] Faragher, “Should We Treat Aging as a Disease?,” 4.
[xxvii] Faragher, “Should We Treat Aging as a Disease?,” 4.
[xxviii] Suresh I. S. Rattan, “Aging Is Not a Disease: Implications for Intervention,” Aging and Disease 5, no. 3 (June 1, 2014): 196, https://doi.org/10.14336/AD.2014.0500196.
[xxix] Juengst et al., “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement,” 26.
[xxx] Stephen Garrard Post and Robert H. Binstock, The Fountain of Youth: Cultural, Scientific, and Ethical Perspectives on a Biomedical Goal, (Oxford University Press, USA, 2004), 308.
[xxxi] Post and Binstock, “The Fountain of Youth,” 308.
[xxxii] Post and Binstock, “The Fountain of Youth,” 308.
[xxxiii] Post and Binstock, “The Fountain of Youth,” 308.
[xxxiv] Post and Binstock, “The Fountain of Youth,” 308.
WORKS CITED
Caobi, Allen, Rajib Dutta, Luis D. Garbinski, Maria Esteban-Lopez, Yaesmin Ceyhan, Mickensone Andre, Chet Raj Ojha, et al. “The Impact of CRISPR-Cas9 on Age-Related Disorders: From Pathology to Therapy.” Aging and Disease 11, no. 4 (October 11, 2019): 1–21. https://doi.org/10.14336/AD.2019.0927.
Faragher, Richard G. A. “Should We Treat Aging as a Disease? The Consequences and Dangers of Miscategorisation.” Frontiers in Genetics 6 (2015). https://doi.org/10.3389/fgene.2015.00171.
Fishman, Jennifer R., Robert H. Binstock, and Marcie A. Lambrix. “Anti-Aging Science: The Emergence, Maintenance, and Enhancement of a Discipline.” Journal of Aging Studies 22, no. 4 (December 1, 2008): 295–303.
Giubilini, Alberto, and Sagar Sanyal. “Challenging Human Enhancement.” In The Ethics of Human Enhancement. Oxford: Oxford University Press, 2016. https://doi.org/10.1093/acprof:oso/9780198754855.003.0001.
Gruman, Gerald J. “A History of Ideas about the Prolongation of Life: The Evolution of Prolongevity Hypotheses to 1800.” Transactions of the American Philosophical Society 56, no. 9 (1966): 1–102. https://doi.org/10.2307/1006096.
Juengst, Eric T., Robert H. Binstock, Maxwell Mehlman, Stephen G. Post, and Peter Whitehouse. “Biogerontology, ‘Anti-Aging Medicine,’ and the Challenges of Human Enhancement.” The Hastings Center Report 33, no. 4 (2003): 21–30. https://doi.org/10.2307/3528377.
Lagay, Faith. “Gene Therapy or Genetic Enhancement: Does It Make a Difference?” AMA Journal of Ethics 3, no. 2 (February 1, 2001). https://doi.org/10.1001/virtualmentor.2001.3.2.gnth1-0102.
Post, Stephen Garrard, and Robert H. Binstock. The Fountain of Youth: Cultural, Scientific, and Ethical Perspectives on a Biomedical Goal. Oxford University Press, USA, 2004.
Rattan, Suresh I. S. “Aging Is Not a Disease: Implications for Intervention.” Aging and Disease 5, no. 3 (June 1, 2014): 196–202. https://doi.org/10.14336/AD.2014.0500196.
Schuler, Emily. “ICD-11 and an Argument about ‘Old Age.’” Oxford Institute of Population Ageing (blog), June 30, 2021. https://www.ageing.ox.ac.uk/blog/ICD-11-and-an-argument-about-old age.
Wheeler, Heather E., and Stuart K. Kim. “Genetics and Genomics of Human Ageing.” Philosophical Transactions of the Royal Society B: Biological Sciences 366, no. 1561 (January 12, 2011): 43–50. https://doi.org/10.1098/rstb.2010.0259.
Featured image by National Cancer Institute via Unsplash
EXORDIUM 
Thanks Emma, a tricky scientific and philosophical issue indeed! I accept that ageing is natural, normal, even universal, and thus not a disease. I think I am more sympathetic to human enhancement in general though, including anti-ageing research. I’m guessing you came across his work already, but I tend to respect what Julian Savulescu has to say in this space.
The single biggest persuasive factor for me here was a brilliant piece of short fiction by Oxford philosopher Nick Bostrom: https://www.nickbostrom.com/fable/dragon.html
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