The Evening of Life is a collection of essays exploring ageing and dying well from an American philosophical perspective. The book is the consequence of a conference on the ethics of later life held at the Institute for Advanced Studies in Culture (IASC) at the University of Virginia. Comprising ten chapters, the book begins with an Introduction by the first editor and closes with the Conclusion by the second; in between are ten separate essays organised into three sections: ‘Our Deficit Model of Aging’, ‘Living Old Age Well’ and ‘An Old Age that Goes Well’. The Introduction sets out the structure of the book and previews the subsequent chapters, whilst also framing the overall philosophical foundation, that there needs to be a re-imagining of ageing culture in the United States of America (USA) in order to accept decline and dependency and embrace finitude, as opposed to stigmatising them. The authors suggest a multi-disciplinary approach is needed to confront and create positive visions whilst also incorporating what the authors consider to be inevitable physical decline and dependency.
The first section sets out the ‘Deficit Model of Aging’, beginning with the first chapter, ‘The Devalued Status of Old Age’ by one of the editors, Joseph E. Davis. The chapter contrasts the depictions of American ageing as valuing vitality, fitness, productivity and independence without recognising possible needs for care, interdependence and a recognition of vulnerability in later life. The result is that ‘normal’ ageing is viewed as failure, with the field of ageing commercialised by the ‘anti-ageing’ business, which suggests that old age can be avoided, although at a cost of increased isolation and a medicalised late life and death. Chapter Two, ‘The Structural-ethical Source of the Matter: The Medical–Industrial Complex’ is written by Sharon Kaufman, a social medicine anthropologist, who focuses on how American health policies shape clinical practice, connecting science, industry, politics and insurance, although at the expense of the concerns and wishes of the ageing person and relationships with loved ones. She uses the example of a gentleman in late life living with an implanted cardiac defibrillator (ICD) which, for the first five years, had kept him alive but increasingly shocked him regularly, impacting the way he wanted to live his life. Against the wishes of his family and his medical team, he had the ICD deactivated and died two days later. The final chapter in this section, ‘Beyond Avoidance and Autonomy’, written by editor Paul Scherz, an associate professor of moral theology and ethics, notes that the two strategies for ethicists in addressing ageing and death are to avoid the topic entirely, or discuss it in terms of patient autonomy which he views as the same thing. Drawing on Christian philosophy, he suggests that Christian meditations suggest that to have a ‘good’ death, one needs to have had a ‘good’ life, having developed virtues, lost attachment to things and submitted to the will of God, so that human vulnerability, dependence and weakness are transformed to agency.
The central section of the book, ‘Living Old Age Well’, explores various philosophical approaches to ageing. Chapter Four, ‘Epiphanies, Small and Large’, is written by Wilfred McClay, a specialist in the cultural history of the USA. Citing a Yeats poem about the losses of ageing, he explores what is essentially Prospect Theory (although not labelled as such in the book), in that how people view gain or loss is based on their reference point (Bern-Klug, Reference Bern-Klug2017). His example is of his mother who in earlier life was clear that she would never want to live after a stroke which would ‘rob’ her of the person she was, until she had a stroke, and lived many years which he termed a good life, although he didn't report his mother's opinion on the subject. Chapter Five, ‘Contraction of Time and Existential Awakening, a Phenomenology of Authentic Aging’ by Kevin Aho, a professor of philosophy, makes the case for ‘authentic’ ageing, free from trivial concerns in order to loosen control, to reinterpret who we are as we age, that suffering derives from avoiding finitude as opposed to accepting it and engaging in the vulnerabilities of ageing. An exploration of Heidegger and existential time is noted in this chapter and in the next, Chapter Six, ‘End of the Story, a Narrativist View of Life's Finale’, by Charles Guignon, also a philosophy professor. Both explore Heidegger's concept of authenticity and time, being true to oneself and creating belongingness in the world. Guignon also describes Améry's concept of lived, social and cultural time, so that older people increasingly become strangers in the contemporary cultural context. The final chapter of this section, ‘Happiness and Aging, an Unlikely Combination’, by Bryan S. Turner, a renowned sociology professor, begins with the Bette Davis apocryphal quote, ‘Old age ain't no place for sissies’, although this is misinterpreted to be a pessimistic view of ageing when the quote actually suggests that resilience and fortitude are needed in old age. He further explicates Aristotle's concept of eudaimonia and purposeful activity to achieve wellbeing and Pinker's enunciation of old age and happiness, that older people develop resilience and self-awareness and define their own happiness. Ultimately, the message of this section is that people should accept finite existence and temporality, engage in an authentic life and the vulnerabilities of age, in striving to achieve wisdom.
The final section of the book, ‘An Old Age That Goes Well’, has sections on dementia, the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) programme in the USA, and an explanation of the US Medicare system and how this helps shape a medicalised approach to ageing. Chapter Eight, ‘Friendship, Citizenship and Abandonment, Older Adults With Dementia and Without Family Caregivers’, by Janelle Taylor, a medical anthropologist, draws on Taylor's ‘interview-based research’ talking to people who are non-related informal carers for people with dementia, exploring these relationships in the context of the American legal system. The author notes that many of these informal care-givers have specific knowledge of working with and assisting the person with dementia, yet there are no formal designations for such relationships which leads to challenges when legal or medical decisions must be made. Chapter Nine is co-written by Sarah Szanton and Janiece Taylor, professors from the Johns Hopkins School of Nursing involved in the CAPABLE programme, which is delivered by physiotherapists and occupational therapists to assist older people experiencing declining health to remain ageing in the community. The final chapter, ‘From Diagnosis to Person-focused Prognosis: Toward a Health Political Economy of Aging in America’, is written by Justin Mutter, a professor in family medicine and geriatric medicine who explains in detail how the US health-care system drives the approach to ageing in the USA. Although noting signs of change and improvement in some parts of the USA, the author feels that the system overall needs structural change in order to deliver a service which would better suit the ageing population, by focusing on prognosis and how symptoms impact the health trajectory as opposed to a fixation on individual diagnostic codes.
The Conclusion, by editor Paul Scherz, describes the bleak future for Americans growing older, one of ‘ballooning medical expenses to pay for treatments of questionable benefit’ combined with ‘epidemics of loneliness and anxiety among the aging’ (p. 181). He sets forth three main themes, enunciated as three opposing dyads: the conflict between self-optimisation and dependence, perception of a limitless future versus finitude, and envisioning self as independent versus relational, where embracing the second in each dyad leads towards an acceptance of the evening of life.
The basic assumption of the book is that the anti-ageing culture and the pursuit of autonomy and individualism in US society, combined with the US health-care system's medicalisation of ageing and death, means that old age arrives without meaning or a role in society. The book proposes that this situation should be addressed by taking a multi-disciplinary approach to creating a positive understanding of late life that embraces decline, interconnectedness and finitude. This book is most effective in describing how the US health-care system and its focus on diagnosis-related payment codes fragment and work in opposition to holistic, person-centred care. Whilst the book claims to provide a multi-disciplinary approach to late life and death, in reality, it focuses mainly on philosophical and religious perspectives. The only gerontological theory cited was socioemotional selectivity theory, yet philosophical concepts described easily fit within gerontological discourse of personhood, gerotranscendence and comfortable ageing, as well as broader concepts of social networks. The intended audience for the book is for those studying late life and death, but without a broader contribution from all academic disciplines, this collection of essays feels incomplete.
