I am the mother of two young children and the primary care physician of a thousand or so aging patients. Twenty-four hours a day I am either “on-call” for or providing care directly to needy, dependent little people. And about ten hours a day plus some nights and weekends, I am caring for needy, ailing older adults. Whether at work or at home, the nature of the care I provide often feels very much the same. Both my children and patients have come to me frightened, hungry, exhausted, and in need of reassurance. Both have sought advice and both have needed help with their activities of daily living such as grooming or toileting. Both ask that perpetual question, “Why?”
But children and adults differ in many important ways, one of which an example from science illustrates well. In the language of molecular biology, changes to a cell’s genetic code, or DNA, are called mutations. Many factors cause mutations, including radiation, chemicals, or viruses. Mutations can affect how a gene is expressed: the gene might, for example, become more productive (i.e., the so-called “gain of function” mutation) or it might become less productive (i.e., “loss of function” mutation). Unlike the promises of youth, in which so much function stands to be gained, the aging are subject to loss of function, to diminishing faculties. Whereas children become more robust, the elderly become frailer. Children evoke a sense of immortality, while the mortality of the aging haunts us.
As a mother and medical practitioner straddling the two worlds of early child development and of end-of-life care, I am not surprised by the enthusiasm and energy devoted to developing in children their “gain of function.” And I am saddened (but perhaps not amazed) by the sidelining and even outright dismissal of the value of the elders in our midst. We might sit patiently with a toddler as she slowly stammers out an explanation for, say, how milk comes from cows, in order to encourage her speech development and self-confidence, but we have scarcely a moment to inquire of the octogenarian the wisdom of his life’s experiences. And while an older friend once commented that “wisdom does not necessarily come with age – there are a lot of old people who aren’t wise at all” – I maintain that wisdom comes with experience, and the longer one lives, the more experience one accumulates. But do we tap into that experience?
Some use the phrase “the circle of life” to describe the processes of aging. The word “circle” suggests that life and death are on a continuum; indeed, as Joni Mitchell sings, “We’re captive on the carousel of time . . . go[ing] round and round and round in the circle game.” But “circle” also suggests that the young become old and the old become young, and while we might expect children to grow to maturity, it does not follow that adults are but infants waiting to happen. My sense is that there is something unique to the aging process that we dilute by using jargon such as “the circle of life.”
In my view, birth and death are distinct, equally important events that occur over time and demand our respect. The ancient poetic book of Ecclesiastes captures well this understanding of life’s processes. In it, Qoheleth, or Teacher, writes, “There is a time for everything, and a season for every activity under the heavens.” He provides a long list of activities for which there are seasons: a time to plant and a time to uproot; a time to weep and a time to laugh; a time to tear and a time to mend; a time to be silent and a time to speak; a time for war and a time for peace, to name several. At the very top of the list, Qoheleth writes that there is “a time to be born and a time to die.” The seasons of birth and of death frame the whole of the rest of life’s experiences. They are given equal weight and merit. They equally command our attention.
My sense is that contemporary Western society is not at risk of making too much of a fuss over the elderly. As the much-celebrated World War II generation departs this life, subsequent generations of seniors will likely have to work harder than ever to find their voice. But on behalf of my generation, behind the closed doors of the exam room, I will seek the wisdom of the more experienced and walk with them through the season of death.
Lydia S. Dugdale, M.D., 35, is an assistant professor of medicine at Yale School of Medicine.