Aging, Autonomy, and Social Determinants of Health

A few weeks ago I came across notes I had written five decades ago on the subject of aging. I had been struck by a distinction drawn by David Riesman, in an essay on “Clinical and Cultural Aspects of Aging,” between the different ways in which aging takes place for three types of people.

He saw some individuals, whom he called “autonomous” (referring in a note to The Lonely Crowd, published four years earlier) who bore within themselves certain psychological sources of self-renewal. As examples of how aging can bring accretions of wisdom, with no loss of spontaneity and ability to enjoy life, Riesman mentioned Bertrand Russell, Arturo Toscanini, and Franz Boas, even Freud. Others, the “adjusted,” possibly the majority, have within themselves no such inner resources. Many in business and the professions fall in this group. They are sustained by the world of work and of routines, but only while they can continue to be active within this world. A third group, the “anomic,” protected neither from within nor from without, simply decay with age.

Riesman had seen physiological vitality as one cause for the sources of self-renewal among those in the autonomous group. Twenty-six years old at the time, I noted the need, if health permits, to prepare oneself long before old age to have the kind of existence that needs as few outer “props” as possible. How best to do that was the question. It would matter, I felt, for my husband and myself to travel to many corners of the world to explore different approaches to finding a durable inner peace, “when children are on their own and our responsibilities lesser.” This would clearly be some time off, since we had one child and were expecting another.

My response also drew on a visit a few months earlier to Denmark and Sweden, where I had had the opportunity to study what I found to be imaginative ways to counter the sense of futility, of loss of contact with life, that old age could bring. It was cruel and unnecessary, I felt, to enforce idleness and isolation on the part of old people. I had visited, for example, a cheerful, roomy apartment building in Copenhagen, with apartments for young families along with housing for older persons, and a day care center where the latter could interact with small children, perhaps only reading occasional stories, perhaps more, depending on their strength. The joy that could come from such contacts between old and young could “rub off,” I believed, so as to make the old feel younger and the young more secure.

Looking back at Riesman’s essay a half-century later, I am more conscious of his stark distinction between people possessing inner and outer resources. It was clear where his preference lay, from his mention of his own “dream of autonomy” to his bleak view of the inner emptiness of the “adjusted.” According to Todd Gitlin, introducing the 2001 edition of The Lonely Crowd, Riesman later came to regret having contributed to “the snobbish deprecation of business careers.” He had been only 40 years old at the time of publishing that book, 44 when his essay on aging appeared.

To be sure, Riesman explained that the distinction he described between “autonomous,” “adjusted,” and “anomic” individuals was one between three “ideal types,” using sociological terms drawing on Max Weber. Riesman might well have agreed that all of us, at whatever stage of life, require both inner and outer resources to thrive. In addition to whatever genetic and other inner strengths possessed by Russell, Toscanini, and the other people he mentioned, they had surely all benefited from external resources, including financial security, educational opportunities, and family and other social networks.

The study of what are now called such “social determinants of health” has accelerated in the decade since Riesman died, at the age of 91. It is increasingly recognized how powerfully the very ability of people to exercise optimal independence over a lifetime – to be able to share his “dream of autonomy” – is influenced by inequalities when it comes to such factors as poverty, poor housing, inadequate health care, stressful employment or unemployment, and social isolation.

There is always more to be learned about how to enhance the prospects for autonomy within ourselves, but we have made progress in creating external environments that can provide new meanings, and new forms of engagement, in later years. And while no society has succeeded in eradicating the inequalities that most affect the aging, we now know a great deal more about how much farther some have come on this path, including Canada, Switzerland, the Netherlands, and the Scandinavian countries.

Sissela Bok, 77, is Senior Visiting Fellow at the Harvard Center for Population and Development Studies. Her most recent book is Exploring Happiness: From Aristotle to Brain Science (Yale University Press, 2011).