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I.2 The point of view of complex organisms and modern medicine For complex organisms such as animals or humans, aging and death are phenomena that are only remotely related to the aging and death of single cells. Complex organisms result from the assembly of myriads of individual cells, which group themselves in different functionalities or organs (e.g. bones, muscles, brain) and which form in turn the complementary parts of complicated machines (or bodies) that can live and multiply autonomously. In such machines, it is the interplay between these various groups of cells or organs rather than the life of any individual cell that is critical for life or death. For instance, if the pumping function of the heart stops, as occurs during a severe heart attack, the whole machine will die in spite of the fact that many other organs (e.g. the kidneys, the liver, the brain) are still in perfect condition. This happens because an essential functionality is abruptly lost. Likewise, the functions of the brain may be severely altered resulting in irreversible coma in spite of the fact that individual neurons are still alive. Physiological brain activity results from the coordinated interplay between innumerable individual neurons. Thus, brain dysfunction may result from alterations in neuron coordination rather than in neurons themselves. More ordinarily, bones may become eroded and lead to arthritis and limping though the power of the muscles may remain intact. Thus aging and death of complex organisms imply multiple cellular players and more particularly the coordination among them. The fact that a dead machine may be constituted of parts (or cells) that are still alive poses critical questions about the definition of death in a complex organism. This is a major challenge for contemporary medicine. Modern technology can artificially maintain physically alive (sometimes for extended periods of time) patients who are terminally ill. As a result, caretakers are now confronted with situations where they have to decide on maintaining or stopping the artificial life support of their patient, and hence decide on the patient’s life or death. Ethical committees have worked out these concerns worldwide, and agreed on consensus decisions. As in other instances, the Swiss Academy of Medical Sciences has put brain functionality in the center of the definition of life. However, the dilemma remains. It becomes even more complicated when a patient who is maintained alive artificially is simultaneously a potential organ donor ; sacrificing that patient might help saving or improving someone else’s life. The timing of the death of that patient might even have to be synchronized with the timing of transplant. Such decisions are always taken by multidisciplinary teams that include close relatives of the patient. However, although the collective decision may facilitate the acceptance of the terminal act, it does not alleviate its symbolic burden, nor does it ease the conscience of those implicated in the decision. 6
I.3 The point of view of society Medicine and increased standards of living have dramatically modified the age pyramid and the proportion of elderly people in Western countries (Figure 1). In Switzerland, the proportion of individuals over 60 has been multiplied by 8 over the last century. While living older is not bad news in itself, it is accompanied by a decrease in birth rates and thus a lower renewal of the population, which is biologically vital. The aging of the population has emphasized new diseases related to old age, such as cancers, cardio-vascular diseases and neurodegenerative illnesses. The accumulation of such diseases has resulted in the physical frailty of the individuals and their social dependency. The shift in the age distribution of the population has been accompanied by new social needs, changes in the allocation of resources, and cultural changes. In strictly economic terms, this aging population contributes little to the rest of society while placing high demands on it. © cmglee -wikimediacommons Figure 1 Life expectancy of females (vertical axis) and males (horizontal axis) from the time of birth. Females tend to live longer. There is a statistically significant relation between age expectancy and social wealth One logical answer to the downward dynamics of the population would be to try to improve physical and mental fitness – which are considered to reflect the quality of life – up to the oldest possible age. This is an undisputed goal of medicine because everybody wants to live older in good shape. The drawback, however, is that elderly in good physical and mental shape have become an ideal representation in Western societies, while physical and 7
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a summary of the topics - UniversitÃ© de Lausanne

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