Leon R. Kass

Although growing old is a natural part of being human, the circumstances in which most Americans age and die are increasingly "unnatural" and surely unprecedented. Longer life expectancies and lower birth rates lead to the graying of society; smaller and less stable families weaken the ties that bind. Death comes on the doctor's watch and in high-tech surroundings, almost always following years of chronic illness, typically preceded by decisions about further medical intervention, increasingly made on behalf of patients incapable of making decisions for themselves. Caregivers often do not know how to honor those who have lost their most human qualities. Thanks to medicine's prowess in sustaining life on the edge, it is harder than ever to know when it is "time to die."

I.

The miseries of aging and decline were hardly unknown to our ancestors. When asked if he would choose to live over again, Thomas Jefferson said yes, but only between ages twenty-five and sixty. After that, he wrote, "the powers of life are sensibly on the wane, sight becomes dim, hearing dull, memory constantly enlarging its frightful blank and parting with all we have ever seen or known, spirits evaporate, bodily debility creeps on palsying every limb, and so faculty after faculty quits us, and where then is life?" Yet in Jefferson's time, most people never reached this extended period of debility, because they died suddenly in the nursery of life or at the peak of their flourishing. Living to old age was the dream of the vulnerable many; living with old age was the problem of the fortunate few.

In developed societies today, by contrast, old age is the norm. Average life expectancy in the United States is now seventy-eight years and rising (up from forty-seven in 1900), and those over age eighty-five are already the fastest growing segment of the population. People are not only living longer; they are staying healthier well into their sixties, seventies, and eighties, and they expect to enjoy many years of vigorous retirement. On balance, it is a wonderful time to be old, and the democratization and expansion of old age are among modernity's greatest achievements.

Yet the coming of the mass geriatric society is also a source of tremendous anxiety. Americans worry about the soaring costs of Social Security and Medicare, the collapse of private pensions, the shortage of good nursing homes, and the potential clash between the young and the old over resources and priorities. Our deepest worries are personal: we dread spending our final years in a degraded state, resented by caregivers or abandoned by loved ones, of little use to ourselves, never mind to others.

Such worries are not unjustified. Although most Americans can expect to live healthily well past sixty-five, many of us will also live long enough to endure a prolonged period of frailty at the end of our life. According to a recent Rand study, 40 percent of deaths in the United States are now preceded by a period of enfeeblement, debility, and (often) dementia lasting up to a decade. Prominent are those suffering from Alzheimer's disease, a condition that today claims over four million Americans; by mid-century, that number is expected to rise to over thirteen million--all of them requiring many years of extensive, expensive, and exhausting full-time care.

Yet precisely as the need for long-term care is rising, the pool of available family caregivers is dwindling. Families are smaller, less stable, and more geographically spread out. Most women are now employed outside the home. The well-to-do can afford to hire professional caregivers, but there are already shortages of geriatricians and nurses. Those jobs requiring great humanity but offering little paid reward--like feeding Alzheimer's patients or changing bedpans--are greatly undersubscribed. We are already facing a crisis in long-tem care.

All this creates the perfect social storm. As the number of retired baby-boomers expands, they will seek to augment existing social programs for the elderly, creating novel fiscal challenges for Medicare and Medicaid. Politically, long-term care benefits might become the sequel to prescription drug benefits--and far more costly. At the same time, the burdens of caring for needy elders will test the strength of already fragile modern families. Those in middle age may wonder about the wisdom (or duty) of sacrificing so much, for so long, on behalf of lives that seem so diminished. And they may come to believe that the death of the elderly is preferable to life in what seems like such a miserable condition. In the face of such burdens, two "solutions" appeal today to different strains of American pragmatism: one medical and one legal. Both are seductive, and both, in instructive ways, are misguided.

II.

In an age of medical triumphs, it is not surprising that our first approach to the dilemmas of old age is to think that we can cure our way out of them. Commemorating the 40th anniversary of Medicare and Medicaid in July 2006, my colleague Dr. Mark B. McClellan, then the top official at the Centers for Medicare and Medicaid Services, said that "Medicare can do so much more than give you dignity in old age." It can, he continued, extend life; it can improve health; it can save money by preventing and curing debilitating diseases.

This is the medical gospel of healthy aging. In its triumphalist vision, things for older Americans are, in McClellan's words, "always getting better." Nearly everyone in public life embraces this faith in the saving powers of medical progress, although conservatives emphasize drug development and free-market medicine while liberals emphasize embryonic stem-cell research and cheap drugs from Canada.

Many of McClellan's reform initiatives seem quite sensible, including promotion of preventive health measures, improved "customer service" for Medicare recipients, and reimbursement for home visits. And the twin goals of attacking debility and caring for the debilitated are not intrinsically or necessarily opposed to each other. But it is also foolish to act and speak as if medical progress (whether in prevention or in cure) will liberate us from the realities of decline, debility, and death or from the unavoidable duties of caregiving at the end of life.

First, medical progress often leads to greater debility in later years even as--and precisely because--it cures deadly diseases at earlier ages. This is the paradox of modern aging: We are vigorous longer and we are incapacitated longer. To be sure, no one wants to turn back the medical clock--when mothers and children died regularly in childbirth, when infectious diseases decimated helpless communities, when heart disease was largely undiagnosed and untreated, and when a diagnosis of cancer meant swift and certain death. But severing medicine's sweetest fruits from its sourest consequences may prove impossible.

Second, to see medical progress as a "cost saver" seems simplistic, if not misguided. Medical care is more expensive than ever precisely because we can do so much more to treat disease, and Medicare and Medicaid are more costly because more people are living longer. Even if the cost of curing today's diseases decreases over time, no one knows the cost of dealing with the diseases that will replace them. Only if people live free of illness to the very end and then die suddenly will medical progress really result in less expensive medicine. Otherwise, it will continue to purchase greater longevity and better health at an increased overall expense.

Finally, there is something weird about treating old age as a time of life when things should always be "getting better." While old age affords some people new possibilities for learning and "growth," aging also means--eventually and inevitability--the loss of one's vital powers. Some people may ride horses or climb mountains into their seventies and eighties, just as they do in the commercials for anti-arthritis medication, and such vigor is both a great achievement and a great blessing. But these idealized images of old age offer a partial and misleading picture of the realities of senescence, that series of small dyings on the way to death. Our endless chatter about "healthy aging" is at bottom a form of denial. For in the end, the nursing home refutes the dream of limitless progress toward ageless bodies, and America will surely build many more nursing homes in the years ahead.

None of this implies ingratitude for the blessings of medical progress--including current research aimed at curing age-related diseases such as Alzheimer's. But as medical successes fuel our love of youthfulness and limitless life, we are seduced into believing that opposing death through medicine is the highest good, trumping all other ethical and social concerns. As the campaign for healthy aging fuels our hatred of senescence and decline, we may devalue the need to give care and comfort to those we cannot cure, and seek instead a more absolute control over death when aging does not bring the good tidings we were promised. Instead of cultivating stoic endurance of our inevitable demise, we may continue our quest for ever-more-perfect mastery over nature and come to embrace the pseudo-mastery of "death-on-demand" as the cure for our unconquerable miseries.

III.

The goals of mastery and control in the face of death also lie behind the second prominent "solution" to the dilemmas of aging and debility: the gospel of the living will. During the national drama over Terri Schiavo, many argued that the real tragedy was that her wishes were never put clearly in writing; the moral lesson was that everyone should prepare a living will, saying exactly what should be done if and when incapacity strikes. Living wills are as "vital as regular exams," wrote the San Antonio Express-News. "The case of Terri Schiavo may have one important legacy: spurring more people to talk with family members and put down in writing what they would want if they become incapacitated," editorialized the San Francisco Chronicle. "If a year earlier she had signed an 'advance directive' that called for no such heroic end-of-life treatment, Rep. Tom DeLay and the right-to-life movement could have done nothing about it," wrote the Sacramento Bee. And so on and so on, in virtually every major newspaper in the country.

This enthusiasm for living wills did not emerge overnight. In the 1960s and 1970s, many people began to fear the prospect of living indefinitely on machines in a profoundly diminished condition. They feared the indignity of becoming a permanent burden on loved ones, a living body without a life, a helpless ward of the nursing home. To prevent this dehumanizing possibility, people began putting their treatment preferences in writing, to be followed by surrogates in the event of serious illness or injury. During the 1970s, state legislatures and courts began to extend formal legal recognition to these "living wills." Since then, this legal instrument has gained a passionate chorus of defenders and advocates--including lawyers, doctors, hospitals, patient advocacy groups, and most bioethicists.

At first glance, the case for living wills seems compelling, especially in a nation that places such a high value on individual autonomy. Living wills extend our irrevocable right to speak for ourselves, even when our powers of speech and reason are gone. They honor our preferences regarding how we wish to die, by allowing us to dictate all future medical interventions. They protect debilitated patients from having other people's wishes imposed on them, whether in the form of over-treatment or under-treatment. They give family members explicit permission to fight on or let go, especially in medically ambiguous situations where they might otherwise be incapable of making morally wrenching decisions about life and death. They protect financial resources from being squandered, whether on heroic interventions made in crisis or endless long-term care required for years.

But after three decades, there is increasing evidence that living wills have failed to meet these practical objectives. The social science data--compiled by Carl Schneider at the University of Michigan, Rebecca Dresser at Washington University in St. Louis, and many others--is compelling. First, most people do not have living wills, despite a very active campaign to promote them. In 2001, the completion rate nationwide remained under 25 percent, and even the chronically ill do not draft living wills in significantly higher numbers. Second, even those who complete living wills often do not have clear treatment preferences, and they often cannot comprehend the clinical conditions they might face in the future. As a result, they leave vague and often conflicting instructions, and their expressed preferences change depending on how a given medical situation is described. Third, living wills often do not get transmitted to those making medical decisions. According to one study, only 26 percent of medical charts contained accurate information about a living will, and only 16 percent had the actual document.

Finally, and most telling, the written instructions contained in living wills--even when they are consulted!--often have little effect on the actual decisions made. One study found that decisions made by surrogates using a pre-drafted living will were no more likely to reflect the patient's prior wishes than decisions made by family members judging on their own. What mattered most was a lifetime of familiarity with the patient: family members predict patient preferences better than physicians, and primary care doctors better than anonymous experts reading legal documents.

The shortcomings of living wills have still deeper roots: the animating ideas behind them--preserving autonomy until the end, giving precedence to prior wishes over present needs--are deeply problematic. Imagine, for example, a professor who watched his own father die of Alzheimer's, and vowed never to live like that, never to burden his daughter with his own care, never to behave shamefully the way his father did in the throes of that terrible disease. So he drafts a living will stating clearly that, once he starts to have trouble recognizing his daughter, he is to receive no more medical interventions. But should his daughter really leave him to die when he contracts a urinary tract infection rather than give him antibiotics? Was the professor in his prime really fit to judge the future worth of his own unfinished life? Is his daughter simply to be the executor of her father's wishes, or is she first of all a moral agent with her own moral responsibilities to care for the person now before her?

One can admire the professor's desire to spare his daughter the burdens of long-term caregiving and the pain of witnessing his extended demise. But he is probably deluded in believing that deliberately seizing an earlier occasion for his death will prove less painful to her. One can admire the professor's willingness to confront mortality rather than pretend he will live forever. But it is foolish to believe that he can control every detail of his own future care with a voice from the past, or that he can rightly assess the worth of a diminished future life from the very height of his own flourishing. One can admire the professor's pride in his own self-control. But being human also means accepting and enduring one's own vulnerabilities and dependencies.

When the sad time finally comes, no legal instructions written in advance--no matter how perfect--can replace our need for loving and devoted caregivers. Inasmuch as the gospel of the living will denies this truth, it perpetuates an illusion of perfect independence, isolating individuals at the very moment when they need others most of all.

Our unavoidable reliance on others is, in fact, recognized by a different--and superior--form of advance directive: the "proxy directive" or "healthcare power of attorney." Rather than dictate various potential courses of action, it empowers surrogates to make medical decisions on our behalf, identifying them as the people with whom doctors and nurses must deal when we cannot speak for ourselves. Reflecting the reality of our interdependence, this approach clarifies the responsibility of physicians and family members to make judgments about best care for patients whose own judgment is gone. But trusting others only makes sense if there are others who are trustworthy--willing to care, able to care, and wise enough to care well. Sad to say, this is often not the case--neither in medicine nor in families.

IV.

One of the ironies of medical progress is that we need family doctors and general practitioners most when medical super-specialization has made them endangered species. Especially for the frail elderly, comprehensive and continuous care is virtually impossible to obtain. One doctor treats our failing heart, another our wheezy lungs, a third our sluggish bowels, a fourth our tired blood, and a fifth our fraying nerves, but often no physician is willing or able to look after us. In eldercare and especially in nursing homes, caregiver burnout is common and high turnover rates prevent continuity of care, not only from doctors but also from nurses and social workers. Even the wealthy are not assured continuity of care. As they age, many will outlive their physicians; the young doctors who take their place will have no familiarity with the lives of their patients. If trustworthy and dependable long-term care is to be had, only the steadfast efforts of devoted family members can secure it--or, in many instances, provide it themselves.

Yet family caregiving also faces unprecedented difficulties; in an aging society, we need our families most when family life has been most weakened. There are the well-known and widespread phenomena of divorce and family rupture, lower birth rates, geographical mobility, and the weakened social importance of extended family. Moreover, many of today's old people--and many aging baby boomers--never had children, and many more have little claim on their children's loyalty. When a neglectful parent needs care from the children he neglected, the sins of the absent father or rejecting mother are often repaid in kind.

Even in the best of intact families, the caregiving picture is sobering. When an aging husband or wife acquires Alzheimer's disease or some other progressive disability, the front line of care is generally manned by the spouse--if he or she is healthy enough for the task. The fidelity between spouses, displayed most poignantly when the marriage bed becomes also a nursing station, was in fact anticipated long ago when husband and wife pledged their mutual devotion, "for better and for worse." No doubt invisible to them when they chose to marry, caregiving at the end of life was nonetheless always part of the marital vocation, and many a husband and wife rise to the occasion, tending their ailing and frail life-partner to the very end, often with strength and dignity.

Eventually, however, even the most blessed of life-long marriages always produces either a widow or a widower, and it is then that the prospects for faithful long-term care become uncertain. Studies indicate that only a person with three or more daughters or daughters-in-law--which is to say, conversely, no one with fewer than three children--has a better than 50-50 chance of never needing to be institutionalized to receive their long-term care. This is not the consequence of mere filial ingratitude or heartless indifference. For truth to tell, it is passing strange--even "unnatural"--when a whole society of adult children is summoned to care long-term for those who once cared for them.

In contrast to the care children once received from parents, eldercare by children is unrewarded by the joyful experience of seeing a new life unfold and flourish. Even in the best cases--where care is lovingly given to a revered parent--there is unavoidable sadness. As the Yiddish proverb has it, "When the father helps the son, both laugh. When the son helps the father, both cry." There is great indignity in seeing one's elders become so utterly diminished, even as children gladly discharge their obligation to "honor thy father and mother." No child wants to uncover the nakedness of his father or mother. No mother or father wants to stand incompetent before the children.

More fundamentally, there is also a disruption of the naturally forward-looking thrust of intergenerational life and familial care. The burdens of caring for one's parents, and of being cared for by one's children, risk obscuring the stake that both the old and the middle-aged have in the rising third generation. For a grown child best "repays" the gifts of his parents less by looking after them, more by raising children of his own; and grandparents have a greater interest in seeing grandchildren flourish than in maximizing the comfort of their own last days. Yet discerning what intergenerational fidelity requires in any given circumstance is often difficult. A caregiving daughter, raising young children of her own, might see the pneumonia that afflicts her father with advanced Alzheimer's as nature's way of restoring the generational balance, to be accepted with sorrow rather than opposed with penicillin. Or she might recognize the moral gift to her children of demonstrating what it means to love another in his gravest need, and what it means to appreciate the blessings of health in the face of the miseries of disease.

Despite these complexities and the "inversion" of the generational order of care, many people nonetheless experience caring for aged parents as a vocation--a duty lovingly fulfilled, giving life its true meaning. Many others experience it as a curse--a duty grudgingly accepted (or not), robbing life of its true pleasures. In some cases, the demands of caring for the elderly reveal the family at its best, faithful to the end; in others, the very presence of the helpless elderly suffocates everything else in family life. Yet we can only imagine what family would become if the old were abandoned in the name of the young, or the weak left to die in the name of the flourishing.

In the years ahead, the greatest familial dilemmas will confront the middle-aged of the middle-class--those who are wealthy enough to have choices (such as hiring paid professional caregivers), yet limited enough to make every choice a real sacrifice (such as forgoing extra income to stay at home with an aging mother or depleting retirement savings to pay for a father's assisted living). Compelled to make such choices, even the most devoted caregivers may feel both resentment and guilt--resentment at what they must give up to care, guilt that they may not have cared well enough. Inevitably, the question will arise: Are these sacrifices "worth it"? Are we really helping Dad by extending a life that seems so diminished? Is his life still worth living?

V.

Until now, our society has been largely spared such questions. And when they have been raised, usually in private, we have had solid moral answers, backed by our religious and political traditions, as well as by the venerable teachings of medical ethics. When it comes to the right to life and human care, most Americans are committed--at least in the abstract--to the view that all human beings are "created equal," owing to our common humanity and the vulnerabilities human life necessarily entails or to our sharing equally an existence cast in the "image of God." And since the days of Hippocrates, physicians have eschewed judging the worth of the lives they treat and have refused "to give a deadly drug if asked" or even "to make a suggestion to that effect." Never are the disabled deemed unworthy of medical or humane care. On the contrary, say our religious and medical traditions, their need for care is precisely the reason we are obliged to provide it.

But as we saw in the Schiavo debate, this general agreement regarding equal human worth can disappear in certain cases. Although many continue to believe that every human life, regardless of debility, possesses equal dignity, others now argue openly that equal treatment for all is best advanced by not diverting precious resources to the severely disabled. Still others believe that the indignities of old age--especially dementia--belie all sanctimonious talk of "equal worth."

Among these people are the advocates of euthanasia. For the time being, America seems immune to embracing this particular "solution" to the burdens of an aging society. Even in those states--like California and Vermont--that have considered joining Oregon in legalizing assisted suicide, the justification is "personal choice," not a category of human beings officially defined by hospitals or the state as "life unworthy of living" or "better off dead." At the same time, however, more and more commentators are deploring the amount of money spent on medical care for people near the end of life. As the American population ages, we can expect to hear even more talk of people with "low quality of life," unworthy of the resources "wasted" on them. What begins today as a campaign to give individual a right to ease themselves out of life can easily turn into a campaign to get the enfeebled and demented to exercise their "right to die," or, since they are unable to do the deadly deed themselves, to "exercise it for them."

But those who pledge their belief in the sanctity of every human being cannot respond to this challenge simply by insisting on the absolute need to sustain life regardless of the condition of its possessor. The existential questions at the bedside are too grave for that, and cannot be avoided. Is it love or is it cruelty to cure the pneumonia in an elderly person suffering from a painful form of terminal cancer--especially one so demented that the mitigating comforts of family and friendship cannot be appreciated? Is it love or is it cruelty to extend a life marked by incontinence of bladder and bowel, uncontrollable outbursts of rage, or psychophysical misery caused by Alzheimer's? Is it love or is it cruelty to force a patient with mild dementia to continue kidney dialysis that he vigorously resists, knowing that he cannot understand either how the dialysis can help him or that ceasing treatment will bring imminent death? Faced with these painful choices, and in moments of weakness, hastening death's arrival may seem the compassionate thing to do.

Traditional medical ethics, ever mindful of this temptation, has been very clear about the duty to resist it: never to kill, always to care. If doctors and others are faithfully to benefit the life the patient still has, they cannot sit in ultimate judgment of its worth, and cannot ever think that lethal intervention is an acceptable "therapeutic option." This holds true even for those (non-demented) patients who knowingly ask doctors or family members to help them die--whether in the present because they are suffering now, or in the future because they cannot bear the thought of living with dementia.

But traditional medical ethics has also long taught that benefiting the life a debilitated person still has does not mean taking every possible medical action to extend it. Senescence leads inevitably to death, medicine or no medicine. And so, while "active killing" may be incompatible with true caregiving, "letting die" is always part of it. In this reasoning, life-sustaining treatment may be--and often should be--forgone or terminated if the interventions themselves impose undue burdens on the patient or interfere with the comfortable death of someone irretrievably dying. Guidance in this area comes from distinguishing between the burdens of a treatment (imposed by caregivers and for which they are thus responsible) and the burdens of living with a terrible disease (imposed by nature and for which they are not responsible).  

Yet as we enter the mass geriatric society, it is clear that our new technological capacities are putting pressure on these sensible distinctions. A century ago, Dr. William Osler could write: "Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes these cold gradations of decay so distressing to himself and to his friends." Today, thanks to antibiotics, the aged have no natural friends--or none that cannot also be regarded as enemies. Life-sustaining interventions, if effective and not especially burdensome, have come to be regarded as standard care and morally obligatory. As a result, well-meaning and morally sound decisions to treat intervening illnesses--like curing the professor's urinary infection despite his living will--can make us complicit in the continuing miseries and degradations of those we love.

Here then is the most poignant dilemma faced by caregivers: not wishing to condemn the worth of people's lives, yet not wanting to bind them to the rack of their growing misery; not wishing to say they are better off dead, yet not wanting always to oppose their going hither. Under these circumstances, with no simple formulas for finding the best course of action, individuals and families must find their way, case by case and moment to moment, often with only unattractive options to choose from and knowing that whatever path they choose, they will feel the weight of the path not chosen.

VI.

Even if the burdens of aging and death are always borne most fully by individuals and families, how we age and die are not only private matters. Our communal practices and social policies shape the environments in which aging and caregiving take place--not only in moments of crisis, when life-or-death decisions need to be made, but in the long days of struggle and everyday attendance. Faith-based institutions and community groups support families in meeting those needs they cannot meet alone. Programs like Medicaid assist those who are old and impoverished, in need of nursing that they cannot themselves afford.

In the years ahead, this need for social supports will only increase, especially if we are to fight the temptation to turn caregiving entirely into a state responsibility. Affordable long-term insurance, respite relief for caregivers, reliable and reimbursable home services, technologies to assist in giving basic bodily care--all these and more can enhance the economic and social supports of those coping with extended debility. Recruitment of volunteers to aid in eldercare is a perfect objective for the many groups, both liberal and conservative, interested in promoting civic engagement and renewing civil society.

But we cannot pretend that individual families, or society as a whole, will have unlimited resources, particularly in a populace with more elderly persons and fewer young workers. Americans will need to make hard choices among competing goods, and to confront the limits of even our own affluent society. And even then the biggest challenges before us will not be economic in nature but cultural and spiritual--how to deepen our understanding of what it means to age and die, how to combat the overly medicalized view of old age that now dominates our attitudes and our institutions, how to recover the wisdom contained in the human life cycle.

As we noted earlier, Americans increasingly regard old age as a bundle of needs and problems demanding solution, or as a time of life whose meaning is defined largely by the struggle to stay healthy and fit. This outlook has generated discontent with the life cycle itself, producing an insatiable desire for more and more medical miracles, and creating the fantasy that we can transcend our limitations--or that death itself may be pushed back indefinitely. More deeply, this same outlook has engendered the illusion that independence is the whole truth about our lives, causing us to undervalue those attachments and obligations that bind and complete us.

We live already in a world in which the life cycle has largely lost its ethical meaning. Aware as we may be that we are on a solitary journey that ends inevitably in the grave, few of us take our bearings from nature's eternal teaching that there is a time to be born and a time to die. We learn little from the rhythm of growth and decay, everything in its season, our own finitude transcended and redeemed by generation upon generation of new birth and renewal, transforming each singular finite trajectory into a permanently recurring cycle of life.

This cultural myopia is no trivial matter. Indeed, in the mass geriatric society it could have deadly consequences. For unless we learn to accept both our frailties and our finitude, we are likely to find the burdens of caregiving intolerable. And unless we learn how to let loved ones die when the time comes, we will be tempted to kill--self-righteously, of course, in the guise of a false compassion. Sooner or later, when the medical gospel of healthy aging and the legal gospel of living wills are shown to have been false teachings, we may easily fall prey to the utilitarian gospel of euthanasia, whose prophets are patiently waiting in the wings for their time upon our cultural stage.

In the end, there is no "solution" to the problems of old age, at least no solution that any civilized society could tolerate. But there are better and worse ways to see our aging condition. The better way begins in thinking of ourselves less as wholly autonomous individuals than as members of families; in relinquishing our mistaken belief that medicine can miraculously liberate our loved ones or ourselves from debility and decline, and instead take up our role as caregivers; and in abjuring the fantasy that we can control the manner and the hour of our dying by learning to accept death in its proper season, as mortal beings replaced and renewed by the generations that follow.

Leon R. Kass, M.D., is the Hertog Fellow at AEI.