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Imagination and idealism in the medical sciences of an ageing world
  1. Colin Farrelly
  1. Political Studies, Queen's University, Kingston, Ontario, Canada
  1. Correspondence to Dr Colin Farrelly, Political Studies, Queen's University, Kingston, Canada; farrelly{at}queensu.ca

Abstract

Imagination and idealism are particularly important creative epistemic virtues for the medical sciences if we hope to improve the health of the world’s ageing population. To date, imagination and idealism within the medical sciences have been dominated by a paradigm of disease control, a paradigm which has realised significant, but also limited, success. Disease control proved particularly successful in mitigating the early-life mortality risks from infectious diseases, but it has proved less successful when applied to the chronic diseases of late life (like cancer). The time is ripe for the emergence and prominence of a supplementary medical research paradigm, the paradigm of ‘healthy ageing’ which prioritises the goal of rate (of ageing) control rather than disease control. This is the difference between extending the human healthspan versus extending survival by managing (or trying to eliminate) the multi-morbidities, frailty and disability currently prevalent in late life. The idealism of the disease control paradigm is myopic because it ignores the health constraints imposed by the inborn ageing process itself, a biological reality which is already inflicting significant economic and disease burdens on the world’s ageing populations. Unless the medical sciences retard the rate of biological ageing, these problems will continue to be amplified as larger numbers of persons survive into late life.

  • Aged
  • Communicable Diseases
  • Public Policy
  • Enhancement

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Introduction

The medical sciences constitute a domain of intellectual enquiry typically lauded for its commitment to ‘epistemic virtues’ like humility and reason, the testing and refining of hypotheses, being detail- oriented and recognising the salient facts. Indeed, the public’s trust in medical science no doubt stems, in large part, from the confidence they have that public health and medicine are informed by these rigorous epistemic virtues. But there are other significant, and often overlooked, creative epistemic virtues that are also integral to the medical sciences and promotion of the public good. Imagination and idealism in medical science are often underappreciated, even eschewed, especially when they challenge established assumptions and modes of thinking. And yet these creative traits are often the main catalysts of medical discovery and the advancement of science.

Imagination and idealism are particularly important creative epistemic virtues to celebrate and refine if we hope to improve the health of the world’s ageing population, such as the estimated 2 billion persons who will be age >60 by the year 2050. To date, imagination and idealism within the medical sciences have been dominated by a paradigm of disease control, a paradigm which has realised significant, but also limited, success. Disease control proved particularly successful in mitigating the early-life mortality risks from infectious diseases, but it has proved less successful when applied to the chronic diseases of late life (like cancer).

The time is ripe for the emergence and prominence of a supplementary medical research paradigm, the paradigm of ‘healthy ageing’ which prioritises the goal of rate (of ageing) control rather than disease control. This is the difference between extending the human healthspan—the period of life spent in good health, free from the chronic diseases and disabilities of ageing’1—versus extending survival by managing (or trying to eliminate) the multimorbidities, frailty and disability currently prevalent in late life. The idealism of the disease control paradigm is myopic because it ignores the health constraints imposed by the inborn ageing process itself, a biological reality which is already inflicting significant economic and disease burdens on the world’s ageing populations. Unless the medical sciences retard the rate of biological ageing, these problems will continue to be amplified as larger numbers of persons survive into late life. Rate control may prove to be both more feasible and desirable, if it extends the human healthspan, that any medical intervention that eliminates or cures a specific disease of late life.

Herter (1910) on the ‘plasticity’ of science

The influence of imagination and idealism in the growth of medical discovery was the focus of Christian Herter’s 1910 JAMA Address titled ‘Imagination and Idealism in the Medical Sciences’. Herter remarked:

In reality, our science is fortunately plastic, constantly subject to revision of its facts, and ever ready to welcome new interpretations of old facts as well as new discoveries, both great and small. This very plasticity it is that makes progress attainable and fascinates our minds. But our textbooks and our lectures are necessarily conservative and dispose us strongly to the notion of fixity of facts, making our minds statical in conception.2

Herter went on to note, ‘it is growing every day clearer that the progress of the medical sciences depends in a remarkable degree on discoveries made by indirect methods—that is, by methods not looking to the immediate relief of disease’. The suggestion that significant medical discoveries could be reaped by methods that are not looking to the immediate relief of disease may be somewhat jarring to researchers in the medical sciences today, over a century after Herter’s published reflections. And this is so because for the past century the medical sciences have been dominated by the imagination and idealism of a disease control paradigm that has fixated on the immediate relief of disease. As Herter warned, our minds have become ‘statical in conception’. But Herter’s appeal for imagination and idealism that transcends the concern with the immediate relief of disease is perhaps more important than ever, given the health predicaments facing today’s ageing populations.

The idealism of disease control is predicated on the aspiration that we could potentially realise a ‘disease-free’ world, or at least a world where we have more success in preventing and treating both infectious and chronic diseases. This ideal has fixated the imagination of medical researchers on attenuating to the proximate causation of disease. This idealism has inspired many significant public health advances, such as improved sanitation and nutrition, behavioural changes, vaccine development and a host of surgical and pharmacological treatments for specific diseases. But the paradigm of disease control has marginalised what many scientists now believe may prove to be among one the most significant advances in public health this century—an applied gerontological intervention that slows the rate of molecular and cellular decline, thus extending the human healthspan.

The United Nation’s goal of a ‘Decade of Healthy Ageing’ (2021–2030) inspires an idealism that transcends the limitations of the disease control paradigm. By doing so, medical researchers can now expand their imagination beyond the confines of simply ameliorating the proximate causation of disease. Given the world’s changing demographics, and the current state of biomedical research on the biology of ageing, rate control (vs disease control) ought to preoccupy an ever-expanding degree of the imagination and idealism of the medical sciences.

More than a century of ‘wars’ against specific diseases

When Herter published his JAMA Address in the early 20th century, the American population faced significant early-life mortality risks from a variety of viruses and bacteria. Contaminated food, milk and water carried the risks of serious infections like polio, typhoid fever, and salmonella. In the year 1900 life expectancy at birth in the United States (for all races, both sexes) was only age 47.3.3 Half a century later and US life expectancy at birth had risen to age 68.2 (a 44.2% increase). And nearly all the mortality decline in the first half of the 20th century is accounted for by reductions in infectious disease, which today is only a small share of total mortality.4

The imagination and idealism that helped the medical sciences make serious inroads against the early-life mortality risks from infectious diseases were:

  1. The idealism of safer environments for humans to live, work and play in, such as safer food to consume, cleaner water to drink and swim in, safer working conditions, safer vehicles for driving, etc.

  2. The imaginative capacity to understand we could enhance the human immune system beyond what evolution by natural selection had given us, through vaccines. Vaccines helped improve protection against small pox, polio, diphtheria, tetanus, pertussis, measles, mumps and rubella, etc.

Both of these strategies also proved vital in the recent COVID-19 pandemic, a public health predicament that also required imagination and idealism. The prospect of safer environments for humans to work and live in were aided by compliance with public health protocols like regular hand washing, the wearing of face masks, improved ventilation and social distancing. And the rapid speed with which the COVID-19 vaccines and boosters were developed, authorised and globally distributed has rewritten the history books on what is possible for novel public health interventions to achieve.

Since the COVID-19 pandemic the confidence Americans have in the medical sciences and science appears to have increased. A 2020 PEW survey,5 for example, found that the percentage of Americans who expressed ‘great confidence’ in medical scientists to act in the best interest of the public increased from 24% in 2016, to 43% in 2020. A similar increase was found in the ‘great confidence’ rating that scientists were acting in the best interest of the public, with 21% of the population expressing such a sentiment in 2016, and that had risen to 39% by 2020.

While the paradigm of disease control has achieved quantifiable success with respect to preventing the infectious diseases that historically caused most early-life mortality, the public health challenges posed by the chronic diseases of late life have proven more intractable. In his state of the union address in 1971, President Richard Nixon asked for an appropriation of an extra US$100 million to launch an intensive campaign to find a cure for cancer. This 50-year ‘war on cancer’ has resulted in a steady annual funding increase in cancer research, with US$6.56 billion being allocated to the National Cancer Institute in 2021. The 21st Century Cures Act reaffirms Nixon’s aspiration for the medical sciences, that the goal should be to eliminate diseases like cancer.

But today cancer still is, as it was half a century ago, the second leading cause of death in the United States. The prospect of a ‘cancer-free’ world is certainly an alluring one, and the end-game of eliminating cancer is a logical goal for the medical sciences considering the fact that cancer kills an estimated 10 million people globally every year.6 And while significant progress has been made with cancer prevention (eg, identifying tobacco as a carcinogen), diagnosis and treatment, the prospect of a ‘cancer-free’ future does not seem to be any closer to being realised than it was half a century ago.

The idealism that guided the medical sciences in tackling the infectious diseases combined the dual strategy of creating safer environments and enhancing the human immune system through vaccinations. But such strategies have proven less useful in combating the chronic diseases of late life, given that the inborn ageing process itself the major risk factor for most of those diseases. The incidence of chronic disease rises sharply with age and the majority of patients with a chronic ailment are over the age of 65 years.7 On 11 January 1964, the American Surgeon General Luther Terry released the first report of the Surgeon General’s Advisory Committee on Smoking and Health, identifying smoking as a cause of lung cancer. Despite decades of promoting smoking cessation public health campaigns, the Centers for Disease Control and Prevention (CDC) estimates that smoking accounts for more than 480 000 deaths every year, with about 15 of every 100 adult men (15.3%) and nearly 13 of every 100 adult women still smoking.8 And smoking cessation is not a silver bullet to protect past smokers from eventually developing lung cancer, as four of ten lung cancers occur in former smokers with more than 15 years since quitting.9

And obesity, defined in adults as a body mass index ≥30 kg/m2, is associated with higher incidence of a number of cancers10 and has become increasingly prevalent over the past three decades. The prevalence of obesity doubled between the 1976–1980 and the 1999–2000 National Health and Nutrition Examination Surveys. And between 1999–2000 and 2017–2018, the prevalence of obesity increased from 30.5% to 42.4% (and the prevalence of severe obesity increased from 4.7% to 9.2%).11 The CDC’s The National Center for Health Statistics (NCHS) Data Brief ‘Prevalence of Obesity and Severe Obesity Among Adults: USA, 2017–2018’ estimates that the age-adjusted prevalence of obesity in adults is 42.4%.12

Despite unprecedented amounts of investment in biomedical research in recent years, US life expectancy has plateaued, and even declined. Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for three consecutive years after 2014 due to midlife mortality increases across all racial groups, caused by drug overdoses, alcohol abuse, suicides and a diverse list of organ system diseases.13 And the increase in life expectancy between 2017 and 2018 for the total population was only 0.1 year, of which approximately 30.2% of the positive contribution can be attributed to decreases in cancer mortality.14 The COVID-19 pandemic is estimated to have reduced US life expectancy in 2020 by 1.13 years.15 The disease control paradigm has diminishing marginal utility as populations reach the upper bounds16 17 of the human lifespan.

Comfort (1969) and rate control

Disease control continues to capture the imagination and idealism of the medical sciences. And while there is room for optimism that further progress can be made in preventing and treating cancer, for example, we must acknowledge the biological reality that eliminating chronic diseases of late life is much more challenging than ameliorating the proximate causation of disease, which was the strategy employed to effectively combat infectious diseases. Furthermore, the latter added decades more of healthy life to the young persons that had the opportunity to enjoy life free from the health threats of small pox, polio, diphtheria, tetanus, pertussis and measles, mumps and rubella. But for the diseases most prevalent in late life, like cancer, heart disease and stroke, the prospects of realising significant health benefits by ameliorating the proximate causation of chronic diseases looks much less promising. The reason for the this is simply the realisation that eliminating any single type of cancer (eg, prostate or breast cancer) would not reduce the health risks of other cancers, or heart disease, or Alzheimer’s disease, etc. As Olshansky notes, finding a cure for one of the late onset diseases like cancer can mean that more debilitating diseases can become more prevalent:

The hazard in old age is not so much that one disease displaces another but that the new diseases are often much more debilitating. For example, finding a cure for cancer may cause an unintended increase in the prevalence of Alzheimer disease.18

Herter’s insight that progress in the medical sciences can be made by methods not looking to the immediate relief of disease is perhaps more paramount than ever for today’s ageing populations. Because science is plastic, it must now ‘pivot’ to better address the health realities of today’s ageing populations. In order to do this the medical sciences must once again exercise imagination and idealism, but it must transcend the limitations of the disease control paradigm.

Even before Nixon’s 1971 ‘war on cancer’ the presuppositions of a rival vision of imagination and idealism in the medical sciences was articulated by the gerontologist and Head of UCL’s MRC’s Group of Ageing Alex Comfort. In 196919 Comfort proposed a radically different approach to human longevity than the strategy of disease elimination. Comfort contrasted the two approaches as follows:

Science can be expected to affect human longevity favourably in two quite distinct ways. It already does so by suppressing causes of premature death, through the repertoire of applications which now render our lives less nasty, brutish and short than they would otherwise be. It could also affect longevity by postponing the process which causes our liability to disease and death to increase logarithmically with time. The first of these two influences already means that in privileged countries more and more people reach the so-called ‘specific age’ (75~80 years), but it has not altered that age appreciably. The second, which is now in the stage of active research, would aim at postponement or slowing of ageing itself.

Comfort, and many other biogerontologists,20–26 invoke an idealism that transcends the limitations of disease control, an idealism that aspires to improve the quality of life for older people (ie, increasing the healthspan) versus preventing death by helping older populations manage multimorbidity, frailty and disability.

Having the imagination and idealism to envision safer environments and an enhanced immune system enabled the medical sciences, through the exercise of the ‘epistemic virtues’ of the scientific method, to increase US life expectancy at birth by nearly 30 years in the 20th century. But the risks posed by the infectious diseases of the early 20th century are quite distinct from the health challenges facing today’s ageing populations and the chronic diseases associated with late life. Can we enhance our biology to reduce the risks of frailty, disease and disability in late life? This is the Herculean task facing the medical sciences in the 21st century.

Substantive progress in the medical sciences, especially with respect to basic scientific research, relies on creative and imaginative modes of thinking which can often face resistance from established traditions and research paradigms. It is in the finessing of the ‘push and pull’ tension that can arise between maintaining a fidelity to the proven methods and assumptions of traditional knowledge and empirical insights, and a willingness to experiment with innovative ideas and methods, that progress is often made. Cautious optimism, coupled with experimentalism rather than foolhardiness or ‘status quo’ inertia, is the tenuous middle group that enables prudential change and evolution within the medical sciences. The 18th century conservative Edmund Burke captured this sentiment with his famous motto ‘At once to preserve and reform’.27

Imagination and idealism in the medical sciences must now transcend the aspirations of disease control. The sequencing of the genomes of long lived species and individuals, from the naked mole rat and bowhead whale to centenarians and supercentenarians (humans age ≥100 and age ≥110, respectively), coupled with experiments in manipulating the ageing process through caloric restriction and pharmacological interventions, reveals the potential for imagination and idealism in the medical sciences that transcends the paradigm of disease control. Improving the human healthspan versus simply aspiring to eliminate the specific diseases of ageing, could dramatically improve the quality of life for persons surviving into late life this century.

Alex Comfort was overly optimistic in his predictions about where science would take us during the latter part of the twentieth century. He made the following three predictions in 1969:

  1. That direct experiment on the delaying of ageing in Man is virtually certain to be in hand somewhere by 1975, using battery techniques, and probably at more than one centre.

  2. That if by good luck one of the currently fancied rodent techniques proves directly applicable, some agent colorably reducing the rate of human ageing is likely to be known within 15 years. (It would not be fully proven until most of the untreated controls had aged.)

  3. That the increase from such a technique could be as much as 20%, possibly more, and would be worth while if it were less. (There is, of course, a staircase effect here-the greater the success, the greater the further investment, from which the beneficiaries might in turn live to benefit: this is quite unforeseeable.)

These predictions did not come to fruition, at least not on the timescale Comfort had expected. But the medical sciences needs more of the imagination and idealism Comfort embodied. These creative epistemic virtues are necessary components of well-ordered science in the 21st century.

The health predicaments imposed by the inborn ageing process cannot be abated by the same imaginative aspirations which shaped the disease paradigm. The paradigm of rate control invites medical researchers to expand the scope of their enquiries beyond the proximate causation of disease, to better understand the evolutionary history of the biology of ageing, and the different ways in which the ageing process could be modulated to improve health in late life. The idealism of ‘healthy ageing’ holds the promise of developing a drug that retards the processes of senescence, thereby delaying and possibly compressing the infirmities and diseases of late life. Herter’s articulation of the plasticity of science offers hope that the paradigm of rate control can expand the imagination and idealism of the medical sciences beyond the confines of what disease control has offered.

There are signs that the myopic lens of the disease control paradigm is starting to lift, as some policy makers have become more cognisant of its limitations. For example, in 2021 a House of Lords ‘Science and Technology Select Committee’ UK report28 was released, the catalyst of which was a 2019 assessment of the feasibility of the Government’s Ageing Society Grand Challenge mission. Chapter 6 of this report is entitled ‘The Ageing Society Grand Challenge’ and it sets the goal of increasing healthy life expectancy by 5 years by 2035. The report acknowledges (p. 177) that there has been a lack of effort since the 2005 report to ensure priority is given to research into ageing versus research into specific age-related diseases. The report notes that this may have contributed to the poor translation of basic research into clinical trials or new medicine. The report recommends that UK Research and Innovation commit to funding further research into the biology of ageing as a priority to support studies to improve healthspan. This signals the type of plasticity of scientific innovation that Herter championed. Further momentum in the direction of realising the idealism of ‘healthy ageing’ might mean significant medical breakthroughs are realised in time for the 2 billion persons who will be age >60 by the year 2050.

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Footnotes

  • Contributors CF is the sole author of this submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.