Richard Smith: Whom to trust on old age—Matt Hancock or Cicero?

The Manifesto of the Conservative Party promised us all five more years of healthy life by 2035. At the launch of the strategy for healthier longer lives from the All Party Parliamentary Group for Longevity, Matt Hancock, the Secretary of State for Health, urged the audience to stop thinking of the growing proportion of elderly people in the population as a problem and recognise it as a boon, the result of success.

At the part of the meeting I attended nobody mentioned that life expectancy has stalled in Britain and even fallen among some groups. Nobody mentioned that most evidence does not support the much desired “compression of morbidity” (whereby people live long, healthy lives and fall quickly into death): instead, we seem to be spending longer periods in poor health and unable to live independently. Hancock did produce as evidence that the Conservative promise can be achieved the fact that people in some places already have healthy lives that are more than five years longer than people in other places. He talked about “places” rather than income and failed completely to acknowledge the intractability of the problem of difference in life expectancy between rich and poor.

At the age of 67 soon to be 68 (no presents, please) I’m interested in old age. When I was at medical school you were old at 60. Then it became 65 with the “old-old” beginning at 75. Am I old? I have a strange condition that I’ve called the Dorian Gray syndrome: “the central feature of the disease is the conviction–indeed, the knowledge–that you are the youngest person in the room when you are actually the oldest or one of the oldest.” But a week ago I ran the 5 km of the Park Run, did a personal best, came second (of two) in my age group, and have spent the past week hobbling rather than walking because of damage to my knee. “There’s no fool like an old fool,” my wife reminded me, urging me to stop running so far.

Even if I’m not old now I soon will be, and so I have turned not to Matt Hancock or the All Parliamentary Group for Longevity, but to Cicero for advice on old age. Cicero did not reach old age by today’s standards in that he was beheaded by Mark Anthony’s supporters at age 63. His head was exhibited in the Forum in Rome, and Fulvia, Mark Anthony’s wife, is said to have repeatedly stabbed his tongue with a hatpin in vengeance for his power of speech.

But I have no doubt that Cicero will give better advice on old age than Matt Hancock, and I suggest that his short Treatise on Old Age should be recommended reading to all medical students and doctors. Cicero agrees with Hancock that old age can be delightful: ”The arms best adapted to old age are culture and the active exercise of the virtues. For if they have been maintained at every period—if one has lived much as well as long—the harvest they produce is wonderful, not only because they never fail us even in our last days (though that in itself is supremely important), but also because the consciousness of a well-spent life and the recollection of many virtuous actions are exceedingly delightful.”

Cicero sees four reasons why, against Matt Hancock’s plea, people may see old age as miserable: “I find that there are four reasons for old age being thought unhappy: First, that it withdraws us from active employments; second, that it enfeebles the body; third, that it deprives us of nearly all physical pleasures; fourth, that it is the next step to death.” He then addresses each in turn.

There is no reason he suggests for the old to withdraw from active employment, and he might be impressed that three men close to 80 are competing to be the next president of the modern-day Rome, the United States. “The great affairs of life are not performed by physical strength, or activity, or nimbleness of body, but by deliberation, character, expression of opinion. Of these old age is not only not deprived, but, as a rule, has them in a greater degree.” (Some of the American electorate will, I suspect, disagree.)

Cicero is not in favour of retiring to the golf course.Old men [please read “men and women” for “men” throughout] retain their intellects well enough, if only they keep their minds active and fully employed. Nor is that the case only with men of high position and great office: it applies equally to private life and peaceful pursuits…. Is it not rather the case with all these that the active pursuit of study only ended with life?” Indeed, for the old Cicero writing his treatise was a great pleasure: “To myself, indeed, the composition of this book has been so delightful, that it has not only wiped away all the disagreeables of old age, but has even made it luxurious and delightful too.”

To guard against the enfeeblement of old age Cicero recommends that “Active exercise…and temperance can preserve some part of one’s former strength even in old age.” He is very modern in urging us to think of aging as illness or disease: “We must stand up against old age and make up for its drawbacks by taking pains. We must fight it as we should an illness. We must look after our health, use moderate exercise, take just enough food and drink to recruit, but not to overload, our strength. Nor is it the body alone that must be supported, but the intellect and soul much more. For they are like lamps: unless you feed them with oil, they too go out from old age.”

He advises study and continuing labours: “The man who is always living in the midst of these studies and labours does not perceive when old age creeps upon him. Thus, by slow and imperceptible degrees life draws to its end. There is no sudden breakage; it just slowly goes out.”

The third worry about old age, the waning of physical pleasures, Cicero sees positively because: “No more deadly curse than sensual pleasure has been inflicted on mankind by nature, to gratify which our wanton appetites are roused beyond all prudence or restraint. It is a fruitful source of treasons, revolutions, secret communications with the enemy. In fact, there is no crime, no evil deed, to which the appetite for sensual pleasures does not impel us. Fornications and adulteries, and every abomination of that kind, are brought about by the enticements of pleasure and by them alone….For pleasure hinders thought, is a foe to reason, and, so to speak, blinds the eyes of the mind.”

Cicero is thankful to old age, which has increased my avidity for conversation, while it has removed that for eating and drinking.” He doesn’t want wine, women [or men], song, and games, and wisely he observes “my contention is that not to want is the pleasanter thing.”

The final argument against old age is the closeness of death, but, observes Cicero, “who is such a fool as to feel certain—however young he may be—that he will be alive in the evening? Yes, you will say; but a young man expects to live long; an old man cannot expect to do so. Well, he is a fool to expect it. For what can be more foolish than to regard the uncertain as certain, the false as true?”

Death is a good thing not to be feared because it brings either oblivion or happiness among old friends. (He doesn’t mention hell, a concept brought to full power by Christianity.) “All things that accord with nature are to be counted as good. But what can be more in accordance with nature than for old men to die? Just as apples when unripe are torn from trees, but when ripe and mellow drop down, so it is violence that takes life from young men, ripeness from old. This ripeness is so delightful to me, that, as I approach nearer to death, I seem as it were to be sighting land, and to be coming to port at last after a long voyage.”

Cicero makes no reference to any condition like dementia, nor does he mention loneliness. Few lived long enough in his time to develop dementia, and the Mediterranean diet probably helped those who did live long enough. Loneliness was also unknown. Cicero concludes: “End of life is the best, when, without the intellect or senses being impaired, Nature herself takes to pieces her own handiwork which she also put together. Just as the builder of a ship or a house can break them up more easily than anyone else, so the nature that knit together the human frame can also best unfasten it.”

Matt Hancock made no mention of death in his speech—there are no votes in death. And scanning the All Parliamentary Group’s report I can find no mention of death. The chances of achieving five more healthy years for all by 2035 seem to me tiny, but what we can be sure of is that annual deaths will increase by some 30% by 2050—and, God willing, I will be one of them.

Richard Smith was the editor of The BMJ until 2004.