壽命預測技術使老人重新規劃人生
賈森·卡拉威什 2014年10月24日打印
這個周末，歌手兼詞曲創作者萊昂納德·科恩點上一支香煙，慶祝他的80歲生日（9月21日——譯註）。去年他宣布，自己打算一到80歲就恢復吸煙。「這是重新開始的好年紀，」他說。
吸煙在任何年紀都是不明智的。吸煙者和那些吸二手煙的人都會出現健康問題，既有長期的，也有急性的，比如感染和哮喘等。但是科恩的計劃提出了一個刺激的問題：我們什麼時候可以把未來的人生拋到一邊，全新享受當下的快樂？
- 檢視大圖
Alfred Steffen/Corbis Outline萊昂納德·科恩，攝於1988年。去年他宣布自己打算一到80歲就重新開始吸煙。
在20世紀伊始，美國只有0.5%的人口超過80歲。肺結核和脊髓灰質炎等傳染性疾病在工業化國家發病率很高。骨質疏鬆等普通的老年疾病在當時甚至不被視為疾病。
如今，美國3.6%的人口年過八旬，而我們的生活也被嚴格地規定了：不僅要注意避免某些行為，還要注意吃藥。65歲以上的人之中，有一半人以上要吃五種乃至更多處方葯、非處方葯或膳食補充劑，其中很多並非用來治療急性病，而是為了降低未來的發病率。中風、心臟病、心力衰竭、腎衰、髖關節骨折……這個名單很長，而且美國衛生和公眾服務部計劃到2025年實現預防阿茲海默症，這個名單還會變得更龐大。
在21世紀，衰老只與風險以及和它所帶來的衰退有關。保險公司獎勵客戶常去健身，如果他們吸煙，就會懲罰他們。製藥公司告誡醫生們，就算他們給病人開了減少心臟病發病率的葯，但仍然有「殘餘風險」——於是醫生們就經常開出更多的葯。一種健身產品的宣傳詞把握了這種時代精神：「健康就是財富！長壽萬歲！」
但是什麼時候才能停止儲蓄，花一點我們的本金？如果你覺得自己馬上就要死掉，你可能會點上一支煙，停掉每天的阿司匹林、斯他汀和降壓藥。你可能就不會那麼憂慮未來，而是多花點時間和金錢來享受當下的快樂，比如和朋友出去吃飯之類的。
預防措施也有可能過猶不及。美國預防工作組(Groups like the United States Preventive Services Task Force)等組織經常研究支持預防指導方案的證據，發現到了特定年齡，預防措施所帶來的好處並不能抵消檢查、外科手術和服藥所帶來的風險。比如說，最近美國心臟病學學院和美國心臟協會發佈的膽固醇治療指導手冊把79歲作為上限，超過這個年齡就不必評估10年內心力衰竭、中風和心臟病發展及死亡的風險了。他們還建議，75歲以上、沒有心臟病的人服用斯他汀可能並沒有好處。但這不意味着所有人都應該聽從這個建議。
另外，75歲不就是新的65歲嗎？在決定停止做某事的時候，年齡似乎是一個模糊的標準。80歲的科恩真的是80歲嗎？在他75歲左右的時候還保持着嚴格的巡演計劃，經常從台上跳下來。或許對於他來說，80歲重新開始抽煙還太年輕了。
預測科學的進步可以為這些問題提供答案。加州大學舊金山分校和哈佛大學的醫學研究者們開發了ePrognosis網站，它整理出19種風險計算法，可供老人計算自己在未來6個月到10年內的死亡率。ePrognosis的開發者說，較為脆弱的老年人想知道自己的預期年齡，以便規劃自己的保健計劃，同時做出財務選擇，比如說花掉一些積蓄。
更有革命性的是Sharecare公司開發的產品RealAge。我們當中有些人比實際年齡顯老，有些人比實際年齡顯得年輕，RealAge就是把這種感覺量化出來。它使用一種算法，通過生活習慣、服藥數據等資料計算你「事實上」有多大年紀。
類似網站可以成為方便的工具，向病人傳播信息（以及市場信息）。但是複雜精算數據中包括了各種不確定性和局限性，病人最好還是同醫生當面交流。
我們成了一個過着量化生活的計劃者之國。但是生活會積累各種互相衝突的風險。通過心臟病和癌症預防，我們的壽命更長了，但這同時也增加了喪失認知能力的風險，患者會完全喪失生活能力，必須由照顧他們的人去決定他們該活多長、該怎樣活。生物倫理學家蒂娜·戴維斯(Dena Davis)說，目前正在發展的生物標記技術或許有一天可以預測出一個人是否會出現阿茲海默症的早期癥狀（比如通過PET掃描腦澱粉樣蛋白），這或許會使一些人去規劃自殺——或者至少是開始吸煙。
我們的老齡文化是在走極端。你要麼就保持健康，並且積極努力，建立自己的健康賬戶，要麼你就死。然而，正當我們開始如科恩的歌中所唱：「在我們曾經嬉戲的地方受苦」，我們也想關注當下。我有很多老年病人，他們和他們的照顧者常常抱怨整天都在到處求醫問葯，國民健康訪問調查(National Health Interview Survey)的數據提供了一個原因——在那些9年內死亡風險達到75%或以上的老年人中，有1/3到一半的人仍在接受對他們來說並不推薦的癌症篩查。
我並不打算用香煙或結腸鏡檢查來慶祝我的80歲生日，我也不希望我的衰老體驗會僅僅變成網上的精算數據。最近，我在一個社區團體內做了一次關於阿茲海默症的講演。在問答環節，一個人大聲說：「老年醫療保險為什麼不付我們每周一次與朋友共進晚餐，再來兩杯紅酒的錢。」他的意思是責備我們不只是想要活着，還想幸福地活着，醫藥很重要，但並不是獲得這種幸福的唯一手段。一項在社區和服務業內的全國調查表明，提高老年生活質量或許能幫助我們獲取這種幸福。或許我們應該開始討論「快樂項目」而不是「死亡項目」（Death Panels，美國民眾對奧巴馬醫改不信任的代稱——譯註）了。
賈森·卡拉威什(Jason Karlawish)是賓夕法尼亞大學醫學、醫學倫理學與健康政策學教授。
本文最初發表於2014年9月21日。
翻譯：董楠
Too Young to Die, Too Old to Worry
October 24, 2014THIS weekend, the singer and songwriter Leonard Cohen is celebrating his 80th birthday — with a cigarette. Last year he announced that he would resume smoking when he turned 80. “It’s the right age to recommence,” he explained.
At any age, taking up smoking is not sensible. Both the smoker and those who breathe his secondhand smoke can suffer not only long-term but acute health problems, including infections and asthma. And yet, Mr. Cohen’s plan presents a provocative question: When should we set aside a life lived for the future and, instead, embrace the pleasures of the present?
- 檢視大圖Alfred Steffen/Corbis OutlineLeonard Cohen, 1988. Last year he announced he would start smoking again when he turned 80.
At the start of the 20th century, only one-half of 1 percent of the United States population was over the age of 80. Industrialized nations were preoccupied with infectious diseases such as tuberculosis and polio. Many of the common diseases of aging, such as osteoporosis, were not even thought of as diseases.
Today, 3.6 percent of the population is over 80, and life is heavily prescribed not only with the behaviors we should avoid, but the medications we ought to take. More than half of adults age 65 and older are taking five or more prescription medications, over-the-counter medications or dietary supplements, many of them designed not to treat acute suffering, but instead, to reduce the chances of future suffering. Stroke, heart attacks, heart failure,kidney failure, hip fracture — the list is long, and with the United States Department of Health and Human Services’ plan to prevent Alzheimer’s disease by 2025, it grows ever more ambitious.
Aging in the 21st century is all about risk and its reduction. Insurers reward customers for regular attendance at a gym or punish them if they smoke. Physicians are warned by pharmaceutical companies that even after they have prescribed drugs to reduce their patients’ risk of heart disease, a “residual risk” remains — more drugs are often prescribed. One fitness product tagline captures the zeitgeist: “Your health account is your wealth account! Long live living long!”
But when is it time to stop saving and spend some of our principal? If you thought you were going to die soon, you just might light up, as well as stop taking your daily aspirin, statin and blood pressure pill. You would spend more time and money on present pleasures, like a dinner out with friends, than on future anxieties.
When it comes to prevention, there can be too much of a good thing. Groups like the United States Preventive Services Task Force regularly review the evidence that supports prevention guidelines, and find that after certain ages, the benefits of prevention are not worth the risks and hassles of testing, surgeries and medications. Recent guidelines forcholesterol treatment from the American College of Cardiology and the American Heart Association, for example, set 79 years as the upper limit for calculating the 10-year risk of developing or dying from heart attack, stroke or heart disease. They also suggest that, after 75, it may not be beneficial for a person without heart disease to start taking statins. But that doesn’t mean everyone follows this advice.
Besides, isn’t 75 the new 65? Age seems a blunt criterion to decide when to stop. Is Mr. Cohen at 80 really 80? In his mid-70s, he maintained a rigorous touring schedule, often skipping off the stage. Maybe 80 is too young for him to start smoking again.
Advances in the science of forecasting are held out as the answers to these questions. Physician researchers at the University of California, San Francisco, and at Harvard, have developed ePrognosis, a website that collates 19 risk calculators that an older adult can use to calculate her likelihood of dying in the next six months to 10 years. The developers of ePrognosis report that frail older adults want to know their life expectancy so they can not only plan their health care but also make financial choices, such as giving away some of their savings.
Even more revolutionary is RealAge, a product of Sharecare Inc. that has quantified our impression that as we age, some of us are really older, while others are younger than the count of their years. It uses an algorithm that assesses a variety of habits and medical data to calculate how old you “really” are.
Websites like these can be a convenient vehicle to disseminate information (and marketing materials) to patients. But complex actuarial data — including its uncertainties and limitations — is best conveyed during a face-to-face, doctor-patient conversation.
We are becoming a nation of planners living quantified lives. But life accumulates competing risks. By preventing heart disease and cancer, we live longer and so increase our risk of suffering cognitive losses so disabling that our caregivers then have to decide not just how, but how long, we will live. The bioethicist Dena Davis has argued that emerging biomarkers that may someday predict whether one is developing the earliest pathology of Alzheimer’s disease (like brain amyloid, measured with a PET scan) are an opportunity for people to schedule their suicide. Or at least start smoking.
Our culture of aging is one of extremes. You are either healthy and executing vigorous efforts to build your health account, or you are dying. And yet, as we start to “ache in the places where [we] used to play,” as one of Mr. Cohen’s songs puts it, we want to focus on the present. Many of my older patients and their caregivers complain that they spend their days going from one doctor visit to the next, and data from the National Health Interview Survey suggests one reason. Among older adults whose nine-year mortality risk is 75 percent or greater, from one-third to as many as one-half are still receiving cancer-screening tests that are no longer recommended.
I don’t plan to celebrate my 80th birthday with a cigarette or a colonoscopy, and I don’t want my aging experience reduced to an online, actuarial accounting exercise. I recently gave a talk about Alzheimer’s disease to a community group. During the question and answer session, one man exclaimed, “Why doesn’t Medicare pay us all to have dinner and two glasses of wine once a week with friends?” What he was getting at is that we desire not simply to pursue life, but happiness, and that medicine is important, but it’s not the only means to this happiness. A national investment in communities and services that improve the quality of our aging lives might help us to achieve this. Perhaps, instead of Death Panels, we can start talking about Pleasure Panels.
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