Developments in the realms of medical innovation and geriatric clinical intervention impact our understanding of the nature of late life, the possibilities for health in advanced age, medical decision making, and family responsibility in ways that could not have been predicted 15 years ago. This essay begins to map new forms of biomedicalization in the U.S. and to underscore their emergence in a new ethical field. We suggest that a new kind of ethical knowledge is emerging through "routine" clinical care, and we offer examples from the following interventions: cardiac procedures, kidney dialysis, and kidney transplant. This new ethical knowledge is characterized by the difficulty of saying "no" to life-extending interventions, regardless of age. We explore the intensification of the biomedicalization of old age through a discussion of three features of the new ethical field: (a) the ways in which routine medical care overshadows choice; (b) the transformation of the technological imperative to a moral imperative; and (c) the coupling of hope with the normalization and routinization of life-extending interventions. We argue that societal expectations about longevity and standard medical care come together today in a shifting ethics of normalcy, with unexplored socio-cultural ramifications.

Provider and patient practices together reveal how the standard use of medical procedures at ever older ages trumps patient-initiated decision making.

.eduSharon R. Kaufman is professor of medical anthropology at the University of California, San Francisco. Her recent research explores life extension, technologies of dying, and subjectification in an aging society. She is the author, most recently, of … And a Time to Die: How American Hospitals Shape the End of Life (Scribner, 2005). Contact information: Institute for Health and Aging, Box 0646, University of California, San Francisco, Abstract Increasingly, in the United States, lives are being extended at ever-older ages through the implementation of routine medical procedures such as renal dialysis. This paper discusses the lives and experiences of a number of individuals 70 years of age and older at two dialysis units in California. It considers what kind of life it is that is being sustained and prolonged in these units, the meanings of the time gained through (and lost to) dialysis for older people, and the relationship of "normal" life outside the units to an exceptional state on the inside that some patients see as notquite-life. Highlighting the unique dimensions of gerontological time on chronic life support, the article

With the trend toward an older, sicker dialysis population in the USA, discussions of ethical issues surrounding dialysis have shifted from concerns about access to and availability of the therapy, to growing unease about non-initiation and treatment discontinuation. Recent studies report treatment withdrawal as the leading cause of death among elderly dialysis patients. Yet, the actual activities that move patients toward stopping treatment often remain obscure, even to clinicians and patients themselves. This paper explores that paradox, drawing on anthropological research among patients over age 70, their families, and clinicians in two California renal dialysis units. It concludes that many older patients sacrifice a sense of choice about dialysis in the present to maintain "choice" as both value and possibility for the future. Yet, patients desire more information and communication, provided earlier in their illness, about prognosis, how long they can expect to be on dialysis, and what the impact of the treatment will be on their daily lives. That, with time, there is a transition to be made from dialysis as "treatment" to end of life care could be better explained and managed to alleviate patients' confusion and unneeded isolation.

Studies of end-of-life communication and care have emphasized physician-patient conversations, often to the exclusion of family members' discussions and interactions with providers, or with patients themselves. Relatively little is known therefore about families' experiences of end-of-life care in the hospital, or the concrete meanings and practices through which families conceive and define communication. Yet increasingly, family members are asked to serve as surrogates and thereby to participate in the facilitation of decisions for medical procedures and the withdrawal of treatments. It is thus worthwhile to consider their perceptions and involvement in hospitalization at the end of life. This paper offers a descriptive account of families' assessments of communication at life's end in the hospital--focusing in particular on their understandings of and conversations about prognosis and its implications. It reflects on the burdens of responsibility and regret posed to families by the ways communication is both conceived and evaded by different players in the hospital setting.