寿命预测技术使老人重新规划人生

THIS 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.

这个周末，歌手兼词曲创作者莱昂纳德·科恩点上一支香烟，庆祝他的80岁生日（9月21日——译注）。去年他宣布，自己打算一到80岁就恢复吸烟。“这是重新开始的好年纪，”他说。

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?

吸烟在任何年纪都是不明智的。吸烟者和那些吸二手烟的人都会出现健康问题，既有长期的，也有急性的，比如感染和哮喘等。但是科恩的计划提出了一个刺激的问题：我们什么时候可以把未来的人生抛到一边，全新享受当下的快乐？

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.

在20世纪伊始，美国只有0.5%的人口超过80岁。肺结核和脊髓灰质炎等传染性疾病在工业化国家发病率很高。骨质疏松等普通的老年疾病在当时甚至不被视为疾病。

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.

如今，美国3.6%的人口年过八旬，而我们的生活也被严格地规定了：不仅要注意避免某些行为，还要注意吃药。65岁以上的人之中，有一半人以上要吃五种乃至更多处方药、非处方药或膳食补充剂，其中很多并非用来治疗急性病，而是为了降低未来的发病率。中风、心脏病、心力衰竭、肾衰、髋关节骨折……这个名单很长，而且美国卫生和公众服务部计划到2025年实现预防阿兹海默症，这个名单还会变得更庞大。

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!”

在21世纪，衰老只与风险以及和它所带来的衰退有关。保险公司奖励客户常去健身，如果他们吸烟，就会惩罚他们。制药公司告诫医生们，就算他们给病人开了减少心脏病发病率的药，但仍然有“残余风险”——于是医生们就经常开出更多的药。一种健身产品的宣传词把握了这种时代精神：“健康就是财富！长寿万岁！”

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.

但是什么时候才能停止储蓄，花一点我们的本金？如果你觉得自己马上就要死掉，你可能会点上一支烟，停掉每天的阿司匹林、斯他汀和降压药。你可能就不会那么忧虑未来，而是多花点时间和金钱来享受当下的快乐，比如和朋友出去吃饭之类的。

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 for cholesterol 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.

预防措施也有可能过犹不及。美国预防工作组(Groups like the United States Preventive Services Task Force)等组织经常研究支持预防指导方案的证据，发现到了特定年龄，预防措施所带来的好处并不能抵消检查、外科手术和服药所带来的风险。比如说，最近美国心脏病学学院和美国心脏协会发布的胆固醇治疗指导手册把79岁作为上限，超过这个年龄就不必评估10年内心力衰竭、中风和心脏病发展及死亡的风险了。他们还建议，75岁以上、没有心脏病的人服用斯他汀可能并没有好处。但这不意味着所有人都应该听从这个建议。

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.

另外，75岁不就是新的65岁吗？在决定停止做某事的时候，年龄似乎是一个模糊的标准。80岁的科恩真的是80岁吗？在他75岁左右的时候还保持着严格的巡演计划，经常从台上跳下来。或许对于他来说，80岁重新开始抽烟还太年轻了。

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.

预测科学的进步可以为这些问题提供答案。加州大学旧金山分校和哈佛大学的医学研究者们开发了ePrognosis网站，它整理出19种风险计算法，可供老人计算自己在未来6个月到10年内的死亡率。ePrognosis的开发者说，较为脆弱的老年人想知道自己的预期年龄，以便规划自己的保健计划，同时做出财务选择，比如说花掉一些积蓄。

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.

更有革命性的是Sharecare公司开发的产品RealAge。我们当中有些人比实际年龄显老，有些人比实际年龄显得年轻，RealAge就是把这种感觉量化出来。它使用一种算法，通过生活习惯、服药数据等资料计算你“事实上”有多大年纪。

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.

类似网站可以成为方便的工具，向病人传播信息（以及市场信息）。但是复杂精算数据中包括了各种不确定性和局限性，病人最好还是同医生当面交流。

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.

我们成了一个过着量化生活的计划者之国。但是生活会积累各种互相冲突的风险。通过心脏病和癌症预防，我们的寿命更长了，但这同时也增加了丧失认知能力的风险，患者会完全丧失生活能力，必须由照顾他们的人去决定他们该活多长、该怎样活。生物伦理学家蒂娜·戴维斯(Dena Davis)说，目前正在发展的生物标记技术或许有一天可以预测出一个人是否会出现阿兹海默症的早期症状（比如通过PET扫描脑淀粉样蛋白），这或许会使一些人去规划自杀——或者至少是开始吸烟。

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.

我们的老龄文化是在走极端。你要么就保持健康，并且积极努力，建立自己的健康账户，要么你就死。然而，正当我们开始如科恩的歌中所唱：“在我们曾经嬉戏的地方受苦”，我们也想关注当下。我有很多老年病人，他们和他们的照顾者常常抱怨整天都在到处求医问药，国民健康访问调查(National Health Interview Survey)的数据提供了一个原因——在那些9年内死亡风险达到75%或以上的老年人中，有1/3到一半的人仍在接受对他们来说并不推荐的癌症筛查。

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.

我并不打算用香烟或结肠镜检查来庆祝我的80岁生日，我也不希望我的衰老体验会仅仅变成网上的精算数据。最近，我在一个社区团体内做了一次关于阿兹海默症的讲演。在问答环节，一个人大声说：“老年医疗保险为什么不付我们每周一次与朋友共进晚餐，再来两杯红酒的钱。”他的意思是责备我们不只是想要活着，还想幸福地活着，医药很重要，但并不是获得这种幸福的唯一手段。一项在社区和服务业内的全国调查表明，提高老年生活质量或许能帮助我们获取这种幸福。或许我们应该开始讨论“快乐项目”而不是“死亡项目”（Death Panels，美国民众对奥巴马医改不信任的代称——译注）了。