The Medicalization of Aging and Death

An Essay

A man turns fifty-five. He feels fine. He exercises, sleeps well, has energy. His wife suggests a checkup — it’s been a few years. Reasonable enough. He makes an appointment.

The doctor orders bloodwork. Standard panel. The results come back and the conversation shifts. His total cholesterol is 225. His fasting glucose is 108. His blood pressure reads 134/82. His PSA is 3.2. The doctor furrows her brow at the numbers on her screen.

He walked into the clinic healthy. He will walk out a patient.

Not because anything changed in his body between the waiting room and the exam room. Nothing happened to him. Something happened to the numbers — or rather, something happened years ago to the thresholds against which his numbers are measured. The definitions of disease were rewritten, and he was on the wrong side of every new line.

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Medicalized Motherhood: From First Pill to Permanent Patient documents 123 interventions across the reproductive timeline, tracing how the medical system captures women from their first birth control prescription through their postpartum year.¹ The cascade logic is consistent throughout: each intervention creates conditions requiring the next. The woman who enters the system healthy exits as a permanent patient.

Medicalized Motherhood: From First Pill to Permanent Patient

The same logic operates at the other end of life. The target is different — not a pregnant woman but an aging one, or an aging man. The entry point is different — not a prenatal appointment but a routine checkup. The interventions are different — not Pitocin and fetal monitors but statins and DEXA scans. But the architecture is identical: manufacture a problem from a number, prescribe a solution that creates new problems, treat those new problems with new prescriptions, and repeat until the person who walked in well is managing a pharmaceutical portfolio for the rest of their life.

The cascade runs in one direction. Toward dependency.

I. Manufacturing Patients

The most efficient way to create patients is to redefine disease.

In 1988, the first report of the National Cholesterol Education Program established that a total cholesterol level below 200 mg/dL was “desirable,” between 200 and 239 was “borderline high,” and above 240 was “high.”³ Subsequent revisions — in 1993 and again in 2001 — progressively expanded treatment eligibility and lowered intervention targets. The 2001 ATP III guidelines tripled the number of Americans with cholesterol levels classified as abnormal. The guideline panels that made these decisions included members with financial ties to the companies manufacturing statins.⁴ With each revision, millions of people shifted categories without a single person getting sicker. The disease didn’t expand. The definition did.

The pattern repeated with blood pressure. In 2017, the American College of Cardiology and the American Heart Association redefined hypertension from 140/90 mmHg to 130/80 mmHg. The revision converted 31 million additional Americans into hypertension patients in a single announcement.⁵ Their blood pressure hadn’t changed. A committee’s opinion had changed. The guidelines technically recommend lifestyle modification for most people in the 130-139 range — but guidelines don’t write prescriptions. Doctors with seven minutes per patient write prescriptions. The clinical infrastructure is built for pharmaceutical intervention, and a new diagnosis feeds that infrastructure regardless of what the guideline document says.

Then blood sugar. The threshold for pre-diabetes — a condition that did not exist as a clinical category until recently — is a fasting glucose of 100 mg/dL. The old threshold for impaired fasting glucose was 110. The American Diabetes Association lowered it in 2003, adding millions to the pre-diabetic rolls.⁶ Pre-diabetes is not diabetes. Many people classified as pre-diabetic will never develop diabetes. But the label creates patients: patients who are monitored, tested, counseled, and increasingly medicated with metformin for a number on a lab report, not for symptoms anyone is experiencing.

The bone density industry invented its own pre-disease. When DEXA scans became widely available in the 1990s, a WHO panel defined “osteopenia” — not osteoporosis, not a fracture, not pain, not disability, but a statistical category indicating bone density between 1 and 2.5 standard deviations below the mean of a thirty-year-old woman.⁷ The reference population matters: measuring a sixty-year-old woman against a thirty-year-old guarantees that most older women will fall short. Osteopenia is not a disease. It is a deviation from youth. But it became a diagnosis, and the diagnosis became a prescription — bisphosphonates like Fosamax, prescribed to millions of postmenopausal women for a number, not for a fracture.

The bisphosphonates themselves produce a grim irony. These drugs, prescribed to strengthen bones, are associated with osteonecrosis of the jaw — death of the jawbone — and atypical femur fractures, where the very bones they are supposed to protect break in unusual patterns under minimal stress.⁸ The treatment for a manufactured pre-disease creates real disease.

Each threshold revision follows the same playbook. A guideline panel meets. Its members have financial relationships with pharmaceutical companies that manufacture the drugs used to treat the condition being redefined. The panel lowers the threshold. Millions of people become patients. Prescriptions increase. Revenue increases. No one gets healthier.

The man at his checkup is caught in all of these nets simultaneously. His cholesterol of 225 exceeds the threshold established in 1988 and progressively tightened since. His blood pressure of 134/82 exceeds the post-2017 threshold. His fasting glucose of 108 exceeds the post-2003 threshold. Three numbers, three pharmaceutical interventions, three entry points into a cascade that will occupy him for the rest of his life. He walked in feeling fine. He leaves with three prescriptions and three follow-up appointments.

The transformation is complete. He is a patient now.

II. The Polypharmacy Cascade

One prescription is never one prescription.

The statin prescribed for his cholesterol begins working immediately — not primarily on his cardiovascular risk, which statins reduce by a smaller absolute margin than most people realize,⁹ but on his muscles. Statin-associated muscle symptoms affect between 7% and 29% of users, depending on the study and the definition used.¹⁰ The range is wide because the medical establishment has spent decades arguing about whether patients’ reported muscle pain is “real” — a debate that tells you something about how the system regards patient testimony.

He reports muscle aches at his next appointment. The ache is attributed to aging — not to the drug he started taking three months ago. Perhaps he’s referred to a rheumatologist. Perhaps he’s prescribed a pain medication. The statin stays.

The muscle pain reduces his activity. He walks less, exercises less, moves less. Reduced physical activity accelerates bone density loss. At his next screening — because he is now in the screening pipeline — his DEXA scan shows declining bone density. Osteopenia. A bisphosphonate is prescribed.

The blood pressure medication produces its own tributary cascade. ACE inhibitors cause a persistent dry cough in roughly 10-15% of patients.¹¹ The cough is evaluated — chest X-ray, possibly a pulmonary function test. When these come back normal, the cough is treated symptomatically or the ACE inhibitor is switched to an ARB, which may produce dizziness. The dizziness is a fall risk. A fall at sixty-five is not what it was at twenty-five. The fall risk is now documented, monitored, possibly medicated.

Metformin for his pre-diabetes may cause gastrointestinal distress — nausea, diarrhea, cramping — in up to 25% of patients.¹² The GI symptoms are addressed with additional medication or attributed to irritable bowel syndrome, which becomes its own diagnostic and treatment pathway.

The cascade arithmetic is straightforward. In the United States, the average adult over sixty-five takes five or more prescription medications.¹³ Each drug carries its own side-effect profile. Each side effect is a potential new diagnosis. Each new diagnosis is a potential new prescription. The term for this is polypharmacy, and it affects roughly 40% of older adults.¹⁴

The drug interaction problem compounds everything. A person taking five medications is navigating a web of pharmacological interactions that no clinical trial has ever studied in combination, because clinical trials test individual drugs against placebo in carefully selected populations that exclude the very comorbidities and co-medications that characterize real patients. The person taking a statin, an ACE inhibitor, metformin, a bisphosphonate, and a proton pump inhibitor for the reflux the other drugs gave her is a pharmacological experiment with no control group and no protocol.

When things go wrong — and they do, frequently, with adverse drug reactions accounting for roughly 4.5% of hospital admissions in older adults¹⁵ — the system’s diagnostic reflex is to identify a new condition rather than question whether an existing prescription is the cause. The dizziness that is a drug side effect becomes a vestibular disorder. The confusion that is a drug interaction becomes early cognitive decline. The fatigue that is a predictable consequence of pharmacological burden becomes depression. And depression gets its own prescription.

I have written extensively about statins and the cholesterol deception, about how a molecule essential for brain function, hormone production, and cell membrane integrity was transformed into a public enemy to justify the most profitable drug class in pharmaceutical history.¹⁶ I have written about the blood pressure paradigm, about diabetes diagnostics, about the PSA testing regime and its consequences. Each of these topics has its own evidence base, its own history of manufactured consensus, its own trail of harm. Brought together, they are not separate subjects. They are tributaries feeding the same river: the conversion of healthy older adults into permanent, polypharmacy-dependent patients.

The man who walked into his checkup feeling fine is now managing five medications, attending quarterly appointments, undergoing annual screenings, and experiencing symptoms he didn’t have before his first prescription. The system that created this situation will never identify itself as the cause. It will manage the consequences of its own interventions indefinitely, billing for each one.

III. The Screening Trap

The polypharmacy cascade converts a healthy person into a managed patient. Screening extends the net further — finding conditions that would never have caused symptoms, harm, or death, and treating them as if they will.

Prostate cancer screening through PSA testing is the clearest case. Richard Ablin, the scientist who discovered prostate-specific antigen in 1970, has called its widespread use for cancer screening “a hugely expensive public health disaster.”¹⁷ PSA is not specific to cancer. It is elevated by infection, benign prostatic enlargement, vigorous exercise, sexual activity. It is a nonspecific marker adopted as a cancer test because it could be measured cheaply and sold as vigilance.

The consequences are measurable. The U.S. Preventive Services Task Force estimated that for every 1,000 men aged 55 to 69 screened over 13 years, 1 to 2 deaths from prostate cancer are prevented. In that same group, 240 will receive false positives, and 100 will undergo biopsy, with complications including infection, bleeding, and pain. Between 20 and 50 will be diagnosed with cancers that would never have caused symptoms or death — overdiagnosis — and many of these men will undergo surgery or radiation that causes incontinence and impotence.¹⁸

The survival statistics conceal this harm through an artifact called lead-time bias. Screening detects cancers earlier, which automatically extends the measured “survival time” from diagnosis even if the person dies at exactly the same age they would have without detection. The five-year survival rate looks spectacular. The mortality rate barely moves. The illusion of lifesaving activity is sustained by the gap between these two numbers.

Mammography follows the same pattern. The Cochrane systematic review on mammography screening — first published in 2001, updated in 2013, and updated again with data through 2023 — found that the most reliable trials showed no statistically significant reduction in breast cancer mortality. For every 2,000 women screened over 10 years, one will have her life prolonged. Ten will be treated unnecessarily — subjected to surgery, radiation, or chemotherapy for cancers that would never have progressed. Over 200 will experience significant psychological distress from false-positive results requiring further investigation.¹⁹

These ratios — one saved for every ten treated unnecessarily, one saved for every two hundred frightened — are not presented to the people entering screening programs. The marketing says “early detection saves lives.” The evidence says early detection occasionally saves a life while damaging many others. The distinction between these two statements is the difference between informed consent and a sales pitch.

The cascade from a positive screening result is brutal in its momentum. An elevated PSA leads to biopsy. Biopsy leads to diagnosis. Diagnosis leads to treatment. At each stage, the patient is offered intervention and declining becomes progressively harder — psychologically, socially, legally. The man who refuses treatment for a diagnosed cancer, even a low-grade cancer that statistics say will never kill him, is going against medical advice, worrying his family, and carrying a label that will haunt every future medical interaction.

Colonoscopy, thyroid screening, full-body CT scans marketed directly to consumers, cardiac calcium scoring — the screening industry expands continually, each test justified by the possibility of finding something, each finding generating its own cascade regardless of clinical significance.

IV. The Capture of Death

The cascade that begins with a routine checkup at fifty-five ends, for many people, in an intensive care unit at eighty-two. The medicalization of aging does not stop at managing chronic conditions. It extends to the management of death itself — the final capture.

Dying used to happen at home. Within living memory, most people died surrounded by family, in their own beds, attended by people who knew them. The process was understood as natural, inevitable, and — within limits — manageable without professional intervention. It was not comfortable. It was not painless. But it was not medicalized.

Now roughly 60% of Americans die in hospitals or nursing facilities.²⁰ The percentage has declined somewhat in recent years, partly due to the hospice movement, but the institutional default remains powerful. The dying person is transferred from home to emergency department to hospital ward to ICU, each transfer adding interventions, each intervention adding billing codes.

The final weeks of life are among the most medically intensive — and most expensive — of the entire lifespan. Approximately 25% of Medicare spending occurs in the last year of life, with a substantial portion concentrated in the final months.²¹ ICU admissions in the last month of life remain common. Chemotherapy administered within two weeks of death — treatment that cannot extend life meaningfully and almost certainly worsens its quality — happens to a measurable percentage of cancer patients.²²

The system does not have a protocol for stopping. It has protocols for doing: intubating, resuscitating, monitoring, medicating, scanning, testing. Each protocol triggers the next. The patient who arrives at the emergency department is evaluated, admitted, treated. The treatment generates complications. The complications generate further treatment. The question “should we continue treating?” is structurally difficult to ask in an environment designed around the assumption that treatment is always the answer.

Families navigating this machinery face impossible decisions under impossible conditions. The ICU physician asks about “goals of care” — a conversation that should have happened months or years earlier, that should have been ongoing, that should have been supported by a healthcare system invested in honest communication about mortality. Instead, it happens at 2 AM in a fluorescent hallway while a ventilator breathes for someone who cannot speak for themselves.

Advance directives — documents specifying end-of-life preferences — exist and are recommended. Their limitations are considerable. They are frequently unavailable when needed. They are often vague enough to be interpreted in multiple directions. They are overridden, ignored, or reinterpreted under pressure. And they assume a level of prognostic precision that medicine does not possess. The person who wrote “no extraordinary measures” at sixty-five may not have imagined the specific scenario confronting their family at eighty-three, and the ambiguity becomes a site of conflict rather than clarity.

The hospice movement represents a genuine counter-current — an acknowledgment that dying people deserve comfort over intervention, that the goal of medicine shifts when cure is no longer possible. But hospice itself has been subject to the forces that capture everything in the medical system. The hospice industry in the United States has consolidated rapidly, with for-profit hospice chains now accounting for the majority of providers. Length-of-stay optimization, patient selection for profitability, and quality concerns have followed the money.²³

The deeper issue is cultural. A society that medicalizes aging — that treats every decline as a treatable condition, every symptom as a solvable problem, every lab value as a variable to be optimized — cannot easily accommodate the reality that bodies wear out and people die. The medicalization of aging creates the expectation that death is failure: a failure of treatment, a failure of vigilance, a failure that someone should be held accountable for. This expectation drives the machinery of terminal intervention. If death is failure, then everything must be tried to prevent it, regardless of cost or suffering.

The family that asks “are we doing everything possible?” is asking the question the system has trained them to ask. The answer is always yes — more drugs, more procedures, more monitoring, more intervention. The question nobody is trained to ask is “should we be doing less?”

V. The Full Arc

The medical system captures people at birth and holds them until death. Medicalized Motherhood documents the first capture — 123 interventions that convert a healthy pregnancy into a managed condition. This essay documents the last.

The man at his checkup is the woman at her prenatal appointment. The cascade logic is identical. The statin is the Pitocin. The threshold revision is the “failure to progress” diagnosis. The polypharmacy cascade is the intervention cascade that turns a normal labor into a cesarean. The hospice-industrial complex is the formula-industrial complex. Different products, same architecture, same direction of travel: toward dependency, away from trust in the body’s capacity to manage its own processes.

The cascade test from Medicalized Motherhood applies here without modification: Does this intervention create conditions requiring further intervention? The statin that causes muscle pain that reduces activity that accelerates bone loss that triggers bisphosphonates that cause jaw necrosis fails this test catastrophically. So does the PSA test that detects a cancer that would never kill you but leads to surgery that leaves you incontinent. So does the blood pressure medication that prevents a cardiac event you probably wouldn’t have had while causing a fall that fractures your hip.

The question is always: what comes next?

VI. The Horizon

Denis Rancourt observed that in the limit, aging and death are advanced as curable — “needing only more research.”² This is the ideological frontier of medicalized aging.

Silicon Valley has invested billions in longevity research, framing aging itself as a disease to be conquered. Calico (Alphabet/Google), Altos Labs (funded by Jeff Bezos and Yuri Milner), Unity Biotechnology, and dozens of other ventures pursue the elimination of senescence as an engineering problem.²⁴ The language is revealing: aging is a “bug” to be fixed, death is a “problem” to be solved, the human lifespan is a “limit” to be transcended.

This is the medicalization of aging taken to its logical conclusion. If cholesterol levels can be pathologized, if bone density can be pathologized, if blood pressure can be pathologized — why not aging itself? If every biomarker of aging is a medical condition, then aging is a medical condition. And if aging is a medical condition, then death is a treatment failure.

The practical consequences are already visible. The “anti-aging” supplement industry is worth billions, selling compounds with limited evidence to people who have been taught that aging is a disease rather than a process. Metformin is being trialled as an “anti-aging” drug — the same metformin prescribed for the pre-diabetes that was manufactured by lowering a threshold.²⁵ Rapamycin, an immunosuppressant, is being explored for life extension. Each compound promises to extend the pharmaceutical relationship beyond the management of individual conditions to the management of time itself.

The destination is a person who takes medications not because anything is wrong, but because being alive and aging is, under this framework, what’s wrong.

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The man at his checkup could walk out. He could ask the three questions that interrupt any cascade: What happens if we wait? What are the alternatives? Is this required, or recommended?

He could note that his cholesterol of 225 is a number, not a disease. That his blood pressure of 134/82 fluctuates throughout the day and was measured once, in a stressful environment, by a machine. That his fasting glucose of 108 might respond to dietary changes that no one will suggest because dietary counseling doesn’t generate pharmaceutical revenue. That his PSA of 3.2 is within a range that means almost nothing without context.

He could decline the prescriptions, request retesting in six months, make changes he controls — diet, movement, sleep, stress — and see what the numbers do without pharmaceutical intervention.

He could. Most don’t. The system is not designed for refusal. It is designed for compliance, calibrated by the careful adjustment of thresholds to ensure that nearly everyone, given enough time, qualifies as a patient. The routine checkup is the entry point. The polypharmacy cascade is the mechanism. The institutional management of death is the terminus.

The medical capture of birth and the medical capture of death are bookends of the same project: the transformation of human life into a managed condition. From the first prenatal appointment to the last ICU admission, the architecture is the same. Natural processes redefined as medical events. Interventions that create conditions requiring further intervention. A cascade that runs in one direction, for an entire lifetime, toward dependency.

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References

¹ Unbekoming, Medicalized Motherhood: From First Pill to Permanent Patient, Edition 1.0, 2026. Free download at unbekoming.substack.com.

² Denis Rancourt, comment on “The Five Walls,” Denis’s Substack, 2026.

Five Walls

³ National Cholesterol Education Program, Adult Treatment Panel I (1988). “Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.” Archives of Internal Medicine, 148(1), 36-69. See also: NCEP ATP III (2001), which tripled the number classified as abnormal. American Academy of Family Physicians (2002). “Cholesterol Treatment Guidelines Update.” American Family Physician, 65(5), 871-880.

⁴ Lenzer, J. (2004). “Majority of panelists on cholesterol guidelines have current or recent ties to drug industry.” BMJ, 328(7452), 8. See also: Abramson, J. and Wright, J.M. (2007). “Are lipid-lowering guidelines evidence-based?” The Lancet, 369(9557), 168-169.

⁵ Whelton, P.K. et al. (2018). “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.” Journal of the American College of Cardiology, 71(19), e127-e248. Muntner, P. et al. (2018). “Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline.” Circulation, 137(2), 109-118.

⁶ Genuth, S. et al. (2003). “Follow-up Report on the Diagnosis of Diabetes Mellitus.” Diabetes Care, 26(11), 3160-3167. American Diabetes Association (2003). “Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.” Diabetes Care, 26(Suppl 1), S5-S20.

⁷ Kanis, J.A. et al. (1994). “Assessment of fracture risk and its application to screening for postmenopausal osteoporosis.” WHO Technical Report Series 843. World Health Organization.

⁸ Shane, E. et al. (2014). “Atypical subtrochanteric and diaphyseal femoral fractures: Second report of a task force of the American Society for Bone and Mineral Research.” Journal of Bone and Mineral Research, 29(1), 1-23. Khan, A.A. et al. (2015). “Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus.” Journal of Bone and Mineral Research, 30(1), 3-23.

⁹ The absolute risk reduction for statins in primary prevention (people without existing heart disease) is approximately 1-2% over five years. See: Abramson, J.D. et al. (2013). “Should people at low risk of cardiovascular disease take a statin?” BMJ, 347, f6123. The relative risk reduction — the number typically presented — is much larger, illustrating how the same data can be framed to maximize perceived benefit.

¹⁰ Stroes, E.S. et al. (2015). “Statin-associated muscle symptoms: impact on statin therapy — European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management.” European Heart Journal, 36(17), 1012-1022.

¹¹ Dicpinigaitis, P.V. (2006). “Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines.” Chest, 129(1 Suppl), 169S-173S.

¹² McCreight, L.J. et al. (2016). “Metformin and the gastrointestinal tract.” Diabetologia, 59(3), 426-435.

¹³ Kantor, E.D. et al. (2015). “Trends in Prescription Drug Use Among Adults in the United States From 1999-2012.” JAMA, 314(17), 1818-1831.

¹⁴ Masnoon, N. et al. (2017). “What is polypharmacy? A systematic review of definitions.” BMC Geriatrics, 17(1), 230.

¹⁵ Oscanoa, T.J. et al. (2017). “Hospital admissions due to adverse drug reactions in the elderly. A meta-analysis.” European Journal of Clinical Pharmacology, 73(6), 759-770.

¹⁶ See relevant essays at unbekoming.substack.com.

¹⁷ Ablin, R.J. (2010). “The Great Prostate Mistake.” The New York Times, March 9, 2010.

¹⁸ U.S. Preventive Services Task Force (2018). “Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement.” JAMA, 319(18), 1901-1913.

¹⁹ Gøtzsche, P.C. and Jørgensen, K.J. (2013). “Screening for breast cancer with mammography.” Cochrane Database of Systematic Reviews, Issue 6. Updated 2024 with data through February 2023: Gøtzsche, P.C. et al., medRxiv preprint 2024.06.06.24308542. The updated review’s conclusions are consistent with the 2013 findings.

²⁰ Cross, S.H. and Warraich, H.J. (2019). “Changes in the Place of Death in the United States.” New England Journal of Medicine, 381(24), 2369-2370.

²¹ Riley, G.F. and Lubitz, J.D. (2010). “Long-term trends in Medicare payments in the last year of life.” Health Services Research, 45(2), 565-576.

²² Earle, C.C. et al. (2004). “Trends in the aggressiveness of cancer care near the end of life.” Journal of Clinical Oncology, 22(2), 315-321.

²³ U.S. Department of Health and Human Services, Office of Inspector General. Multiple reports on hospice quality and oversight concerns, 2018-2024.

²⁴ Campisi, J. et al. (2019). “From discoveries in ageing research to therapeutics for healthy ageing.” Nature, 571(7764), 183-192.

²⁵ Barzilai, N. et al. (2016). “Metformin as a Tool to Target Aging.” Cell Metabolism, 23(6), 1060-1065. The TAME (Targeting Aging with Metformin) trial, proposed in 2015, seeks FDA approval to treat aging itself as a medical indication.

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