Aging Medicine. 2019;2:99–103. | 99wileyonlinelibrary.com/journal/agm2 Received:	5	March	2019 | Accepted:	17	March	2019 DOI: 10.1002/agm2.12061 C O M M E N T A R Y Ethical perspectives on advances in biogerontology Jean Woo1 | Dave Archard2 | Derrick Au3 | Sara Bergstresser4 | Alexandre Erler3,5 | Timothy Kwok1 | John Newman6 | Raymond Tong7 | Tom Walker2 1Department	of	Medicine	&	Therapeutics,	Faculty	of	Medicine,	Chinese	University	of	Hong	Kong,	Shatin,	Hong	Kong	SAR,	China 2School	of	History,	Anthropology,	Philosophy	and	Politics,	Queen's	University	Belfast,	Belfast,	UK 3CUHK	Centre	for	Bioethics,	Chinese	University	of	Hong	Kong,	Shatin,	Hong	Kong	SAR,	China 4Office	of	Medical	Education,	Faculty	of	Medicine,	Chinese	University	of	Hong	Kong,	Shatin,	Hong	Kong	SAR,	China 5Department	of	Philosophy,	Chinese	University	of	Hong	Kong,	Shatin,	Hong	Kong	SAR,	China 6Buck	Institute	for	Research	on	Aging,	Novato,	California,	USA 7Department	of	Biomedical	Engineering,	Chinese	University	of	Hong	Kong,	Shatin,	Hong	Kong	SAR,	China Correspondence Jean	Woo,	Department	of	Medicine	&	Therapeutics,	9/F	Lui	Che	Woo	Clinical	Sciences	Building,	Prince	of	Wales	Hospital,	Shatin,	Hong	Kong	SAR,	China. Email:	jeanwoowong@cuhk.edu.hk 1 | INTRODUC TION Worldwide	populations	are	aging	with	economic	development	as	a result of public health initiatives and advances in therapeutic discoveries. Since 1850, life expectancy has advanced by 1	year for every	four.1	Accompanying	this	change	is	the	rapid	development	of anti‐aging	science.	There	are	three	schools	of	thought	in	the	field	of aging science.	One	perspective is the life course approach,	which considers	that	aging	is	a	good	and	natural	process	to	be	embraced as	a	necessary	and	positive	aspect	of life,	where the	aim is to improve the quality of existing lifespan and "compress" morbidity. Another	view	is	that	aging	is	undesirable,	and	that	rejuvenation	and indeed	immortality	are	possible	since	the	biological	basis	of	aging	is understood, and therefore, strategies are	possible for engineering negligible	senescence.	Finally,	a	hybrid	approach	is	that	life	span	can be	extended	by	anti‐aging	medicines	but	with	uncertain	effects	on health.	While	these	advances	offer	much	promise, the	ethical	perspectives are seldom discussed in cross‐disciplinary settings. This article	discusses	some	of	the	key	ethical issues	arising	from	recent advances	in	biogerontology. 2 | ADVANCES IN GEROSCIENCE The	biological	basis	of	aging	is	increasingly	understood,	and	myriad ways of altering aging are now known.	One cause of aging is the accumulation of molecular damage, such as DNA mutations and misfolded	proteins.	Damage	can	further	lead	to	"meta‐effects,"	such as	the	emergence	of	senescent	cells	or	dysfunctional	mitochondria, which	contribute to	a feedback loop	of	damage	and	dysfunction.2 These	deleterious	causes	of	aging	are	offset	by	endogenous	repair and rejuvenation pathways,	many of	which are linked to nutrition and	metabolism.	Dozens	of	genetic,	pharmacological,	and	other	interventions	can	slow	aging	in	the	laboratory,	in	species	ranging	from yeast	to	non‐human	primates.	Two	major	classes	of	interventions	are currently	entering	human	clinical	trials.	One	class	activates	nutrient signaling	pathways	to	turn	on	endogenous	repair	and	rejuvenation pathways.	The	other	class	targets	deleterious	meta‐effects	of	aging, such	as	senescent	cells	or	stem	cell	dysfunction.	Metformin	is	a	diabetes	drug	that	appears	to	activate	aging‐related	nutrient	signaling pathways.3	A	large	randomized	controlled	trial	to	test	if	metformin can	delay	age‐related	multimorbidity	is	being	planned	in	the	United States. Inhibitors	of	the	protein‐sensing	TOR	complex	can	activate protein	repair	pathways	and	extend	lifespan	in	the	laboratory,4 and a	clinical	trial	recently	showed	that	TOR	inhibitors	can	prevent	respiratory	infections	in	vulnerable	elderly	patients.5	Drugs	that	restore the	metabolic	signaling	molecule	NAD6	and	activate	NAD‐dependent sirtuin	enzymes	are	also	under investigation.7,8	Eliminating	senescent	cells	extends	healthy	lifespan	in	the	laboratory	by	reducing damaging	inflammation,9,10	and	a	number	of	drugs	to	target	senescent	cells	are	entering	clinical	trials.11	Stem	cells	can	be	rejuvenated in the laboratory with factors derived from young blood,12 or by This	is	an	open	access	article	under	the	terms	of	the	Creative	Commons	Attribution‐NonCommercial‐NoDerivs	License,	which	permits	use	and	distribution	in any	medium,	provided	the	original	work	is	properly	cited,	the	use	is	non‐commercial	and	no	modifications	or	adaptations	are	made. ©	2019	The	Authors.	Aging Medicine	published	by	Beijing	Hospital	and	John	Wiley	&	Sons	Australia,	Ltd. 100 | direct	infusion	of	healthy	stem	cells.	Both	approaches	are	now	being studied	in	clinical	trials	to	treat	physical	frailty13	and	dementia.14 In the	future,	direct	genome	editing	could	be	used	to	treat	aging.15	An international consortium is working to move anti‐aging therapies more	rapidly	into	clinical	trials.16 3 | TECHNOLOGIC AL ADVANCES If	maintenance of function rather than life extension is a key desirable	outcome	during the	aging	process, then technology	has	an important	role	in	achieving	this	goal	in	the	presence	of	physical	disabilities	as	well	as	cognitive	function	impairments. Stroke is a commonly encountered	disease that increases	with age	and	is	a	major	contributor	to	disability	burden.	Advances	in	technology‐assisted	rehabilitation	are	developing	rapidly in	augmenting neuroplasticity	during	the	recovery	period	through	the	use	of	exoskeleton robotics. Robotics are also being used for surgical procedures to improve accuracy, and to a smaller extent, service and companion	robots	are	being	developed	and	adopted	in	care	of	older people	with	physical	and	cognitive	impairments.	Artificial	intelligence is	being	applied	to	diagnosis	and	treatment	using	algorithms.	Another rapidly	developing	field	involves	surveillance	of	older	people	in	hospitals	or	residential	care	settings,	as	well	as	at	home,	to	prevent	adverse	outcomes,	such	as	falls,	accidents,	acute	medical	conditions	for which	older	people	may	have	reduced	ability	to	call	for	help,	and	also for	health	maintenance (monitoring	of	drug	compliance,	vital	signs, activity	patterns).	Older	adults	are	not	always	involved	in	the	development	or	deployment	of	these	systems.	For	both	biogerontological research	and	gerotechnological	developments,	other	than	addressing	the	scientific	question,	the	needs	of	older	people	should	also	be	a driver	and	hence	older	people's	input	is	desirable. 4 | ETHIC AL PERSPEC TIVES 4.1 | Is aging a disease? It is commonly	assumed, in the	debate	on the	ethics	of anti‐aging research,	that	the	question	of	whether	aging	is	a	disease	or	not	carries high normative significance. For instance, some people hold that	if	(and	only	if)	aging	is	a	disease,	then	it	is	an	appropriate	target for	medical intervention;	otherwise it is	not.	On	a	more	pragmatic note,	it	seems	clear	that	being	able	to	label	aging	as	a	disease	would facilitate	access	to	research	funding, the initiation	of	clinical trials, and	potential	coverage	of	future	anti‐aging	interventions	by	medical insurance. The	question	of	whether	aging	is	a	disease	or	not	depends	on how	we	should	understand	disease	and	health,	which	is	a	contentious issue in the philosophy of medicine. One approach holds that	disease	is	a	departure	from	"normal"	human	functioning,	and that	if	a	condition	is	universal	and	the	result	of	internal	biological processes,	it	cannot	be	abnormal.17	Since	all	humans	age,	this	approach	implies	that	aging	itself	is	not	abnormal,	and	therefore	not a	disease.	On	a	different,	conflicting	approach,	any	condition	that demonstrates	sufficient	structural	similarity	with	paradigm	examples	of	disease	should	itself	be	regarded	as	a	disease,	even	if	it	is universally	shared.	Some	authors	have	argued	that	this	description applies	to	aging.18 When it comes to establishing the	medical legitimacy of anti‐ aging interventions, it might be possible to sidestep that difficult issue by considering the fact that a medical, preventive rationale can	be	offered	for	slowing	down	(or,	if	at	all	possible,	reversing)	the aging	process,	regardless	of	its	status	as	a	disease.	Indeed,	a	growing number	of	biogerontologists	are	suggesting	that	doing	so	might	help delay,	if	not	prevent	completely,	the	advent	of	diseases	like	cancer, Alzheimer's,	or	cardiovascular	disease.	That	being	said,	the	existence of	such	a	medical	rationale	does	not	automatically	put	an	end	to	the ethical	debate	about	the	overall	permissibility	of	this	kind	of intervention:	at	least	in	principle,	it	could	be	overridden	by	countervailing considerations.	Neither	does	it	show	that	the	question	of	the	status of	aging	as	a	disease	can	be	avoided	completely,	if	only	because	of the	significant	practical implications	of the	answer that	we	collectively	decide	to	give	to	that	question,	as	mentioned	previously. Still,	it	would	seem	that	the	preventive	rationale	for	anti‐aging	medicine	is	not	always	sufficiently	taken	into	account	in	the	ethical	debate. The	onus	is	on	those	who	oppose	intervening	in	the	aging	process	to offer	an	explanation	as	to	why	the	putative	undesirability	of	doing	so outweighs	the	preventive	rationale	for	intervention.	Without	prejudging	whether	they	can	succeed,	one	can	at	least	note	that	it	is	important for	them	not	to	confuse	the	effects	of	biological and chronological aging. Of	course,	the	same	point	applies	to	those	who	support	anti‐aging	research:	They	must	take	care	not	to	overestimate	the	potential	impact of	such	research	on	the	diseases	of	the	elderly-on	this,	it	is	primarily scientific	experts	who	can	provide	the	needed	reality	check.19 4.2 | Life extension, justice, and equity Modern	medical science could give humans an extended lifespan, increased	life	expectancy	at	birth,	and	a	compression	of	morbidity	in late	life.	Would	this	be	desirable?	An	extended	life	is	not	(yet)	the	immortality	that	has	been	viewed	by	some	philosophers	(e.g.,	Bernard Williams)	as	undesirable	for	being	intolerably	"boring"	and	as	undermining	the	conditions	of	continued	identity.20 Reasons	for	and	against	extending life	may	be	divided into	the personal	and	external.	The	latter include	the	increased	costs	of	an older	population.	But it is	not	clear	that	this is	problematic if	morbidity is	compressed.	Moreover, longer lives increase	the	temporal discounting	of	costs,	as	well	as	the	number	of	productive	years. It is also	not	evident that	extended lives	mean that the	young would	unfairly	subsidize	the	old	if	we	adopt	a	whole‐life	perspective and	think	in	terms	of	turn‐taking. Longer lives	might, of course,	mean	more lives and thus raise population	ethics	issues.	Yet	the	evidence	here	is	unclear.	Moreover, the	extensions	envisaged	by	geroscience	need	not	be	dramatic;	and the	problematic	pressure	on	global	resources	is	a	broader	one	than that	of	prolonging	human	lives. | 101COMMENTARY It	would	not	be	ethically	problematic	to	control	reproduction	and thereby	balance	a	right	to	a	longer	life	against	a	right	to	procreate. Personal	reasons	to	want	more	life	are	for	more	of	what	life	offers.	Such	reasons	for	longer	life	should	be	clearly	distinguished	from impersonal	reasons	for	longer	life.	Whether	everyone	has	such	reasons	is	doubtful.	If	Williams	is	right	that	longer	life	will	be	intolerably boring	and	undermine	the	conditions	of	continued	identity,	after	a certain	age	(which	might	differ	from	person	to	person)	they	will	not. Concerns	are likely to	be raised	about justice	when	considering	any	interventions	to	extend	life.	One	source	of	such	concerns centers on the ease	with	which	people can access the results of biogerontological	research.	Where	doing	so	is	expensive,	it	is	likely that	the	beneficiaries	will	primarily	be	those	who	are	already	better off-resulting	in	longer	lives	for	the	rich	alone.	But	even	with	equal access,	concerns	about	the	justice	of	biogerontological	research	remain.	This	is	because	differences	in	adult	life	expectancy,	tracking socioeconomic	status,	already	exist	in	all	societies.	In	general,	the rich	live	longer	lives,	on	average,	than	the	poor-something	that	can largely	be	explained	by	social	and	environmental	factors.21,22 While work	in	biogerontology	does	not	directly	address	those	factors,	it has the potential to either reduce or exacerbate their impact. In doing	so	it	can	either	increase	or	decrease	health	inequality. However, inequality is	also inherently	human.	Some	people	on reaching	an	advanced	age	feel	as	though	they	have	already	lived	life to	its	fullest,	and	do	not	feel	the	need	to	extend	it	further.	It	may	or may	not	be that	what life	has to	offer them is	not	something that they	care	to	extend.	The	structural	conditions	of	their	lived	lives	may already	have	been	patterned	by	social	inequality	at	a	very	basic	level. For this reason, assessing the ethical acceptability of work in biogerontology requires taking	account	of its impact	on	both individuals	and	society.	Doing	so	is	not	easy.	It	requires	answering	three questions. First,	what are the	overall benefits, and	how	will those benefits	be	distributed?	Second,	what is	the likely	effect	on	health inequality,	and	would	alternative	ways	of	using	resources	affect	inequality	differently?	Third,	how	should	we	balance	increases	in	wellbeing against increases in inequality	where these occur? The first two	questions	are	empirical.	The	answers	will	depend	not	only	on	the nature	of	the	research.	They	will	also	depend	on	the	social	structures and	makeup	of	each	society.	That is	because	how	new	treatments and	interventions	affect	health	inequality	is	likely	to	vary	with	existing	levels	of	inequality,	and	systems	of	governance	and	welfare	provision.	The	final	question	is	normative	and	requires	an	assessment	of how	different	values	should	be	balanced	where	they	come	into	conflict.23-26	Answering	these	questions	cannot	be	done	in	the	abstract, and	for	each	case	will	require	a	multidisciplinary	approach	that	brings together	scientists,	economists,	political	scientists,	and	ethicists.27 4.3 | The good and the bad (misapplications) Research and	development in the field of anti‐aging	medicine	has fueled a multi‐ billion dollar industry in the past decade,28 with the largest proportion spent on integration of large omics datasets to find patterns in age‐related diseases and the therapy of neurodegenerative	diseases.	While	there	are	robust	guidelines	regulating	clinical	research	in	humans	in	the	form	of	clinical	research	ethics	committees,	the	regulation	of	unjustified	and	misleading	claims about	anti‐aging	products	together	with	unethical	clinical	practices is problematic. Aggressive	marketing and	misleading claims in the pursuit	of	profit	are	not	uncommonly	encountered.	This	industry	is fueled	by	a	universal	desire (albeit	subconscious)	to	remain	young, as	well	as	the	attraction	of	taking	a	product	(medicines,	hormones, dietary	supplements) instead	of	changing	behavior to lead	healthy lifestyles,	even	though	there	is	ample	evidence	of	the	health	benefits of	the	latter.	The	recent	case	of	gene	editing	of	an	implanted	human embryo in	a	private facility illustrates	how	regulatory	mechanisms have	failed	to	keep	pace	with	activities	in	these	fields,	even	though there	have	been	widespread	discussions	on	the	ethical	perspectives of gene editing, where there remains uncertainty regarding long term	side‐effects	of	irreversibly	altering	the	human	germ	cell	line.29 4.4 | Issues relating to artificial intelligence and robotics Various	ethical issues	need to	be flagged	up relating to the	above developments. The use of robotic surgical techniques needs to be regularly audited to evaluate performance and complications. Similar data are needed for service and companion/social robots. Widespread use	will depend on cost‐benefit analyses,	which	may guide governments to decide on financing, and this	will raise debates	regarding	prioritization	in	health	care	and	issues	of	justice,	as discussed above. Promising use of artificial intelligence and deep learning	with	big	datasets	from	other	industries	is	being	introduced to	health	care	with	the	availability	of	healthcare	informatics	and	evidence‐based	medicine.	Although	this	is	predominantly	led	by	commercial	companies,	many	clinicians	and	data	scientists	are	beginning to	work	together	to	determine	how	this	may	impact	on	clinical	practice.	Algorithms	in	diagnosis	and	management	are	determined	by	clinicians	based	on	the	latest	evidence.	The	latter	changes	with	time, and	also	there	are	many	clinical	scenarios	for	which	evidence	based on	randomized	controlled	trials is	not	available,	particularly	among frail	elderly	populations,	women,	and	people	of	various	ethnicities who	tend	not	to	be	included	or	are	included	in	inadequate	numbers to	reach	a	definite	conclusion.	There	are	also issues	with	potential misuse	of	patient	data	and	the	legal	framework	if	there	are	adverse outcomes.	Nevertheless,	machine	learning	would	facilitate	diagnosis and	prognosis	as	an	aid	to	doctors	to	manage	increasing	complexity; yet	the	"human"	attributes	of	a	doctor‐patient	relationship	that	distinguishes	a	good	doctor	would	be	difficult	to	replace.30-32 4.5 | Ethics and policies Ethical	recommendations	as	to	what	is	permissible,	obligatory,	or	impermissible	are	clearly	distinct	from	proposals	to	make	a law	or	to institute	a	policy.	What	is	needed	for	proposals	of	this	latter	kind	is	a sense	both	of	what	is	defensible	and	of	what	is	feasible	given	existing laws,	institutions,	and	practices,	as	well	as	public	opinion. 102 | Changes	in	law	and	policy	can	and	should	best	be	made	by	organizations	that	are	sensitive	to	social	and	political	realities,	well	connected	to	policy‐makers,	and	able	to	engage	in	objective	evaluation of	issues.	The	Nuffield	Council	on	Bioethics	is	such	an	organization.	It is	an	independent	body	within	the	United	Kingdom	that	examines	and reports	on	ethical	issues	in	biology	and	medicine.	It	was	established by	the	Trustees	of	the	Nuffield	Foundation	in	1991,	and	since	1994	it has	been	funded	jointly	by	the	Foundation,	the	Wellcome	Trust,	and the	Medical	Research	Council.	The	Council	has	achieved	an	international	reputation	for	advising	policy‐makers	and	stimulating	debate in	bioethics.	It	functions	very	much	as	the	United	Kingdom's	national bioethics	committee.	Its	terms	of	reference	are:	to	identify	and	define ethical questions raised by recent developments in biological and	medical	research	that	concern,	or	are	likely	to	concern,	the	public interest;	to	make	arrangements	for	the	independent	examination	of such	questions	with	appropriate	involvement	of	relevant	stakeholders;	to	inform	and	engage	in	policy	and	media	debates	about	those ethical	questions	and	provide	informed	comment	on	emerging	issues related	to	or	derived	from	the	Council's	published	or	ongoing	work; and	to	make	policy	recommendations	to	government	or	other	relevant	bodies	and	to	disseminate	its	work	through	published	reports, briefings,	and	other	appropriate	outputs.	Many	changes in law	and policy	within	the	United	Kingdom-such	as	the	legislation	to	permit mitochondrial	replacement	treatment-can	be	attributed	to	the	work of	the	Council.	Recommendations	within	Council	reports	may	also	be adopted	by	professional	bodies.	Its	horizon‐scanning	activities	allow it	to	identify	those	topics,	arising	from	new	developments,	that	might fall	within	this	remit.	It	is	for	the	Council	then	to	decide	on	whether to	engage	in	work	on	any	particular	topic.	This	work	could	take	the form	of a	major report or only the	preparation	of a short briefing note	that	can	provide	policy‐makers	and	relevant	stakeholders	with a	clear	sense	of	the	scope	of	the	topic	and	of	the	relevant	social,	ethical,	and	legal	issues.	The	Council	has	already	produced	an	eight‐page briefing	note	on	"The	search	for	a	treatment	for	aging."33	Should	circumstances	or	developments	make	it	important	to	produce	a	longer report,	the	Council	would	be	able	to	do	so. 5 | CONCLUSION Scientists, gerontologists/geriatricians, economists, engineers, bioethicists,	and	politicians	should	take	a	truly	cross‐disciplinary	comprehensive	approach,	with	formation	of	regulatory	bodies	accountable	to	governments,	and	development	of	mechanisms	for	monitoring. Current	clinical	research	ethics	committees	may	need	to	be	expanded to link	with	government regulatory	bodies.	The	exact requirements will	likely	depend	on	variations	in	development	in	this	area	in	different countries;	there	would	be	an	advantage	to	the	formation	of	a	transnational	organization	following	the	principles	of	the	Nuffield	Council. CONFLIC T OF INTERE S T The	authors	declare	that	they	have	no	competing	interests. ORCID Jean Woo https://orcid.org/0000‐0001‐7593‐3081 R E FE R E N C E S 1. Christensen	K,	Doblhammer	G,	Rau	R,	Vaupel	JW.	Ageing	populations:	the	challenges	ahead.	Lancet.	2009;374(9696):1196‐1208. 2. Kennedy	BK,	Berger	SL,	Brunet	A,	et	al.	Geroscience:	linking	aging to	chronic	disease.	Cell.	2014;159(4):709‐713. 3. Barzilai	N,	Crandall	JP,	Kritchevsky	SB,	Espeland	MA.	Metformin	as a	tool	to	target	aging.	Cell Metab.	2016;23(6):1060‐1065. 4. Harrison DE, Strong R, Sharp ZD, et al. Rapamycin fed late in life extends lifespan in genetically heterogeneous mice. Nature. 2009;460(7253):392‐395. 5. Mannick	JB,	Morris	M,	Hockey	HP,	et	al.	TORC1	inhibition	enhances immune function and reduces infections in the elderly.	Sci Transl Med.	2018;10(449):eaaq1564. 6. Tarrago	MG,	Chini	CCS,	Kanamori	KS,	et	al.	A	potent	and	specific CD38 inhibitor ameliorates age‐related	metabolic dysfunction	by reversing	tissue	NAD(+)	decline.	Cell Metab.	2018;27(5):1081‐1095. 7. Yoshino	J,	Baur	JA,	Imai	SI.	NAD(+)	intermediates:	the	biology	and	therapeutic	potential	of	NMN	and	NR.	Cell Metab.	2018;27(3):513‐528. 8. Verdin E. NAD(+) in aging, metabolism, and neurodegeneration. Science.	2015;350(6265):1208‐1213. 9. Baker DJ, Childs BG, Durik M, et al. Naturally occurring p16(Ink4a)‐positive cells shorten healthy lifespan. Nature. 2016; 530(7589):184‐189. 10. Xu M, Pirtskhalava T, Farr JN, et al. Senolytics improve physical function and increase lifespan in old age. Nat Med. 2018; 24(8):1246‐1256. 11. Kirkland JL, Tchkonia T, Zhu Y, Niedernhofer LJ, Robbins PD. The clinical potential of senolytic drugs. J Am Geriatr Soc. 2017; 65(10):2297‐2301. 12. Villeda	SA,	Plambeck	KE,	Middeldorp	J,	et	al.	Young	blood	reverses age‐related impairments in cognitive function and synaptic plasticity	in	mice.	Nat Med.	2014;20(6):659‐663. 13. Tompkins	BA,	DiFede	DL,	Khan	A,	et	al.	Allogeneic	mesenchymal stem	cells	ameliorate	aging	frailty:	a	phase	II	randomized,	double‐ blind,	placebo‐controlled	clinical	trial.	J Gerontol A Biol Sci Med Sci. 2017;72(11):1513‐1522. 14. Sha	SJ,	Deutsch	GK,	Tian	L,	et	al.	Safety,	tolerability,	and	feasibility	of young	plasma	infusion	in	the	plasma	for	Alzheimer	symptom	amelioration	study:	a	randomized	clinical	trial.	JAMA Neurol.	2019;76(1):35‐40. 15. Lau CH, Suh Y. Genome and epigenome editing in mechanistic studies of human aging and aging‐related disease. Gerontology. 2017;63(2):103‐117. 16. Newman	JC,	Milman	S,	Hashmi	SK,	et	al.	Strategies	and	challenges in	clinical	trials	targeting	human	aging.	J Gerontol A Biol Sci Med Sci. 2016;71(11):1424‐1434. 17. Boorse	C.	Health as a theoretical concept.	Philos Sci. 1977;44(4): 542‐573. 18. Izaks GJ, Westendorp RG. Ill or just old? Towards a conceptual framework	of	the	relation	between	ageing	and	disease.	BMC Geriatr. 2003;3:7. 19. Mykytyn	CE.	Medicalizing	the	optimal:	anti‐aging	medicine	and	the quandary	of	intervention.	J Aging Stud.	2008;22(4):313‐321. 20. Williams B. The Makropulos case: reflections on the tedium of immortality. In: Williams B, ed. Problems of the Self. Cambridge, England:	Cambridge	University	Press;	2009:82‐100. 21. Commission	on	Social	Determinants	of	Health.	Closing	the	gap	in	a generation:	health	equity	through	action	on	the	social	determinants of	health.	Final	Report	of	the	Commission	on	Social	Determinants of	Health.	Geneva,	Switzerland:	World	Health	Organization;	2008. | 103COMMENTARY 22. Marmot	M,	Wilkinson	R,	eds.	Soical Determinants of Health,	2nd	edn. Oxford,	England:	Oxford	University	Press;	2005. 23. Gaus	G.	The Order of Public Reason: A Theory of Morality and Freedom in a Diverse and Bonded World. Cambridge, England: Cambridge University	Press;	2012. 24. Norman D. Just Health ‐ Meeting Health Needs Fairly. Cambridge, England:	Cambridge	University	Press;	2008. 25. Rawls J.	A Theory of Justice. Cambridge,	MA:	Harvard University Press;	1971. 26. Ruger JP. Health and Social Justice. Oxford, England: Oxford University	Press;	2009. 27. Vaiserman A, Lushchak O. Implementation of longevity‐promoting supplements	and	medications	in	public	health	practice:	achievements, challenges	and	future	perspectives.	J Transl Med.	2017;15(1):160. 28. de	Magalhaes JP, Stevens	M, Thornton D. The business of anti‐ aging	science.	Trends Biotechnol.	2017;35(11):1062‐1073. 29. Cyranoski	D,	Ledford	H.	Genome‐edited	baby	claim	provokes	international	outcry.	Nature.	2018;563(7733):607‐608. 30. Obermeyer Z, Emanuel EJ. Predicting the future ‐ big data, machine learning, and clinical	medicine.	N Engl J Med. 2016;375(13): 1216-1219. 31. Char DS, Shah NH, Magnus D. Implementing machine learning in health care ‐ addressing ethical challenges.	N Engl J Med. 2018;378(11):981‐983. 32. Lancet	The.	Artificial	intelligence	in	health	care	within	touching	distance.	Lancet.	2017;390(10114):2739. 33. Bioethics Briefing Note. The Search for a Treatment for Ageing. London,	England:	Nuffield	Council	on	Bioethics;	2018.