The Moral State We’re In

Ultimately, this is a book about who belongs to our society and how we regard them. It is about insiders and outsiders, the trusted and the distrusted. If we recognize mutual obligations, how far does that mutuality extend? Who is ‘us’, and to whom can we legitimately say we have no obligation? If we only look to ourselves, we narrow our field of vision and in the end become automata: selfish, self-obsessed, habitually shirking our responsibilities. If we only take the longest view, we somehow forgive ourselves for not noticing what is under our feet or in the next street. But both the longest and the nearest gaze negate the need for trust. It is in the middle distance–amongst our neighbours, our police, our fellow citizens, our politicians–that trust can be found and where debate about making the world a better place can effectively take place. Escaping inside will simply negate our experience of friends and colleagues. Escaping to the ends of the earth will bring excitement but no permanent gain. The issues we need to grapple with are in the here and now, in our cities, towns, and families. Unless we rethink our social obligations and reassess the issue of trust, we will become even more cynical, even more atomistic, even more individualistic–and there will then really be no such thing as society.

If I am not for myself, who will be for me? And if I am only for myself, what am I? And if not now, when?

(Mishnah, Ethics of the Fathers, 1: 14)

* (#ulink_dfb5b06e-6989-5385-a6f3-d21f803a68ab) Article by David Brindle, The Guardian (27 March 2004).

* (#ulink_bbc506f3-7ba7-5989-83fd-f5331485cd3a)Evening Standard (19 March 2004).

* (#ulink_1330de3d-7fc3-5c1f-b29c-4a2d5deb28f1) Richard Layard, Happiness: Lessons from a New Science (2005).

ONE THE ELDERLY (#u65628d9d-9694-53db-a746-b63e5f381da6)

Once upon a time there was an old donkey who had worked for the same owner for many years from being a very young and energetic donkey. One day he saw his master talking to the local butcher and that he was eyeing him up and down. He thought he knew what that meant–that they were going to make him into cat’s meat. He wasn’t having any of that. So that very night he kicked the stable door down and escaped.

Whilst recovering from his exertion in a field full of thistles, which he munched his way through, he thought what to do. He would become a musician in the famous city of Bremen, not too far away. That decided, next morning, with a belly full of the best thistles that ever grew in a cruel farmer’s field, he set out down the Bremen road.

He had not gone very far when he met an old dog lying panting in the road. He asked him what was wrong, for the dog was distressed, with obviously sore paws. The dog replied that he was an elderly dog who had served his master well for eleven years, but, as he got older and more rheumatic, he could not chase and round up the deer as once he had. And so his master was going to have him put down. They both agreed that this was appalling, and then the donkey offered the dog the chance to join him and become a town musician in Bremen along with him.

So they went on together. Soon they tripped over an elderly cat lying in the road with sore paws, her claws split. She was panting. They asked her to tell them her story. She explained she had been a fine fit young cat, a great mouser, and very popular and much loved by her mistress. But now that she was old and tired, and liked to sit and dream by the fire, her mistress thought she was useless and not worth feeding. So she threatened to drown her. The cat heard this and ran away from the house where she had once been so happy. Then she had stopped, thinking that there was no easy way for her to survive. The donkey and the dog were very sympathetic. They said the same thing had happened to them. So they asked her if she would like to join them on the way to Bremen, since with her fine singing voice she could easily become a town musician.

And so they carried on together. As it was nearing nightfall, they saw a cock hopping towards them, making the most terrible noise. They asked the cock what was the matter. He replied that he was getting old and he had heard his master say that he was not much use any more for waking up the farmyard and that a younger cock was needed for the task, as well as for impregnating the hens to ensure they laid enough to make a living for the farmer’s wife. But the worst thing had been hearing his master threaten to cook him up for the soup for Easter Sunday!

The donkey, the dog, and the cat were all very sympathetic. They invited the cock to join them in their journey to Bremen, and then to become a town musician with them. And so he cheered up, and went with them. And they journeyed on till nightfall, when they stopped in a forest and went to sleep, though it was cold and they were very hungry.

But then they saw a light a long way off. The cat cheered up. It must be a house and she could sit warm and snug by the hearth and think her old cat’s thoughts. They decided to go towards the light. When they got there they found a pretty cottage, but it was full of robbers eating a huge meal around the table. They looked at each other. Then the dog jumped on the donkey’s back, the cat on the dog and the cock on the cat, and they looked into the window and made the most terrible noise. The robbers were terrified and ran away into the forest. The animals sat down round the table, had a great meal, and then went to sleep in a cosy cottage that seemed just right for them.

But the robbers began to think they had been silly to run away. They thought it could only have been a group of animals who had found them. So they moved nearer. The chief robber told the younger ones to go into the cottage. All the animals were asleep, and he thought it was safe to attack the sleepers, kill them and take back the cottage–to which, of course, he felt entitled.

But the cat could hear in her sleep, old though she was, and she woke up, and as the robber passed she scratched him viciously with her claws. As he ran from what he thought was a knife, the dog bit into his leg and would not let him go. He wrenched himself away and, as he ran, the donkey lashed out at him with a hoof, and then, for good measure, as he began to get up some speed, the cock swooped down and pecked at his face and ears. He was terrified; the people in the cottage were all armed. The robbers would have to give up and go far far away.

And the animals lived there happily in retirement ever after.* (#ulink_1175aa65-c276-5511-9173-0556fbfd96fc)

In the week before Christmas 2003, a case hit the headlines in all the papers entitled variously: ‘Betrayed’, or’ Frozen to death’, or, in The Guardian, ‘Cold and Old’. An elderly husband and wife, who had lived in the same house in London for 63 years, had died at the ages of 89 (of emphysema and hypothermia) and 86 (of a heart attack) respectively. No real surprises here, except their gas supply had been cut off for non-payment of bills. Yet they were not poor. There was £1,400 in cash in their home and a further £19,000 in a building society account.

They were finding it harder and harder to cope, a nightmare that overtakes many older people and is feared by even more. They may not have Alzheimer’s disease, but at the end of their lives they often find it hard to organize things and get their paperwork sorted, to catch up with the bills and the personal administration, and to keep their affairs in order. Two of the commonest causes of winter deaths are, as we know all too well, heart and chest diseases. Yet the excuse used by British Gas for cutting off their gas supply but not alerting the local social services was the Data Protection Act–i.e. on privacy grounds. The Data Protection Act’s Information Commissioner responded immediately by saying that this was a nonsensical excuse, and there is no doubt that some considerable incompetence was involved. Yet the seriousness of the case lies in the fact that two perfectly innocent, old and frail people–hitherto just about coping with the vagaries of life in their own home–died because no one noticed that they were a bit confused.

This chapter discusses how we view older people, whether we treasure them or simply want them to die. It looks at whether older people can control their own deaths, or whether they are liable to be abused and neglected in their last months and days, and at the question of euthanasia and how we ration healthcare.

It also examines the poverty of many older people, and the general neglect they often experience within the health and social care system and asks: is this how we want our parents to be treated? Is this how we want to be treated ourselves? Has our aversion to risk made us mechanistic and unkind? Has government made a mistake in refusing to allow more funding for the care of older people in care homes and nursing homes?

Finally, it looks at the question of how older people have been slow to use their political muscle and whether that might change.

Poverty

As well as the difficulty of coping with personal administration, nightmarish though that may be, many old and frail people also have to cope with extreme poverty. Whilst the focus of much public policy in recent years has been on child poverty, poverty is still a major issue for many older people. This is especially true of what is described by the Faculty of Public Health as ‘fuel poverty’, which is where any household has to spend more than 10 per cent of its income on keeping warm. For older people, this is not uncommon: they need their houses to be warmer than younger people do, and often live in poorer quality housing than younger people. Though there are government programmes to address this, the ‘warm front’ programme, aimed at preventing some of the worst excesses of winter deaths by providing better insulation and heating, is only worth £400 million. But the £1.9 billion spent on winter fuel allowances may be a less than efficient way of tackling the problem. For many older people are still seriously poor. Inequality amongst retired people is even greater than amongst the working population. The top 20 per cent of pensioner couples have a retirement income averaging around £45,000 per annum, whilst a quarter of all pensioners–over two million people–live below the poverty line (£5,800 for a single person.) The Guardian, on the day of the particular story cited above, called for the Government to add to its target for the abolition of child poverty by 2020 a similar target for the abolition of older people’s poverty as well.

The Very Old and Frail

Terrible though the problem of poverty is for many older people, and disastrous though some parts of our pensions system have turned out to be, particularly for those whose company pensions have simply disappeared, the main focus of this chapter is not older people in general. For the majority of the relatively young ‘older people’-the Third Agers, up to 75 or 80-life tends to be quite pleasant, reasonably financially stable, and, until ill health sets in, fun. There is much to be written about this age group and its changing expectations, and our own, as working longer seems likely to be the norm in order to fund future pensions.

But for a particular group amongst the elderly, life is very different: the very old, the very frail, people who need continual care of one kind or another. Much of the media’s attention has focused either on older people who make up the bulk of patients in any NHS ward-especially those amongst them who do not need to be there and who are termed, unflatteringly and unfairly, bed blockers-or on those who have Alzheimer’s disease and other forms of dementia. But the majority of very frail older people are neither bed blockers nor people with dementia, yet they need our support and respect.

So who are they? There were some 737,000 people between the ages of 85 and 89 in the UK in mid 2002,* (#ulink_00347567-3858-5b19-b44a-dfe48e5bbe3c) and a further 387,000 aged 90 and over. That’s over a million people over 85, and growing. The total population of England and Wales is only expected to grow by 8 per cent between 1991 and 2031, whilst of those aged 85+ it will have grown by 138 per cent. So the so-called dependency ratio will escalate. By 2031 there will be 79 dependants for every 100 of working age. This is expensive, and new. It is costly for both pension provision and healthcare, for the over-85s already cost the health and community services five times as much as those aged 5-64. Some 10 per cent of all hospital and community health resources are spent on people of age 85 and over.

(#ulink_bfe6996c-e5fb-5c48-9938-e4c3cf9aa5a3) The impact on families will be huge. The State is unlikely to be able to provide the full costs of care. The implications for families, and for the individuals themselves, are colossal.

It is a vast change, and we have not kept pace with the changes it demands of us, either ethically or politically. The ‘time bomb’ argument was very fashionable in the late 1980s and the 1990s, and still rears its ugly head, despite the fact that people are now more worried by growing suspicion that our increasing longevity has only resulted in pushing the period of frailty to a later age. Indeed, it may be that by increasing our calendar age we are imposing upon ourselves a longer period of frailty and dependence than hitherto. We are certainly seeing an increase in the numbers of people with Alzheimer’s disease, and the Alzheimer’s Society suggests that there will be around 840,000 people with Alzheimer’s in the UK by 2010, rising to more than 1.5 million by 2050. This echoes US figures, where the Rush Institute for Healthy Aging claims that more than 13 million Americans will have Alzheimer’s by the middle of the 21st century.* (#ulink_913dbc0c-cee3-58ed-b8cb-2424f27f9c65)

cases?’ Community Care (2003).

Whilst demographic predictions have been wrong before, the increase is certainly taking place and the theory that longevity may not always give one a healthier old age is beginning to look worth examining. However, others argue that the high-dependency period, particularly in terms of NHS hospital use, has simply shifted to an older age and is still roughly parallel with previous experience, being the last three years of life at whatever age.

(#ulink_5904de96-4bd8-5faf-8c9f-70b437c0ba0f) But it also has to be said that since 1969 admissions of people over 64 to NHS beds has quadrupled, whilst for the rest of the population they have barely doubled. It is not clear how much of this is to do with more recent technology-cataract surgery and hip replacements, for instance-and how much to do with the longer term disabling conditions for which there is no ‘quick fix’.

There are also many who argue that concern about the ageing of our society carries heavy ideological baggage-precisely the people who believe we cannot afford welfare support for the frail and needy. If we have more elderly people, frailer and more dependent, then somehow we will have to provide welfare support for them if they cannot provide it for themselves; and that, for those who wish to draw back the provisions of the State, is a highly unsatisfactory situation.

This is perhaps best expressed by the author Phil Mullan in his excellent book The Imaginary Timebomb. Mullan argues that the preoccupation with ageing has little or nothing to do with demography in itself but is much more to do with ideology–in this case, the curbing of the welfare state. He also argues–as does Frank Furedi in his excellent introduction–that the ‘problematization’ of older people coincides with ‘the tendency to marginalize the elderly from the labour market and from society at large’. The real problem, according to this argument, is not that there are not enough younger people working to support a growing population of older people, but that older people still find it hard to find employment. In the late 1970s and early 1980s, the employment rate of older male workers declined sharply. These rates have improved slightly in recent years, but they are still below the employment rates seen in the 1960s.* (#ulink_e0254c0d-a75e-5f9f-9abc-832e69a84ad0)

The argument here is that it is the shortening of the period of working life that is likely to be the cause of difficulties, in financial terms, rather than demography per se. There is plenty of evidence to support this theory. The Chartered Institute of Personnel and Development (CIPD) surveyed its members, arguing that Europe’s population would age faster than almost anywhere in the world, and found that two out of every five workers felt they had been discriminated against on the basis of age. Older people are seen as doddery and out of touch, whilst the young are seen as immature and unreliable. In looking at the data, Patrick Grattan, Chief Executive of the Third Age Employment Network, identified the media, fast-moving information technology, financial services, and manufacturing as industries that have yet to embrace an equal age policy.* (#ulink_fb4a5174-9257-5d28-8ee2-7c36ed510776) Mike Saunders, the 66-year-old owner of an employment agency entitled Wrinklies Direct, argues that older people also sometimes lack the right attitude at interview, arguing that ‘They have to sell their experience; they have to stand up against the young and be counted.’ There is cynicism amongst employers, too. Older workers in traditional sectors like banking tend to have built up expensive employment rights, such as increments and pension entitlements. By making people redundant early, firms save themselves a lot of money.

(#ulink_90085437-8094-5c9c-adf9-99fcc1e6f73d) Nor are government schemes particularly effective: ‘New Deal 50+’, launched in 2000, is open only to those already on benefits, rather than to all those over 50 who are finding it hard to get new jobs.

(#ulink_387a07c4-6c36-5efc-b9ed-e29af5d931e1) Even more significantly, Mullan argues convincingly that the fear of the demographic time bomb, rather than its actuality, is what promotes insecurity and a lack of inter-generational trust. If older people cannot trust the next generation down to look after them when they are frail and dependent, an increasingly individuated way of caring for oneself will develop. Meanwhile, if the next generation down fears that the older generation will consume all the assets of the family or the state, then respect and care are likely also to be in short supply. This truly is a vicious circle, and Mullan is on to something when he points to the fear of the demographic time bomb as an example of the generalized lack of trust between individuals in our society, particularly between the generations.

So the responses to this apparent demographic threat are many and numerous. Some say that this supposed time bomb is not all it seems because the UK will be importing a huge amount of labour from overseas to carry out the caring jobs and to feed our economic growth. According to this argument, the panic is unreasonable, we should stop worrying and simply get on with providing better care for very frail older people. At the other extreme is the enormous change in attitude, both in younger and older people, towards the euthanasia argument.

Euthanasia/Assisted Dying

There is a view expressed by some that there is no need to have ‘useless’ old people around who can no longer make a contribution to society. Though no one is suggesting that they should be forced to die, there are some who think that it should be possible for them not to have to continue living if they do not wish to. These are people who might be said to be arguing for euthanasia on the grounds of age and uselessness.

At its most extreme, the ‘uselessness’ view is one that could be compared to that held by the Nazis about people with severe mental and physical disabilities. There was already a respectable view of ‘mercy killing’, as propounded by Ernst Haeckel (1834–1919), the scientist and philosopher. So when the Nazis came to power in Germany, they set up the General Foundation for Welfare and Institutional Care, or T-4 as it came to be known, made up of doctors and psychiatrists, and carried out 70,000 killings of men, women, and children in institutions before the programme was stopped as a result of protest, largely from clergymen.

Obviously, those who are in favour of euthanasia for older people have no desire to go that far. But in arguing that very frail older people are of no use to society they are going down that road, though they would naturally be appalled at the comparison. Their aim is to make it respectable for older people-particularly those who really are near the end of their lives, who are suffering, and whose continuing care is costing the health and social services considerable amounts of money and resources–to ask for euthanasia. In order for that to happen, it has to become morally acceptable to eliminate (with their consent) older people who cost the state too much to maintain.

Other countries have euthanasia, after all. In Holland some argue strongly in its favour, whilst others are far less happy about it. Bert Keizer, a physician in the Dutch state-run nursing home system who has written extensively about death and dying, argues that there is virtually no abuse of the system and that people themselves do genuinely ask to be put out of their misery.* (#ulink_0a4e15fb-5331-51ba-9643-77668b7c8273)

The Dutch Catholic Church tends to take a different view, claiming that children put pressure on their parents in order to inherit. It has to be emphasized, however, that, unlike in much of the UK (Scotland being the exception), nursing home care is free in Holland and there is little in the way of private-sector provision. So how strong is the pressure from children likely to be once elderly parents are ensconced in a free nursing home, when they have reached a stage where relatives can no longer manage to provide care at home?

In Britain, on the other hand, the bulk of nursing home care for older people is provided by the private sector and children may well see their parents’ nest egg, which they often regard as theirs by right, swallowed up in nursing home fees. Parents certainly have a strong desire to pass on their wealth and savings–and often the house they live in–to their children. The result is considerable anxiety about the lack of free provision and about the need to draw down on savings. Anyone who has capital of their own above £20,000 will be assessed as being able to pay the standard rate. In the case of a care home providing nursing care, this would be the fees less the contributions the NHS might make towards the cost of nursing care. Those whose capital is between £12, 250 and £20,000 will be expected to make some contribution from their capital on a sliding scale, until the capital goes down to £12,250. Pensions and provision for older people have become major political topics in Britain, as discussed below.* (#ulink_7d34661d-afee-5bc2-b5ad-aa437092a808)

Those in favour of euthanasia argue that it might be easier if older people, instead of costing the country so much, could simply ask to have themselves put quietly and painlessly to death before the money runs out. The argument is rarely spelled out that way. But remember the story of the dog, the cat, the donkey, and the cock at the beginning of this chapter. Their owners thought them useless and felt that it would be fine to finish them off. We are not the owners of our older people, but as a society we see them as a problem. Hence the political issue that has blown up over long-term care for older people, which the Labour government promised to sort out on coming to power in 1997. It soon realized that this was a truly difficult task because of the conflicting and complex moral and financial arguments. Are older people entitled to free care by virtue of being old? Or should they pay for their care on the grounds that it is an unreasonable burden to place on the younger people who will end up paying the bill? Should they, in fact, regard it as a normal part of the costs of life?

In this climate of concern about ageing and its costs, the Patient (Assisted Dying) Bill was introduced in Parliament in February 2003 by the cross-bencher peer Lord Joffe. As it did not have government support it had virtually no chance of becoming law. Nevertheless, it was seen as an opportunity to air, once again, the complex and varied views held by all kinds of people and organizations on the subject. It had its second reading, unopposed, in accordance with tradition, in June 2003. After that, significant changes were made to it, to deal with some of the objections. These reduced its scope in a variety of ways, including limiting application of the Bill to terminally ill patients and stating that in assisting someone to die the attending physician might only provide the means to end the person’s life, unless the latter was physically unable to do so, in which case the physician could become actively involved. The idea that the physician would only provide the wherewithal, rather than actually kill the person, had considerable attractions for some objectors to the original Bill, since it largely removed the great problem of doctors killing their patients, rather than attempting to heal them or temporarily alleviate their suffering. The changes also included additional safeguards, requiring a specialist to attend the patient to discuss the option of palliative care. After all this, and with these changes, the Bill was reintroduced as the Assisted Dying for the Terminally Ill Bill, in January 2004.

In March 2004, there was a second-reading debate in the Lords and the Bill was sent to a select committee, and it began to look as if it might become law. At that point, Lord Joffe suggested that the select committee might wish to consider the current experience of assisted dying in the Netherlands and Oregon, in particular whether vulnerable members of society had been put at risk and whether doctor/patient relationships had been adversely affected. He also suggested it would be worth examining whether palliative care could, in all cases, enable terminally ill patients to die with dignity and free from unnecessary suffering. He further asked for the committee to look at whether recent polls showing that 80 per cent of the public supported assisted dying reflected public opinion accurately. Finally, the committee was to examine whether the safeguards contained in the Bill to protect vulnerable members of society were adequate and, if not, what further measures might be necessary. The Joint Committee on Human Rights, in its report on 23 March 2003, was of the view that they were, but the Bill’s opponents were not persuaded.

The aim of the Bill was to enable a competent adult, suffering unbearably as a result of a terminal illness, to receive medical assistance to die at his or her own considered and persistent request; and to make provision for a person suffering from a terminal illness to receive pain relief medication. The main argument made in favour of the Bill was that attitudes had changed in the ten years since the possibility of helping terminally ill people to die was last considered by the House of Lords Select Committee on Medical Ethics. Ten years on, Baronesses Jay, Warnock, and Flather, formerly opposed to assisted suicide, were now supporters of a change in the law.