Ageing, Autonomy and Resources

A.Harry Lesser

• Publisher: Taylor & Francis
• Year: 2018
• eBook ISBN: 9780429860782
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

First Published in 1999, lesser collects fourteen papers to create a discourse on the practical importance in a society where the proportion of elderly people is increasing. Exploring how autonomy and how it should be defined, and ethically when is it right to preserve a person's autonomy and in comparison is it ever ethically right to bring elderly peoples autonomy as a secondary concern is it saves them from harm?

1 The effect of ageing on autonomy

Caroline Dunn

The issues raised by the question of the relationship between ageing and autonomy are considerable, but this chapter will be limited to considering the fundamental issue of the consequences of ageing on autonomy. In order to do this, of course, it is first necessary to have a definition of autonomy, and this is not as straightforward as might be imagined. Although autonomy is a central issue in the Western conception of a person and features prominently in ethical theories of post-Enlightenment Western culture, it is an ill-defined notion, often equated with liberty, self-rule, dignity, integrity, individuality, independence, freedom of will, responsibility, freedom from obligation and the absence of external constraints, amongst other things; it therefore simultaneously encompasses political, moral and social ideals. Gerald Dworkin (1988) has concluded that

About the only features held constant from one author to another are that autonomy is a feature of persons and that it is a desirable quality to have (Dworkin, 1998, p.6).

Despite the difficulties in reaching a definitive definition of autonomy (arguably, an impossible task), the essence of autonomy would appear to be that a person is autonomous if and only if he or she is self-governing. Dworkin’s own definition of autonomy defines it as

...a second-order capacity to reflect critically upon one’s first-order preferences and desires, and the ability either to identify with these or to change them in the light of higher-order preferences and values. By exercising such a capacity we define our nature, give meaning and coherence to our lives, and take responsibility for the kind of person we are (Ibid., p. 108).

The relationship between the definition of a person and the ascription of autonomy is a somewhat circular one. To be a person is a necessary, though not sufficient, condition for the ascription of autonomy; no-one seriously suggests that animals possess autonomy. But equally, the non-autonomous are likely to be regarded as to some degree less than fully human, for if autonomy is perceived as a fundamental feature of persons, one’s humanity is likely to be perceived as diminished to some extent if autonomy is diminished. The equation of autonomy with personhood and self-identity raises problems, however. Babies and young children are not autonomous; neither are patients in a comatose state nor those under an anaesthetic; nor indeed is a sleeping person. Yet none of these groups would be considered to be less than fully human - Joe does not cease to be Joe to those who know and love or hate him simply because he is comatose or asleep or undergoing an anaesthetic while his appendix is removed. In the case of the comatose patient, it might be argued that, after a certain period of time, when all hope of recovery has been abandoned and brain death has been established, his or her essential humanity exists no longer; this is the justification for switching off life support systems. But one does not necessarily lose one’s humanity simply by virtue or being in a coma, for many coma patients recover consciousness and their autonomy.

It therefore follows from this that autonomy must be recognised as a matter of degree, not an absolute, for an individual’s autonomy may - and does - very in degree and over time. And it also follows that autonomy may be restricted in many ways and to varying degrees, although there are essentially only two basic ways in which autonomy may be restricted; these are by external constraints - the actions of others - or internal constraints - what might be called limitations in oneself. The process of ageing has a direct bearing on both these forms of constraint upon autonomy.

If autonomy is a feature of persons, then it follows that autonomy is intimately connected with notions of what it is to be human, and, by extension, what constitutes human needs. Certain needs are fundamental to human beings, the needs for food and shelter being the obvious ones; for if these needs are not met the question of autonomy becomes largely irrelevant, since the individual will die. But needs on this basic level are no more than needs that any animal, human or otherwise, possesses. These needs must be met if the animal is to survive, but if only these needs are met for the human animal, it very soon ceases to be fully human, for the essence of what it is to be human lies in the more complex needs that the species has, and these needs are intimately related to values; all the concepts equated with autonomy have value judgements embedded in them.

Meeting the basic human needs of food and shelter can be done in many ways; in contemporary Britain, it is left to what remains of the Welfare State to meet these very basic needs for those unable to do so for themselves. Similarly, the law enshrines basic rights which govern the relationship between individual rights and needs and the needs and rights of the social group, in an attempt to ensure that all are treated equally.

But the human animal also has other, very specific, needs which differentiate it from the rest of the animal kingdom and define it as a human being; these needs are for things such as love, respect and dignity, which are every bit as important as the basic need for food and shelter. These needs cannot be met by the welfare state or enshrined as rights because their provision depends upon the compassion and respect for others that can only come from the feeling of one person for another. In other words, the needs which define us as human can only be met by other humans; and meeting these needs depends upon an acknowledgement of a shared, common humanity between individuals, a feature of which is respect for the autonomy of others. Respecting the autonomy of others not only entails acknowledging their right to be self-governing, but also treating their views and wishes with respect, accepting them as individuals and being aware that their needs are not limited to the bare necessities required for survival. But acknowledging a shared humanity and respecting the autonomy of others does not mean demanding identical values from other individuals; autonomy also means having one’s individual differences respected, having a voice which is listened to and taken seriously. Having these uniquely human needs met makes the difference between surviving as little more than an animal and thriving as a human being.

In these respects the elderly are no different from any other persons. Ageing need not necessarily be detrimental to autonomy; indeed, at some stages in life, it is a prerequisite for it. The law prohibits an individual gaining full legal autonomy until the age of eighteen; young children are not considered to be fully autonomous by virtue of their immaturity rendering them incapable of making fully rational or fully informed decisions. But in the context of the consideration of ageing and autonomy, it is taken as read that we are dealing with old age, and that old age carries with it certain factors that may affect autonomy; in Western culture, it is invariably taken for granted that the effects of old age on autonomy must be detrimental. Given the attitudes to ageing that are current in contemporary Western society, this is hardly surprising.

Ageing is not simply a matter of chronology; there is also an element of social construction involved in the concept. One may be considered old at forty in the job-market, but a man of fifty who is head of state of a powerful nation may be considered to be young. The socially constructed aspects of ageing may be reflected in the meanings attributed to old age, which in contemporary Western culture are invariably pejorative; Shakespeare summed up the situation when he wrote:

...Youth is full of pleasance, age is full of care;

Youth like summer morn, age like winter weather;

Youth like summer brave, age like winter bare.

Youth is full of sport, age’s breath is short;

Youth is nimble, age is lame;

Youth is hot and bold, age is weak and cold;

Youth is wild and age is tame.

Age I do abhor thee; youth I do adore thee.

The prospect was obviously such a gloomy one for Shakespeare that it adversely affected the quality of his verse! And certainly his sentiments do not appear out of place four centuries later.

Certainly the physiological deterioration that generally accompanies ageing in various degrees is very real and it may result in the elderly becoming less able to care for themselves and consequently more dependent on others. But family structures in the West no longer assume a responsibility to care for elderly members; this, coupled with medical advances in the treatment of the elderly which have resulted in greater numbers of people living to become elderly or, as is more and more the case nowadays, very elderly, means that the old are increasingly the responsibility of the state, with the concomitant financial burdens this places on a population seemingly ever more reluctant to pay taxes for the provision of social services. The elderly may therefore be seen to be consuming continually increasing resources in terms of pensions, medical and social services, and contributing nothing to the provision of these services. And another consequence of medical technology means that not only are far more people enabled to live for much longer, but increasingly, conditions which were regarded as an unpleasant but inevitable consequence of old age may now be alleviated, giving a much better quality of life, but making yet more demands on scarce resources. As a result, the old are increasingly seen as a problem at best and a nuisance at worst, rather than being valued for their wisdom and experience.

This situation may be exacerbated if the elderly are ill (and by virtue of their age they are more likely to be ill than younger people) for illnesses also have meanings ascribed to them. All illness carries with it ethical implications, for it alters our moral status; if this were not the case, then concepts such as malingering, hypochondria and psychosomatic illness would not be necessary; there is a certain comfort to be derived from a definition of illness as a physiological state that can be objectively defined by science, but such a view ignores the human element involved in our view of illness. It is this human element in illness that complicates it, for, as Sacks has pointed out: ’...animals get diseases, but only man fells radically into sickness’ (Sacks, 1986, p. ix). The distinction implied by Sacks’ differentiation between human sickness and animal disease lies in the meaning that humans attribute to sickness.

Becoming sick involves a form of metamorphosis for the sufferer, a metamorphosis that is not limited to her bodily state, for in subtle ways it will affect her moral status; as Sontag has pointed out, ‘(sickness suggests) judgements of a deeper kind, both moral and psychological, about the ill’ (Sontag, 1990, p.43). Sickness causes a paradoxical moral state, for the sick are likely to lose certain rights, but at the same time acquire others, and will be excused certain moral obligations whilst acquiring others. Such changes in moral status will depend upon the meaning that is ascribed to an individual’s sickness.

Those involved with the sick have a responsibility not to upset them or do anything that might be perceived as exacerbating their situation. This opens the door to a variety of tactics on the part of the sick person which can be considered as emotional blackmail. Those nearest and dearest to the sufferer can experience considerable guilt, in which case sickness can be used to manipulate. The rights which the sick acquire are bought at a cost; the sick person must forgo pleasures as well as responsibilities, must obey the orders of medical experts and generally do as she is told; the loss of autonomy can, in extreme cases, result in her being treated like a child. Thus the moral overtones associated with illness do not remove moral conditions from the sick, but they do shift the boundaries of the moral conditions that apply to a well person.

Just as the meanings ascribed to illness generally affect the moral status of the sick, so the meanings ascribed to old age may affect the treatment - both in the specific sense of therapeutic treatment and the general sense of the way society reacts - received by the elderly. To begin with, the elderly are more likely to suffer from a wider range of illnesses than the young; so all the meanings and altered moral status that accrues to illness will affect them. The illnesses associated with old age often have pejorative meanings associated with them; they are seen as demeaning, indicative of decay, loss of control, loss of reason, and dependency. And the ‘rights’ that sickness grants to the old may be bought at the expense of autonomy. Having to behave in certain ways, be grateful for help and treatment, not complain and generally do as one is told may mean that one is not able to exercise one’s autonomy if to do so conflicts with the prescribed behaviour. The old therefore may suffer from the negative perception of old age that permeates our culture (and also illnesses they may suffer from have pejorative meanings associated with them) and may have the burden of gratitude imposed upon them as the cost of care which should be theirs as of right. Such attitudes to old age cannot help but diminish the autonomy of the elderly, for they may result in a perception of the elderly as somehow less than fully human; and to be regarded as less than fully human means that one will be denied a voice, or at the very least, that one’s voice will in all probability not be listened to or taken seriously. In this respect, the elderly may experience a similar diminution of their autonomy as is experienced by the mentally ill. They may be ignored, regarded with contempt, be perceived as worthless and in extreme cases may suffer neglect, abuse and even death.

It may be argued that such gross denial of autonomy that would result in such appalling treatment of the elderly is extremely rare (though that is arguable), but it remains a fact that the granting or withholding of autonomy is at least to some degree dependent upon the socially constructed meanings that individuals attribute to ageing. No matter what rights may be enshrined in legislation, they cannot guarantee that the autonomy of the elderly will be respected because laws cannot enforce those aspects of autonomy that are outside the scope of the law. Thus laws may protect people from physical maltreatment but cannot protect them from contempt - carrying out the letter of law is possible whilst disregarding its spirit.

There is another aspect of old age that has significant repercussions for the elderly. In a society obsessed with youth and beauty, the manifestations of old age may be feared and found repulsive, for they remind every young, beautiful person that this will be their lot too one day. In Kafka’s Metamorphosis, Gregor’s transformation into a giant beetle is used as a metaphor for disease and its hidden meaning; but it might equally be a metaphor for some of Western society’s meanings attributed to ageing and the elderly. Gregor’s transformation renders him repulsive, frightening and shameful to his family; it strips him of his humanity and denies him the moral consideration which we take to be a right. Gregor retains his human feelings but his metamorphosis leads his family to begin a slow process of dehumanising him, and they ultimately reject him entirely, feeling only relief when he is dead. This sometimes happens to the old; they may be characterised as smelly, useless, senile wrecks, with a disregarded past and no future.

This may seem to be exaggerating the case, and it is certainly an extreme, but can we really deny that such attitudes exist and are far from uncommon? Thus the meaning of old age goes far beyond that of a person who has lived for a specified number of years; it has a subtext, frequently hidden and denied, but one that is very real nonetheless, and if the social construction of old age is such that old age is perceived to be a problem, associated with negative conditions such as loss of control and dependency, the elderly may undergo a form of metamorphosis similar to that experienced by Gregor which renders them as less than fully human in the eyes of the rest of society.

All the above may be regarded as the malign consequences of diminished autonomy which result from the hidden meanings of old age being pejorative. But the autonomy of the elderly may also be unwarrantedly diminished as a result of the best of intentions - the result of benign but misplaced paternalism. The right of the elderly to be cared for may be given freely and with great compassion; but if the elderly are nonetheless characterised by illness and dependence they may be seen as childlike and helpless, deserving of care and consideration but largely non-autonomous. They may then experience the ‘does he take sugar?’ syndrome which is often the lot of the disabled. Decisions may be made for them, or their wishes ignored on the grounds that they are not competent to decide for themselves. And they may simply not be seen as individuals at all, but simply as a member of a group - the elderly - which somehow obliterates individuality. Calling old people ‘granny’ or ‘granddad’ is a classic example of this, denying them the dignity of being an individual, Mrs X or Mr Y.

It must surely be obvious that the pejorative meanings of old age must be challenged and replaced with an attitude that sees the old as persons just as much as any other members of the human race. If this were done, then the moral imperative that requires us to respect the autonomy of persons would require us to treat the elderly as self-governing agents, and the elderly should be as free as any other autonomous beings to do whatever they choose insofar as the exercise of their autonomy does not infringe the autonomy of others. This would include things that might be considered to be dangerous or stupid, just as the autonomy of younger people is respected when they choose to do dangerous or stupid things, such as motor racing or steeplechasing. Equally, the elderly would be subject to the same considerations regarding conflicts between the respect for autonomy and other values that apply to anyone else; thus, for example, age alone would not be sufficient justification for preserving one individual’s autonomy at the expense of another’s; in all issues relating to autonomy, age as such would be irrelevant.

At this point attention must be drawn to another aspect of autonomy generally and ageing and autonomy specifically, which is increasingly becoming a feature of contemporary Western society. This is the apparently inexorable growth of consumerism. I have argued that autonomy is not absolute, but a matter of degree, and increasingly autonomy seems to be related to one’s power as a consumer - a case of ‘to those who can consume shall be given’. In this respect, we are increasingly being made aware of ‘grey power’ - those elderly people who by virtue of their increased numbers and their spending power are set to become a force to be reckoned with in the years ahead. Of course, the wealthy have always been able to enjoy more autonomy than the poor, for wealth brings with it power. Since autonomy necessarily requires the juggling of individual autonomy with the needs of the social group, which must result in compromises being made, and generally speaking the powerful are more likely to juggle things to their advantage, there is nothing surprising about this. But increasingly things such as autonomy, dignity, respect and the provision of basic social and medical services, which should be taken as a right in a civilised society, appear to be becoming the prerogative of those with money - or to use the term that is becoming increasingly popular, with consumer power. Thus the elderly poor are increasingly seen as a problem; they are not just relatively worse off, but may well lack decent living conditions and an adequate income to enable them to eat well and keep warm enough. They may have to wait for a very long time for medical treatments, such as hip replacements, that will greatly improve the quality of their lives; their social life may be limited or non-existent as a result of poverty and lack of mobility. Those fortunate enough to possess ‘grey power’, however, are portrayed as having choices - the choice of living in specially designed retirement apartme...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Contributor
• Acknowledgements
• Introduction
• 1 The Effect of Ageing on Autonomy
• 2 Personal Development in Old Age
• 3 Ageing and Autonomy: The Case for Genetic Enhancement
• 4 Practical Problems with the Discharge of Old People from Hospital - A Physician’s Perspective
• 5 A Mental Health Perspective on Ageing
• 6 Ending Lives: Age, Autonomy and the Quality of Life
• 7 Therapy Abatement
• 8 The Global Distribution of Health Care Resources
• 9 Population Ageing, Social Security, and the Distribution of Economic Resources
• 10 ‘Last Time Buyers’; Markets and Marketing in Services for the Elderly
• 11 Justifying Ageism
• 12 The Felicific Calculus Strikes Back
• 13 Justice and the Principle of Triage
• 14 Health Care Access, Population Ageing, and Intergenerational Justice