This text is a comment on the book “Ageing and disability” corresponding to the XX General Assembly of the Pontifical Academy for Life, celebrated in Rome from 26th February to 1st March, 2014.
The increased life expectancy of the world population, due to better quality of life, hygiene-healthcare measures available to increasing numbers of people, and progressively expanding prevention efforts, raises new and serious challenges to which we must provide answers.
Greater longevity is also associated with an increase in morbidity with respect to other stages of life. In the elderly, these often manifest as multiple pathology, which complicate the situation of disability and dependence typical of old age.
Confronting this issue from a proper perspective requires solid ethical principles that allow the elderly and disabled to be treated as individuals in all their aspects, i.e. by respecting their dignity, providing human and material resources proportionate to their physical and psychological needs, and also facilitating the spiritual guidance that allows them to accept the loneliness, dependence, the disability itself and the event of death from a perspective of reason, which may relieve their suffering and open their hope to transcendence.
Dignity of the elderly and disabled
Post-modern society often experiences a distortion of the concept of human dignity. The influence of utilitarian theories and hedonist ethics leaves little or no room for the treatment and care of the disabled or elderly.
Dignity and usefulness often appear as closely related concepts, so that the first is inconceivable without the second. It seems that productivity (mainly economic) and the level of autonomy (applied in all senses) are what determine the level of personal dignity that might be attributed to someone.
An elderly person is increasingly more dependent and less productive, which would mean – if we hold to the above theories – a gradual loss of dignity that would make them less deserving of the resources allocated to their medical and psychological care, rehabilitation, daily assistance and spiritual guidance.
Unfortunately, this is not a new phenomenon in our post-modern society, and there are many sad events in history where man unduly takes it upon himself to decide who has dignity and who does not, favouring the former and penalising, enslaving or eliminating the latter.
While this is nothing new, the scale at which this phenomenon is occurring is, and is a challenge before which we cannot simply stand by and do nothing. Having dignity is peculiar to human beings, whether or not they are productive (in an economic sense). Having dignity is inherent to the person, whether or not they are dependent (even completely dependent). Therefore, considering the human person as a subject of dignity beyond their physical, mental or spiritual conditions is the opposite of that proposed by utilitarianism or hedonism.
Productivity, usefulness and level of well-being, postulates of post-modern society, turn the elderly and dependent into enemies. It is within this framework where arguments advocating euthanasia, eugenics and social marginalisation gather strength.
Similarly, there are more than a few elderly people who, endorsing these theories, try to live as if they were not old, i.e. sculpting their appearance to simulate the youthfulness of the past, adopting slogans that incite “dynamism” in old age, artificially promoting late fertility and motherhood (rather anachronistic), and even being pushed into experiencing youthful adventures, as a way of pretending what is not.
Old age, however, should be reclaimed as a stage, the last stage of life, which offers its own richness, not in any way inferior to the richness of other stages, just different.
It is precisely in old age that the right circumstances occur to discover the value of human life aside from its productive capacity, client of consumerism or victim of hedonism.
The elderly man is a person, wiser than he was, and with a new perspective closer to looking towards transcendence. This, which the elderly have an opportunity to assess in their old age, is paradigmatic for the rest of society. The elderly and dependent bring awareness to the true value of existence beyond consumerism, productivity or the search for pleasure. This value is not the legacy of old age, though, but of wisdom, serenity of the mind, the perspective gained from experience and the need to provide answers to the basic questions of life: what am I? why am I? where am I going? why do I suffer? These represent a richness for all human beings, which the elderly person manifests with their dependent and limited way of living.
This stage can thus be defined as a prophetic time for every human being who, confronted with the purpose of their existence, is questioned about the meaning of their life, the hierarchy of their values and the urgency of their demands. Old age lays bare the depth of the person, who devoid of consumerist ties and pleasurable obsessions, asks himself in his solitude about his purpose and the reason for his existence.
Medical care in old age
Increased life expectancy in the elderly is changing the health care environment that they need. Living longer implies prolonging periods of dependence and increasing the likelihood that new chronic diseases will appear that complicate their care and require the dedication of major resources by healthcare systems.
Vascular diseases, hypertension, other cardiovascular problems, anaemia, eyesight and hearing problems, cognitive loss (especially memory loss), anxiety and depression, diabetes-related complications, obesity and smoking make up the framework of multiple pathologies that healthcare personnel must address in the treatment of the elderly.
Dementia cases are chronic and progressive in 30% of those affected, and only 10 % are reversible.
Alzheimer’s disease is one of the major causes of dementia in old age, and of death in people aged over 65 years.
In Italy, stroke is the second most common cause of dementia in the general population, and the third leading cause of death, after cardiovascular disease and cancer. Patients who survive these events show varying degrees of disability, which can make them completely dependent on a carer. This means a radical change in their lives, which will not allow them to return to their usual activities as normal.
Routine diagnosis of cognitive deficiencies in the elderly should be promoted to improve their treatment and future progress. Physiotherapy is a fundamental link in the chain of care for these patients, and should be properly coordinated with the other multidisciplinary interventions that will have to be adopted.
These situations of chronic disease are a challenge not only for the clinicians who must treat them, but also for carers, family members and professionals, who will require support and psychological-emotional training to enable them to confront very difficult and potentially long-lasting situations, in which the elderly or disabled person is cared for in a manner that their dignity as a person merits, by proper assistance, clinical support and spiritual guidance. The balance necessary in the way of caring for the elderly and disabled requires excellence in the quality of this care, which implies exhaustive exercise of care and attention to the anthropological complexity of the patient, in their physical, psychological and spiritual aspects.
From the above, it follows that proper management of available resources becomes a key principle in the care of the elderly and disabled. The growing availability of diagnostic and treatment methods, together with greater demand by patients for interventions that improve or relieve their condition, in many cases cause care costs to rocket. Rational management, which neither squanders nor skimps on what the personal dignity of these patients requires for their care, as persons as deserving of this care as healthy or independent people, is essential. This is what is known today as the biopsychosocial model in medicine.
Proper distribution and use of available resources requires an exercise in solidarity and generosity by all social establishments, which must award the elderly and disabled collective the same importance in terms of addressing their needs as the rest of society, but also greater healthcare requirements due to their condition of growing dependence.
Finally, the training of healthcare personnel is a major challenge, so that the necessary competence levels that the complex situation requires are reached. In some professional settings, it may seem more attractive to practice medicine in patients with high expectations of cure or rehabilitation. The outcome of recovering health can be a strong motivation for the clinician.
Based on this view, the dedication of the professional who treats and attends old age or disability will not be rewarded by recovery of their health or lost autonomy, which can be demotivating. This can lead to considering the care of the elderly as a matter of minor importance, which would require lower professional qualifications than other medical specialities. This is far from the case, and given that dignity and health do not go hand in hand, care of the elderly requires sufficient communication between medical and healthcare professionals and specialities, so that the increasing specialisation and modernisation lead to an improvement in quality of care, and not in the fragmented and uncoordinated exercise of super-specialities that lose sight of the global nature of the person treated, which reduces its efficacy. Furthermore, the complexity of the diseases that present in this stage require professionals to be sufficiently prepared, no less than in other medical specialities.
It must not be forgotten, within these specialities, to coordinate those that attend the psychological and spiritual needs of the elderly or disabled.
The spiritual aspect in old age and disability
Beyond the expectations placed on any person, whether physical, mental, spiritual or social, human life has intrinsic value in itself, value which does not decline according to the specific circumstances through which that life passes. Old age and disability are one example of this. Moreover, they represent a privileged occasion to get close to its true value: a being that transcends.
Dependence (sometimes complete) and the closeness of death confront the person face with their finite reality. Life, the biographic history of an individual, cannot be governed in all its terms. Neither can death, which should neither be anticipated nor attempts made to delay it indefinitely.
Health or the capacity to live independently, while precious assets, escape the absolute control of the human being. To pretend otherwise (and there are those who do so) is to alienate oneself from what reality shows, and to become alienated from what one really is.
Accepting old age, with the dependence and suffering that it entails, or disability and its loss of independence, as a final stage of existence, meaningful and fruitful, is but the truth of old age.
Old age and disability are propitious times for humility – and humility approaches the truth. The experience of limitations and dependence on others is an undeniable aid for the elderly person, who can gradually abandon positions of power, to identify instead with the fragile and weak. Far from devaluing their person, though, this fragility makes them more truthful, showing more vividly the true human reality, a fragile and dependent creature, who has received life free and cannot keep it for himself.
However, this is not only an opportunity for himself: the elderly person worthy of care can help to increase the virtue of those who care for him. A virtuous attitude is necessary to care for and attend another who will find it difficult to return the good received. Virtue and gratitude, which foster real charity, can and must gradually dwell in people who surround the old person and give him the care that he requires. In this consists respect for his dignity.
Finally, old age offers a privileged place to peer into transcendence, everlasting life, Love beyond all, from which we came and to which we will return.
The precariousness of life in this stage represents a place to meet the Creator, who has wanted to experience all suffering, as a constituent element of human nature. Therefore, it is an opportunity to cooperate with Grace, and experience its company.
The suffering and loneliness that accompany it are a place for meeting and comfort, where God, who has suffered in Christ, and knows all suffering, consoles and fills with meaning a fruitful stage of life. Fruitful not only for he who prepares himself to leave permanently, but also for those who accompany him and remain here for a while, who after contact with old age and suffering, can learn to think more on the ultimate goal of the things that they do, rather than on satisfaction of the immediate need.
Catholic University of Valencia