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The Moral State We’re In
Julia Neuberger
A study of the moral state of the nation – the acid test of this being how we treat the weakest among us. Rabbi Julia Neuberger will assess the situation in the UK from her own unique viewpoint, and promises to draw some challenging and thought-provoking conclusions.Just as Will Hutton looked at the political landscape at a turning point in Britain, Rabbi Julia will take the moral temperature of the nation by looking at the ways in which we treat the weakest amongst us. The National Health Service, government pensions and asylum seekers all make daily headlines, and here is a writer with the moral authority and mastery of the necessary information to undertake this timely project.The way we treat the weak and vulnerable members of society has long been an established way to judge how civilised a society is. In this book, Julia will look at the extent to which the elderly are thought a burden, the way we care for the mentally ill, attitudes to asylum seekers, support for ex-offenders as well as the care of children and the future of society in the UK.Her straight-forward approach to what has elsewhere proven highly esoteric, is here written with ease and fluidity and with a style that is highly approachable for those interested in the state of their nation with purely social, rather than academic, motivations.With her uncomplicated but extremely intelligent and candid take on the issues that make daily headlines, and with Julia’s high media profile, this book is guaranteed to tap into the state of our nation.
THE MORAL STATE WE’RE IN
A MANIFESTO FOR A 21ST CENTURY SOCIETY
Julia Neuberger
CONTENTS
Introduction (#ub291a974-a8fc-5ca8-af88-07d637cc2452)
1 The Elderly (#u47a5260d-ae5d-5323-a591-2766cfbd9c47)
2 The Mentally Ill (#udadbde77-3147-5157-9e1a-ddef837df2fa)
3 The Young and Vulnerable (#litres_trial_promo)
4 The Prison System (#litres_trial_promo)
5 The Outsider (#litres_trial_promo)
Bibliography (#litres_trial_promo)
Index (#litres_trial_promo)
Acknowledgements (#litres_trial_promo)
Copyright
About the Publisher (#litres_trial_promo)
INTRODUCTION (#u65628d9d-9694-53db-a746-b63e5f381da6)
In March 2004, a wonderful story appeared in The Guardian headed: ‘Q. How many care workers does it take to change a light bulb? A. Ask a risk assessor.’* (#ulink_25392752-858f-522f-9441-d9391d67b00b)
The Department of Health had devised an advertising campaign to attract people into becoming care workers that showed a care worker reaching up to put a new bulb in for an old man–without any obvious assistance. The advertisement read: ‘If you could do the small things that make a big difference, you could earn a living in social care.’ But many care workers say they are not allowed to change light bulbs–not on their own, at least. One local authority said it might take four people to do it: one to hold the ladder, one to turn off the electricity at the mains, one to stay with the old person, and one to change the light bulb. This is to comply with both Health and Safety rules and electrical safety legislation, but it obviously leads to some considerable difficulties. It is this kind of risk aversion–extreme though this case is–that this book is about: rules and regulations, well founded, well meant, even theoretically sensible, that yet lead to an extraordinary situation in which a care worker cannot change a light bulb for fear of the consequences, and which makes the lives of vulnerable people more difficult than they need be.
This is an extreme example, but it is not unusual. For six years I was Chief Executive of the King’s Fund, a charity devoted to the health and healthcare of Londoners, with a watching brief for the National Health Service as well. During that time–and indeed before–I have watched bemused as we have apparently become less and less caring for, or even aware of the suffering of, the most vulnerable in our society. This is not to say that there are not hundreds of thousands of people who, every day, carry out acts of kindness for a variety of people in trouble. Nor is it to say that we are bad people, or uncaring–though we may be–or insensitive to the needs of others, or incompetent, or somehow unaware in other ways. Nor is it to argue, as religious leaders have often done, that we have become selfish–though that, too, may be partially true. I believe that something else is going on: a complex pattern of interacting ideas, events, the Zeitgeist, and personal human attitudes that has somehow allowed us to reach this position. In this book I hope to tease out some of the contributing factors by examining what has happened to some of the most vulnerable groups in our society–the elderly, the mentally ill, children in care, offenders, and asylum seekers.
As I began the thinking for this book, I realized that I was not alone in my concerns. I was astounded by the number of people of all political persuasions, all backgrounds, classes, and creeds, who told me I needed to write it, that it was somehow important. They were not necessarily going to agree with me, but they believed we needed to ask ourselves some questions, and that the stories in our daily newspapers, the material with which we argued over politics–insofar as anyone did any more–or social issues or economics suggested some deep-seated problems in thinking about how we might sort our society out.
Concerns varied. There was a passionate concern about how we treat the elderly in our society, about the welfare of people with mental illness, and about what happens to children in care.
There was also a widely expressed view that our penal policy is a mess: we are putting more and more people into prison, but we have less and less idea about whether we are trying to punish, rehabilitate, contain, or simply forget about them.
Then there was a growing body of opinion that felt our policies towards asylum seekers were plain cruel, that if we could not sort out our immigration and appeals system then it was hardly fair to blame those who were trying to come to the UK, even if some were–to use the jargon–economic migrants rather than true refugees.
These are some of the issues that concern many of us–and may also touch us directly. The proper care of our elderly relatives is an issue that we all have to face at some time. Many of us know someone with mental health problems, and we may ourselves have had some period of depression or some other relatively minor mental illness and so will have seen first-hand something of what the system offers (or fails to offer) by way of help and support. Most of us will have read horrendous stories about children in care and what happens to them when they leave–we may even have experienced this ourselves. We may also have read about, or have first-hand experience of, ex-offenders, some of whom will have been in care and many of whom have mental health problems. And whilst most of us will not have direct experience of today’s asylum seekers, many of us may know someone whose family came to this country as refugees.
What kind of society is it that locks up those with mental illness in prisons, rather than placing them where they can get help and care, that fills them up with drugs but shows them little kindness?
What kind of society is it that allows our young care leavers to gain access to the criminal fraternity so easily and denies them the support of mentors and befrienders in their late teenage years and early adulthood?
What kind of society is it that makes so little effort regarding ex-offenders that many of them feel so unsupported that they fall back into offending for want of anything else to do?
What kind of society is it that locks up children from asylum-seeking families, that fails in its duty of kindness towards the stranger, and that fails to recognize the rights of children, who are in no way to blame for their lot?
And what kind of society is it that fails so lamentably to protect older people from abuse whilst also failing to offer proper long-term care for those who need it?
We have made it more difficult to help such people. Part of this book will examine why it is so hard for ordinary people to help those less fortunate than themselves–the kid in care, the old lady next door whose life is getting tough. For, as a result of scandals surrounding some of our institutions–for example in children’s homes, schools, and foster homes–we do not allow ordinary people to help. For instance, an obsession–not wholly misplaced–with sexual predators has made it necessary for anyone who works with children to undergo a police check. Until recently it also meant that a child in the care of foster parents could not spend a night with a friend unless the friend’s parents agreed to undergo police checks too. The need for school teachers and helpers to be checked for their past record also means that those who might be willing to help on an occasional basis must also be checked by police.
Such vigilance in itself may be no bad thing. But the fact that we have become so stringent in our requirements for checks on those who work or have any relationship with children means two things: first, that children themselves are encouraged to be suspicious of adults in a way that may be quite unhealthy, both for themselves and for society as a whole; second, that those who are inclined to look after a child or young person who is distressed–who is, for instance, lost, or is being attacked by older children–will be very nervous of getting involved. Suspicion of motives has forced some people, particularly men, to restrain ordinary common decency and kindness. Yet many of our most troubled young people–though by no means all–have no regular, stable male role model in their households. Add to that an ever-growing worry over paedophilia and you have a picture of a society that wants to protect children from potential attack but which may end up by destroying valuable relationships between young people and their elders, purely because fear of sexual attack takes precedence over a belief in ordinary common humanity. When photographs of children at nursery school cannot be taken without parental consent, for fear of pornographic use, we have a problem. When we are so suspicious of adults’ motives in wanting to help a child that one cannot help in a school–even one’s own children’s school–without a thorough and lengthy police check, we may have a legitimate point of concern, but we will deter all but the most determined helpers.
Our fears are not wholly unfounded. We have, in recent years, lived through the Soham murders and through a series of scandals surrounding children’s homes and special schools. In the USA, one smart California nursery was thought to be the centre of a wave of bizarre sexual and other attacks on small children. The Roman Catholic Church is still reeling from revelations about the number of attacks on young children by priests and from stories of violence and abuse by priests and nuns in Catholic-run children’s homes, about which senior church members knew and did nothing–or, worse, simply moved the offending priests or nuns on and did nothing to protect the children or heal their wounds. Yet, for all that, such a level of protection of children will lead to them being unable to trust anyone. Anyone accused of an attack on children is likely to go underground. The situation may well arise in which those who want to help children whose own families may be the worst abusers, or children whom circumstances have let down in a big way through parental death or family breakdown, are deterred by the bureaucracy through which they have to go. It is as if we are trying to create a risk-free society, which we know in our heads and our hearts is impossible. The result is that we restrict and regulate, hoping to make terrible things impossible whilst knowing we cannot, and, in the process, deterring the willing and the kind.
Then there is the unwillingness of many nurses to do what they once did best–holding the hand of an elderly person and dispensing simple TLC–through fear of being accused of assault; or being unwilling to offer a dying person a drink in case they choke, thereby risking legal action against themselves or, more likely, the hospital. The bureaucracy involved in serious untoward incidents, as they are called, is now so enormous that many senior nurses spend huge amounts of their time in filling out forms, making a nonsense of their nursing and caring roles in an increasingly risk averse culture. Professionals have become polarized into those who do case management–including when things go wrong–and those, more junior, who do the actual caring. Because of the requirements of the Health and Safety Executive, nurses cannot even lift an elderly person who has fallen out of bed: they often have to be left until suitable hoists can be found.
None of these things is necessarily wrong in itself. But the cumulative effect of a risk-averse culture results in an erosion of simple human kindness. A nurse will put a line into an elderly person for drugs to be given intravenously, but she will not hold a hand or stroke an aching back. An ordinary decent man, in his thirties say, with energy and skills that could be put to good use working with young people, will give a charitable donation to Childline or to the National Society for the Prevention of Cruelty to Children, but is unlikely to sign up to a mentoring scheme that would give him regular contact with an individual disturbed and deprived 14-year-old boy: it is simply too much trouble to go through the checks. If the man is himself gay, then official doubt and suspicion will be all the greater. If he is heterosexual and wants to mentor a girl, yet again suspicions are aroused–and his computer will be checked for pornographic images.
Aversion to risk pushes out common sense, and the smallest of risks now takes precedence over what we used to call kindness and care. The result is that the kindness one sees in hospitals often comes from porters and care assistants rather than from senior staff. Similarly, kindness to people with severe mental health problems often comes more from the owners of the cafes in which they sit for much of the day, or from the staff in public libraries, than from the nurses and outreach workers who are in a position to really extend a hand. This is not because of ill will or lack of feeling but because the system is increasingly unwilling to allow nurses and carers to take on any risk. An arm around the shoulders might be thought to be common assault. An invitation to have a meal might be seen as some of kind of sexual lure. And so we reach a situation in which social care assistants are told that it will take four people to change a light bulb for one vulnerable old person, whilst one of the teachers’ unions has called for an end to school trips for fear of accidents after three children have died in recent years.* (#ulink_b438af1a-8885-5054-91fd-1be45e3a5ef0)
Risk aversion has made for part of the difficulty and has increased a natural human reluctance to get involved. That reluctance has been exacerbated by urban living. Many city dwellers lead isolated lives, in contrast to the sense of community still possible in rural or suburban areas, and have an unspoken, unofficial code of not interfering in each other’s lives. This means that those in trouble can become totally alienated. Around Christmas and New Year, when many of the regular support services close for ten days at a time, the needy can find themselves totally unsupported. No friends, no family-and the reluctance of strangers to get involved. Kindness is in very short supply.
That reluctance will grow unless we look carefully at why we have deliberately allowed this culture of risk aversion to grow, why we are so suspicious of sexual motives, and why we no longer trust the stranger. And this requires examining our own personal experiences. If we fall in the street, it is the stranger who picks us up and dusts us down. If we have a car crash, it is the stranger who calls the police and stays with us to give comfort. If we are mugged, it is the stranger who all too often gives us the wherewithal to get home. If we suddenly become distressed, or ill, or overcome with fatigue, it is often the stranger who carries our bags, asks if we are all right, and offers to take us to the Accident and Emergency Department of the local hospital. Of course there is always risk: the person who carries our bags home may proceed to burgle the house; the person who takes us to the emergency room after we have been raped may turn out to be the rapist. But these are exceptions. There are still people out there who give up their seats on the underground or the bus to older people. There are still people who pick you up and dust you down. And yet we are making it more difficult for such people to do good deeds. Why, as evidence grows that crime is down, are we ever more fearful, ever more timid?
To answer this, I think we have to look in detail at some of the major inquiries that have been carried out into abuses of the vulnerable. In each section of this book, I shall try to examine some of the reports, the newspaper stories, and the official responses to such inquiries looking for clues as to why we are increasingly reluctant to get involved and why that reluctance may have its root, at least in part, not only directly within ourselves, but also in the culture we have created for ourselves with the best of intentions: to protect the weak and to deter the aggressor.
Today, it seems we have a desire to do everything possible. We want to stretch the limits: cure the incurable, reach the unreachable, do the undoable, explore the inaccessible, travel to the most exotic and impossible places. Yet at the same time we have never been so internally reflective, so obsessed with ourselves and our feelings, so dedicated to understanding ourselves. Our gaze runs both to the furthest horizons and into the deepest recesses of ourselves. Yet by our desire to go to the extremes in medical treatments we often cause damage and bring suffering, as well as sometimes achieving miraculous cures. By our desire to go to the furthest reaches of the world we may cause environmental damage or destroy the lives of those we encounter. And, as we look deeper and deeper into ourselves, we lose the will to think beyond ourselves to others, lose the inclination to help others, to serve others, to work for others, to look into the middle or near distance. We fail to deal with what we find at our feet or in our communities.
This is, of course, a huge generalization. Yet our obsession with self–which may not necessarily be selfish but is perhaps self-indulgent–does lead to some strange behaviour. As the death of Princess Diana recedes into the middle distance, it is hard to remember the reaction many people had to it. Yet a walk through London’s parks in those days immediately after her death was a curious experience. All over, there were groups of people–largely women–sitting in small groups, often round a lighted candle, contemplating, reminiscing, remembering, memorializing. But they were not, after the first few minutes, thinking of Princess Diana. Their grief, though real and genuine at the time, was not truly about the death of the fairy princess. This was something quite different. They were remembering themselves, grieving for those they had not grieved for before, remembering mothers, fathers, siblings, even children, remembering the grandparents whose funerals they had not been allowed to go to. This was a sentimental wash of grief, hitherto unexpressed and even unrecognized. But the mood was not one of enormous sadness over Princess Diana’s death. The sadness was for them, and it played out as something truly self-indulgent. It also meant that those participating were looking inward, at themselves and their experiences, one of the curses of our age, rather than thinking about what outward action they might be taking to improve things for others worse off than themselves.
This, perhaps, has been the most dramatic recent example of group behaviour that caused a combined rush of sentimentality and genuine grief. Self-indulgence was combined with necessary grieving processes, sometimes much delayed. Yet the light was not shone externally. We were not looking to see who else might be suffering, or why. Instead, the light was directed inwardly, on ourselves. What we felt became what mattered. When the Queen did not come straight back to London from Scotland, we complained–irrespective of what her feelings might have been, or her desire to protect her two grandchildren. The Queen needed to be back at Buckingham Palace because we wanted her there. It was an astonishing example of the triumph of the group desire for personal gratification over common sense and understanding. Yet part of this desire to look inside ourselves is precisely what leads to that lack of a longer, more measured view. Though psychotherapy has brought great gains, it has encouraged an emphasis on personal priorities over those of the group; and whilst counselling has made a huge difference to many people with a variety of mental health problems, as a tool for everyday self-examination it can, at worst, lead to an inability to act.
What has happened might be argued to be an unfortunate confluence of events–or of intellectual and emotional pressures. At the same time that individualism became paramount, the then Prime Minister, Mrs (now Lady) Thatcher was alleged to have declared that there was no such thing as society and consumerism hit its heights, making the consumer king, rather than the citizen. Concurrently, the obsession with introspection grew in intensity, combined with a political and philosophical view that the individual should control what happened to him or her. The combination of all these factors led to a distaste for looking at the welfare of society as a whole. As a philosophy, utilitarianism–the doctrine that the correct course of action consists in the greatest good for the greatest number–was held in severe disrepute. Individual endeavour was what was needed. Utilitarianism might deter the huge efforts, for huge gains, of the talented entrepreneur. Society looked less at the welfare of the whole and more at the welfare of the individual, whilst the intervention of the state was seen to be less than desirable, and often less than benevolent to boot. In addition, it was perhaps inevitable that a utilitarian state found it difficult to deal with minorities of whatever kind since it was predicated on the idea of a one-size-fits-all approach to the world. There was little appreciation that minorities might choose not to fit, something that needs to be remembered when ideas about multiculturalism are becoming unfashionable and the opposing idea that we should all comply with something uniquely British is growing again.
This contrasts curiously with a strongly held belief in the values of the National Health Service, the only truly universal service in the UK, used by everyone. The NHS was predicated originally on the idea that the best possible care would be provided for the greatest number of people. It encapsulated utilitarianism at its height, in an immediately post-war world in which having a population fit enough to work well to rebuild Britain was a priority. The original view was that universal health care would lead to a country in which everyone would be healthy and less state care would be necessary. It did not work out like that; indeed, pressures on costs have continued throughout the history of the service. The NHS expressed a philosophy–these days a series of values which do not wholly fit together–about the obligation of society to look after the sick and the needy. We pool the risk, and we share the care and the responsibility. Despite worries about quality and standards, and worries as to whether the service will be there for us when we need it most, the NHS is still highly trusted and much loved, even though there are concerns about its ability to provide a service fit for the new millennium. The welfare state may have its difficulties, but the UK population still believes in it. The way it works may change: there needs to be greater choice, greater acknowledgement of diversity. But by providing health services relatively cheaply and efficiently to the whole population, the NHS is part of the glue that holds British society together.
For we are individuals now. We demand things. We go for the personal. We understand our own needs. The idea that we might not be able to have what we believe we want and need is anathema to us. We have become demanders, not citizens; we look to ourselves rather than to society as a whole. This tendency is not new, but it has acquired far greater weight. The words so often uttered, particularly by elderly people, until just a few years ago, that ‘I have had my turn, it’s someone else’s go now’ are becoming rare. We see no need to moderate our demands. We see no reason to say that we have had our share. It is no longer about our fair share, but instead about when we feel-as autonomous individuals-that we have had enough.
The idea of an obligation to society, beyond the demands we ourselves wish to make, has become unfashionable. Utilitarianism is out of the window, as is mutualism. We are into understanding ourselves, into self-improvement, into improving our homes, our looks, our minds. Our view of faith is also increasingly individualistic. We choose the elements of faith that suit us. Individual salvation is part of the appeal of the evangelical movement. Personal salvation is the carrot held out. But the requirements which our faiths put upon us to consider others may get less than their fair expression. Despite all the surveys demonstrating widespread belief in God, despite the huge readership of religious books and the increasing attendance at evangelical churches, the idea of social solidarity-about evening up the inequalities, about making a difference to groups or individuals who suffer-has taken a battering.
This book seeks to examine some of these issues. It does not attempt to be a philosophical work, nor a work of political theory. Rather, it is an attempt to show the ordinary reader where we have got to with our system of care for the less fortunate, and why, and to examine whether there are things we can do to improve it. Though the welfare state will be seen by some as being critiqued in the book, I am a profound believer in its values. But I also believe that, in the light of social change and huge increases in wealth and expectations, we will need to reassess what we can reasonably expect to provide for everyone. Throughout my adult life, we have tinkered with the welfare state at the edges, be it in changing the provision for the very elderly–the greatest consumers of the welfare state’s provision–or in how we provide health care. The question that arises is whether such tinkering has gone on long enough and whether we might now need to rethink some aspects of the welfare state and its basic value system as we assess what we can and should do for the most unfortunate.
This is both a political and an ethical issue. In a society where voting figures are reducing and where trust in politicians is at an all-time low, reassessing what we provide for the most disadvantaged is difficult to do. What we have is a failure of trust combined with an aversion to risk: those who work in our health and welfare services do not trust the politicians not to blame them when things go wrong. And we have a society that thinks politicians lie when they promise various services for all of us, including the most disadvantaged. Improvement in education? Show me. More higher education? Where is it, and why have I got to pay for it? Yet trust is essential if we are to value our services, and risk aversion will make for bad services, where no one will do what seems natural and kind in case they get accused of behaving improperly or riskily. We look at ourselves and make our demands. But we fail to look out at others. Our sphere of endeavour is both vast–we see the world and beyond as never before–and tiny, as we sit glued to our television screens and fail to go out of our front doors.
I believe we have reached a stage where trust is under threat, where politicians–often unfairly–are regarded as being only out for their own ends. Yet we cannot just turn our backs. If we want a society where people feel that fairness is part of the ethos, we need to be seen to be involved with our politicians and thinking about our society. We cannot just let our concepts of fairness and mutuality go, and then complain. If we are too individualistic, then we will suffer, for our happiness, as Richard Layard argues so cogently,* (#ulink_85edb5d9-a835-5f5d-a14d-442501482afb) will suffer, but so will our sense of belonging.
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.
