Table Of ContentAGING: CULTURE, HEALTH, AND SOCIAL CHANGE
INTERNATIONAL LIBRARY OF ETHICS, LAW,
AND THE NEW MEDICINE
Editors
DAVID C. THOMASMA, Loyola University, Chicago, U.S.A.
DAVID N. WEISSTUB, Universite de Montreal, Canada
THOMASINE KIMBROUGH KUSHNER, University of California, Berkeley, U.S.A.
Editorial Board
SOLLY BENATAR, University of Cape Town, South Africa
JURRIT BERGSMA, Rijksuniversiteit Utrecht, The Netherlands
TERRY CARNEY, University of Sydney, Australia
UFFE mUL JENSEN, Universitet Aarhus, Denmark
GERRIT K. KIMSMA, Vrije Universiteit, Amsterdam, The Netherlands
EVERT VAN LEEUWEN, Vrije Universiteit, Amsterdam, The Netherlands
DAVID NOVAK, University of Toronto, Canada
EDMUND D. PELLEGRINO, Georgetown University, Washington D.C., U.S.A.
DOM RENZO PEGORARO, Fondazione Lanza and University of Padua, Italy
ROBYN SHAPIRO, Medical College ofW isconsin, Milwaukee, U.S.A.
VOLUME 10
The titles published in this series are listed at the end of this volume.
AGING: CULTURE, HEALTH,
AND SOCIAL CHANGE
Edited by
DAVID N. WEISSTUB
Philippe Pinel Professor of Legal Psychiatry and Biomedical Ethics,
Faculte de Medicine, Universite de Montreal, Canada
DAVID C. THOMASMA
Professor and Fr. English Chair of Medical Ethics,
Neiswanger Institute for Bioethics and Health Policy,
Loyola University of Chicago Medical Center, U.S.A.
SERGE GAUTHIER
Professor ofN eurology, Neurosurgery and Psychiatry, Centre for Studies on Aging,
Faculty of Medicine,
McGill University, Canada
and
GEORGE F. TOMOSSY
Ross Waite Parsons Scholar,
Faculty of Law,
Unive rsity of Sydney, Australia
SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.
A C.I.P. Catalogue record for this book is available from the Library of Congress.
ISBN 978-90-481-5896-6 ISBN 978-94-017-0677-3 (eBook)
DOI 10.1007/978-94-017-0677-3
Printed an acid-free paper
AU Rights Reserved
© 2001 Springer Science+Business Media Dordrecht
Original1y pub1ished by K1uwer Academic Publishers in 2001
Softcover reprint of the hardcover 1s t edition 2001
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means, electronic or mechanical,
including photocopying, recording or by any information storage and
retrieval system, without written permission from the copyright owner.
TABLE OF CONTENTS
Preface ..................................................................................................................... vii
Acknowledgments .................................................................................................... xiii
Contributors ............................................................................................................. xv
PARADIGMS
PATRICIA M. THANE
Changing paradigms of aging and being older: An historical perspective ................. I
GEORGEJ. AGICH
Implications of aging paradigms for bioethics ......................................................... 15
JOHN MCCALLUM
Health in the "grey" millennium: Romanticism versus complexity? ....................... 29
SOCIAL RESPONSES
TERRY CARNEY
Protecting aged citizenship: Rethinking the "mutuality" of state
and civil society? ...................................................................................................... 43
DANW. BROCK
Discrimination against the elderly within a consequentialist approach
to health care resource allocation ............................................................................. 65
MARSHALL B. l(App
Therapeutic jurisprudence and American elder law ................................................. 83
LINDA S. WHITTON
Finding the elder voice in social legislation ........................................................... 101
NICOLE DELPEREE
European social policy for the elderly .................................................................... 119
MARTHA PELAEZ & ALEXANDRE KALACHE
Aging in developing countries: A public health and human rights issue ............... 145
v
Vl WEISSTUB, THOMASMA, GAUTHIER & TOMOSSY
CULTURAL DIMENSIONS
PETER H. STEPHENSON
Aging and dying in cross-cultural perspective: An introduction to a critical
cross-cultural understanding of death and dying .................................................... 161
ANNE LEONORA BLAAKILDE
Old age, cultural complexity, and narrative interpretation: Building bridges
in a 2151 Century world of diversity ........................................................................ 175
CHERRY RUSSELL, DENISE TOUCHARD, HAL KENDIG & SUSAN QUINE
Foodways of disadvantaged men growing old in the inner city: Policy issues
from ethnographic research .................................................................................... 191
REFLECTIONS
GEORGEB. PALERMO
The affective alienation of the elderly: A humane and ethical issue ...................... 217
RENZO PEGORARO
Reflection on aging: A time to live and to share .................................................... 231
Index ....................................................................................................................... 245
PREFACE
Culture, Health, and Social Change is the first of three volumes on Aging conceived
for the International Library of Ethics, Law, and the New Medicine, followed by
Caring for our Elders and Decisions at the End of Life. We have assembled this
collection of essays to include perspectives from colleagues from a range of
disciplines - history, medicine, philosophy, anthropology, sociology, nursing, and
law. These contributions only scratch the surface of what are a great number of
socially relevant issues that merit investigation. Indeed, it is clear from this series of
reflections why "aging" commands such an expansive multidisciplinary body of
scholarship that goes well beyond its study merely as a biological process. Our
foremost objective is that the chapters included in this volume stimulate further
dialogue and contemplation in this vitally important field of inquiry.
PARADIGMS
Demographic studies are consistently predicting the increasing proportion of "aged"
members in our global population. Corresponding pressures on the allocation of
public and private resources will make it more difficult for individuals and
governments to balance the needs of present and future generations. This is (and
promises to be) a daunting task for developed nations, not to mention for emerging
economies. Not surprisingly, planning for the health of an aging society raises
profound issues in law, ethics, and public policy. Yet how we approach and
understand aging as a social phenomenon may have indelible effects on existing and
future "elders." Understanding cultural preconceptions of aging and how these have
changed - or should change - is therefore of immediate relevance.
It is appropriate that we begin this series on Aging with an historical perspective.
Patricia M. Thane cautions us against the pitfalls of prediction, that is, assuming that
paradigms based upon the experience of past or present generations can be
extrapolated into the future. Clearly, the life experience of someone in their 80s,
born before World War I, was markedly different from that of a baby boomer, the
latter having been exposed (at least in developed nations) to vastly improved living
standards and medical advances. Likewise, while fixed age thresholds are essential
for demographers to make statistical comparisons over time, it is important to
acknowledge that "'old people,' though often referred to as an undifferentiated mass,
is the most disparate of age groups," with definitions of aging having varied at
different times, in different contexts, and for different social groups. Prof. Thane
reminds us that "old age is and always has been the most complex of stages of life,"
and that negative perceptions of aging, such as the belief that family ties have
eroded in western societies, are not necessarily accurate. It is important to recognize
vii
Vlll WEISSTUB, THOMASMA, GAUTHIER & TOMOSSY
the fallacies of negative popular and official perceptions that continue to shape
government policy and interactions between older people with family and
professionals, but which seem "increasingly at variance with the potential capacities
of very many older people."
Reflections on aging also form a core component of the bioethics literature. In
this area, George J. Agich challenges what he describes as the single-most
influential paradigm, the "life span model," which involves "a set of normative
beliefs that conceive aging as a conventional process of development through
distinct stages or phases, each composed of a set of characteristic features or tasks."
He argues that if one is attentive to autonomy-enhancing aspects of aging research,
rigid reliance on the life span paradigm is problematic as it fails to account for the
malleable nature of aging. Bioethicists have failed to critically analyze the
conceptual and value assumptions underlying the life span model, and cannot
thereby provide an adequate framework to interpret ethical issues associated with
aging. The author submits that bioethicists must overcome this way of thinking and
be open to alternative normative structures.
John McCallum explains why common metaphors of aging - such as, pessimistic
(the elderly as a burden on society) and romantic (good health and long life available
to all) - do not adequately respond to the complex range of ethical and political
issues in an aging society. He illustrates how comparing disability-adjusted life
expectancies provides a better measure of the health of a population, thus
highlighting the well-supported policy objective of maximizing periods of life free
of disability, rather than merely increasing length of life. In the context of broad
historical changes, trends in disability have been characterized by a theory of
epidemiological transition, which identifies a series of sequential stages of disease
types and their prevalence. Prof. McCallum argues that the last phase ("compression
of morbidity") "does not capture the realities of disease in an aging and affluent
society." Instead, he proposes a new phase, "substitute and comorbid disease,"
which better reflects the complexity of co-existing diseases and expectation of
others as death approaches. It recognizes the importance of understanding complex
events and syndromes, as opposed to single diseases, in the context of national
health trend monitoring and the development of best practices guidelines or
evidence-based practice methods.
SOCIAL RESPONSES
Having canvassed various paradigms on perceptions of aging, the next focus is to
examine responses to aging (including their social and philosophical underpinnings),
particularly with regard to implementing legal structures to support - and where
necessary, protect - older citizens. These chapters demonstrate why progressive
policy formulation requires constant re-evaluation of existing policies in order to
determine their efficacy and fidelity to their underlying philosophical or social
foundations.
WEISSTUB, THOMASMA, GAUTHIER & TOMOSSY ix
Approaching this question from a socio-legal perspective, Terry Carney makes
the following observation:
The quality of law, civil society, and state services is ultimately to be judged by the
adequacy of their engagement not only with the atomized "individual," but also with
their micro communities of family, friends, and local communities. To do this, they
must reflect something of the richness and diversity of human existence.
With this in mind, Prof. Carney contrasts traditional and "new" welfare state
theories, that is, notions of the state as guarantor or distributor of fairness and
protection of vulnerable persons versus ideas of "mutual obligation" that underlie
the privatization of welfare. He points out that while guardianship laws and services
aim to protect, they may also oppress or prove ineffectual; advancing individual
autonomy, although important, should not be an exclusive goal if it condemns the
lonely or friendless to their own devices or neglects those who failed to plan (or plan
adequately) for their future needs. He counterpoises ideas of aged citizenship as
"freedom from" (external threat) with "freedom to" (actively engage in society).
Grounding his analysis in guardianship laws and services, he advocates the pursuit
of a model of "republican citizenship" through practical measures (such as tribunals
instead of courts) demonstrated to engage those networks, together with adequate
public funding to enable them to serve all aged citizens able to benefit from them.
He concludes that guardianship demonstrates the theoretical synergy between new
welfare and ideas of globalization and "postmodernism," but that a more inclusive
paradigm is required, one that expresses a communitarian conception of the aged as
active citizens connected to networks of relations with close others.
Policies must not only be evaluated, but also monitored to obviate undesired
effects. For example, an obvious dilemma presented by an aging population for all
nations is the allocation of healthcare resources. A common method for assessing
various models is on the basis of cost-effectiveness or cost-benefits, and which
employs the concept of a quality adjusted life year (QAL Y). Prioritization of health
care services in this manner raises a host of ethical issues. Dan W. Brock examines
these questions against the philosophical framework provided by consequentialism,
which provides that "human actions are morally right if, and only if, they produce at
least as good consequences as any alternative action open to an agent." Prof. Brock
explains why a consequentialist or cost-effectiveness analysis, though not using age
as a criterion, in fact discriminates against the elderly, and is hence morally
unacceptable.
Marshall B. Kapp evaluates elder law through the analytical lens of therapeutic
jurisprudence, which holds out the view that law itself is a social force that can have
a therapeutic effect. This method would determine whether specific legal enactments
in the United States intended to benefit older persons actually accomplish their
objectives. He examines relevant empirical research, as well as legal and ethical
commentary. His goal is not to answer this question in its entirety, but to identify a
policy-relevant research strategy to explore it more fully. As Prof. Kapp proposes,
"the ultimate policy objective ought to be to pair, as exactly as possible, specific
x WEISSTUB, THOMASMA, GAUTHIER & TOMOSSY
regulatory requirements with desired, beneficial outcomes, while allowing everyone
involved the greatest feasible amount of flexibility to pursue the public's goals."
In contrast, the concern expressed by Linda S. Whitton is not whether legal
enactments are true to their goals, but whether they resound with the voices of those
for whom they were implemented. In her retrospective analysis, she approaches this
question by first examining how our aging culture shapes the substance and
application of selected pieces of American social legislation, or whether it is the
other way around. Prof. Whitton reasons that social legislation in the twentieth
century has been significantly influenced by our aging culture, which is comprised
of "beliefs, behaviors, and attitudes about age, aging, and the aged." She concludes
that we must re-examine age-based legislation in cases where the perceptions upon
which they are founded are false or rooted in negative stereotypes, and in order to
accomplish this, embrace our own aging as a normal part of life.
A human rights-based approach is the focus of the next two chapters. They
illustrate the challenge of locating a set of universal values in aging.
Nicole Delpen!e provides us with a review of European social policy for the
elderly. She contrasts principles promoted by the United Nations, World Health
Organization, and Council of Europe, and compares various states within the Union.
She notes that while European consensus is "far from having been reached," due to
"strong philosophical differences" and different historical and cultural traditions,
one can nonetheless note convergence. From these principles, she argues for
"vigorous allocation of resources" in order to ensure a decent quality of life for
elderly in the European states.
Martha Pelaez and Alexandre Kalache address the very different situation of
aging in developing countries. They ask whether persons are more likely to suffer
human rights violations because of age, such as in the context of discrimination
(with respect to health status, labor force participation, and intergenerational
transfers) and vulnerability (lack of capacity to satisfy basic needs). This question is
difficult to answer because "old age, declining health, poverty, and inequity are
intimately linked to each other for people in developing countries." The response,
therefore, requires action across local, national, and international levels, and "must
be grounded in strong values that set equity objectives and assesses the impact of
present policies on the health of persons regardless of age with special provisions for
the most vulnerable persons."
CULTURAL DIMENSIONS
The human experience of aging is subjective, being influenced by factors such as
one's economic or social status, level of education, health, history, race, religion or
beliefs, familial ties, geographical location, and gender. Indeed, the diversity with
which aging is perceived, anticipated, and endured, both within and across cultural
groups, defies attempts to define a universal "aging culture," and understanding
these specificities may expose cracks in what might otherwise appear to be sound
social policy based on impressive (but general) demographic data. Ensuring that
