Paper for II Jornadas Internacionales Bioetica
Granada, 25 September 1998
Granada, 25 September 1998
Why begin a Conference on the elderly with a paper on `Human dignity and respect for the elderly'? For a variety of reasons there is a widespread questioning in our society of what respect for the elderly requires, and even a questioning of whether certain sections of the elderly population are owed any respect at all. By respect in this context I mean, at a minimum, recognition of basic human rights. In view of this questioning the position of many elderly people in Western societies has become distinctly precarious. There is a need to reflect on this situation, to identify its roots, and to see at least in broad terms what response to it is called for.
The background to the questioning I refer to is complex. Here, without pretending to be exhaustive, we can usefully distinguish economic and cultural factors in the background.
For some time now economic support for the elderly has been perceived to be a critical issue for societies which have had systems of welfare provision for the elderly. The reasons are well known. The percentage of the population who are elderly is increasing, while the percentage of those who are generating wealth and earning incomes is contracting. More particularly, the percentage of the frail elderly who are dependent on the support of others is increasing precisely when the resources for state provision of welfare are under stress both because of the changing population profile and because of levels of unemployment in advanced capitalist societies.
Thus, ten years ago, the Organization for Economic Cooperation and Development (OECD), in its 1988 Report Ageing Populations: The Social Policy Implications, predicted that the average annual growth rate of member states' populations would decrease from 0.5% during the decade 1980-1990 to -0.3% during the decade 2040-2050. The eventual decline of the total population would be accompanied by significant changes in the age-structure of the population. Between 1980 and 2040 the average proportion of persons aged 65 and over will have increased from 12.2% to 21.9% of the total population while the average proportion of those aged 15 years and under will have fallen from 23.4% of the population in 1980 to 18.3% in 2050.
The most significant aspect of the growing percentage of elderly people in the population is the marked increase in those aged 85 and over. Among this group is a large number of elderly people who are severely impaired physically and/or mentally. The expansion of the elderly population will result in a significant increase in those suffering from dementias. Estimates of the number of dementia sufferers vary considerably but the figure among those aged 85 and over has been put at 20%.1 In general, demand for health and social care rises sharply with age: 1% of those aged 75-79 have severe disabilities compared with 41% of those aged 85 and over.
The cultural factors in the questioning of respect for the elderly have a much longer history than the demographic trends to which I have alluded, and the economic implications of those trends. When I speak of cultural factors I have in mind whatever is directly involved in the creation, maintenance or modification of those shared meanings in terms of which members of a society understand and live their lives.
Cultural historians of the condition of the elderly in society have noted a radical change in that condition emerging over recent centuries. As one such historian has noted "improved medical and economic conditions for older people have been accompanied by cultural disenfranchisement - a loss of meaning and vital social roles".2
In our Christian past old age was seen as an integral part of a spiritual journey which gave meaning to the whole of one's life. The goal of this journey was known to be union with God in the beatific vision. The characteristic condition of old age, with its frailties and dependency, could be an occasion for spiritual transformation and transcendence - for acknowledging the fundamental truth of the human condition, our dependence on God and on his love and mercy. The frailty and dependency of old age were understood both as belonging to the given order of life - as inescapable in character - and as having a positive role in disposing us to the fulfilment for which we were made by deepening our awareness of our dependence on God. Hence old age, precisely in its ineluctable frailties and dependency, could be understood to have a positive significance.
What emerged in the nineteenth century was a dichotomised view of ageing, in which a `good old age', free of disease and frailty, was seen as the reward of healthy living, and a `bad old age' was seen as the consequence of ignoring the requirements of healthy living. On this view old age ceases to be an ineluctable challenge to self-transcendence and becomes a "problem" to be solved by will-power aided by medical science and technology. Precisely in so far as this project fails - as it must fail, since physical decline and frailty are ineluctable - then the failures, on this view of old age, must seem to lack positive meaning.
This is the pathos of the situation of the elderly in Western, urbanised countries today. Medical science has helped to save them from premature death from acute disease and has given them longer healthy lives than their ancestors, but has left them to be overtaken by death from chronic disease; and our secularist culture offers no sense of what might redeem this fate.
This pervasively negative sense of the frailty and dependence which overtake the elderly is the broader cultural context for a radical tendency in contemporary philosophy which would deny value to the lives of those elderly who have lost control of their lives in the sense of having lost the capacity for self-determination. This denial of value is equivalent to a denial of dignity. For to possess human dignity is to possess a value which commands respect in the sense of commanding acknowledgement of the human rights which belong to a person.
The philosophical radicalism I have in mind denies that value and dignity belong to human beings just in virtue of the fact that they are human. For a secularist account of our existence recognises no goal (`telos') proper to it and no objective order of values in responding to which we achieve that goal. Human lives are said to acquire value just in so far as the persons whose lives they are invest them with value. To invest one's life with value one must, of course, have certain developed abilities - in particular, abilities to understand and to choose. So possession of these developed abilities is a minimal condition for a human life having value. Hence, human beings lacking the requisite developed abilities lack lives with a value of their own.
Advocates of this kind of position characteristically hold that unborn children, and infants and young children, and those with serious mental handicaps, and those suffering from advanced senile dementia, and those who are permanently unconscious lack value and dignity and so lack basic human rights. For on the radical philosophical view of the value of a human life which I am describing, basic rights, if they exist at all, exist to protect the choices and the chosen activities of the person who is presently capable of investing his life with value. The slogan for this position might be: "Autonomy creates value". Meaning: it is a person's own preferences and choices that determine what it is for his life to have value.
Let us just pause to reflect on the social significance of the philosophical radicalism I have identified in relation to the position of the frail and dependent elderly in our society. On the one hand, as we have seen, our society does not in general accord any positive significance to their condition. Furthermore, the demands they are perceived as making on systems of health care and social support are increasingly thought to be unsustainable. Philosophical radicalism presents itself in this social context as a useful rationalization for policies of neglect and non-voluntary euthanasia.
There is an increasingly powerful movement of advocacy of voluntary euthanasia in Western societies. Reflection on the rationale for voluntary euthanasia ought to make it clear that what purports to justify a doctor killing a patient is not the mere request to be killed but the judgement that the life of the patient is no longer worthwhile. To believe that there is continuing worth in the life of a patient is to have a conclusive reason not to kill that patient. 3
This analysis of the fundamental rationale for voluntary euthanasia makes clear that its legal accommodation must usher in the legal accommodation of non-voluntary euthanasia. If there is a case for saying one benefits human beings by putting an end to lives they themselves think no longer worthwhile, there is an equally plausible case for saying one benefits, or at least does no harm to, those one kills who are deemed no longer to have worthwhile lives because they are incapable of attaching value to their lives.
The social significance of philosophical radicalism's case for non-voluntary euthanasia is that it rationalizes our culture's failure to see positive meaning in the ineluctable frailties and dependency of old age, while at the same time offering a tantalizing solution to the problem of relieving the strains placed on the social budget by the increasing needs of the dependent elderly. For this reason philosophical radicalism's view of human worth and dignity has ideological attractions, i.e. the attractions of rationalizing what people are inclined to do in face of their perception of a pressing problem.
It is indeed important to understand that philosophical radicalism is offering no more than ideology- rationalizations for what some want to do. And we can see this if we recognise the inherent unreasonableness of the understanding it proposes of human dignity and value.
To see the unreasonableness of the proposal consider first its implications for our understanding of justice in society. My thesis is that the radical philosophical position on human value and dignity makes a defensible understanding of justice impossible.
One of the key questions which requires to be answered if there is to be a framework of just relationships in society is the question: Who are to be counted as the subjects of justice? In other words: Who are entitled to be treated justly?
Obviously we need an answer to this question which is not arbitrary, since an arbitrary answer plainly cannot settle in a satisfactory way which human beings should be treated justly. Arbitrariness in determining the answer to such a fundamental question would incontestably appear to be unjust discrimination. But the view that human lives possess no intrinsic value simply in virtue of being human, and that whatever value they have is something that has to be acquired and may be lost, is a view which can yield only an arbitrary answer to the question `Who are the subjects of justice?'
On the radical view the minimal conditions for investing one's life with value were that one possessed certain developed abilities, more particularly abilities for understanding and choice. Confronted with such a conception of the conditions for a life having value one is bound to ask: Precisely how developed do the relevant abilities have to be for a life to have value? Take, for example, the ability to understand. A crucial part of the ability to understand is demonstrated in the mastery of concepts. Mastery of the word `eschatological', for example, is shown in the correct use of the word in sentences. If I hear someone say "The colour of the sunset was eschatological" I can be fairly sure he is floundering and does not understand the meaning of the word. But depending on what existing body of concepts the person has already mastered one may be in a position easily and rapidly to teach him the correct use of the word `eschatological'.
Now proponents of the thesis that you need some degree of developed understanding in order to be able to invest your life with value typically have in mind that people should have some understanding of the fact that they are subjects, who have a future, which is potentially desirable and enjoyable for what one can do in it and make of it. To be able to understand that much requires a fairly sophisticated mastery of concepts. It is clear that the achievement of such understanding does not neatly correlate with a precise chronological age. More importantly, the difference between any one person in possession of such understanding and another person not evidently in possession of it may be marginal in developmental terms: one week you are not clearly there, the next you have evidently arrived. It would be absurd to suggest that that sort of difference between human beings should make the difference between whether or not they were entitled to be treated justly.
In general, the entire proposal that to be counted a subject of justice one must have arrived at some stage in the development of psychological abilities, such as understanding and choice, is afflicted by the vice of arbitrariness. Any stipulation of what the relevant developmental stage is involves drawing a line which is bound to invite the charge of arbitrariness given the function of the line-drawing exercise in this context. It is clearly arbitrary to determine who is and who is not entitled to be treated justly by drawing a line defining a developmental stage which many will be close to achieving but who, in failing to achieve it, will be deemed not to possess basic human rights. Wherever one draws a proposed line its role in determining who are entitled to be treated justly is exposed to this objection.
This shows, I think, that the view that the value of life is something which can be acquired only by acquiring certain psychological abilities and that it may be lost when those abilities are lost is a view which entails arbitrary discrimination between human beings of the most radical kind. Since within the logic of this view we cannot arrive at anything other than a discriminatory way of determining who are the subjects of justice, we are driven back to the only assumption which will support a non-discriminatory way of determining who are the subjects of justice. That assumption is, of course, the belief that every human being possesses an inherent worth and dignity simply in virtue of being human.
This indispensable assumption is also intrinsically reasonable. It is true that the distinctive dignity and value of human lives are manifested in those specific exercises of developed rational abilities in which we achieve some share in such humanly significant goods as truth, beauty, justice, friendship, integrity and the love of God. But the necessary rational abilities are acquired in virtue of an underlying or radical capacity, given with our nature as human beings, for developing precisely such abilities. It should be clear, however, that the dynamic of this radical natural capacity is not directed to the acquisition of rational abilities in order for them to be exercised in just any fashion. Our abilities to know and choose are not properly exercised by, for example, believing falsehood or choosing to act unjustly. The nature in virtue of which we come to acquire rational abilities has its proper fulfilment, then, in exercises of rational abilities in which we recognise worth and dignity. But if it is characteristic of the nature of human beings to acquire abilities which are properly exercised in ways which are inherently valuable, then it is reasonable to hold that there is an inherent value or dignity in the nature we share in common, and seriously unreasonable to judge that the lives of some human beings lack inherent value because those human beings lack developed and presently exercisable abilities of understanding and choice.4
There is a second way in which one can show the ideological character of the philosophical radical's understanding of human dignity, i.e. its character as rationalization made plausible by its consonance with pervasive cultural assumptions rather than by reason. The radical's claim is that autonomy creates value, in the sense that it is a person's preferences and choices which determine what it is for his life to have value.
The exercise of autonomy as the capacity for self-determination through choice cannot as such determine what is valuable. It is clear that our preferences and choices can be self-destructive - can leave us viciously addicted, for example, or disposed to lies, hatred, or sexual perversions. If our choices are valuable they are derivatively valuable, because in our choosing we have been open to and respectful of an order of human goods: truth, friendship, marriage, justice, the love of God, and so on. We live our lives with dignity - with what one might call an existential dignity - in so far as our choices are consistent with an objective order of values. But part of this objective order of values is the prior ineradicable dignity which belongs to our nature - what we might call our ontological dignity.
How far does this critique of the philosophical denial of dignity to many debilitated elderly persons take us? Some distance in theory, I hope, but perhaps not very far in practice. Some distance, because I think it shows that we must defend the basic human rights of all the elderly against ideologically rationalised discrimination. Not far in practice, because it confronts the combined inertial forces of ideology and economic trends characteristic of our culture and societies. A struggle which simply aims to secure justice for the elderly, important though it is, is inadequate to the challenge which confronts us. Why precisely that is so I shall turn to consider in a moment. First, however, there is a general point to be made about the prospects of argument converting those for whom an ideology does serve to rationalize what they do or what they want to do. The general point is that intellectual conversion requires moral conversion and moral conversion requires religious conversion. Intellectual conversion requires moral conversion because most people need to begin to be freed of their investment in certain patterns of behaviour before they become free to criticise what they have relied on to rationalise those patterns of behaviour. And moral conversion requires religious conversion because sin is at the heart of the problem of living an adequate human life and we cannot overcome sin without the love of God.
I have argued elsewhere5 that Catholics who work in the field of bioethics need to adopt a dual intellectual strategy: of first unmasking influential ideological positions which subvert respect for human beings, and of secondly seeking to sustain and make intelligible practices which meet human needs in ways consistent with human dignity.
There is a need for a counter-cultural witness in face of the pervasively negative valuation of dependency and debility which is characteristic of our culture. This counter-cultural witness ought at least to be found in those Catholic institutions dedicated to the care of the dependent elderly.
I am not proposing that institutions devoted to the care of the elderly should not strive to maintain the independence of the elderly where that is possible, or that they should not strive to ameliorate the physical condition of those who are declining. Those kinds of commitment do not need defence in our culture, though the defence should not rest, as it frequently does, on the view that failure to achieve these goals is more or less of a disaster. What does need defence is a commitment to those who see no meaning in their debility and dependency and who need to be put in touch with a lived faith in the possibilities of transformation through suffering and dependency.
Ours is a culture which exalts autonomy in face of our inability to sustain a shared sense of an order of objective values. A secularist world-view has no reason to accept that there are certain 'givens' of the human condition which it is the part of wisdom to accept. This is more and more evident in relation both to the beginnings and the endings of human lives. Many cannot see that it goes with the recognition of human dignity to accept that children should be begotten through normal marital intercourse and not produced as the result of technological intervention. For technologically assisted conception (as in IVF and GIFT) envisages the child as a designer product, subject to quality control to satisfy `parental' wishes, and disposable if unsatisfactory.
Similarly, for many in our society the debility and dependency of numbers of elderly people - also `given' features of the human condition - are unacceptable. Within an inner-worldly perspective these human beings are failures, for they are no longer healthy or in control of their lives. And the radical philosophical proposal is that they too should be regarded as disposable.
For three reasons there is a need to accept these human beings in love. The first is their need to be accepted. If the dominant voice of your culture says that your condition of debility and dependency is without meaning and value you need to find some human beings who through their evident love affirm your meaning and value. It is only through being so affirmed that those who have been falsely catechised by the `world' about the meaning of their condition can discover the voice of the Gospel.
Secondly, the elderly are our ancestors, most of them parents of one or more who follow them. Children should honour their parents. Many are no longer disposed to do so. Our generation is in danger of conspiring, or colluding by indifference, in the criminal neglect and even killing of many of the elderly. We need to do more than name this conspiracy for what it is. We need to redeem our times. In this sense we are the ones who need to love our elders.
Thirdly, we need to love the frail elderly because we need to relearn the conditions of accepting debility and dependence as ways to spiritual transformation. We need to discover what an oppressive idol autonomy is by helping to liberate others from it. For to do so is the surest way of liberating ourselves.
It perhaps hardly needs to be said that we cannot meet this challenge to love without a radical conversion of heart in ourselves.
These three needs, it seems to me, amount to a duty to care lovingly for the elderly when it falls to us to do so. What that duty, and the prior duty to do justice to the elderly, entail I leave it to others at this Conference to explore. I was asked to provide a framework for our thinking and I hope that what I have had to say goes some way to doing so.
1.M Henwood, Community Care and Elderly People, London: Family Policy Studies Centre, 1990.
2.Thomas R Cole, The Journey of Life. A Cultural History of Ageing in America, Cambridge: Cambridge University Press, 1992, p.xix. Cole's history is not confined to ageing in America, and is certainly relevant to cultural changes throughout Northern Europe.
3.I have explained more fully this analysis of the rationale for voluntary euthanasia in a number of publications. See, for example, Luke Gormally, "Against Voluntary Euthanasia", in Ranaan Gillon (ed) Principles of Health Care Ethics, Chichester: Wiley, 1994, pp.763-74; Luke Gormally, "Walton, Davies, Boyd and the legalization of euthanasia", in John Keown (ed) Euthanasia Examined: Ethical, Clinical and Legal Perspectives, Cambridge: Cambridge University Press, 1995, pp.113-40; Luke Gormally (ed) Euthanasia, Clinical Practice and the Law, London: The Linacre Centre, 1994, passim.
4.This paragraph repeats, almost verbatim, what I wrote at p.124 of Luke Gormally (ed) Euthanasia, Clinical Practice and the Law. Fuller analyses of the roots of human dignity may be found in Josef Seifert, What is Life? The Originality, Irreducibility and Value of Life, Amsterdam: Rodopi 1997, especially pp. 101-9; and in John Finnis, Aquinas: Moral, Political and Legal Theory, Oxford: Oxford University Press 1998, section V.8 "The Root of Human Dignity", pp. 176-80.
5.See Luke Gormally, "Goals and Initial Assumptions in Bioethics: the necessity of methodological pluralism", in E.Sgreccia, V. Mele, G.Miranda (eds), Le Radici della Bioetica vol.1, Milan: Vita e Pensiero 1998, pp.317-25.
- Professor Luke Gormally