The Abbeyfield concept
As our population ages, new ways of living with respect and dignity are required. The family home might no longer be accessible or suitable, a unit might be too lonely and/or a retirement village a step too far or too expensive. One solution, available in several New Zealand towns and cities, is the international model of community-based supported flatting known as ‘Abbeyfield’, a volunteer-based organisation providing housing for older people. Founded in the mid-1950s in a poor borough of London, now more than 10,000 residents in over 16 countries live in Abbeyfield homes.
The concept has operated in New Zealand since the early 1990s when it was introduced to Nelson by a local GP who travelled to the United Kingdom to look at older peoples’ housing options. Enthused by the Abbeyfield concept, he returned home where he promoted the idea and recruited supporters and Abbeyfield New Zealand was born. The Foundation was registered in July 1999 and regions run their own Abbeyfield Society centred on their residences.
There are now 14 Abbeyfield houses in towns and cities around the country, including Whangarei, Sandringham, Takaka, Nelson, Christchurch, Westport, Queenstown and Dunedin with more in the planning and development stages. Some are the result of partnerships with local community groups such as with the RSA in Motueka. Most houses have between 8 and 10 residents who are aged from their mid-60s. Every home is purpose built and residents have their own large studio room with ensuite. As with most family homes, there is a communal lounge, dining room, kitchen and laundry and in some houses a guest room for visitors.
Each house is staffed by a live-in housekeeper who takes care of the shopping and prepares the two main meals of the day which are served at the communal dining table. But other activities, from gardening to governance and social and leisure activities, are done by volunteers who form voluntary house committees. Residents contribute as much as they can, are involved in the management of their house and in the selection of new members of their house. An Abbeyfield House aims to be ‘a typical house in a typical street’ (although usually a large one) offering companionship, independence and support in rental accommodation at a price affordable to most older people on a pension.
The aim is to enhance the quality of life for older people by enabling independence, privacy and companionship, dignity, involvement and housing security.
The philosophy centres on the older person, with the skills and time of volunteers the key to the concept and to keeping prices down. Abbeyfield houses are a home, not an institution, and provide full board and accommodation at a rate which is no more than National Superannuation. Each resident nominates a friend or relation as a personal advocate who can be contacted and consulted in case of an emergency or difficulty, by either the resident or the Society. Care services are not provided but residents can be assisted to access home care services if needed. There is housing security for as long as they can live in the relative independence of the communal flatting environment, and many residents are well into their 90s.
Values underpinning the concept include the belief that people can work together to help older citizens have a secure, comfortable and companionable life in a regular household. As well, older people have an important role to play in the lives of their families, friends and communities. For example, residents of Abbeyfield Dunedin recently staged a protest against the planned removal of their local New Zealand Post post-box, a threat which would limit their participation in the wider community.
Several projects were completed with the help of Housing New Zealand’s Innovation Fund. With the government’s enthusiasm for social housing the Abbeyfield national board has looked at how Abbeyfield might be best positioned to take advantage of that policy.
The whole concept depends on dedicated volunteers locally, nationally and internationally. JB Munro is one New Zealand volunteer who has had a significant role in the movement, following his retirement as head of the IHC. He chaired Abbeyfield New Zealand for many years and also served as the organisation’s International Chairman, overseeing Abbeyfield work in numerous countries. When he retired from that role in March 2014 his contribution was recognised at a dinner in London attended by the movement’s patron, the Prince of Wales. He had previously been awarded the Abbeyfield International Royal Patron's Award, an honour which is presented to only one volunteer per year from across the world.
There are still many regions in New Zealand without Abbeyfield Houses or without spare capacity. But each residence starts because volunteers gather and organise around an identified need. For many middle aged people the Abbeyfield concept of gently supported affordable flatting provides an appealing concept for parents and older relations. But by getting together now with a group of friends to establish a society of volunteers and develop a purpose built facility they may also be addressing their own future housing needs.
Dr Hilary Stace is a disability researcher attached to the Health Services Research Centre at Victoria University. She has a particular interest in autism, intellectual disability and human rights. She is currently working on a biography of JB Munro, formerly head of the IHC.
London without old people is just a factory floor
Harry Leslie Smith describes how living and getting around in London, one of the world’s richest cities, has become a challenge for the elderly and especially the poor elderly. The visible absence of the elderly in cities like London does not affect just the elderly, but the city itself becomes less civilised and vibrant.
Like The Nathaniel Centre, the Caroline Chisholm Centre for Health Ethics is a Catholic bioethics centre. We are based in Melbourne, the capital city of the Australian state of Victoria. Every year, the Chisholm Centre hosts a one-day conference which explores a significant issue in health and aged care. On 7 October 2015, our annual conference was on ageism or age discrimination.1 This article reports some of the key insights from that conference.2 It has three parts. The first explores age discrimination. It defines what age discrimination is, and surveys some of its various manifestations. The second part of this article overviews important Catholic teaching about ageing and age discrimination. As we will see, as well as critiquing age discrimination, Catholic teaching offers a positive vision of ageing and the contribution which older persons can and should make. Finally, the third part of this article considers briefly some of the challenges which come to us from this discussion.
I. Age Discrimination
What is age discrimination?
It is hard to say when a person should be classified as ‘old.’ The term ‘older person’ is used to describe someone who is 65 years or older – an age chosen because in recent times it has been regarded as the retirement age.3 Older persons are further divided into the young-old (65–74), the middle-old (75–84), and the old-old (85+).4
At the Chisholm Centre conference, Judy Gregurke, National Manager Aged Care Reform at COTA Australia, defined ageism or age discrimination as “the stereotyping or discrimination of a person or group of people because of their age.”5 There are positive stereotypes, but even these can be problematic. For example, elderly women should not feel pressured or compelled always to be “sweet.” That being said, in Western culture most stereotypes of older persons are overwhelmingly negative, and older persons are regarded as being dependent, frail and incompetent.6 These negative stereotypes are expressed both in negative attitudes about older persons and in negative behaviours towards them. Age discrimination predominately impacts upon those who are over 65, but it can also affect persons considerably younger than this.
Particularly when this is an ongoing experience, age discrimination can have a profoundly negative effect on older persons. They can internalise the ageist messages, and come to believe that they are indeed dependent, frail and incompetent. This self-deprecation, in turn, leads to poorer health, diminished wellbeing, and reduced mental ability.7 It can also diminish the older person’s motivation to be an active member of society. This in turn can lead to social isolation, which further diminishes the individual’s health and wellbeing.8
Research reported by the Australian Human Rights Commission in 2013 found that 71% of Australians felt that age discrimination was common in Australia. 35% of Australians aged 55 to 64, and 43% of Australians aged over 65 reported having experienced discrimination because of their age. This included being turned down for a position, being ignored, and being treated without respect. It also included service invisibility (as service people ignored them), relationship invisibility (as they were made to feel a burden in a relationship), and cultural invisibility (with people like them not being represented in popular culture).9
Denigration, exclusion, and abandonment
There is a certain dynamic to age discrimination. It begins with the denigration that flows from negative stereotyping, whereby older persons are regarded as dependent, frail and incompetent. The logic is then that we do not need to include older persons, for such incompetent people would have little or nothing to contribute. This in turn leads to their exclusion from positions of influence, including employment (see below). However, it also includes the exclusion of older persons from important social, cultural and political decision-making processes and forums at the local, regional, national and international level. It even includes their exclusion from processes and forums which make decisions about older persons.
When older persons are excluded in this way, society as a whole is disadvantaged. Older persons have a privileged position in remembering our history. They remind us where we have come from, and therefore who we are, and where we are heading. When all this is forgotten, we can lose our way as a society. Our society suffers when this happens, and all of us are disadvantaged. Older persons are particularly disadvantaged when they are excluded from the processes and forums which consider their own care.
The ultimate outcome of the dynamic of age discrimination is the abandonment of older persons, as those who are already denigrated and excluded are denied the resources that they need to live a meaningful life. While this dynamic continues in society, any talk of legalising euthanasia and assisted suicide is particularly fraught. Might those who are already denigrated, excluded and abandoned ‘choose’ euthanasia as the only way out? Indeed, might euthanasia be the ultimate form of abandonment?
It must be stressed that there is nothing inevitable about any of this. Traditional societies usually have great respect for their elders. The negative dynamic has developed in Western societies because of choices which we have made. As our societies have become more materialistic and consumerist, a utilitarian calculus has taken over. This calculus places great value almost exclusively on economic contribution, devaluing all the other ways that people contribute to society. We need to remember that this utilitarian culture has arisen because of choices which we have made, and it can therefore be reversed if we make other choices.
One place in which age discrimination occurs is the workplace. Older workers are generally experienced and productive, hard-working and reliable. However, persistent negative stereotypes lead to discrimination against them. A 2013 Australian report found that 1 in 10 business respondents had an age above which they did not recruit, with the average age being 50 years. Further, 29% of business decision-makers believed that older employees had difficulty adapting to change; 36% believed that older employees were less likely to be promoted; and 50% agreed that older employees were at higher risk of being made redundant.10
25% of Australian workers over the age of 50 report that they have experienced workplace discrimination. More than 80,000 Australians over the age of 50 are unemployed, and workplace discrimination is a significant factor in this. If only 5% more people over the age of 55 had jobs, the Australian economy would be $A48 billion better off.11
In New Zealand, a 2014 Human Rights Commission report on the Ageing Workforce found that two in five (40%) older workers had experienced age related discrimination in the past 5 years. Similar proportions (46%) of workers (of any age) have witnessed it over this time period. The discrimination is most commonly manifested in the form of withholding interesting tasks, reduced access to promotions and bullying.12
Ignoring the contributions of older persons
Older persons contribute to the community in many ways. Most of these contributions, however, do not involve financial payment or the exchange of money. For this reason, the utilitarian calculus of the dominant materialistic and consumerist culture has difficulty in both recognising and valuing these contributions. In this section, we will highlight some of these contributions. Further, to prevent these contributions being undervalued, we will assign economic value to them.
Older persons provide a lot of care. Some are primary carers, perhaps of their spouse, a disabled adult child, or sometimes their own grandchildren. Many are informal carers, caring for family and friends, and particularly providing child care to their grandchildren. The economic value of the informal aged care provided by older Australians in 2015 was about $A60.3 billion. In 2014, Australian grandparents provided child care to 837,000 children. Indeed, they provided more child care than was provided by formal or paid carers. Older persons also contribute as volunteers. Without financial reward, their contributions often draw on a lifetime of skill, experience, and wisdom.13 In 2010, 2.9 million Australians over 65 were involved in volunteer work.14 In 2006, 5.4 million Australian volunteers (including many older persons) provided services equivalent to 454,000 full-time jobs.15 Older persons also provide peer support, visiting and befriending other older persons. When so many older persons are socially isolated, this is a very significant contribution which enhances what is called social capital.16
Moving beyond these merely economic measures, we should also recognise and celebrate important features of the contribution of many older persons. Many have reached a place of genuine altruism, where they are able to give without any thought of return. As we noted above, they are also able to draw on a lifetime of experience. Further, they are the memory of society, reminding us where we have come from, and therefore who we are, and where we are heading. This is of particular importance when older persons contribute to social, cultural and political decision-making processes and forums at the local, regional, national and international level. Finally, drawing on both their lifetime of experience and their early socialisation in a kinder and wiser time, older persons often offer us a more complete vision of life.17 These are very valuable contributions indeed.
Sadly, we must recognise that older persons who can be denigrated, excluded and abandoned are sometimes also abused. Elder abuse is committed by someone with whom the older person has a relationship of trust, such as a partner, family member, friend or carer. It can be physical, social, financial, psychological, or sexual, and can include mistreatment and neglect. Its most common forms are financial abuse and psychological/emotional abuse.18 Data from the World Health Organisation estimates that 1 in 10 older persons experience some form of elder abuse every month.19
The victims of elder abuse are predominately older women, particularly those who are very dependent and socially isolated. Sadly, about 90% of perpetrators are family members.20 In the finance industry, elder financial abuse is somewhat ironically called “inheritance impatience.” It can involve significant amounts of money. For example, in the 2013–14 financial year, the Elder Abuse Prevention Unit in the Australian state of Queensland assisted 139 older people who together had lost a total of $A56.7 million.21
In New Zealand, most research estimates that 2 to 5 percent of the older population may be victims of elder abuse.22 Age Concern reports that it receives more than 2,000 confirmed referrals each year of older people facing abuse or neglect.23 If, as estimated, only 16 percent of the actual number of abuse incidents reach service agencies,24 this means that the likely number of elderly people subject to abuse is greater than 12,000. A study of respite care patients and caregivers in England found that 45% of caregivers admitted either verbal (41%) or physical abuse (14%).25
II. Catholic Teaching
This is a necessarily brief overview of some of the more important Catholic statements about age discrimination. These statements, while critiquing age discrimination, also offer a positive vision of ageing and the contribution which older persons can and should make.
The best short statement of the Church’s positive view of older persons is perhaps found in paragraph 222 of the Compendium of the Social Doctrine of the Church. It recognises the positive contribution that older persons can make in the workplace, in the family, and in all of society. It therefore calls everyone to pay “generous attention” to them, and to see them as “partners in shared projects.” It also calls us to care for the needs of older persons, particularly those who are most frail and most marginalised. It quotes Psalm 92 to present the Church’s vision and hope for all older persons: ‘They still bring forth fruit in old age.’26
Below, we will look at statements from the last three popes, along with the Church’s contribution to the UN International Year of Older Persons in 1999.27
John Paul II
On 23 March 1984, Pope John Paul II addressed 8,000 older persons who had gathered from the dioceses of Italy. He described old age as “a time of life which is humanly and spiritually fruitful.” He reminded the assembled older persons, “You still have a mission to fulfil, a contribution to make.” He stated clearly, “According to the divine plan, each individual human being lives a life of continual growth, from the beginning of existence to the moment at which the last breath is taken.”28 John Paul’s vision of old age is at once an inspiration and a challenge to older persons – and to all of us.
UN International Year of Older Persons
1999 was the United Nations International Year of Older Persons. It was officially launched on 1 October 1998, the International Day of Older Persons. On the same day, the Pontifical Council for the Laity issued The Dignity of Older People and Their Mission in the Church and the World. A year later, on 1 October 1999, Pope John Paul II issued a Letter to the Elderly. The Australian Catholic Bishops also contributed through their 1998 Social Justice Statement, which was titled The Challenge of Ageing.
The document from the Pontifical Council for the Laity is probably the most complete statement of Catholic teaching about ageing and age discrimination. It is just over 10,000 words in length. It has two chapters on the meaning and value of old age, with the first drawing on human insight, and the second drawing on the wisdom of the Bible. It has a chapter on age discrimination and the other problems that older persons can face. It has two chapters (the first general, the second more specific) on the Church and older people. Perhaps its most important sentence is the following: “The Church should heighten awareness of the needs of older persons, not least that of being able to contribute to the life of the community...”29
Pope John Paul wrote to his elderly brothers and sisters as an older person himself. An interesting feature of this letter is his analysis of the Fourth Commandment to ‘Honour your father and your mother’: “Honouring older people involves a threefold duty: welcoming them, helping them and making good use of their qualities.” He also advised young people that “older people can give you much more than you can imagine.”30
2012 was the European Year for Active Ageing and Intergenerational Solidarity. Pope Benedict contributed to this year on 12 November 2012 by visiting a home for the elderly in Rome run by the Community of Sant’Egidio. In his speech, he noted that society “dominated by the logic of efficiency and gain” often views the elderly “as non-productive or useless.” Against this, he insisted that human life even “in the years of old age... never loses its value and dignity.” Indeed, he recognised that “the wisdom of life” which older persons hold is “a great wealth,” and therefore that older persons are “a wealth for society,” “a value for society, especially for the young.” Prophetically, he stated, “The quality of a society, I mean of a civilisation, is also judged by how it treats elderly people and by the place it gives them in community life.”31
On 28 September 2014, Pope Francis met with about 40,000 older persons and their families. He recognised that “old age is a time of grace,” and that older persons, particularly grandparents, “are entrusted with a great responsibility: to transmit their life experience, their family history, the history of a community, of a people; to share wisdom with simplicity, and the faith itself.” A people who do not take care of its seniors, he warned, “has no future.... because such a people loses its memory and is torn from its roots.” Rather confrontingly, Francis described abandoning older persons in aged care facilities as “actually real and hidden euthanasia.”32
Francis returned to these issues in his General Audiences on 4 and 11 March 2015. His first speech focussed on the abandonment of older persons and age discrimination; his second presented the Church’s vision of ageing and the contribution of older persons. In his first speech, he criticised a “culture of profit” or a “throw-away culture” which views older persons as a “burden,” and which therefore throws them away. He gave an example of an older woman in an aged care facility who had not been visited by her family for 8 months. Confrontingly, he called this a sin – indeed, he called it a “mortal sin” which could imperil our eternal destiny.33
In his second speech, he insisted that “old age has a grace and a mission too, a true vocation from the Lord.” He particularly called older persons to prayer, suggesting that “prayer is the purpose of old age.” He also spoke of the “mission” or “vocation” of older persons to transmit true values particularly to the young. “How I would like,” he said, “a Church that challenges the throw-away culture with the overflowing joy of a new embrace between young and old!”34
These same themes are expressed in nn. 191–193 of Amoris Laetitia, the recent Apostolic Exhortation on the family. Paragraph 191 is about the abandonment of the elderly and age discrimination. Paragraph 192 is about the role of grandparents and older persons in transmitting both “history” and the “most important values.” Paragraph 193 warns that the “lack of historical memory” is a serious danger for any society. “Knowing and judging past events is the only way to build a meaningful future.”35
III. A Call to Action
There is something in this material to challenge each of us. If we are older, perhaps the most important challenge is to embrace this positive vision of ageing. This may require that we recognise and overcome anything within us which regards ourselves as older persons or the contribution that we make as second-rate or inferior. It may also challenge us to step forward to become involved in significant projects. It probably will ask us to ‘push back’ when we encounter age discrimination: for example, when a sales assistant serves a younger person before us, we may decide to say politely but firmly, “Excuse me. I was here first.”
If we are younger, one challenge is to ensure that older persons are represented in significant decision-making processes and forums. While this is important for every issue, it is particularly important for issues related specifically to older persons. In all cases, we may be surprised how much older persons have to contribute. Another challenge is to befriend an older person or older persons, and regularly to spend time with them. St Pope John Paul II reminds us that “older people can give you much more than you can imagine.”
Reverend Kevin McGovern was Director of the Caroline Chisholm Centre for Health Ethics for 9 years from August 2007 to July 2016. He is now a consultant at the Centre. He is also a member of Australia's health ethics peak body, the Australian Health Ethics Committee.
- For more on this conference, including reports and photos, our distinguished speakers and their PowerPoint slides, see “The Older Person Today: giving and receiving care,” Caroline Chisholm Centre for Health Ethics (CCCHE), http://chisholmhealthethics.org.au/conference-7-october-2015.
- I also drew particularly on another article written by a Chisholm Centre researcher, and I commend this article to the reader. For this, see Emanuel Nicolas Cortes Simonet, “Older Persons in Australia: Secular and Catholic Perspectives,” Chisholm Health Ethics Bulletin 20, no. 3 (Autumn 2015): 9–12.
- David Wiles, “Who is old?: defining old age,” Australian Journal on Ageing 6, no. 4 (1987): 24.
- Laurence McNamara, “Walking on Three Legs in the Afternoon,” (paper presented at the annual conference of the Australian Catholic Theological Association, Melbourne, 7–10 July 2016).
- Judy Gregurke, “Older Persons Giving Care,” CCCHE, http://chisholmhealthethics.org.au/system/files/jg_presentation.pdf.
- Mary Kite et al., “Attitudes Toward Younger and Older Adults: an Updated Meta-Analytic Review,” Journal of Social Issues 61, no. 2 (2005): 241–266 at 245.
- Jennifer Richeson and Nicole Shelton, “A Social and Psychological Perspective on the Stigmatization of Older Adults,” in When I’m 64, ed. Laura Carstensen and Christine Hartel (Washington: The National Academies Press, 2006), 190.
- Jon Nussbaum et al., “Ageism and Ageist Language Across the Life Span: Intimate Relationships and Non-Intimate Interactions,” Journal of Social Issues, 61 no. 2 (2005): 287–305 at 294.
- Australian Human Rights Commission (AHRC), Fact or fiction? Stereotypes of older Australians (Sydney: AHRC, 2013), 4–5, https://www.humanrights.gov.au/sites/default/files/document/publication/Fact%20or%20Fiction_2013_WebVersion_FINAL_0.pdf.
- Ibid., 8
- Lonergan Research Pty Ltd, "Ageing Workforce in the New Zealand Crown Entity Sector Survey Report 2014," online at http://superseniors.msd.govt.nz/finance-planning/paid-work/age-discrimination.html.
- Volunteering Australia, State of Volunteering in Australia, 2012, http://www.volunteeringaustralia.org/wp-content/uploads/State-of-Volunteering-in-Australia-2012.pdf.
- Gregurke; Anne Gray, “The social capital of older people,” Ageing and Society 29, no. 1 (2009): 5–31 at 6. Social capital is “the array of social contacts that give access to social, emotional and practical support” within communities.
- Pontifical Council for the Laity, The Dignity of Older People and Their Mission in the Church and in the World, 1 October 1998, Holy See, http://www.vatican.va/roman_curia/pontifical_councils/laity/laity_en/archivio/rc_pc_laity_doc_05021999_older-people_en.htm. The Pontifical Council calls these qualities the “charisms of old age.”
- “Your Rights – Elder Abuse,” Senior Rights Victoria, http://seniorsrights.org.au/your-rights/.
- Judith Ireland, “Financial abuse of seniors a problem for all ages,” 19 October 2015, Sydney Morning Herald, http://www.smh.com.au/federal-politics/political-news/seniors-at-risk-of-fraud-financial-abuse-warns-age-discrimination-commissioner-20151016-gkaomk.html.
- Senior Rights Victoria; Scott Pape, “The dirtiest, slimiest, most heartbreaking scam of them all,” 22 May 2016, Barefoot Investor, https://barefootinvestor.com/the-dirtiest-slimiest-most-heartbreaking-scam-of-them-all/.
- K. Glasgow and J.L.Fanslow, "Family Violence Intervention Guidelines: Elder Abuse and Neglect", Wellington: Ministry of Health. 2006
- National Center on Elder Abuse, 1998, p. 12, in “Under the Radar: New York State Elder Abuse Prevalence Study,” May 2011, http://www.ocfs.state.ny.us/main/reports/Under%20the%20Radar%2005%2012%2011%20final%20report.pdf.
- Homer and Gilleard (1990), reported in Acierno et al, “National Elder Mistreatment Study,” March 2009, https://www.ncjrs.gov/pdffiles1/nij/grants/226456.pdf.
- Pontifical Council for Justice and Peace, Compendium of the Social Doctrine of the Church, n. 222, 2 April 2004, Holy See, http://www.vatican.va/roman_curia/pontifical_councils/justpeace/documents/rc_pc_justpeace_doc_20060526_compendio-dott-soc_en.html.
- The Australian bishops’ 2016-17 Social Justice Statement will also explore these issues. It is titled A Place at the Table: Social Justice in an Ageing Society. I am honoured to have been invited to launch this statement in September.
- John Paul’s speech on this day is quoted in John Paul II, Christifideles laici, n. 48, 30 December 1988, Holy See, http://w2.vatican.va/content/john-paul-ii/en/apost_exhortations/documents/hf_jp-ii_exh_30121988_christifideles-laici.html
- The reference details for this statement are above in endnote 16.
- John Paul II, Letter of His Holiness Pope John Paul II to the Elderly, n. 12, 1 October 1999, Holy See, http://w2.vatican.va/content/john-paul-ii/en/letters/1999/documents/hf_jp-ii_let_01101999_elderly.html.
- Benedict XVI, “Visit to the Community of Sant’Egidio’s Home for the Elderly Viva Gli Anziani, 12 November 2012, Holy See, http://w2.vatican.va/content/benedict-xvi/en/speeches/2012/november/documents/hf_ben-xvi_spe_20121112_viva-anziani.html.
- Francis, “Meeting of the Pope with the Elderly,” 28 September 2016, Holy See, http://w2.vatican.va/content/francesco/en/speeches/2014/september/documents/papa-francesco_20140928_incontro-anziani.html.
- Francis, General Audience, 4 March 2015, Holy See, http://w2.vatican.va/content/francesco/en/audiences/2015/documents/papa-francesco_20150304_udienza-generale.html.
- Francis, General Audience, 11 March 2015, Holy See, http://w2.vatican.va/content/francesco/en/audiences/2015/documents/papa-francesco_20150311_udienza-generale.html.
- Francis, Amoris Laetitia, n. 191–193, 19 March 2016, Holy See, http://w2.vatican.va/content/francesco/en/apost_exhortations/documents/papa-francesco_esortazione-ap_20160319_amoris-laetitia.html.
Book Review: “Dear Life. On Caring for the Elderly” by Karen Hitchcock
Quarterly Essay. Issue 57, March 2015. Black Inc., Schwartz Publishing Pty. Ltd. Collingwood, Australia.
Reviewed by Sue Buckley
Karen Hitchcock is a staff physician at a large Australian city public hospital. In this Essay (short book) she describes how social attitudes towards the elderly shape the way rest-homes, hospitals, and health professionals organise and either limit or extend their care of the elderly. Hitchcock addresses a number of ethical issues – futility, over- and under-treatment, burden, euthanasia, advanced care directives – interspersing these with moving stories of real people and events. These stories are not just dramatic devices but beautifully rendered accounts of interactions she has experienced with her own family members and her patients.
The Essay as a whole challenges current pejorative views of the elderly - the ‘oncoming grey tsunami of the sick and frail’, the ‘swelling ranks of “greedy geezers”’ - but it is especially critical of the attitudes towards the elderly held by some health professionals and how these influence treatment decisions. If you are old, with two or three organs failing, ‘can no longer negotiate your stairs to go and buy food’, then you are seen as having problems that cannot be cured. These patients, described variously as ‘crumbles’, ‘bed blockers’ or ‘gen med specials’ are not just unwanted in acute hospitals, but if they do arrive they are likely to receive different treatment from younger patients as physicians view their treatment as ‘futile’. Hitchcock provides some captivating accounts of particular patients and how they responded to treatment when ‘futility’ was overruled.
Hitchcock bravely confronts the costs of treatment while challenging some commonly held assumptions. One that we hear often is that ‘the last year of our lives is when the most health-care dollars are spent’. Hitchcock acknowledges that increasing age and increasing health expenditure ‘go hand in hand’, but points out that this is because there is a greater chance of dying when you are old than when you are young. In fact, the same amount is spent on each death, young or old and, contrary to most commentary, hospital costs associated with the last year of life actually fall with age; data from New South Wales indicates that people aged ninety-five years and over incurred less than half the hospital costs of those who died aged 65-74 years. Responding to critiques that claim the public health system is ‘unsustainable’ and that push for a more private, US-style system, Hitchcock points out that as far as treatment of the elderly goes, ‘free markets lead to over-treatment, while publicly funded systems risk sometimes unexamined and discriminatory rationing’. She concludes that ‘we need to shift our focus to improving care. It has been limited enough.’
The second half of the Essay deals with dying. It begins with stories of patients for whom decisions about ending treatment needed to be made. The first describes Hitchcock’s own father’s death and the burden of having to make a decision to switch off the machines keeping him alive. The second story tells of an elderly man with severe heart failure who ‘hated hospital’ and wanted to die. Hitchcock describes spending time with him, learning why he no longer wanted to live and finding ways of enabling him to be discharged from hospital to an enjoyable life. The third story describes the admission to hospital of an elderly man with mild dementia who had completed an advance care plan, possibly under the duress of a much younger wife. The wish not to be a burden was prominent in the plan and caused concerns for Hitchcock. She questions the reliance on advanced care plans which might be made by someone in their seventies but no longer reflect their wishes as they reach their nineties. Impairments once thought of as intolerable may turn out to be bearable after all. She quotes Thomas Nagel: ‘Does autonomy really give your past self the authority to kill off this later self?’
Hitchcock also questions the reality of the ‘good’ or ‘ideal’ death and challenges the notion that dying at home is preferable to dying in hospital. As she points out, the practicalities of dying at home are often too much for family members and besides, there may be no one at home to look after them.
The essay ends with a challenge to ‘we, the living’ to see ‘the elderly’ as the people they actually are: ‘The elderly, the frail are our society …They worked and loved and lived – and can continue to do so. … Right now we need the resources to care better for the elderly in the institutions we have imperfectly built, and we need deep social transformation so that many more people can live on in their communities and homes. We must remain aware of our ageism in every program and policy we implement.’
This moving essay is written with warmth and elegance and discusses some important ethical issues with clarity and practical wisdom. Its questioning of many current assumptions about the elderly and how they should be treated is well-timed given the upcoming challenges to our health and care systems from an aging population.
Sue Buckley is a researcher for The Nathaniel Centre
Submissions to the Health Select Committee Investigation into Ending One’s Life:
Submissions to the Health Select Committee from:
JoCare: Caring for Neighbours
Kerri Anne Brussen
Australians prefer a faith that “rolls up its sleeves.1”Recently at St Joseph’s in Melbourne an outreach program, JoCare, has been introduced to engage with older socially isolated persons within the local neighbourhoods. Drawing on a strong tradition of volunteering in Catholic parishes, the JoCare program seeks to involve volunteers from within our parish as well as our local community. Thus, for some, volunteering with JoCare is their faith in action, however, for others it may be a desire to do something for the common good – helping out a neighbour and building community.
The main focus of JoCare is volunteers visiting socially isolated older persons in their homes on a regular basis, either weekly or fortnightly. They share an activity such as the crossword, reading a book or doing a puzzle. Others go out for a gentle walk. We also run a monthly gathering where older persons from the parish and local area come together to play games and cards or just to have a chat. Furthermore, we have a number of volunteers who either regularly or on an ad hoc basis provide transport for short local trips to go shopping or to attend medical appointments and church services. After each visit, volunteers provide a brief written report to the JoCare coordinator2. Our first ‘neighbours’ 3 came from within the parish, but we are now receiving referrals from local council and other agencies who deliver in-home care to older persons.
Our volunteers undertake the visiting in pairs (where possible) to ensure the safety of all involved. It also provides continuity - if on occasions one volunteer is unavailable then the other can visit. The other benefit for JoCare is that as new volunteers become part of our program they are able to be mentored in their role by a seasoned volunteer.
To provide the best possible service to those who access the JoCare program we run a training day for our volunteers which involves looking at the world of volunteering and the gifts a person brings to volunteering. We examine volunteer rights, responsibilities, and boundaries4. We discuss privacy and harassment laws. But more importantly we have conversations concerning the mind-set that volunteers may bring when visiting an older person. We talk of orientating ourselves to the person. We ask our volunteers to give full attention to the person they are visiting, encountering them as they are, for who they are. We discuss the limitations of a person’s “life space”5. We consider this day of conversation an important aspect of the JoCare program. Volunteers also undergo police checks and working with children checks6.
Thus, we at JoCare seek to act responsibly toward our volunteers just as we strive to encourage our volunteers to act responsibly. The documentation for JoCare is written within the framework of The National Standards for Volunteer Involvement7. While, this standard is not mandatory for Australian organisations that engage with volunteers, by establishing procedures and policies for JoCare within this framework, all involved in the program can be assured that JoCare is run in accordance with the ‘best practice’ for volunteering. We consider documentation is important for volunteers just as it is for paid workers. Volunteers are also provided with a volunteer manual.
What follows is a rationale for JoCare and its implementation.
Theology of Ageing
The Hebrew Bible has at least two hundred and fifty references to old age, embracing views of human aging as an integral part of Israelite society and a blessing from God. The God of the Old Testament is sometimes known as a liberator of the poor and marginalised. “Learn to do good; seek justice, rescue the oppressed, defend the orphan, plead for the widow,” (Is 1:17). The incarnation of Jesus authenticates the dignity and worth of human beings. As the early Christian church developed it gave considerable attention to the role and contribution of elders and widows in the faith community. They are owed respect as ageing persons and are called upon to mentor and provide spiritual guidance to other Christians (1 Tim. 5:1-3, 1 Tim. 5:9-10, Titus 2:3-5)8.
Christ gave two commandments. The first is to love God with all your heart, and the second is to love your neighbour as yourself (Mt. 22:36-40). This is what we seek to do at JoCare. Neighbourly love entails rising above the differences between persons and realising that each person is equal to the other; no-one has a greater value than another. A person's value and dignity belongs with who they are, not with what they can do.
Trinitarian theology offers an insightful window on relationships. The Trinity is profoundly relational with each of the three persons of the Trinity, the Father, the Son and the Holy Spirit, being unique but ultimately bonded to the other in relationship, signifying unity yet diversity. Each person of the Trinity is irreplaceable and cannot reach their potential unless in relationship with the others. This is the cornerstone of community love where our humanity is completed. God in his love takes creation into a personal relationship through the humanity of his Son and through the gift of the Spirit we become whole. Therefore, when we reach out to others in companionship our humanity is deepened by the humanity of the other9.
Social isolation has become a major health issue for older people living independently in local communities. One of the main reasons JoCare has initially focussed on older persons is to minimise this experience of isolation and provide a sense of connectedness10. Social isolation is often used interchangeably with loneliness. It can come about when an individual experiences a sense that they do not belong or are engaged with others. Social isolation may be voluntary where an individual may withdraw from contact with others. It may also be involuntary when an older person experiences feelings of loneliness through a lack of close friends or confidants11.
Social isolation in older persons and its related health implications has been the subject of much research. Contributing factors may be psychological and physical. Economic constraints, as well as environmental safety issues, also affect a person’s ability to maintain relationships with others. Increased drinking, smoking, a greater risk of suicide, re-hospitalisation, cognitive decline, mental health issues and cardiac heart disease are all factors bringing about serious health outcomes12.
Research shows that involvement with a religious organisation aids in significant ways to maintaining social networks. Other research has focussed on attendance at church services. Frequent attendees of religious services experienced lower rates of mortality than those who were infrequent participants13. One of the main emphases of the JoCare transport program is assistance to those requiring access to transport to attend church services. This enhances their continuing participation in their community.
While many parishes run programs similar to JoCare or undertake some aspects of the JoCare program within their parish, there is considerable evidence in support of extending such programmes beyond parish boundaries as JoCare does. Demographically, in Australia between 1994 and 2014, the percentage of the population aged 65 years and over increased from 11.8% to 14.7%. Between 1994 and 2014 the percentage of the population aged 85 years and over increased by 153% while the total population growth for Australia was only 32%14. These groups are expected to grow at an even greater rate over the next decade.
In recent times, a number of social determinants of health have been discerned. Two of these highlight the importance of social inclusion. The first emphasises being part of a community, where a person engages with a support network of family and friends. The second is the provision of and access to affordable transport. This allows a person to access services and social supports15.
Further, Australia is a signatory to The Madrid International Plan of Action on Ageing which was adopted in April 2002. The key task of the plan is “building a society for all ages”. We are challenged to oppose discrimination towards the older person and to assist in creating a secure future, where the dignity of everyone regardless of age is respected16.
Pope Saint John Paul II in Familiaris Consortio notes "the life of the aging helps to clarify a scale of human values; it shows the continuity of generations and marvellously demonstrates the interdependence of God's people.”17
Pope Francis describes abandoning or discarding the elderly as a sin, commenting that a civilisation can be judged on its treatment of the elderly. He went further when he noted, "[t]he church cannot and does not want to conform to a mentality of intolerance, even less so one of indifference and disregard toward old age," concluding that "[w]here the elderly are not honoured there is no future for the young."18
Elizabeth MacKinlay observes that a “life without meaning is a life without hope”. Finding meaning is essential for human flourishing particularly when older persons undertake the “last great task of life”.19
Some have questioned the structure of JoCare and the requirements for volunteers to become part of the program. Our response is often a question. If your parent was receiving visitors in their home through a program such as JoCare, would you not feel more comfortable knowing that someone cared enough about your parent to ensure that the best possible practises had been undertaken prior to the commencement of the visiting schedule? While we agree a balance needs to be struck between regulations and care, we also need to be mindful of the contemporary world in which we live.
lrenaeus describes “the glory of God as human beings being fully alive.”20 At JoCare our vision is to enhance the lives of others, encouraging them to become ‘fully alive’. While our initial focus has been to augment the lives of socially isolated older persons in our local area, we anticipate expanding the program to include all those who for a variety of reasons find themselves isolated within their communities.
Kerri Anne Brussen is the JoCare Coordinator at St Joseph's Parish, Malvern. JoCare is a free service supported by St Joseph's Malvern and Cabrini Health.
 N. Connolly, “New Evangelisation in Australia,” SEDOS Bulletin 45 (2013): 128-139 at 129.
 These reports are written within the limits of the privacy regulations.
 Those who access the JoCare program are known as ‘neighbours’. We chose this name as our vision is to create neighbourhoods where people are connected. Clients, patrons or customers did not fit our vision.
 Catholic Community Services NSW/ACT, http://catholiccommunityservices.com.au/volunteer-log7.in/video-index/video-personal-and-professional-boundaries. This is an excellent video demonstrating the boundaries between a volunteer and those they are assisting.
 “Life space” reflects the range of a person’s physical and social mobility and how this range is impacted by gender, physical functioning, cognitive functioning, financial means, culture and the ability to drive. Julie E Byles et al., “Life space and mental health: a study of older community-dwelling persons in Australia,” Aging and Mental Health 19, no. 2 (2015): 98-106.
 In Australia these are legal checks which provide information on a person’s criminal record.
 Volunteering Australia, “The National Standards for Volunteer Involvement,” Volunteering Australia, http://www.volunteeringaustralia.org/policy-and-best-practise/national-standards-and-supporting-material/ (accessed May 28, 2015).
 DeeAnn Klapp, “Biblical Foundations for a Practical Theology of Aging,” Journal of Religious Gerontology 15, no. 1-2 (2003): 69-85 at 69-77.
 Rosalie Hudson, “Ageing and the Trinity, Holey, Wholly, Holy,” in Ageing, Spirituality and Well-being, ed. Albert Jewel (United Kingdom: Jessica Kingsley Pty Ltd, 2003), 86-100.
 Robyn A. Findlay, “Interventions to reduce social isolation amonst older people: where is the evidence?” Ageing and Society 23 (2003): 647-658 at 648.
 A. P. Dickens et al., “Intervention targeting social isolation in older people: a systematic review,” BMC Public Health 11 (2011): 1-22 at 2.
 Nicholas R. Nicholson, “A Review of Social Isolation: An Important but Underassessed Condition in Older Adults,” Journal of Primary Prevention 33 (2012): 137-152 at 137, 140-5.
 Ibid., 143-4; Simone Couzens et al., “Social Participation and Depression in Old Age: A Fixed Effects Analysis in 10 European Countries,” American Journal of Epidemiology (2015): doi: 10.1093/aje/kwv015
 Australian Bureau of Statistics, “3101.0 - Australian Demographic Statistics, Jun 2014,” Australian Bureau of Statistics, http://www.abs.gov.au/ausstats/abs@.nsf/0/1CD2B1952AFC5E7ACA257298000F2E76?OpenDocument (accessed May 25, 2015).
 Inner South East Partnership in Community and Health, Population Health Atlas Planning Resource, (LDC Group: Melbourne, 2013), 7.
 P. Theron, “Practical theologians'calling to serve in the field of gerontology,” Theological Studies 69 (2013): 1-7 at 1-2.
 Pope John Paul II, Familiaris consortio, Holy See November 22, 1981, n. 27, http://w2.vatican.va/content/john-paul-ii/en/apost_exhortations/documents/hf_jp-ii_exh_19811122_familiaris-consortio.html (accessed May 24, 2015).
 Pope Francis, “Vatican Insider, Francis: It is a sin to abandon or discard the elderly,” La Stampa (2015), http://vaticaninsider.lastampa.it/en/the-vatican/detail/articolo/francesco-francis-francisco-39513/ (accessed March 8, 2015).
 Elizabeth MacKinlay, “Baby Boomers Ageing Well? Challenges in the Search for Meaning in Later Life,” Journal of Religion, Spirituality and Aging 26 (2014): 109-121 at 115.
 Stephen Ames, “Finding the way - A Theology of Ageing,” Benetas, http://www.benetas.com.au/research-opinion/research-projects/finding-way-theology-ageing#.Vi7W3bcrKUk (accessed May 15, 2015).