In the final chapter (“We, the living”) of Dear Life, Karen Hitchcock quotes the French philosopher Simone de Beauvoir: “What should a society be, so that in his last years a man might still be a man? The answer is simple: he would always have to have been treated as a man.”
Hitchcock’s essay is more than an essay. It is an incendiary proclamation that calls to mind another French writer, Émile Zola, whose inflammatory article “J’accuse,” published in the magazine L’Aurore in 1898, resulted in his conviction for libel. Zola accused the French army of perpetrating a malicious injustice upon one of its own, an officer named Alfred Dreyfus. Dreyfus, a victim of a gross miscarriage of justice, was publicly humiliated by being stripped of his rank and having his jacket torn off him, and then imprisoned. His family launched a long public campaign, led by Dreyfus’s elder brother, who wrote: “After the degradation emptiness was around us. It seemed to us that we were no longer human beings like others, we were cut off from the world of the living.”
Hitchcock’s essay is also likely to provoke controversy. It is particularly likely to provoke objection from workers in the health sector whose vocational devotion is buttressed by good works and moral conviction. But more importantly it should lead to wide public debate, because the issue she is campaigning on will not go away and demands our attention. Hitchcock tells us with considerable passion that the elderly are being stripped of their respect as fellow citizens, that their identities are being removed, and that they are being consigned to institutions that keep them at arms length from society. Her iconoclastic pen does not spare any of our sacred institutions, be they homes, hospitals or hospices. She wants us to know that these institutions cannot provide respect and dignity if the social climate in which they operate is inimical to the elderly. She is calling for social and possibly political change as the foundation for any change in treatment. She is accusing us of ageism at its most brutal – cutting off the elderly from the world of the living.
Like Zola, Hitchcock does not fail to draw attention to triumphs – in our times, the extraordinary achievements of contemporary medicine. Zola, after congratulating the French president Félix Faure on his political successes, drew his attention to the “spot of mud” that was the Dreyfus affair and went on to describe it as a social crime. In Dear Life, Hitchcock tells us that a serious gap has opened between our medical advancement and our social development. Among the casualties of that widening gap between our technological triumphs and our social awareness are the elderly: they have fallen right into the chasm. Hitchcock presents us with evidence, based on both personal experience and diligent research, that this chasm is not narrowing. She is passionate because she fears that we are unaware of the truth and that if we were aware we would act otherwise. We would extend our hand to the elderly.
The evidence is not comforting – to be told that well-intentioned initiatives such as the Liverpool Care Pathway for the Dying Patient have been abandoned because their implementation made a mockery of the ideals that inspired them is disturbing. A national project that had as its aim assisting inexpert doctors and other staff to provide better care merely revealed that non-experts are not turned into experts overnight by providing them with a more efficient instrument. Rather, it demonstrated that such instruments can quickly become weapons when professionals have not, along with much of the rest of society, undergone the necessary social transformation of attitude essential to address the needs and uphold the rights of the elderly.
Hitchcock points out the major defect of such initiatives. She shows that what such processes do is generate a momentum that doesn’t allow either trained professionals or elderly patients to catch their breath. If we did catch our breath, we might then be able to have a conversation. “Conversation” is a word that is rapidly becoming debased though appropriation by the young, the cool and politicians bent on obfuscating. The elderly, despite lifetimes of experience and endurance, are not being invited to conversations about decisions that determine how they will live the remainder of their lives.
It is the idea of an ongoing conversation with a fellow citizen, albeit an older and infirm one, that is at the heart of Hitchcock’s essay. Not a conversation that is a “one-off.” Not a conversation that binds the elderly to a contractual obligation that is final for all time. Not a conversation that subjugates them to the dictates of the vigorous, the knowledge-rich and the powerful. For Hitchcock, the decisions that set the boundaries of the lives of the sick elderly must come from an open conversation, not one guided by tick-boxes on a checklist. The conversations Hitchcock envisages are “mutual acts of decision-making.”
Hitchcock’s title, Dear Life, pricks our inflated vanities because it points to a culture that is both selfish and consumerist. The elderly have simply become too expensive. The cost of their frailty, their emotional needs and their sorrows may be too much for us to bear.
Hitchcock wants us to think carefully about whether it’s time we restored to the elderly their status as respected citizens – a rehabilitation that would be as much ours as theirs. But before we accord them this respect, before we return to them the clothing of their identities based on the authority of their life experience, we might have to face honestly our own wish to be rid of them. Above all, we must realise that where they tread we will surely follow. We may try to avoid glimpsing the horror of our own futures by blinding ourselves to the sight of just how helpless and needy a frail elderly person can be. But we thereby invite the same fate.
Hitchcock, like Zola, has “neither resentment nor hatred” for those whom she sees as failing the needs of the elderly. She writes with humility about her own failings and with deep respect for the efforts of health workers constrained by limited resources resulting from a failure of collective will. But she evokes disturbing visions of the herding, segregating and separating of the elderly under the banner of “aged care” when the true nature of this social “crime” might be better titled “aged consignment.”
Hitchcock points out correctly that the core issue is not limited resources but, rather, how we dispose of our resources. Why do we spend money on countless procedures such as arthroscopies and “preventative tests” (for the relatively young and healthy) when there is little to show for them beyond a rueful recognition that illnesses take their natural course regardless of such interventions or that no amount of preventative testing will avert the consequences of life choices and social policy? Hitchcock also points out the difficulty of resolving such dilemmas in a healthcare system that values private care (for good reasons) but also encourages private profligacy of resources without adequate scrutiny.
Hitchcock doesn’t take a stance on the question of euthanasia. Rather, she provides many rich perspectives on how the elderly feel as they approach the end of their lives. She simply asks the hard questions, such as “Who was scared of being burdened?” and “Whose distress are we seeking to curtail?”
When my mother was in the last months of her life, months marked by a relentless dementia, she would have occasional moments of what I took to be lucidity. During one such moment, in the leafy garden of a small nursing home in a Melbourne suburb, I said to her, “I love you.” She looked at me and said, “I love you too.” That moment was precious for both of us. I think this is what Hitchcock is saying in her outstanding essay: the elderly deserve our love. Perhaps the shift of focus that Hitchcock is striving to achieve involves convincing us that “we, the living” owe it to them?
Jack Kirszenblat is a psychiatrist to the cancer services at the Alfred Hospital, Melbourne, and also works in private practice.
This correspondence featured in Quarterly Essay 58, Blood Year.
ALSO FROM QUARTERLY ESSAY