In the 1970s, Americans concerned themselves with death and dying; in the 1980s, they are increasingly concerned with aging. Preoccupation with the one subject seems to imply an interest in the other. What could be more natural than a shift in focus from dying to those about to die?
And yet, from the perspective of most other cultures it would seem odd to fuse the subjects of old age and death. Until recently, dying was not a peculiar specialty of the aged. People died at any time. Indeed, the cradle was closer to the grave than the rocking chair. In one sense, the aged were peculiarly distanced from death. They had passed beyond the perils of infancy and the uncertainties of childhood; they had weathered the ills that plagued adults who were their juniors. They were the survivors, those who had won out in the struggle for life in a world beset by death.
In our own time, however, the vast majority of people live seven decades. For the first time, becoming old is commonplace. This fact, as much as any other, may account for the ways in which we break the fourth commandment today. Honor comes harder when the elderly are no longer rare.
But neglect of the elderly has many additional causes. An attitude of disrespect particularly tempts an immigrant, perpetually migrant, pragmatic, secular, and proudly independent people. By its nature, an immigrant country distances itself from ancestors. Coming to America entailed a kind of abandonment of the aged. Immigrants made an extraordinary sacrifice and placed extraordinary pressure on their children. In Great Britain, W. H. Auden once said, children feel pressure to live up to their parents; but in America, until the 1950s, parents expected their children to outstrip them. In turn, an immigrant people became a perpetually migrant people. Children left home for college in quest of better jobs than their fathers’ and better homes and kitchens than their mothers’—and eventually spilled out of the cities and across the land, hoping to improve their lot. They left their elders behind or saw them off to those huge territorial nursing homes, Florida and Arizona.
Americans, furthermore, tend to identify with doing rather than being. When retirement strips them of their work, people lose their self-respect and therefore their hold on the respect of others.
The aged slip to the margins of consciousness for the ruling generation. In this regard, America is the most secular of countries—in the original characterization of a culture that orients itself to the current generation. That may be closer to the root of things than the conventional characterization of America as a “youth culture.”
But that does not tell the whole story. To the degree that the aged increase in numbers they become an active threat to the ruling generation. The elderly have become a political power bloc; they have already influenced legislation and court decisions. They currently get 150 billion dollars out of the annual federal budget, and by the year 2040, it has been predicted, some 20 percent of the total population will be elderly, and at current rates, some 40 percent of the federal budget will be devoted to their care. We may be moving rapidly into an age of resentment and hostility toward the elderly.
But there is a deeper internal threat. The aged remind the middle-aged of their own imminent destiny. As Ronald Blythe puts it, the middle-aged “frequently find themselves timidly yet compulsively, like tonguing a tooth nerve—measuring their assets against those of youth to see what they have left, and against those of old age to see what has to go. It is often a great deal in both cases” (The View in Winter, Harcourt, Brace, 1979).
What the middle-aged fear, however, is not merely physical decay, but the humiliation of dependency. They do not want the elderly to encumber them, and the elderly do not want to lapse into becoming a burden. Few of us, however, can avoid the awkwardness and dependencies of aging; the elderly are one minority that, sooner or later, almost all of us join.
Strategies For Care Of The Aging
The strategies we have adopted for the care of the elderly provide further clues to the American character and ideals.
Family care. No institution compares with the family in the care of the elderly. Seventy-five to 80 percent of the elderly have families nearby; 80 percent have seen a family member in the last week. Of those not institutionalized, half live alone and half with relatives. The government informally subsidizes this family-centered care through social security payments that far exceed the pensioner’s original contribution. This income allows many older people to live for a time near children or other relatives without becoming a full-time dependent. But little subsidy exists in the United States for other kinds of services, whereas, for example, in Great Britain there are respite houses where the elderly may go for brief periods to provide adult children with a break from constant care, and home visitation services that permit more elderly to function independently and longer near their children.
Also, the migration of large numbers of the elderly to the Sun Belt has led to the growth of extended families of the elderly who help one another and no longer depend upon children to take care of them. The ancient take care of one another. Some are a little better off than others, but all are roughly in the same boat—in need of someone who will play bridge, talk, or monitor the window shade daily to check whether all is well. This extended family functions within the limits of fragile resources and energies. Like the biological family, it relies on the reciprocities of giving and receiving and mutual dependence.
Public support and the marketplace. Within the bonds of family life, taking care of the elderly presupposes mutual, though not simultaneous, dependency. We honor our fathers and mothers (and other elderly people within the family circle) because, at least in part, we have received so much from them. Thus the care we give has a responsive element; so much precedes it. Our caring for them answers, in part, to our original dependency upon them.
Care beyond the family circle occurs usually within a different moral horizon, chiefly that of the marketplace. The ethical standards of buying and selling control much professional care and nonprofessional service. The elderly usually rely on money to purchase these services. Abhorring dependence on the family, they prefer, or seem to prefer, to purchase care, service, and attention. (Perhaps this is partly because they perceive how difficult it is for us to take them in.)
Social security provides a major support for the freedom of the elderly to continue participating in the marketplace. Until recently, a worker has withdrawn much more from the system than he or she put in. Unfortunately, this indiscriminate subsidy creates a drain on the system. Some liberals increasingly wonder whether it is fair to let entitlement programs for the elderly grow apace while poverty programs for mothers, children, and others are cut to the bone; some conservatives want to cut benefits back to a level too low to support the modestly fixed. A fair compromise may be to subject one-half of a pensioner’s social security income benefits to income tax rates. The poor would not make enough from all sources to be taxed, and the rich would no longer receive an untaxed windfall. Meanwhile, funds would increase to support basic income for the poor and the modestly fixed.
Total institutions. Eventually the day arrives when the elderly can no longer participate directly in the marketplace. The need arises then to purchase a total environment of care for them. To that end, we mobilize professional and subprofessional services in large institutions (hospital, retirement center, and nursing home) to address their needs.
The strategy of placing the aged in large facilities springs from a variety of motives, some benevolent, others self-serving, and often a mixture of both. In some cases, the elderly flourish best in total institutions. Either they have no family or they require a level of care that their family can no longer provide.
Still, 20 to 30 percent of the residents in total institutions do not need to be there for reasons of health or family circumstances. These older people require more care than they previously received or knew how to secure in the outside world, but they do not need the environment of the total care facility. Often a few strategic services would make independent or family life possible, and such services would cost far less than total institutional care. But the economics of our delivery system favors institutionalization.
The reason for institutionalizing does not spring wholly from the special interests of those who profit financially thereby. Society would not tolerate the cost if the segregation of the elderly did not also meet a deep psychic need. The nuclear family is already overloaded; both adults work, leaving no one at home to provide care; the house seems too small to accommodate. To have to face the elderly daily would be too depressing. We prefer to remove the decrepit from sight because they inspire fear. To address them in their needs would require us to acknowledge our own needs. What better way to place them in the shadows and obscure our own neediness than to put them in the hands of professionals whose métier it is to make a show of strength, experience, and competence in handling a platoon of the distressed?
Geriatric Barracks
However one adjudicates the cultural and religious forces at work behind unnecessary sequestering, the human cost of total institutions is great. Often they impoverish, with the same stroke, what they attempt to aid. In their very design, most nursing homes mock the word “home.” They are often little more than geriatric barracks. Like dogs who tremble as they are about to be left at the veterinarian’s, the elderly shiver at the thought of permanent consignment to a nursing home. Less than 6 percent of the elderly reside in such facilities, but the percentage is misleading: many more people will spend some time in a nursing home, and many will die there. Moreover, I am convinced that those who fear ending up in a nursing home far exceed in number those who spend time there. The nursing home now occupies the same place in the psyche of the elderly that the poorhouse and the orphanage did in the imagination of Victorian children.
The design of space for old bodies. The deprivations they impose hardly argue for the dismantling of total institutions. But serious thought must be given to their design, particularly to what might be called the moral significance of turf. Before the twentieth century, only the poor went to the hospital. Now, rich and poor alike get transported to the professional’s domain. The very architecture of the hospital and nursing home tends to serve the convenience of staff and the machines that dominate the institution. Patients are removed from the familiar settings where they feel in charge; strangers assume control. Not surprisingly, the elderly balk even more than the sick at entering total institutions. Sick people hope to come out of the hospital alive; the elderly usually move to the care center permanently. The institution swallows them up; it condemns them to a premature burial.
Successively and progressively, disease, impairment, old age, immobility, and death restrict space. The world is reduced to a single room, and ultimately to a casket. Ordinarily, the bedroom is only part of our total world, often a sanctuary from it. Meanwhile, psychic life also shrinks, as the elderly become increasingly preoccupied with the body and its troubles. The design of humane institutions requires sensitive reflection about the older person’s perception of his or her body and the contracting world it inhabits.
The body has a threefold meaning for a human being. First, and most obviously, it is an instrument for controlling our world. Illness and aging threaten us with a loss of control. Moving into a facility diminishes control not only because the elderly person moves to another’s turf, but also because the shock of the move assults the memory and, with it, the capacity to function. The man in his eighties, living alone and long familiar with his surroundings, may live and care for himself competently despite a tattered memory. He turns off the gas jet seven or eight times after preparing breakfast. He has enough memory left to know that he should turn off the gas, but not enough left to know whether he has done it. But if the society denies him supplementary services to sustain him in familiar surroundings and locates him in a large institution with its architectural accommodation to staff rather than to residents, then his memory and competence can precipitously deteriorate. Sensitive institutional design should attempt to minimize the loss of control and the humiliation.
Further, the body is a means for savoring the world. A move into a home for the elderly substitutes a functionally bland, salt-free environment for the variegated texture of the world that each of us has come to savor. Conscientious administrators need to admit into the room/world of the elderly a few of the bona fide sensations.
Finally, we are our bodies. Separate me from my body and I am divorced from my community. With old age this separation increasingly takes place, and in two forms. In some cases, the mind remains alert but the body sinks into ruin; in others, the body persists adequately, but the mind abandons it. In the first instance, the alert experience their bodily defects less as imperfections than as stigma that affect not just the flesh but the whole person. One’s body, and therefore one’s self, no longer feels lovable, touchable, cherishable. This experience has its implications for institutional design. It calls for respect for the body and respect for modesty. And it reinforces the warrants for creating an attractive environment. People find the bedridden more approachable if the room they inhabit is attractive. When the elderly offer a chair to a visitor, in a limited way they offer and extend themselves.
The Ideal Of Philanthropy
Philanthropy provides a motive for care largely outside the family circle (though it is not entirely absent when the blood tie is weak). The ideal of service to others helps keep the professional relationship from reducing itself to a commercial transaction alone; hence the term the “helping professions.” The philanthropic ideal also provides motive for amateurs who want to help others.
The ideal of philanthropy presupposes a fundamental asymmetry. It describes a one-way street from giver to receiver. It is an ethic of love without ties. It presupposes sufficiency and independence on one side and needy dependency on the other. Therein lies its spiritual danger: it tends to reinforce a great divide between giver and receiver.
This ideal also reflects the moral ideals to which Americans generally, and the Protestant churches in particular, have been committed. The Protestant social ethic has been almost obsessively and exclusively an ethic of love, an ethic of giving. The mark of the Christian life is responsiveness to the plight of the neighbor. Americans defined themselves out of the human race, and the American church out of Christendom, when they presumed that they were the exclusive specialists in philanthropy, serving others from a promontory above them. Members of the helping professions tend to define themselves by their giving alone—with others indebted to them.
In fact, however, a reciprocity of giving and receiving is at work in all professional relationships. To be sure, the student needs a teacher, but the professor also needs students to work out what he has to say and to rediscover his subject afresh through the discipline of sharing. During medical crises, patients need physicians, but physicians also need patients. No one can watch a doctor nervously approach her retirement without realizing how much her patients have helped her to be herself. And more than one minister has ventured tentatively into the sick room wondering what to say to a parishioner only to discover that the patient’s composure ministers to him.
Love defines the role of giving in human life, but humility makes possible (and tolerable) the act of receiving. Who can deal tenderly with the distress of the aged without acknowledging personal distress?
The Ethics Of The Aged
Ethicists unwittingly contribute to the exclusion of the elderly when they talk about the ethics of care givers but neglect the ethics of care receivers.
As John Yoder has pointed out, the New Testament appears to be ethically conservative in its discussion of the duties of husbands and wives, parents and children, masters and slaves. It emphasizes the duties, rather than the rights, of the subordinate in each pair. But, in fact, the New Testament table of duties had a revolutionary potential in that it addressed both persons in the pair as moral agents. In this respect, the New Testament writers broke with the stoic table of domestic duties that addressed only the person in a superior position—as though only the more powerful had a moral existence. But in the New Testament, says John Yoder, “the subordinate person in the social order is addressed as a moral agent.” There was no precedent for this, he argues, in Hellenistic thought. In addressing wives, children, and slaves, Christian Scripture assigned “personal moral responsibility to those who have no legal or moral status in their culture, and makes of them decision-makers.” Western culture (and the church) took a long time catching up with this change of status (The Politics of Jesus; Eerdmans, 1972).
Any serious reflection on the moral status of the aged requires reflection on the specific virtues that age calls for.
First on the list is courage, which Thomas Aquinas defined as a firmness of soul in the face of adversity. That firmness shows itself far from the battlefield. An 80-year-old bachelor faces resolutely his declining years; a widower takes his first steps alone after 50 years of marriage; an aged mother finds her children too busy to have her around.
Just as care givers need to evince the virtue of humility, care receivers need the same virtue. All the care in the world cannot overcome the sting of humiliation; only humility can. Perhaps midlife would not be so spoiled by pretension, so shadowed by the fear of failure, if we knew how to keep our feet in the soil of humility.
Patience is hardly a natural characteristic of old age. Just as readily, advancing age and infirmity provoke anger, frustration, and bitterness. Patience is surely misunderstood when it is interpreted as pure passivity. It is a most intense activity, a way of taking control of one’s spirit precisely when all else goes out of control.
Simplicity should also mark the elderly, and not merely because memory lapses into its familiar, repetitive grooves, but because the pilgrim has at long last learned how to travel light.
Benignity is, according to the Benedictine monks, a kind of purified benevolence. It hardly goes with the territory of old age. Quite the contrary, the ars moriendi of the late Middle Ages identified avarice as the chief besetting sin of the aged. The closer one gets to the final dispossession of death, the more fiercely one may be inclined to clutch at possessions: holding, grasping, manipulating. Avarice strikes those who are most insecure and least mobile.
Hilarity is a curious virtue to associate with the aged. Yet the monks talk about hilaritas, a celestial gaiety in those who have seen a lot, done a lot, grieved a lot, but now acquire that detachment of the fly on the ceiling looking down on the human scene. Children are blessed if they experience in grandparents a lightness of spirit that offers sunny relief from their parents’ gravity.
Voluntary communities and the aged. The aged are agents as well as patients; but they still need care, and care requires the mobilization of social resources. I take for granted the need for substantial government aid. The government has a responsibility for distributive justice in addressing human need. But the demography of the aged makes it clear that we are headed for disaster if we handle their care solely in the conventional ways.
This raises the question of other options. The major alternative to the huge bureaucracy that organizes professionals is the voluntary community that mobilizes amateurs.
We may be moving into a period in which we need to sustain two kinds of social organizations: first, the bureaucracies, the organizational equivalent of of the Egyptian pyramids—massive, formal, geometrical, hierarchical; but second, small-scale, informal, and spontaneous communities that counterbalance the bureaucracies—just as the Egyptians developed spontaneous, lyrical, naturalistic arts and crafts to compensate for the impersonal and massive forms of the pyramid.
In such a dual world, the voluntary communities have several social functions. First, they must provide services above and beyond those that the bureaucracies provide. Amateurs who can offer companionship to the elderly may sometimes better address their deeper needs than those with expertise.
Second, voluntary communities must provide a critical check to bureaucracies, placing representatives on their boards of directors and frequenting the halls of their institutions as advocates for the elderly. Too often teachers, administrators, and health care practitioners develop a defensive, proprietary relation to their institutions. The sheer repetitiveness of their work tends to give them spiritual callouses. But the amateur has the advantage of seeing the environment afresh. Every institution needs to be exposed to the “dumb” questions: Why do you do this rather than that? Why this kind of building, not that? One needs to sort out the difference between procedures that merely serve the convenience of institutions and their managers and those that best serve the needs of the elderly.
Further, outsiders need to enter total institutions in order to acquaint the community at large with the needs of the elderly. How else can we effect a favorable ethos of support for the bureaucracies in the society at large? I am not in favor of the romanticism of the late sixties that urged us to dismantle the bureaucracies and eliminate the expert. The work of amateurs is too inept, too easily discouraged, too episodic to dispense with the professional. But we must find ways of bringing the outside community into contact with the service bureaucracies.
Finally, voluntary communities will need not only to work with existing institutions, but also to create alternative patterns for the delivery of care. A church basement in San Francisco, where elderly folk received meals, offers a modest illustration of such experimentation. The church and other cooperating institutions provided this noonday service through a federal grant. At first glance, the basement setting was conventional enough. The elderly ate. But then it became clear that retarded and variously handicapped folk served the meal. It took the federal government to support the program, but it took the church to conceive and execute it, a cooperative venture between the two. With one stroke the program benefits not only the elderly, but also another deprived group, and, last but not least, a middle-class community of organizers and hosts.
Bold experiments will be required, against the day that the great institutions about us should crack and decay. I do not believe, however, that voluntary communities will be able to devise attractive alternatives unless they also recognize that they are beneficiaries at the hands of those they serve.
Tim Stafford is a free-lance writer living in Santa Rosa, California. He is a distinguished contributor to several magazines. His latest book is Do You Sometimes Feel Like a Nobody? (Zondervan, 1980).
