SYDNEY, New South Wales / Australian Broadcasting Corporation / News / The Drum / June 6, 2010
By Scott Stephens
The disgraceful state of residential aged care in Australia points to a crisis far worse than the inadequate funding, provision and regulation of health and welfare services. It suggests a cultural ailment, a kind of moral amnesia, of which the inattention to our obligation to care for the elderly is an especially disturbing symptom.
Rosie Squires's reporting in the Telegraph was a timely reminder of the utterly inhumane conditions in which far too many of our elderly are forced to live, and under which far too few properly trained carers are allowed to work.
But, for me, the most troubling aspect of Squires's expose of maltreatment and neglect of residents in two Sydney-based aged care homes is that there was nothing new or even particularly egregious about what she described. In fact, anyone who has had any experience whatsoever working or volunteering in residential aged care would have found themselves overtaken by a disquieting sense of deja-vu.
Perhaps there is something unnatural about the outsourcing of the care of our elderly to a disinterested third party. (Reuters: Michaela Rehle, file photo)
With some noble but all too rare exceptions, this is the ubiquitous experience of residential aged care in the West. But perhaps this is the way it has always been. Perhaps there is something unnatural about the outsourcing of the care of our elderly to a disinterested third party, as if it tore a hole in the proper order of things. Just take Elizabeth Jennings's haunting poem "Old People's Nursing Home," written at the end of the nineteenth century (with thanks to Kim Fabricius for the reference).
The faces differentiate themselves,Jennings captured the unreality - and, indeed, the immorality - of the nursing home as a place where past and future, memory and hope are somehow eradicated, and all that is left is the nightmare of this hellishly changeless present in which not even cups can break.
The men half-women, the women half-men
And each entirely children
Except in anger, except in ignorance.
These wrinkled faces know too much, these gnarled
Hands have touched the pulse of love, have known
The family increase and birth's harvesting.
But that was the past and this house has shut out the past
And it dare not face the future:
So it lives in a perilous present that could be cracked
By a broken cup or a laugh.
Cups are unbreakable here,
Jokes are in print too small
And the noisy future, the passionate past are dammed
Partly by deafness, partly
By doctors' decisions and nurses'
Hiding the stuff of life and death away -
Tear-heavy handkerchiefs, the whiff of pain.
But how can it be otherwise when it is one's family and community that safeguards memory and embodies hope, and the expressed purpose of residential aged care is to separate the elderly from their families and communities? And while it is inevitable that residents would look to the staff to function as an ersatz family, the staff themselves are too often unequipped and incapable of meeting the residents most basic material needs, much less provide the kind of emotional succour so necessary in old age.
The tragedy of residential aged care - and Squires's piece demonstrates this quite subtly - is that there is no way of simply dividing the different players into the victims and the perpetrators, the indigent and the sadistic. Instead, the staff and the residents are bound, as it were, back-to-back in an institution that makes human affection and mutuality well-nigh impossible, and that is cruel in its very indifference.
But this situation is set to become more profound because of two interrelated trends.
The first is the dramatic increase in the number of large residential aged care facilities - that is, those with over 100 beds - run both by not-for-profit and by private for-profit operators, such as the Moran Health Care Group, TriCare and Macquarie Capital Alliance Group. According to the Productivity Commission's 2008 report, the number of such large facilities has increased by 121 per cent since 1998.
The effect of this expansion on smaller not-for-profit facilities - those with 40 or fewer beds - has been devastating, forcing them to contract from over 50 per cent of the total number of residential aged care facilities in 1998 to less than 30 per cent in 2009.
The same report by the Productivity Commission tracked a second, more disturbing trend. There has been a sharp reduction in the willingness of family members and communities to care for their elderly. As David de Vaus observed, "The more the obligation has a direct impact on people's lives the more reluctant they are to accept responsibility."
It is not hard to imagine the future that awaits our elderly as these trends continue to converge: ever increasing numbers of the frail and infirm herded into an ever-decreasing number of sterile profit-based mega-facilities, and there left to vanish in anonymous isolation.
To be sure, there are family members that agonise over having to leave their loved ones in such a degrading environment but simply cannot see any other option. But for far too many Australians, the ability to go on living in our consumerist nirvana is predicated on the capacity to forget our obligations to the elderly.
And so it seems that the elderly have become a kind of ritual sacrifice that we as a society offer to the most implacable of our modern idols: what Herve Juvin has described as a kind of lived immortality sustained by unlimited choice and the delusion that we can somehow indefinitely defer our deaths.
But can there be a moral response to this intolerable and mutually demeaning situation? Alongside the Federal Government's increase in the funding of supported accommodation and community-based care, there must necessarily also be a change in what I described as a cultural ailment, a moral amnesia. And the first way that this change might manifest itself would be to remember that morality itself, as Gilbert Meilaender puts it, "consists in large part in learning to deal with the unwanted and unexpected interruptions to our plans" - which the demands of the elderly undoubtedly are.
But there is a second facet of such a cultural change that is far more demanding, and requires the strength of an entire community to sustain. It is the patience to help the elderly die. Residential aged care, paradoxically, does not let its wards die, but rather consigns them to an interminably aseptic life. Again, Elizabeth Jennings captured this with grim accuracy.
But there was no smell, not even the deathly sickWe forget that the ars moriendi or the "art of dying" - of which Langland's Piers Plowman is perhaps the best literary example - was cultivated in the mediaeval Christian tradition as an indispensable part of living well. But it was never understood as an individual virtue. It was instead a communal effort, whereby the community gathers to listen with patient gratitude to lives that have finally learned to tell the truth about themselves.
Odour of death. And then I realised:
Death is shut from this house, the language of death,
The accoutrements of dying.
A ghost would be lively. Ghosts are not allowed here
And neither is talk of birth.
Dying, in other words, was deemed the last theatre of virtue and courage, the manifestation of the bond between the living and the dead.
Surprisingly, the custodian of the Christian tradition of the ars moriendi is one of the most notorious modern atheists. In the final volume of the His Dark Materials trilogy, Philip Pullman tells the story of Lyra and Will, two children who have made a perilous journey to the world of the dead so that Lyra may apologise to a friend she inadvertently betrayed, and for whose death she was responsible.
But once there, it becomes clear that their destiny is to destroy death itself by, quite literally, cutting a hole in the other side, thereby permitting the ghosts of the dead to disperse into the benign indifference of the universe.
When one of the harpies - whose role it is to torment the dead by spitting venomous reminders of their failed lives - complains that releasing the dead would negate the very reason for the harpies' existence, the children's travelling companion makes a touching suggestion:
"'Then', said Tialys, 'let's make a bargain with you. Instead of seeing only the wickedness and cruelty and greed of the ghosts that come down here, from now on you will have the right to ask every ghost to tell you the story of their lives, and they will have to tell the truth about what they've seen and touched and heard and loved and known in the world. Every one of these ghosts has a story; every single one that comes down in the future will have true things to tell you about the world. And you'll have the right to hear them, and they will have to tell you.'"
If we don't recover this patient art of dying, whereby we learn to tell the truth about ourselves, it is not simply our elderly that will suffer. We will find ourselves immeasurably poorer.
Scott Stephens is the ABC's Religion and Ethics editor.
© 2010 ABC