Quarterly Essay 58 Blood Year: Terror and the Islamic State (16 page)

Inga Clendinnen

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

“Hospital is not a bad place to die,” Karen Hitchcock quotes a general hospital physician as saying. “People aren’t really preoccupied by their environment when they’re dying.” Hitchcock makes a compelling case for spending more money rather than less at the end of life and for embracing the kind of intervention the Intergenerational Report seems to be saying we can’t afford. In anecdote after anecdote she argues that we spend too little time with the aged and dying and put too little effort into ensuring that they can keep living. She says the alternative view, that old people should be left to die quietly at home, is often driven by concerns that are “primarily fiscal.”

The good news is the fiscal concerns are misplaced.

Treasurer Joe Hockey put them most starkly shortly after taking office when he said that if nothing changed, Australia would “run out of money” to pay for its health, welfare and education systems.

The fine print of the Intergenerational Report shows no such thing. Sure, it shows that by 2055 the proportion of gross domestic product devoted to Australian government spending on health will have climbed from 4.2 per cent to 5.7 per cent. But it also shows that the size of the pie – GDP itself – will have more than tripled. That’s a real (inflation-adjusted) measure. By 2055 Australians will be able to buy twice as much again as they can now. To be sure, the extra buying power will be divided among more people (just as the extra health spending will be divided among more people), but after adjusting for population, GDP per person will be 80 per cent bigger than it is now. That’s right. We will find it far, far easier to boost the slice of the pie going to health than we would today. Not only will we not run out of money to spend what’s projected, we are also likely to spend more than is projected – because we will want to.

Health is what economists call a “superior good.” As incomes climb, we want more of it, not only in absolute terms but also as a proportion of our higher incomes. Most goods aren’t superior goods. Cars and holidays are usually “normal goods.” As our incomes climb, we spend more on them, but not more as a proportion of our higher incomes. A small number of goods are “inferior”: powdered milk is one. As our incomes rise, we not only spend less on them as a proportion of our higher incomes but also less in absolute terms – in the case of powdered milk, next to nothing.

We will pay for the extra health spending we will want by paying more tax, as we’ve been doing for decades as our incomes have grown. At the start of the 1970s we paid the Commonwealth only 17.8 per cent of GDP in tax. We now pay 22 per cent. I am betting we will pay at least 26 per cent by 2055, but the Intergenerational Report assumes only 23.9 per cent, apparently in the belief that we won’t be keener and keener to spend on health as our incomes climb further. The ANU election surveys show that as recently as the late 1990s voters were more concerned about tax (23 per cent) than they were about health (10 per cent). By 2001 the two were on level pegging at 16 per cent, and by 2013 concerns about tax (11 per cent) were dwarfed by concerns about health (19 per cent). The richer we become, the more we want to be well looked after, and the more tax we are prepared to pay to ensure it, regardless of what’s assumed in the report.

It’s entirely sensible behaviour. Extra spending on health is helping buy big increases in life spans and, just as importantly, big increases in
healthy
life spans.

Australian Institute of Health and Welfare data shows that back in 1998 a woman who had turned sixty-five could expect sixteen more years. Now it’s nineteen. A man who had reached sixty-five could expect twenty more years. Now it’s twenty-two. For both genders, all but a few months of those extra years are free of disability. Our longer life spans are mainly
pushing out
the uncomfortable and expensive final years, rather than extending them.

And in any event, it isn’t ageing that’s driving health spending. The Intergenerational Report says only 20 per cent of the projected increase in health spending will be driven by changing demographics. The other 80 per cent will be driven by higher incomes, higher wages and better and more expensive technologies – the kind of things that usually drive health spending.

Hitchcock quotes a NSW finding that hospital costs associated with the last year of life
fall
rather than climb with age. The older people get, the healthier they have to have been and the more years of life they have left. The government actuary finds that an Australian who has reached 100 can expect another 2.5 years of life, an Australian who has reached 105 can expect another 2 years, and an Australian who has reached 109 can expect an extra 1.7 years. The attitude that Hitchcock finds among hospital staff and among some of her aged patients themselves that older Australians aren’t worth treating owes little to evidence.

The financial problem scarcely exists. There will be something of a labour problem as the ratio of Australians of traditional working age to those of non-working age shrinks. But it’s pretty easily solved by extending working lives (as is already happening) and by accepting more workers from overseas. Many of Hitchcock’s colleagues in the general wards would be from overseas. (I’ll leave to one side for the moment the ethics of importing doctors from places such as India, where the needs are greater.)

The ANU surveys suggest the public backs Hitchcock. People want better medical care and are prepared to pay for it. The government doesn’t, really. It’s prepared to build a fund to bankroll medical research, but when it comes to hospital staff on the ground it has offered the states a ludicrous funding deal based on the consumer price index rather than wages or medical costs.

But governments can change. We are heading towards a future in which one third of the electorate will be aged sixty-five or older. Freed from the traditional political loyalties of earlier generations, the new generation of seniors is likely to swing their votes behind whichever side of politics offers them the best deal. Unless I am very wrong, part of that deal will be medical care, care that enables them to hang on to “dear life.”