This article appears in the November 1998 edition of the Catholic Medical Quarterly
Ageing, Health and Society
FIAMC, the International Federation of Catholic Medical Associations, was asked by the council for the Laity (Concilium pro Laicis) to prepare a paper reflecting the opinion of the Federation on the preparation for the International Year focusing on health related problems. This paper reflects our considerations from a medical point of view. Quite obviously, it does not encompass the vast array of problems, aspects, hopes and needs which old age per se causes.
There is ample evidence that the world is experiencing a demographic revolution characterised by increasing numbers of aged persons: therefore, the traditional demographic pyramid no longer represents the population. In the USA for example, population in general is expected to increase by 19.8% up to 2050, but for the aged segment the increase is estimated at 117%. According to WHO, in Europe senior persons (aged 65 years and above) represent 15-20% of the population. Even in the developing countries the trend is noticeably upwards, due to betterment of life and health conditions and to (sometimes forced) decrease in natality. It is estimated that India and China harbour about 200 million aged people. Moreover, the extreme old age segment (over 80-85 years) is steadily increasing and can be considered as a risk group. Italy counts more than 5,000 and Japan 7,371 centenarians, mostly female. On the whole, and accepting the criteria established in 1995 by the United Nations, world population is rapidly moving from an "ageing society" to an "aged society", the 14% of 65 years plus being the borderline between the two types of society. These are facts which cannot be refuted.
From a social point of view, in many countries the situation of the aged has deteriorated. Changes in family structure and tradition have undermined the status of old people, deprived them of power and influence, and placed them in kinship dependence or on institutions or the State. Social evolution has reduced their importance and prestige and discharged them from employment or activity at increasingly younger ages, transforming them from working people receiving a salary into retired persons receiving a pension. Indeed they may be resented by many as representing a sort of alimony grudgingly paid by their former spouse, society. Moreover, solitude represents an additional and serious problem. It is calculated (on the basis of data collected by the European Region of the International Association of Gerontology) that, in Europe, about one third of aged persons, mostly women, live alone. Solitude is associated with lesser interpersonal relationships, lesser input from outside, self depreciation and less attention to personal care and hygiene: it often verges on abandonment; an important cause of social and mental deterioration.
Medically, old people require frequent consultations, many with minor but chronic ailments, but necessitating attention, time and patience. They are sometimes regarded by health authorities as requiring disproportionally more expenditure than the remainder of the population as, 10-15% of the population, they account for 30-35% of the total drug expenditure. Furthermore, doctors are taught during medical studies to diagnose and treat (and even prevent) illnesses but not to deal with those who are not actually ill or affected with chronic degenerative illness but nonetheless are in need of medical advice and care. Care of aged persons demands insights into a constellation of diverse circumstances of a bio-psycho-social nature: medicine, therefore, cannot be separated from these factors. Social and economic conditions, interpersonal relations, spiritual and religious attitudes play an important role in the medical needs of this group of society. Well-being is often more important than the objective health state. Medical intervention must he addressed, not only to the alleviation of symptoms and treatment of the underlying pathology, but also to the prevention of chronicity and disablement. Rehabilitation and reactivation assume great importance.
Two conclusions arise from this necessarily superficial overview:-
An interdisciplinary approach is required to answer the needs and anxieties of aged people; the doctor or health system not being able to cope alone with this complex situation. It must in- volve the collaboration of a number of professionals including social workers, psychologists, nurses and voluntary workers. Ecclesiastical assistance cannot be overemphasised: the minister of religion is an important agent. Old people are vividly conscious of death with its mysteries; they confide in health personnel, sharing with them their anxieties, hopes or fears. It is part of medical care to listen to them, to manifest empathy, freely to discuss the issues respecting their beliefs and, where suitable, to help them find appropriate spiritual advisers.
A second conclusion is that ageing in itself is not a tragedy or a fateful event: society should not anticipate it as a gloomy prospect. Ageing persons are not always at the receiving end: their experience, knowledge, tolerance and absence of radicalism may contribute enormously to the health and happiness of the world. They have their own charisma, described in moving words by His Holiness John Paul I (speaking to Vie Montante members in October, 1982). The Aged Society is not an imperfect group to be cured of its ills by all possible means but should be regarded as a signal of the times.
The prospects of Intervention
It is unrealistic to foresee a dramatic increase in means and funds allocated by governments to the aged; better use of available resources must be made, and all possibilities of preventing a landslide evolution into an out of control situation must be used. Social chaos and indescribable misery would ensue if developed countries were not able to provide the moneys for pensions and other social duties of the state. In order to preserve the capacity of the state to intervene, it may be necessary to review the age of retirement, allowing those with good health to continue in work for longer, if they wish to do so (flexibility of retirement age). The health system should treat old people predominantly at home, hospitalisation being reserved for acute or technically demanding events. The community should be encouraged, with fiscal incentives, to create and maintain day centres, homes and other institutions providing services, entertainment and possibilities for productive activity for old people. Using their acquired culture, experience and wisdom, and their almost unlimited free time, the elderly may prove immensely useful to society, collaborating in many areas, such as volunteers in hospital and health centres, in the educational system (teaching optional courses - cooking, embroidering, languages, crafts etc.) More important than these measures are the continued efforts to change mental attitudes.
The aged person is neither a burden nor a wreck, but a human being endowed with dignity, able to receive and give love and support, a full member of human society. He or she may be a helper, a counsellor, a confidant, or just a friend. Even in extreme age and in poor conditions of health, he or she remains in the image of God and (even for non-believers) a member of the human race, someone with a life story and a past. The Catholic Church is well aware of this reality and has repeatedly reaffirmed its stance, as expressed by the Pontifical Council for the Family in its 1983-1984 survey: there is no talk of assistance and good work but of the valuation of man, stating the dignity and content of all human persons.
The possible roles of the Church
The Church has always been attentive to the problems of old age, respecting, employing and caring for old persons: its record in the charities for them is impressive and cannot be denied. Many orders, brotherhoods and "Misericordia" have devoted themselves to this charitable work, especially when health conditions are poor. The Church is less stringent than civil society in establishing a retirement age for the members of the Hierarchy; bishops and cardinals ask for retirement at 75, but may stay in function until 80. Many priests just do not retire. The Church has a background and a practical attitude which allows her to advise, to co-operate and to take initiatives in the preparation of the International Year.
It may advise governments, and international bodies but especially communities to avoid or treat the serious problems we have outlined. It has the moral authority to insist on the need to rebuild the family as the normal place for action and care of old people. The family should receive credits (including material compensation) due to those looking after senior incapacitated citizens. The Church has always given prime attention to the family; it is logical that its place and role in the prevention and care of sickness are to be strongly underlined. Renewed zeal should be recommended to Catholic hospitals charities, and lay movements which deal with senior citizens. Above all the right and the need of old people to receive spiritual and religious support must be stressed and put into practice. Terminal states often evoke the question of euthanasia and the discontinuance of assisted nutrition. Our Federation has discussed this theme frequently in its publications and national and international congresses.
Suffice it to say here that scientific and ethical arguments overwhelmingly deny the need and legitimacy of causing death by action or omission, by assisted suicide or discontinuation of assisted nutrition. Such proposed interventions are symptomatic of a devaluation of the elderly and an unwillingness to provide support to the handicapped or terminally ill.
Needless to say, we fully support adequate analgesic measures, even if they may shorten life's expectancy, qualified and comprehensive health care of these patients, and psychological and spiritual assistance to their and their relatives.
Practical considerations on the role of the Church
An official document of the Magisterium would be most important for the, definition of the task and the role of Catholic Christians in this world-wide problem; forms of prevention and guide-lines to efficient management and care for age-related social, personal and medical problems could be delineated and the needed change in mentalities authoritatively recommended.
Episcopal conferences could contribute by publishing documents of national relevance; diocese and parishes being invited actively to collaborate in the movement to change mentalities. In close co-operation with the Pontifical Council for the Pastoral Care of Health Professionals, the Catholic lay movements working in the health areas (doctors, nurse, pharmacists, hospitals) should respond to the actions directed at their members, diffusing the documents of the Magisteriuin with their own statements and establishing protocols of concerted actions at the international level, particularly the WHO. FIAMC, with the present position paper, addresses the Universities and Schools of Medicine with recommendations concerning the place of geriatrics in pre-graduate and post-graduate teaching, urging these institutions to improve research and teaching on the biology of the elderly. The opinion is expressed that old age may be a fruitful and happy stage of life and the aged person a helpful and invaluable member of the community; that the health care professionals must be prepared and willing to engage in the fight against loss of health and social deterioration, taking care of disabled or terminal patients in their final phase. Our common tasks represent a real challenge for all those who live in solidarity with people of all (or none) religious beliefs. They are in line with the doctrine expounded in the beginning of the Constitution Gaudium et Spes:
"The joys and hopes, the griefs and anxieties of the men of this age, especially those who are poor or in any way affected, these are the joys and hopes of the followers of Christ.
Indeed, nothing genuinely fails to raise an echo in their hearts. For theirs is a community composed of men".
I am indebted to the many colleagues who participated in the preparation of this document.
Special thanks are due to Dr. Eugene Diamond (Chicago), Professor Hiroaki Kahyo (University of Yitakyushu) Dr. T.P. Linehan (London), Mr. Alberto Marxuach (Madrid), Professor Yukio Moriguchi (University of Rio Grande do Sul), and Professor Mario Passeri (University of Parma).
Dr Walter Osswald, is President of the International Federation of Catholic Medical Associations (FIAMC).