Death Control: The Last Taboo
Professor Tim Connell
May I begin by claiming no particular knowledge of today's subject.[i] But increasing maturity has led to my becoming so much more familiar with old age, infirmity and death. Certainly, I attend more funerals these days than christenings. The attrition rate among the older generation (friends' parents, old neighbours, teachers and now colleagues) is running at the rate of about one a month and I pay closer attention to the obituary columns than I once did. One colleague of mine (who I don't get on with terribly well) said to me recently, 'I see you're writing obituaries for The Times now,' to which I replied (quite without thinking), 'Yes, and I'll write one for you any time you like.'
The greying of the population (there are now more people in this country over 65 than under 17), the social and financial cost of care for the elderly, the pensions scandal, even the debate on immigration, all contribute to make this a major issue that needs to be considered with care. Recent debates arising from the attempts over a three-year period to introduce an Assisted Dying Bill into the House of Lords[ii] range from the purely ethical to the fiercely practical, though there does seem to be a growing trend towards accepting the fact that keeping someone alive at all costs is probably not in anyone's interest. There have been comparisons with legislation in Holland, Oregon and parts of Switzerland, all of which serve to heighten awareness as to the sheer complexity (some would even say hopelessness) of finding a solution to the problem of longevity which is just, ethical - and workable.
a) Death Control
So why Death Control, and why do I call it the Last Taboo?
A key topic for debate in the Twentieth Century revolved around birth control, from the controversial topic of eugenics to the more modern concept of family planning. Writers such as Somerset Maugham highlighted slum conditions through his best-selling first novel Liza of Lambeth of 1897, which was based on his experiences as a sixpenny doctor working out of St Thomas' Hospital. Marie Stopes caused enormous scandal with the publication of her first work Married Love or Love in Marriage in 1918, and which went through six editions in a fortnight.[iii]Although population growth has not followed the pathways predicted by the Reverend Malthus[iv], population pressure has become a subject touching on a whole variety of areas, ranging from urban planning to climate change. The shift in the demographic balance in Western Europe now leaves most EU states with more inhabitants in or approaching retirement than going through school. This raises a different range of questions concerning education, employment, re-shaping of the social pyramid, and the underlying question as to how fewer people in work will be able to maintain more retired people who no longer work, and what is to be done about those whose lives can be prolonged because of advances in medicine, but who have no hope of recovery or even of leading a normal life.
Euthanasia, whilst becoming a more frequent topic for comment in the Press, is still viewed with as much suspicion as eugenics - and this was a concept which was given far more credence a hundred years ago than we would perhaps like to admit today.[v] Ethical issues, such as the right to life versus the unnecessary prolonging of pain; legal questions such as assisted suicide; financial matters, such as the cost to both individuals and the State, are touched on but tend to provoke well-worn responses, which rarely lead to objective serious debate. Ironically, pre-natal testing, in vitro fertilisation, genetic counselling and genetic engineering can now be discussed in the way that compulsory sterilisation once could.
b) The Last Taboo
In many ways we have become hardened about death. Military losses in Afghanistan, the spate of fatal shootings and stabbings in London and elsewhere in the UK, the number of TV series that bring us full-frontal autopsies, all contrast strangely with the fact that death is no longer part of daily life as it was for the Victorians. The number of centenarians increases year by year as indeed does life expectancy (in the developed world at least) and as the baby boomers age, so will the number of dementia cases and patients requiring long-term hospital care with little chance of a proper recovery.
This in turn raises a number of ethical issues: will we have to ration medical services, or charge prices that will make them unobtainable to all but a fortunate and affluent few? Will national insurance contributions have to double if people are to be offered long-term care for possibly thirty years after they stopped full-time work? Will public attitudes and (in due course) the Law change so that living wills can have legal status, and will doctors be able to take life and death decisions in the way that they could before the Harold Shipman case? Can the Law protect the vulnerable whilst recognising that medical care can stop people from dying without enabling them to lead anything like a normal life? And will the economy be able to sustain the army of carers who will be needed to look after the legions of geriatric cases that are already anticipated?
Apart from legal and medical issues, what about the personal aspects of longevity? The financial pressure and burden or the family of terminally ill or dying relatives? Baroness Warnock has already raised the question of the impact on people's lives of having to give up work and make other long-term sacrifices in order to become carers - and been heavily criticised for it too.[vi] Equally, the individual at the end of their life must have rights too. Even the last few days, weeks or even hours may be of value, and being able to say goodbye properly, to tie up final loose ends and perhaps be seen to do things properly, may all be of enormous importance to friends and relatives as well as the person concerned. It was the ancient Chinese who said that your last task as a parent is to show your children how to die well.
These are questions which are facing us all now. It is commonplace today for people to retire and find themselves caring for elderly relatives. Problems faced by people in their forties or fifties even twenty years ago are now cropping up or persisting to a point where the elderly may well be caring for the positively aged, unless or until they are no longer able so to do. Bearing in mind the saying, "Get even with your kids - live long enough to be a real nuisance", it is quite possible that our children will have to pick up the tag as social costs for the elderly across Europe will double by the year 2060.[vii] Le Monde produced a supplement only last Saturday about caring for old age in France, which faces the prospect of caring for some two million people over the age of 85 by 2015. It is interesting to see that they are looking at insurance schemes (funded by the employer) which would begin at the age of 55, but the idea of being able to pay for care with 500 Euros a month seems optimistic, to say the least.
The other saying about getting even with the kids is - spend their inheritance. At my pre-retirement briefing I was told not to save my money, not least because all my savings could eventually be taken by the local health authority to pay for my place in the care home, apart from a token sum of £23,500 - and that will not cover the debts that will be incurred by the grandchildren going to university, or even help pay off the mortgage on the family home, which many people have anticipated doing from inherited family money. Equally, an elderly person who is worth more dead than alive needs a special sort of protection under law, which is now being provided by the Court of Family Protection. A report called 'safeguarding Adults' which came out last year, calculated that over 342,000 people are victims of some sort of abuse by carers or relatives in their own homes, ranging from misappropriating money being paid for care through to selling the house without the person's knowledge - and pocketing the proceeds.[viii]
Whether we like it or not, this is a subject we will all have to face up to sooner or later. Sooner because there are ethical, moral and legal issues which have to be faced up to. A number of high profile cases have brought to the fore the questions of euthanasia, living wills, assisted dying and the right to die. The matter is under debate in the press and the House of Lords.
We will have to face up to it later, as we in our turn have to come to terms with our own mortality. We prefer not to ask for whom the bell tolls, partly because medicine does offer so many more chances of survival, even with diseases that were fatal even a few years ago. Palliative care and advances in surgical procedures, equipment and anaesthetics make major operations and long-term treatment perhaps less daunting, and offer a higher degree of hope than ever before. "It is wonderful what they can do these days" is no longer a truism.
Even so, we feel increasingly uncomfortable as we see familiar names in obituaries or attend memorial services for contemporaries or, even worse, younger friends, relatives and colleagues - even if we have not yet reached the point, like Bill Deedes, who used to turn to the obituaries column of The Times first thing in the morning just to check that he was still alive.
Today we are fortunate to have a distinguished range of speakers who will be approaching the topic from a variety of angles: veteran journalist Katharine Whitehorn will be known to you all as a longstanding contributor to The Observer and whose thoughtful broadcast one Sunday morning on Radio 4 led to the inception of this Symposium; Richard Sorabji and Keith Ward are emeritus professors of the College; and Rajeev Shah will be able to put some figures onto this subject and hopefully make a few life insurance calculations for us as a graduate of LSE and a Fellow of the Institute of Actuaries.
As I indicated earlier, Death Control (or at the very least a sensible and workable set of policies and procedures to ease us all smoothly and comfortably out of this world) is a complex matter. I view the matter with increasing sense of urgency myself as I sometimes feel that I am in the early stages of the Charge of the Light Brigade, with the saddles around me beginning to empty, as the Class of 1968 begins to creep slowly and inexorably up the Obituary Page of the Queen's College Record.
The whole situation today regarding infirmity, old age and death is surrounded by doubt and shrouded in secrecy. My great-grandparents both came from large Victorian families where almost half the children died in infancy. (We have a family picture of my Uncle Walter, who died as a baby in the 1880s - and who had been dressed as an angel for one last photo.) Death was accommodated through publicly recognised ritual: the armbands and mourning clothes, jewellery made of jet for full mourning and amethyst for half-mourning; the lavish monuments and memorials in parish churches. Victorian cemeteries, like Highgate and Brompton Road, look like[ix] some ancient necropolis. The disposal of the dead in London became a major issue as the topic grew - there was even a special station adjacent to Waterloo linked to Brookwood cemetery in Surrey, and which operated between 1854 and 1941.[x] Today we are more concerned with environmentally friendly coffins and the space taken up by graveyards which filled up decades ago and whose graves have long since been left untended as the bereaved have, in the fullness of time, followed the dear departed in their turn.
Benjamin Franklin said that there is nothing inevitable in this life, except for death and taxes,[xi] but in the same way that we are urged by Her Majesty's Revenue and Customs to think about the one, at some stage we all have to think about the other. Inevitably, that means that the medical, ethical and legal frameworks will have to be hammered out. This is quite understandably a delicate and difficult topic. The Royal College of Nursing's decision to take a neutral view on assisted suicide provoked a spate of letters and on-line comments to The Times, indicating that in many cases the battle lines are drawn before the matter has even been discussed.[xii] Even the National Council for Palliative Care has a web page to outline its views on Euthanasia and Assisted Dying.[xiii]
We need an informed and dispassionate debate on all these life and death topics, and I hope that Gresham College, as a place for informed debate and consideration not only of new learning, but also new understanding, has been able to shed some light on this important, timely and in many ways, chilling, debate.
© Tim Connell, 2009