In the Department of Health second NSF paper A New Ambition for Old Age, dignity is defined as ‘the moral requirement to respect human beings irrespective of what they suffer from’. Another definition is this : ‘dignity refers to an individual maintaining self respect and being valued by others’.
These definitions remind us that we need to see the inter-relationships and connections in both theory and practice. Dignity relates to respect, privacy and especially autonomy.
Here are some of the ways in which dignity is ignored: disregard for human rights; insensitivity to needs or desires; neglecting or ignoring the individual; our negative or stereotypical attitudes to older people; how our practice or relationships make people feel useless or worthless; the way we treat people as objects; our neglect of a person’s privacy; our neglect or oversight of the views of older people and not treating people with respect at the end of life.
I want to focus my reflections on dignity by demonstrating that dignity is an aspect of all the dimensions of any process or decision or situation. In particular I want to look at the dignity of and in economics, choice and value. I share a passion to see dignity shape our commitment to improving the development of our response to older people and their needs.
I do not under-estimate the challenges of this commitment to dignity. I have been working in old age care for nearly ten years as a provider of housing and residential care to older adults. It feels like standing in the middle of a very fast flowing river. It’s difficult to maintain any balance and very challenging in the maintenance of that balance to see beyond the narrow horizon of the river bank. However, those of us charged with management need to think strategically as well as respond operationally to the challenges and opportunities that change and movement bring us. So we are people who are as energetic in striving to uncover what is wrong in our organisations and with the care that we provide, as we are at recognising that which is good and in need of encouragement and affirmations. We are committed to quality and placing the client or customer or patient at the heart of our work. This has organisational, financial, cultural and political implications.
I want to raise three very simple but fundamental questions in relation to this policy and as the policy relates to the issue of dignity. They are the dignity of economics; the dignity of choice and the dignity of value.
You would expect me to raise the question of economics and I do so without reservation or apology. I want to know and I would like there to be an informed public engagement with the question of how far these social policy decisions have their roots in financial considerations. I realise that those in public life must use money responsibly, but in the rhetoric of modernisation how far are economics shaping decisions about what is possible or impossible?
How are we, in 2007 to understand what is left of the significant debate that took place around the Royal Commission report on the funding of long-term care? Am I right in asserting that there was an overwhelming agreement with the moral force of the findings of that commission but a lack of economic will to resource its recommendations? Am I right in asserting that social care is under funded in the UK today? Have we addressed dignity issues in relation to our generation of wealth and use of money in relation to the care support of older people? Are we continuing to want to fund our older adults on an ever decreasing or limited budget? There can be no dignity without addressing these economic questions. And city councils need to have the courage to speak out where resources are inadequate to meet the ever increasing range of needs that an ageing population presents to them in their localities.
Secondly – choice. Whose choice? At a conference last year I heard a chief executive in the health sector inform a group that older people wanted extra care. How do we know what older people want? Are we really presenting them with a range of choices?
So, let there be a debate about the issue of homes versus extra care, but choice must come into the equation. I believe that we must still allow older people to choose full residential care. Extra care doesn’t deal with loneliness nor with anxiety about falling or becoming ill and being unable to call for help. We no longer live in cohesive community where neighbourliness protects and supports the marginalised and vulnerable. And what about people with dementia? It is as doctrinaire to insist that older people don’t want care homes as to insist that they must go into a home!
Individuals develop all kinds of mechanisms to achieve their aims and objectives. Organisations also have a powerful ability to get their own way – to move forward in a direction that is seemingly necessary for progress. In other words, there is part of us that would assent to the truism that the best decision making group is three people with one person absent. I question how much real choice there is and I challenge the rhetoric of consultation in terms of who we are listening to, on what basis and especially whether we are connecting with those voices in society that are so easily overlooked. Older people are denied choice, sometimes, because we do not listen to their voices. I have listened to hundreds of older people and they inform me when asked about the choice of place for care and support they say:
“I want to stay in my own home but only if I have daily contact with people; the security of knowing there is someone there should I need them; the assurance that help will be there; a guarantee that my domiciliary care will turn up and I wont be left unattended for hours because of lack of staff.”
We have a moral responsibility to provide asylum in the proper sense of the word – dignity in assisting the older person to maintain previous high standards of hygiene and appearance not just accepting that they are refusing help or don’t recognise the level of need they may have. Our social care culture is reactive and not pro active – we would not allow this lack of innovation in children’s or cancer services.
Why are we not exploring a range of options for housing and care in old age? In this range of choices we need to allow older people to choose. Why do so many older people choose to pay for their own care in a care home? If it is such an unwanted option, why are people paying for it out of their own pockets?
I end with perhaps the most significant issue around the dignity debate. It is that of value, and whether, in the end, we really do value older people , who they are and what they represent in a way which recognises them as visible and valuable. I want to leave you with two images. First, I remember being asked by one of our residents to look through some old boxes that we were storing for her in one of our empty garages. I had had two conversations with this frail lady who was in her late 80’s. The boxes were full of books – an amazing collection of books bought over many decades. Travel books, East Anglian, Holland, Italy, Scotland, France, Poetry Books, Medieval History books. They revealed a hinterland, a wisdom, a life that, until then, had remained hidden to me. I had not seen – and therefore valued – the richness of this life lived. For all my rhetoric I had missed some of her value.
Second, in a small gallery in mid Wales, I came across an exhibition of photographs. After the second or third picture, I felt disappointed that these images consisted of dying flowers. Tulips shedding their leaves; dry rose leaves around the foot of the vase. But as I looked more closely, I realised there was both beauty and meaning in the images. There is value in some of that which we disregard and throw out.
How can we see the dignity of age and ageing? How can we value the process of change, diminishment, age as one within which dignity can grow and deepen as a teacher for us all?