Discourses on Aging and Dying
Publication Year: 2008
Aging and dying are inevitable. However, coming to terms with this truth can be difficult, especially in the modern context with an excessive dependence and faith in biomedicine. Advances in biomedicine and life-prolongation strategies along with changes in social-cultural structures pose a different kind of predicament – the percentage of aging population is on the rise and, at the same time, traditional strategies for taking care of the elderly and their problems are being replaced by more impersonal state-driven methods. India, with its large population, poor biomedical facilities for the average person, and widespread poverty, yet fast changing attitudes towards family and the aged, faces a great crisis today.
The collection of essays in this volume addresses different aspects of this issue. The first section is ...
- Front Matter
- Back Matter
- Subject Index
- Section I: Aging and Dying: Spiritual Perspectives
- Chapter 1: Aging and Dying: The Vedantic Perspective
- Chapter 2: The Art of Dying with Dignity
- Chapter 3: Life and Immortality in Indian Thought
- Chapter 4: Death and Dying in Islam: Psychological and Spiritual Perspectives
- Chapter 5: Death and Dying: A Buddhist Analysis
- Chapter 6: The Buddhist Way to Overcome Jarā-Maraṇaṃ
- Section II: Aging and Dying: Issues in the Care of the Elderly
- Chapter 7: Socio-Ethical Issues in the Existing Paradigm of Care for the Older Persons: Emerging Challenges and Possible Responses
- Chapter 8: Gender Issues in Care Giving
- Chapter 9: Views on Aging and Dying among the Middle-class Bengali Hindu Elderly Residents of Kolkata
- Chapter 10: A Plea for a Holistic Approach to Aging
- Section III: Aging and Dying: End-of-Life Care
- Chapter 11: Old Age, Disease and Terminal Care: A Hindu Perspective
- Chapter 12: Paternalistic Decisions for the Comate and Dying Aged: A Neo-Vedantic Perspective
- Chapter 13: Dying with Dignity
- Chapter 14: Culture-Specific and Culture-Sensitive End-of-Life Care: A Case Study Based on Kashi Labh Mukti Bhawan, Banaras
Copyright © Suhita Chopra Chatterjee, Priyadarshi Patnaik, Vijayaraghavan M. Chariar, 2008
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage or retrieval system, without permission in writing from the publisher.
First published in 2008 by
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Library of Congress Cataloging-in-Publication Data
Discourses on aging and dying/edited by Suhita Chopra Chatterjee, Priyadarshi Patnaik, Vijayaraghavan M. Chariar.
Includes bibliographical references and index.
1. Old age. 2. Death. 3. Aging—Psychological aspects. 4. Death—Psychological aspects. I. Chatterjee, Suhita Chopra. II. Patnaik, Priyadarshi, 1969–III. Chariar, Vijayaraghavan M.
ISBN: 978-0-7619-3644-2 (Pb) 978-81-7829-790-3 (India-Pb)
The SAGE Team: Sugata Ghosh, Anushree Tiwari, Rajib Chatterjee and Trinankur Banerjee
In loving memory of Dipi.…[Page 6]
List of Tables[Page 9]
- 9.1 Marital Status of the Elderly in the Sample 194
- 9.2 The Most Convenient Place of Residence for the Aged 195
- 9.3 Persons with Whom the Aged Can Stay Most Peacefully 195
- 9.4 The Fear of Death among the Elderly 196
- 9.5 The Best Time to Die in Old Age 196
- 9.6 The Best Stage of Life to Die 196
- 9.7 The Best Way the Elderly Can Overcome the Fear of Death 197
- 9.8 The Preferred Kind of Death for the Elderly 197
- 9.9 The Most Comfortable Place for an Aged Person to Die 198
- 9.10 The Presence of Persons Most Desired by the Aged When Dying 198
- 9.11 The Mean and Standard Deviation Values of Depression Scores 199
- 9.12 Result of the T-Test: Difference between Mean Depression Scores of the Two Gender Groups 199
- 9.13 Result of the Mann Whitney Test of the Difference between the Depression Scores of Widows (N = 14) and Widowers (N = 15) 200 [Page 10]
- 9.14 Result of T-Test: Difference between Mean Depression Scores of Residents of Old-age Homes and the Elderly Living with Own Families 200
List of Figures[Page 11]
- 1.1 DNA (Deoxyribonucleic Acid) 39
- 1.2 Miller's Experiment 40
- 1.3 Vedantic Hierarchy of Spiritual, Subtle and Gross Bodies 42
- 1.4 Tridosas: Essential Substances that Compose a Body 46
- 1.5 Model for the Basis of the Vedantic Health Care System (Ayurveda) 47
- 1.6 The Vedantic Model for the Transmigration of the Soul 53
- 1.7 A Unique Example of the Enlightenment of Maharaja Parikshit before Death 54
Many of the papers compiled in this volume were presented at the National Conference on Aging and Dying: Relevance of Indic Perspectives to End-of Life Care, held at the Department of Humanities and Social Sciences, Indian Institute of Technology Kharagpur, 4–6 November 2005. We are thankful to our primary sponsor, The Infinity Foundation, USA, and especially to Mr Rajiv Malhotra for his moral and intellectual support. We also acknowledge the supplementary financial support provided by Indian Council of Medical Research (ICMR), Delhi.
We are grateful to those contributors who were not part of the Conference, but helped us in giving the book its present shape. We remain grateful to Professor B. P. Sandilya for his meticulous reading of the manuscript. Finally we would like to thank Dr Sugata Ghosh of SAGE Publications without whose active interest the volume would not have been possible.[Page 14]
Introduction[Page 15]Part 1
Population aging is one of the most distinctive demographic events of the world today. In 1950, just over 5 per cent of the world population was aged 65 and over. That proportion had risen to more than 7 per cent by 2005, and is expected to more than double over the next 45 years to reach 16.1 per cent in 2050. Globally, the number of persons aged 65 and over will more than triple in size—increasing from 476 million in 2005, to almost 1.5 billion by 2050.
The greatest impact of this is being felt by the more developed regions where the percentage of people aged 65 and over is rising—it was 15.3 per cent in the year 2005 and is expected to be 25.9 per cent by 2050. This involves a transfer of population from the working ages to ages 65 and over. In other words, the old-age dependency ratio (the ratio of population aged 65 and over to the population aged 15–64, expressed per 100) will almost double, increasing from 22.6 persons aged 65 and over per 100 persons of working age in 2005 to an expected value of 44.4 in 2050. In Europe, the situation is extreme as the ratio is expected to more than double, reaching 48.0 in 2050. In other words, about two persons of working age will need to support one retiree (United Nations Department of Economic and Social Affairs/Population Division 2004).
Several governments in the developed regions are trying to evolve a strategy for optimal expression of adaptive development in later life, and managing the dynamics between gains and losses as one ages. Many European countries, for instance, have accepted additional immigrants, extended the retirement age and attracted more women into the workforce while enhancing childcare benefits. Japan has relegated some of the responsibility for caring to families and has relied heavily on technology and outsourcing for low-skill [Page 16]and labour-intensive jobs. However, the issues pressing the governments are still enormous as they struggle with the demographic shift. While pension and other social provisions have to be made, providing health services remain the most crucial and pressing concern. Disparities by race and gender further threaten the inequalities in health and aging.
The age composition of the older population has also profound implications for the distribution of health care expenditures. In the more developed regions, for instance, the percentage of all persons aged 65 and over who are aged 90 and over is expected to increase by a factor of 2.5, rising from almost 4 per cent to over 9 per cent between 2005 and 2050, while the percentage of the youngest-old, aged 65–79, declines from 76 to 64 per cent and the percentage of those aged 80–89 is expected to increase from 20 to 27 per cent. Many of these older-old members are likely to be the major consumers of health services.
Health and economic services are not the only determinants of Active Aging—a concept put forth by WHO (World Health Organization 2002) to maintain full functional capacity throughout the life course. Behavioural determinants and changes in physical environment (which contribute to independence) and social settings are equally important. The policy framework on Active Aging requires action on participation and security based on the rights, needs, preferences and capacities of the old. Key determinants related to social environment include social support, freedom from violence and abuse, and access to life-long learning. It may be mentioned here that the subjective experience of aging has been problematic for many who suffer from loss of power, autonomy and privacy. Their choice and opportunities are constrained not only by economic and public policy but also ‘ageism’—a term which implies both discrimination and prejudice against people who are old. It signals the beginning of an inter-generational conflict, prompting younger generations to see older people as distinct from themselves.
Academic response to the problems of the aged has been considerable. The field of gerontology has rapidly grown as a distinctive inter-disciplinary study involving biology, medicine, behavioural and social sciences. Sociological theories subsume several theoretical traditions of aging involving the more classical social gerontological theories (disengagement theory, activity theory, modernization theory and subculture theory), and a second wave of [Page 17]contemporary critical theoretical perspectives as reflected in political economy of aging, feminist theories, theories of diversity and humanistic gerontology (Bengtson et al. 2005; Estes and Linkins 2000). These offer insights at macro-level structural contexts of aging, as well as at the micro-level of agency and individual subject. However, most of these are fragmented, even contradictory, and merely explanatory. They primarily aim at understanding the complex phenomena, rather than suggesting practical steps to ameliorate the problem of the aged. Recently, there has even been a shift from theories of aging to theories in aging in an attempt to bring the findings to a common platform for the welfare of the aged.
Aging, in its final phase, is dying, and inevitably leads to death. Like aging, dying too is problematic in the Western set up. The 17th century intellectual tradition in the West has advanced mechanistic theories of life and this has influenced different fields of knowledge which have intellectual roots in its culture, history and institutions. Bio-medicine, for instance, has shown whole-hearted acceptance of the Cartesian evidence that the body belongs to the world of matter and can be understood as a mechanical system distinct from the mind or the soul. The concept of death has also rested on such mechanistic analogies, and is therefore considered as being in opposition to life. It happens when the body-machine packs up, thus, somehow generating the idea that the process can be controlled through scientific interventions. In other words, death is denied. But, according to Bauman, in post-modern societies, a change of perspective has taken place. Death is not denied but is still held off the agenda by identifying, resisting, postponing each particular case of death and its contingent cause, that is, a disease (Bauman 1992). Thus, both aging and dying are looked at from a disease perspective and as obstacles to be overcome. This perspective governs end-of-life care as well, resulting in excessive medicalization of Death. But there has been little success in achieving a meaningful place for suffering and decline in our life.
The rapid rise in the field of Thanatology and research on end-of-life care has merely fuelled fiery debates on dignified death and appropriate treatment decisions for the aged. Debates have surfaced about how much resource needs to be directed for unlimited life extension, the degree of control that the aged may exert over the dying process, freedom to refuse life-extending treatment and the relative worth of deploying medical technologies for life-extension [Page 18]vs. caring approach for the elderly. Debates on euthanasia, physician-assisted suicide and palliative care have evoked controversial responses and are much easier to resolve in the context of terminally ill, rather than old people dying with multiple problems.
Population aging, initially a feature of the developed countries, is now common even in the less developed countries. The UNDP believes that population aging in the developing world will be even more precipitous than the aging currently experienced in Europe, Japan, Canada and the United States, where social security and health care systems are already starting to go bankrupt. It expects aging to happen more dramatically in Asia, the Middle East and Latin America than it is happening now in Europe, where the elderly already outnumber children (Mosher 2006).
According to the United Nations Population Division (2004) the proportion aged 60 or over in the less developed regions has been rising steadily and is expected to pass from 8 per cent in 2005 to 13 per cent in 2025 and might reach nearly 20 per cent by 2050. That is, the aging of the population of less developed regions is expected to accelerate, particularly after 2025.
The developing countries will have to work very hard to sensitize their systems to the needs of a rapidly changing demographic structure. Unlike most industrial nations, they do not have the capacity to adjust to the challenges of population aging. Efforts have to be made to plan and implement policies and plans for the elderly, evolve better legal structures and financial schemes; but each of these efforts is likely to raise serious ethical issues about resource distribution, and would necessitate fine balancing of the interests of the different age groups.
To compound the problem, many developing countries are already grappling with the magnitude and profundity of change created by chronic and infectious diseases of the young. The long-term care needs of the elderly threaten to pose additional problems in the health delivery system, especially in the wake of privatization of health care. The compression of morbidity thesis, namely, that those who survive into old age will be fitter, may not be relevant in many developing countries due to slow improvements in public health measures and lifestyles changes through health promotion.
The continuing dialectic between aging and changing social structures can hardly be overlooked in other domains as well. Many developing countries too face the problem of changing family [Page 19]structures as they modernize. With increasing involvement of women in the labour market, their role as full-time caregivers can no longer be taken as granted. Moreover, feminist theorization has increasingly contributed to a reinterpretation of caregiving as a mere unpaid domestic work, thereby creating the need for new institutions for the care of the elderly.
Fortunately, many of the developing societies have different symbolic and socio-cultural representations of aging and dying. It may be reiterated once again that age is not only a biological phenomenon but a socio-cultural construct too. Also, while the state and the economy do influence the condition of aged, culture plays an equally important role in distinguishing a person as aged—providing role structures, and guiding normative expectations of type and quantum of work, participation in social life and even level of control over their body functions. In many Eastern societies, aging is imbued with positive features—freedom to be flexible and creative and ability to turn towards other-worldly orientations.
India's elderly population has increased from 12 million in 1901 to 57 million in 1990 and 70 million in 2001, and is expected to cross 100 million in 2013. A nationwide survey conducted by the National Sample Survey Organization 1991 shows that 45 per cent of the elderly suffer from chronic illness and even psychiatric ailments (see Jai Prakash 2005). Elder abuse, poor living conditions, unmet needs for mobile medicare units and self-help groups have been reported by many researchers (Jai Prakash 2003). Although the resources to meet this demographic change are limited, the cultural ethos is remarkably supportive and needs revisiting to help the aged.
The Indic conceptualization of aging and dying offers interesting insights. To begin with, the entire philosophy is death-embracing rather than death-denying. There is a greater realism in accepting the transience of existence, the aging and withering of the body, and the place of the elderly in the social system. This springs from the understanding that death is not annihilation but an integral process of life itself. The body, too, does not enjoy the primacy it does in the West due to the metaphysical ideas concerning the soul. In the Vedic tradition, each individual soul is immortal by nature and continues to exist even after the death of the body. Contemplation on one's mortality is an important aspect of spiritual evolution. There are also in-built cultural mechanisms of preparation for death and self-determination in the manner and timing of dying.[Page 20]
Viewed from an academic perspective, Indic spiritual discourses offer probably the best possible form of theorizing with an integrative framework. They link the issue of aging with dying, and this intertwining of aging and mortality provides interesting insights at micro-level understanding, that is, at the level of personal encounters and interaction. The discourses are also premised on logically ordered propositions about the body and mind, and diminished social roles and responsibilities when senescence sets in. Our ancestors could avoid many of the age-related neuro-degenerative changes in brain functions, as well as social and inter-personal conflicts. In other words, they could age gracefully. For instance, the Asrama Dharma involves four well-designed stages. The third stage of life is the Vanaprasthasrama which coincides with the stage of life when biological decay starts rapidly. Here the householder, after spending 25 years of married life, moves to a secluded place, transfers his responsibility to the younger generations and engages in the pursuit of higher knowledge and spiritual advancement. Needless to say, this stage of life is conceived with both individual and society in mind. It helps younger persons to shoulder responsibilities, thereby ruling out inter-generational conflict. At the individual level, it encourages disengagement from material pursuits and inclines the person towards self-realization. Vanaprasthis often engage in social pursuits like imparting free education and the like. The beauty and practical import of this paradigm has only been recently understood by Western theorists. For instance, the Gerotranscendence theory of Tornstam (1989, 1996) takes into account a shift from a materialistic and rational metaphysical stance to a more cosmic and transcendent one.
The Indian spiritual discourses also have a unique way of preparing one for the decaying body. The prioritization of the body is almost absent in Indian philosophy. Each individual soul is immortal by nature and continues to exist even after the death of the body. Conceptually, a distinction is also made between gross and subtle body. The soul, having enjoyed certain pleasures and having fulfilled certain desires, leaves the gross body for another. The subtle body, on the other hand, accompanies the transmigrating spirit and is the essential link in the continuity of life because it is not destroyed by death. It is in this sense that death does not mean destruction or even reduction of anything into nothingness. This is the most interesting feature of this theorization of death. The entire effect is [Page 21]to ease death anxiety which surfaces with the decline of cognitive faculties and bodily strength—a feature reported by researchers, both in the West and the East.
The Indic perspective, thus, provides not only the art of good living but also good dying, with the result that there are instances of subjective experiences of inner youth despite outer processes of bodily decay. The ancient science of Ayurveda has further contributed to a wealth of information on how to live a healthy and more fulfilling life. It may be mentioned here that unlike Western medicine whose progress has been defined by a positivist value orientation built upon a radical dissociation from metaphysical ideas, Indian medicine has not experienced such a split and is grounded in moral and religious interpretations of various sorts. These also govern perspectives on aging and dying.
If one were to go beyond disease orientation and provide meaning and significance to the aged and dying in our country, we would have to understand the various Indic perspectives on aging and dying, explore the relevance of these perspectives for meeting this-worldly needs of the elderly, and direct special attention to end-of-life care with the purpose of integrating these philosophical inputs into treatment decision-making, thereby developing a culturally embedded bio-medicine.Part 2
This book is divided into three sections—spiritual discourses, socio-economic issues and discourses on end-of-life care for the aged and the dying. The first section provides a rich spectrum of cosmologies and religious beliefs—Hindu, Buddhist and Islamic—that interprets the place of death in our lives. As mentioned earlier, the capacity to contemplate one's mortality reduces many of the anxieties which people face. Death anxiety is a significant predictor of negative attitudes towards aging. Therefore, central to good aging is a strong philosophy of death which gives directions for viewing the aging body. It is in this sense that successful and productive aging not only implies engagement in an active life, minimizing risks and disabilities, maximizing physical and mental abilities, but also imbibing spirituality. The second section incorporates a wide range of issues which provide information about present conditions and problems [Page 22]of the aged. The third section deals with critical issues in end-of-life care for the elderly, including ethical issues on dignity and end-of-life decisions for the dying. The Indic perspective permeates all the three sections.
According to Swami H. H. Bhaktisvarupa Damodara, in order to have a meaningful understanding of aging and dying and to devise practical means for end-of-life care, we need to have a deeper scientific and spiritual understanding of the meaning and purpose of life. In human society, there are two conceptions of what life is. Within the scientific community, life is regarded as an emergent property of the interactions of atoms and molecules. On the other hand, within the spiritual community, life is a divine particle, which is fundamentally different from the material particles. So, in general, when we talk about the meaning, and purpose of life and end-of-life care, the second paradigm is most important. A Vedic understanding of life belongs to the second paradigm.
According to Vedic wisdom, life is sacred and eternal. When life interacts with the material elements, different symptoms of life—birth, disease, old age and death—manifest themselves. Thus, aging and dying are symptoms of various material manifestations. According to the Vedic tradition we are all born in this material world under different circumstances with different identities according to our karma. Some people live a short life, others have a long life and some even have unfortunate births. How should human society take care of such unfortunate individuals? Vedic culture provides meaningful answers to these important questions from a spiritual perspective.
According to Vedic understanding, the life particle, or soul, is eternal and continues even after the body is destroyed; death is just an event in the eternal journey of life. A person with Vedic understanding can optimistically live through old age while preparing for the future journey. He can joyfully face death without any fear or anxiety.
In Western countries, many aged parents are neglected by their children and are placed in old age homes under the care of the government or low-level health care workers. Residents of these homes are either depressed or simply waiting to die, having no hope in life and nothing to provide them inspiration. This is because they have no training in spiritual culture, and therefore have no understanding about the purpose of life. Vedic culture's emphasis is [Page 23]on the spiritual dimension to end-of-life caring. Our present life is a preparation for a better life in our next birth. Imparting spiritual knowledge and providing a positive outlook towards old age and death is the most important principle of Vedic caring. Observing this spiritual view of life, the Vedanta recommends that one should not artificially terminate life by mechanical means. Thus, Vedic culture does not recommend practices such as euthanasia and abortion. Bio-ethics is, in a way, connected with the spiritual concept of life and has close links with Vedic culture. A serious study of Hindu bio-ethics would help in providing satisfactory guidance for end-of-life caring.
Swami Prabhananda and Jitatmananda provide further elaborations on the Vedic perspective. Swami Prabhananda promotes the idea of the art of good dying. According to him, the emotions aroused in the dying are legion—the commonest one being fear. It would be of great help if we can face death with dignity. While we are striving to improve the quality of living, we should also pay due attention to improving the quality of dying. The art of good dying involves thinking beyond the body, overcoming fear of old age and dying, and observing instances of dignified death. It is through a much sustained effort that one learns the art of dignified death which is different from employing technological interventions to hasten death or to prolong life.
The post-modern mood finds us occupied with the project of deconstructing death—the need to be immortal and to remain free from the snares of death. But so far, science has been unable to negate aging and dying. Life can be prolonged through medical technology but that often makes dying a painful reality. The other option is euthanasia which is often juxtaposed with palliative care and raises complex ethical issues surrounding termination of life.
Swami Jitatmananda pitches the debate to a very different level by stating that life's primary function is to avoid death and attain immortality by conquering death. That is so because human beings are essentially immortal. There is no death. Death happens to the body but never to the Spirit, the non-physical Self, the deathless Atman within, which evolves through many lives, until it has transcended the desire for the world and attained the state of infinite Cosmic Self. Infinity has no death. And the most important dimension of this deathless self, according to the Vedanta, is the all-pervading Absolute Consciousness.[Page 24]
Sen and Shaikh show that, like Hinduism, Islam too believes in the eternal nature of the soul vis-à-vis the body, which is perishable. According to the Holy Quran, life, death and their certainty have been created by Allah. Thus, no person can escape death. There is no denial; rather an acceptance and even glorification of death. It frees the individual from all earthly pain and sorrow. Dying also brings an end to temptation. Although death is understood as freedom from all worldly responsibilities and pain, Islam has prohibited suicide or euthanasia in times of great distress. It asks for steadfastness in hours of pain and suffering and also discourages lengthy periods of grief and mourning.
The two chapters on Buddhism approach the issues of death, aging and dying with reference to a comprehensive body of Buddhist literature. Buddhism has always looked closely at the suffering of mankind and tried to find a way out. This gets reflected in its huge body of material.
Chattopadhay begins by focusing on how the Buddhists look at life and at death—their non-belief in a permanent Soul which the Hindus believe in, and their explanation of the continuity of life on the basis of the combination of the five senses (indriyas) which constitutes personal identity. She quickly surveys major Buddhist texts to define death and dying from a Buddhist perspective which primarily focuses on death as ‘dissolution’. Life, for the Buddhists, is not a single unit but a collectivity, and death though a dissolution, is merely a break in the flow of this collectivity.
Probing deeper into the subject of suicide, she brings out finer nuances of the issue and points out that under certain circumstances, suicide can be justified. In the case of euthanasia, she points out that, in principle, the Buddhists are against any such act. However, as with suicide, it is the intention—attainment of nirvana—that would decide if an action is correct or incorrect. Dying is, finally, a process through which one can realize the transitoriness of life.
It is on this aspect of dying, especially aging and dying, that Biswas focuses, referring primarily to the early Theravada texts. Touching upon the issues of aging as discussed in Dharmapada and other texts which claim to present Buddha's views, she moves on to the realizations and reflections on aging and dying in the texts of his direct disciples—especially in texts like the Therāgāthā and the Therīgāthā. The focus here is on change—as the essence of life. It is this realization that points to the endless process of aging and dying. [Page 25]Illustrating this with stories from the Sthabira texts, she finally focuses on Buddha's ethical precepts regarding the care of the aged and the dying.
The next section highlights different socio-economic issues related to aging and dying. Anupama Datta shows how older persons face economic, physiological and emotional insecurities in varying combinations, depending on their life circumstances. Some older persons may be self-sufficient financially but may be suffering due to an emotional void in life. Others may be poor and unable to access services in the family and community.
The general perception—and the accepted norm in India—is that older persons are a concern to the family. However, this accepted institution of care is under tremendous stress and strain from various quarters. The modern ethos—small family norm, spatial relocation of family members and lack of resources and technical proficiency to deal with all aspects of care, have left those expecting care from this unit high and dry. If we wish to deal with the challenges of aging effectively, it is essential that we change our perception to finding solutions to this problem and define a sagacious role for each important player, that is, individual, family, community, government and private sector. We must understand and appreciate the fact that family alone will not and cannot take on the caregiving role for the elderly.
According to Bagga, families have traditionally cared for their infants, children and the elderly without compensation or assistance through much of our history. Informal or unpaid care of the elderly has traditionally been estimated to account for 95 per cent of all care given to older adults in the Indian situation—the main caregivers being women. However, the trend is changing fast. Urbanization modernization, migration, entry of women into the paid labour force and globalization are some of the change agents responsible for the breakdown of the traditional social system. Social changes in family size (nucleation, reduced number of children—and thus of caregivers) and increase in the number of our women in the workforce have now started affecting the ability of natural caregivers to meet the needs of family members. Increase in longevity and late marriages have compounded the issue of providing care by women.
Given the phenomenon of Indian women's increased participation in the labour force, a redistribution of responsibilities among family members in caring for elderly relatives should result. Otherwise, it [Page 26]will mean an additional burden and strain on the working woman, thus aggravating the ‘woman in the middle’ syndrome. Male members need to support—physically and morally—the women caregivers at home.
The importance of family caregiving is likely to prove even more important as Ghosh and Dey's comparative study of middle-class residents of their own dwelling as well as inmates of old age homes of Kolkata suggests. On comparing the levels of depression and attitudes towards aging, dying and the preferred kind of death among elderly persons of both genders and age groups, different marital statuses and types of residence and the like, the authors show that the majority of the elderly would like to die in their homes surrounded by relatives than at hospitals. Fear of death is more pronounced among persons in 60–70 years age group than in the 70–80 years age group, possibly because in later years, the elderly learn to accept death as inevitable. In general, elderly men display greater tendencies towards depression than elderly women. Inmates of the old age homes feel more depressed than the aged people living at their homes with their families.
It is in this context that Nair makes a plea for a holistic approach to aging. The voluminous increase in the relative importance of the aged in the population is almost causing an inter-generational conflict because of the view that the scarce resources of the world are being diverted more and more to support the aged who often appear to be drones on society. The aging of the world population is hence often looked upon as an economic and social disaster. A holistic perception of the issue, however, should convince one that such a conflict is not called for and is, to a great extent, man-made. All those classified as aged are not always mentally/physically disabled, and hence are not in dire need to be taken care of by the rest of society, sometimes even economically. The demographic distinction between the young-old, very old and extremely old people among the aged is a relevant one in this regard. By and large, mostly those who are above 80 and get classified as very old and extremely old fit the description of the stereotype ‘aged’ but they form only around one-third of the aged in the world. Further, even in the case of those aged who need to be taken care of, it is being increasingly recognized that a real bond can exist between the caregiver and the care-receiver if the concept of filial piety is instilled among the caregivers. Equally important is the need for the adoption by the aged care-receivers of an attitude as [Page 27]propounded by the disengagement theory of aging based on the ashram philosophy, in contrast to the attitude implicit in theories of active aging.
Considering both the spiritual and socio-economic issues, we need to devise a sensitive programme of end-of-life care. Dr Jindal, a medical practitioner himself, adopts a medico-spiritual standpoint. Old age is associated with disease and disability, with death as the apex of the triangle. The advances in medical technology have blurred the differences between curable and incurable illnesses. Therefore, terminal care is also a mixture of curative and palliative care. The terminal care which an elderly individual suffering from disease and disability requires is manifold and includes financial, social, psychological, spiritual, physical and medical supports. While curative care aims at cure of the disease and restoration of health, palliative care merely aims at relief from pain and suffering. Palliative care is closer to Hindu bio-ethics which makes the acceptance of death somewhat easier. Care at the end of life also involves crucial decisions about deployment of life-prolonging treatment, locale of care, communication, sensitive handling of the last moments of life, after-death handling and even bereavement care.
George shows how decision-making constitutes an important feature of end-of-life care for the dying. Physicians and relatives of the comate and dying claim right to make decisions, either to terminate or to prolong life, on behalf of the afflicted. Physicians, owing to their expertise, are looked upon as better judges on life-issues, and relatives seem to have legitimate rights over the lives of the dying. These decisions are called ‘paternalistic’, because they appear protective, compassionate and benevolent. In extreme cases, paternalistic decisions are in conflict with the interests of the dying. Generally, the debate on paternalistic decisions is related to diseases and old age. Stepping on a slippery slope, it is argued that quality of life claims prime concern, and dignified death is the right of a person. The major demur against this position is that it makes life of the aged vulnerable. However, questions on paternalistic decisions undergo radical shift in accordance with different socio-cultural contexts. The Indian intellectual tradition, particularly the Vedantic school, attaches high value to life irrespective of its stage, form, and kind. According to the Kēvala Advaita of Śhankara, individual life is unified with cosmic life, for ‘Brahman and Ātman are identical’. Neo-Vedantins belonging to South India extend this idea further to [Page 28]manifold domains of human life. Sree Nārāyaṇa Guru, a neo-Vedantin and a social reformer, reformulates the Śhānkarite dictum, ‘Brahman alone is real, the world is unreal’, as ‘Brahman is the only real, but world is not unreal’. Granting equal status to spiritual life and physical life, neo-Vedantins regard human life, with all its ingredients, holy and inviolable. Maintaining non-dualistic/advaitic position, here the Absolute is regarded as the creator, the created, the object of creation, and the power of unity. Accordingly, Guru advocates kindliness to life in general, and treats human life in particular as a call to serve humanity. Old age (vārdhakya) is the zenith of human flourishing in wisdom, and various convolutions associated with old age are taken to be its corollary, nothing antithetical. Taking this cue, the chapter discusses, from the neo-Vedantic perspective of Sree Nārāyaṇa Guru, the ethical significance of paternalistic decisions adopted by physicians and relatives on behalf of the dying aged.
Among other things, the chapter elucidates the neo-Vedantic vision of human life, the role of death in human life, the idea of right over life, and further explicates the contention between quality of life and sanctity of life positions, and discusses the principle of double effect, and the relevance of palliative care for the aged.
Palliative care is, of course, all about dignity-conserving care. Duttagupta considers ‘Death with Dignity’ as an optimal catalytic pathway which any dying person would desire and should deserve. Providing examples personally witnessed by her, she tries to understand varying conceptions of dignity for the elderly under different end-of-life care contexts.
Dignity-conserving care needs to be culture sensitive as well. In all the major civilizations of the world, death, dying, disposal of dead body and the rituals related to death have been major concerns of the society. Among Hindus, old-age care and death have achieved not only special connotations in terms of spiritual and religious values but have also defined culturally acceptable modes of behaviour. Kashi, the holy city of Hindus, has special significance in the process of old-age care, dying and death. The city abounds in terms of old age care institutions run either by charitable organizations or by social welfare organizations. Singh presents the case of the Kashi Labh Mukti Bhawan, which is a unique organization that illustrates culture specific and culture sensitive end-of-life care. For those living in the sacred space of Kashi, this organization serves as an instrument to [Page 29]fulfil patients' and family's last wish to die in Kashi, and have their last rites and other rituals performed in this sacred city. The Kashi Labh Mukti Bhawan is, thus, not merely a shelter home. It also serves the cause of the aged person in his/her journey towards salvation and spiritual satisfaction at the fag end of life.References[Page 30]1992). Mortality, Immortality and Other Life Strategies. UK: Polity Press.(2000). ‘Critical Perspectives on Health and Aging’ (pp. 154–172). In GaryL.Albreacht, RayFitzpatrick and SusanC.Scrimshaw (eds), Handbook of Social Studies in Health and Medicine. London: Sage Publications.and . (JaiPrakash, I. (ed.). (2003). ‘Aging: Emerging Issues’. CCR-IFCU Project on Aging and Development. Bangalore: Bangalore University.2005). ‘Aging in India: Retrospect and Prospect’. Volume V of the Aging and Development Project. Bangalore: Bangalore University.(2006). ‘World Population Aging 2006’. PRI Weekly Briefing. 20 July, vol. 8, no. 28. Available at http://www.lifeissues.net/writers/mos/mos_82aging.html.. (1989). ‘Gerotranscendence: A Reformulation of the Disengagement Theory’, Aging, 1: 53–63.(1996). ‘Gerotranscendence: A Theory about Maturing in Old Age’, Journal of Aging and Identity, 1: 37–50.(United Nations Department of Economic and Social Affairs/Population Division. (2004). World Population Prospects: The 2004 Revision, Volume III, Analytical Report.2005). ‘The Problem of Theory in Gerontology Today’ (pp. 3–20). In MalcolmL.Johnson (ed.), Cambridge Handbook of Age and Aging. UK: Cambridge University Press., and . (WHO. (2002). ‘Active Aging’. A Policy Framework. Geneva.
About the Editors and Contributors[Page 263]The Editors
Suhita Chopra Chatterjee
Department of Humanities & Social Sciences
Indian Institute of Technology, Kharagpur.
Department of Humanities & Social Sciences
Indian Institute of Technology, Kharagpur.
Vijayaraghavan M. Chariar
Centre for Rural Development and Technology
Indian Institute of Technology, Delhi.The Contributors
Late Swami H. H. Bhaktisvarupa Damodara
International Director, Bhaktivedanta Institute
President, Vedanta and Science Educational Research Foundation
Vivekananda Ancestral House of Culture Kolkata.
The Ramakrishna Math and Ramakrishna Mission
Belur Math, Belur, West Bengal.[Page 264]
Department of Anthropology
University of Pune, Pune.
Department of Pali
University of Calcutta
Department of Philosophy
Professor and Head
Department of Biotechnology
Institute of Technology and Marine Engineering
Research and Strategic Development
Calcutta Metropolitan Institute of Gerontology
K. J. George
Department of Humanities and Social Sciences
Indian Institute of Technology, Kanpur.
Department of Home Science
S. K. Jindal
Professor and Head
Department of Pulmonary Medicine
Postgraduate Institute of Medical
Education and Research, Chandigarh.
K. R. G. Nair
Honorary Research Professor
Centre for Policy Research
Department of Applied Psychology
University of Mumbai.
Department of Arabic
University of Mumbai.
Umesh K. Singh
Senior Lecturer, Department of Sociology
V.S.S.D. College, Kanpur.