Aging and Ethics
The salience of ethics in relation to aging is more pronounced in advanced economies, particularly Western, for three reasons: the relative size of the aging population is increasing because of fewer births; longevity has increased and the vitality of the aged in terms of physical mobility and health has greatly improved; and financial security, largely because their working lives occurred predominantly in a period of sustained economic growth, has significantly increased. In fact, people aged over 65 – the category which previously implied old, retired, and in a process of physical and mental decay awaiting death – have now been re-categorized in the “young-old” and the “old-old” (those aged 85 and above). Four major ethical concerns emerge in relation to the contemporary phenomenon of aging: (1) an aging workforce, (2) the social contribution and cost of a large aged population, (3) the impact on government expenditure of increasing healthcare costs, and (4) end-of-life decisions. The first three are considered below, while the fourth requires an entirely different ethical debate.
While it is still largely true that there is greater respect for older people in non-Western countries, this varies in intensity among countries and regions and appears to be slowly declining as these more traditional countries are impacted by Western cultural mores.
Age becomes an ethical concern when some form of ageism occurs. Ageism is defined as casual or systematic stereotyping and/or discriminating against people on the basis of their age. At the lower end of the scale, prejudice manifests when people are prejudged or an opinion about them is formed before taking into account the facts and context of a case. Systematic bias, a second level of ageism, often occurs because of this prejudice by limiting people’s potential to show their capability and thereby contradict cultural assumptions. Another level of ageism in practice is discrimination, which refers to actions denying or limiting rights and opportunities to people on the basis of age: an example of this is a compulsory retirement age. The most extreme form of ageism is elder abuse. This is defined by the World Health Organization as “a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.” Studies indicate that elder abuse primarily manifests as psychological abuse and neglect. However, financial abuse and, to a lesser extent, physical abuse also occur. Psychological abuse, such as the lack of emotional warmth and care, and neglect are often not so much willful as the outcome of patterns of family organization and lack of respect or filial responsibility. As well as elder abuse, which largely happens within families or aged-care facilities, an extreme form of ageism is hostile prejudice, stereotyping older people in a hateful and aversive way, to the extent of gerontophobia, that is, hatred based on a fear of growing old.
Ageing in the Workforce
The impact of aging on the workforce varies considerably across cultures. For example, Organisation for Economic Co-operation and Development (OECD) countries, regarded as representative of advanced economies, will experience a considerable aging of their workforce. Between 2000 and 2020, it was predicted that the number of people of pensionable age will have risen by 70 million while those of working age will have increased by about five million. It is also predicted that, in 2020, 25% of the US workforce will be 55 years or older – a phenomenon called The Silver Tsunami. The proportion of people over 65 is highest in Japan (26.3%), but in Europe it is also significantly high (e.g., Italy 22.4%; Germany 21.2%). The effect of aging on the workforce varies according to diverse factors such as a livable pension, the level of social security, and the demand for particular skill sets. Despite the potential demand for older workers to remain in the workforce, negative stereotyping continues to be a major obstacle. This negative stereotyping is deeply culturally engrained. This has been shown in word association tests where “old” is negatively associated with various traits.
According to the research by Gringart et al. (2013), the many characteristics of such stereotyping can be grouped in three domains – all based on an implicit or explicit comparison with younger people. The first domain is interpersonal. From a positive perspective, older people are seen as more reliable and harder working. However, negatively, they are considered as less cooperative, less willing to subordinate, and too cautious. The second domain, work performance, incorporates beliefs such as being less capable with new technology, more accident-prone, and indecisive. The third domain is not work specific but includes ageist misconceptions that older people are less healthy, less creative, less mentally alert, and less efficient. In contrast to these stereotypes, research by Roberts et al. (2006) on patterns of mean-level change in personality traits across the life course shows a different story. The “Big Five” trait of agreeableness appears to spike upward from around age 45 and then continues with slight increments from 55. The trait of conscientiousness rises dramatically from age 20 and continues to rise strongly to age 65 before plateauing. Moreover, optimum levels of emotional stability from 55 to 65 suggest the potential for positive organizational cultural influence of older workers. However, the stereotype is partly supported by a slight decline in openness to experience from about age 60, although this may be due to diminishing social circles with retirement, children’s departure from the home, and deaths of friends and family.
The main ethical concern in appointing or retaining older people in the workforce appears to relate to stereotypical attitudes and beliefs held by employers and fellow employees.
Social Contribution and Cost of an Aged Population
With older people’s withdrawal from paid employment, an attitude concerning their lack of usefulness to society can implicitly emerge. Yet there is good evidence that older people contribute significantly to social capital understood as relationships that contribute to the number and quality of social ties, which in turn contribute to trust, reciprocity, and community benefit. It is true that as people age, and particularly as they reach the “old-old” category, they are likely to be more dependent on their adult children for support. However, this varies considerably with the socioeconomic status of the older person, ethnicity, cultural norms of obligation, and family situation (e.g., divorce or spousal death).
Despite the growth of aged care facilities and families’ geographical dispersion, many older people express a preference to age in their own home. Allowing this to happen does involve ethical decisions by families, communities, and governments because with increasing physical frailty, greater levels of in-home support will be needed to ensure medical directives and appropriate nutrition are maintained as well as to provide assistive technologies. This comes at a price that is funded by taxpayers. Within a neoliberal political economy of low taxes and low government expenditure, there is a high likelihood that sufficient levels of care for in-home aging cannot be maintained, thus raising political-ethical concerns. Diametric to in-home aging is the retired persons’ gated community which restricts entry to particular types of people, mostly by age, but very likely (and implicitly) by ethnicity and socioeconomic status. According to Blakely and Snyder’s (1997) Fortress America, these communities can produce a sense of collective citizenship and provide salubrious spaces and activities. Yet the ethical question of reverse discrimination by older people arises, and the social question of the potential loss of wider community diversity is also a consideration.
Impact of Increasing Healthcare Costs on Government Expenditure
It is incontestable that, collectively, as people age they acquire more illness, disease, and/or disabilities. For example, in a developed economy like Australia, with a universal healthcare and subsidized pharmaceuticals, older people living in households have been found to have significant levels of medical conditions: almost half had an arthritic condition, about 40% had hypertensive disease (38%), 22% had heart and vascular diseases and stroke, 15% had diabetes, 7% had cancer, 10% had potentially disabling age-related vision problems, and 35% had hearing loss. About 93% of dementia cases occurred in the over 65 age group. Forty-nine percent of people aged 65–74 had five or more long-term health conditions, increasing to 70% of those aged 85 and over. Not only will the number of older people with these conditions increase, but there also may be increases in expectations about the standard of health services. As older people will comprise a growing proportion of the voting public, it is possible that they can skew already limited welfare spending toward them. For example, 60% of the public healthcare cost was spent on 15% of the European population aged 65 and over as their healthcare costs are three to five times higher than for those under 65.
There is a growing sense of intergenerational injustice favoring the older population in developed countries. The evidence about this is mixed and fairly difficult to determine because, among other factors, older people may not necessarily vote for their own age group’s interests but for fiscally conservative or pro-environment parties, for example. Research by Tepe and Vanhuysse (2010) shows that the countries most heavily biased toward the elderly in public policy spending are the USA, Japan, Switzerland, Austria, and all Southern European welfare regimes. On the other hand, Scandinavian and Anglo-Saxon countries (except USA) had the least pro-elderly regimes. Complicating the picture further are the changing structures of government policy in the “post-welfare” era and the emergence of more recent social phenomena such as women in full-time career-based employment. Another complicating factor is the political psyche of those aged 45 and under. These are people who grew in an age where neoliberalism replaced the welfare state as the prevailing political ideology – thus becoming more cognitively constrained (as suggested by Goerres and Vanhuysse 2011), namely, that they may have more limited expectations of what a state could or should provide.
Community decisions about where to spend the shrinking social welfare budget present ethical problems at both individual and government level. For example, should those who lived in a time of increasing GDP/head and relatively full employment be expected to have shown sufficient responsibility to fund their own retirement? Would this even have been possible considering the amount needed to be set aside each year of one’s working life? Should the social norm or expectation of governments providing retirement income and health benefits, which existed until the 1990s, be retrospectively changed? While these are concerns about our current aged population, the question will be one faced by those who are currently 45 or younger. The average rise in life expectancy at birth within OECD countries rose by 6 years between 1983 and 2008 to an average of 79.3 years (with Japan highest at 82.7). Notably, the USA (77.9) is below the OECD life expectancy average.
Related to this concern is the cost of maintaining life, particularly in cases of extended morbidity (such as Alzheimer’s disease) and terminal disease. Given the capability of modern medical technology to sustain life beyond what was formerly possible, several ethical questions emerge. The most obvious question is to define life and death. However, from a business perspective, a major concern is the extent to which the state has a responsibility to use taxpayer money for expensive treatments and hospitalization to maintain life, particularly in terminal cases.
Not only is this a state responsibility in terms of legislation regarding end-of-life decisions, but it is also likely to be played out in thousands of individual situations where families will need to make decisions where the boundary conditions will be strongly determined by the policies of public and private hospitals and the families’ financial status. While private hospitals may have the legal right to exclude or terminate entry to extended end-of-life treatment, public hospitals will most likely not have that option. Consequently, thousands of private anguished decisions will ultimately have a public impact. An Australian study found that care of people aged 65 years and over in their last year of life represented almost 9% of all hospital inpatient costs (Kardamanidis et al. 2007). Paradoxically, hospital costs fell with age (in the 65 and over age group): people aged 95 years or over cost less than half the average costs per person of those who died aged 65–74 years (AUD 7028 versus AUD 17927). Costs rise almost nine times from 6 months prior to death (AUD 646 per person per day) to the last month of life (AUD 5545 per person per day). Costs also vary by disease (e.g., cardiovascular diseases cost AUD 11069 in inpatient costs while genitourinary system diseases cost AUD 18948). Given the capacity for hospitals and insurance companies to determine likely costs for different medical conditions, it is plausible that some private hospitals may choose to exclude certain types of patients according to their disease type.
A borderline ethical issue related to age-based prejudice is benevolent prejudice, which occurs when older people are pitied or patronized because they are seen as incompetent or deficient. Although often well-intentioned, benevolent prejudice is nonetheless founded on stereotypes and produces feelings of disrespect and diminution in older people. Typical of such behavior is speech over-accommodation when younger people, often carers, talk to older people. This is characterized by speaking more loudly and more slowly, with excessive politeness and intonation, and using simple sentences (baby talk). At a more serious level is the tendency to withhold information or the expression of serious thoughts and feelings for fear of upsetting the older person.
While aging brings physical decrements, it is also clear that, with the emergence of the concept of the young-old in particular, aging people have much to offer to organizations as paid workers or volunteers and to society in general. For example, a characteristic of older people is generativity (first identified by Erikson 1950), namely, a personal inner desire to support the next generation based on the motivation of a conscious concern for their welfare. This characteristic is associated with belief in human goodness, according to researchers McAdams and De St Aubin (1992). It is also known that older people are capable of better moral reasoning than younger people. By allowing this generative desire to be expressed, organizations and society can provide experience-based knowledge to assist younger and less experienced people in dealing with difficult situations.
Changing family and work structures as well as geographic mobility leads to increasing disconnections between children and their grandparents. Despite the increasing longevity of grandparents, the potential for older people to develop strong relationships with their grandchildren may be limited by social class. Evidence shows that children from the most advantaged families are most likely to access this valuable grandparent resource. On the other hand, children in single-parent families and those with less educated mothers will be far less likely to access their grandparents. Not only is this an indirect social deficit for the child, but it also contributes to the social alienation of older people.
In each of these cases we see the problem that underpins the ethical concerns about ageism listed at the start, namely, that of inaccurate and unfair perceptions and evaluations of older people. Thus, developing more ethical approaches to the aged might well be assisted by challenging the often implicit assumptions that we hold about aging. At the same time, particularly as greater numbers of older people move into the old-old category, these more localized and interpersonal problems of aging will most likely spread to the public sphere forcing governments and those who vote for them to make significant decisions, some of them deeply existential, about caring for the infirm aged and about where the boundary of life ends.
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