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Authentic aging and human flourishing Dr. Julian C. Hughes Consultant in Old Age Psychiatry Northumbria Healthcare NHS Foundation Trust and Honorary Clinical Senior Lecturer Institute for Ageing and Health, Newcastle University © Julian C Hughes 2008
Large scale problems Our attitudes to older people Our approach to the care of frail older people Especially with mental health problems such as dementia © Julian C Hughes 2008
Questions for this talk Does the notion of authenticity help in our thinking about older people? If so, how do we characterize authenticity? If we can characterize what it is to be authentic and it’s useful in old age, what constitutes authentic aging? (Or, what are our true colors as we age? Or, what ought they to be?) © Julian C Hughes 2008
A way in? Roughly, to be authentic is to be true to oneself. What is it for older people to be true to themselves? Well, what does the historical record tell us? Susannah Ottaway (2004) The Decline of Life: Old Age in Eighteenth-Century England. Cambridge: CUP. Pat Thane (2000) Old Age in English History: Past Experience, Present Issues. Oxford: OUP. © Julian C Hughes 2008
Complexity: past and present (1) Ottaway (2004): ‘…this period had a flexible definition of old age, where an individual’s unique aging process was recognized, and age categories were in part determined by physical appearance and health.’ (p 64) © Julian C Hughes 2008
Complexity: past and present (2) Ottaway (2004): ‘…the institutionalization of the elderly in workhouses embodies a fascinating nexus of the core Enlightenment themes of humanitarianism, individualism, and classification. Humanitarian concerns for the physical well-being of the aged causes some reformists to violate individualistic ideals of autonomous living…’ (p 276) © Julian C Hughes 2008
Complexity: past and present (3) Ottaway (2004):‘Advanced age often was valued in and of itself, and there was a common assumption that the aged would remain valuable and contributing members of their communities.’ (p 98) © Julian C Hughes 2008
Complexity: past and present (4) Ottaway (2004) [on individualism and autonomy]: ‘poor-relief policies deliberately prioritized the residential independence of the aged.’ (p 121) ‘co-residence with their children’s families was regarded as a temporary solution to a particular problem.’ (p 119) ‘As a rule, the wills seem to reflect a certain level of suspicion about children’s ability to live in peace with their mothers.’ (p 125) © Julian C Hughes 2008
Old age in pre-modern England Thane (2000): “The great majority of old people were poor … But most continued to have active lives, giving to their communities as well as receiving. There is no obvious sign that they were despised or degraded because they were old … Older people appear to have been treated as people, and as ‘old’ only when they became dependent, which could occur at a variety of ages.” (p 118) © Julian C Hughes 2008
Old age in modern England (1) Literature in the 1980s emphasized the burden on ‘carers’. But this literature… “… had the unintended consequence of reinforcing the stereotype of ‘old people’ as objects of care and of fuelling alarm about the inevitability of a period of serious dependency at the end of life.” (Thane, 2000 p 430) © Julian C Hughes 2008
Old age in modern England (2) Old people, “… do not give up their independence easily: with few exceptions they are reluctant subjects in caring and dependency … elderly people desire, often more than anything else, the preservation of their independence.” [See H. Qureshi and A. Walker, The Caring Relationship London, 1989), 18-19. Quoted in Thane (2000) p 431] © Julian C Hughes 2008
Old age in modern England (3) Thane (2000): “… persuasive evidence that old people who live alone are rarely neglected and isolated. They receive a great deal of support from family and friends and they give much in return. Very many older people live alone by choice, preferring independence to dependence in the homes of relatives.” (p 480) © Julian C Hughes 2008
Hence, Evidence of stability over time in terms of people’s determination to remain Active Independent Able to make a contribution Involved with family without being a burden Non-dependent until infirmity makes them dependent © Julian C Hughes 2008
Back to our questions Does the notion of authenticity help in our thinking about older people? If so, how do we characterize authenticity? © Julian C Hughes 2008
Coherence or sincerity of yearning? “… the impulse towards authenticity, and towards recognition and honouring of one’s authentic or real self, does seem to be a culturally entrenched inclination. Although the ultimate coherence of this concept may be in doubt, the intensity and sincerity of people’s yearning for it does not appear to be.” (p 86, endnote 8) J Radden and JM Fordyce (2006) Into the darkness: losing identity with dementia. In Hughes, Louw and Sabat (eds) Dementia: Mind, Meaning, and the Person. Oxford, OUP; pp 71-88. © Julian C Hughes 2008
Being Authentic (Taylor, C. (1991) The Ethics of Authenticity. Cambridge, Mass: Harvard University Press) ‘The ethic of authenticity is something relatively new and peculiar to modern culture. Born at the end of the eighteenth century, it builds on earlier forms of individualism …’ (p 25) ‘One way of describing its development is to see its starting point in the eighteenth-century notion that human beings are endowed with a moral sense, an intuitive feeling for what is right and wrong.’ (p 26) © Julian C Hughes 2008
Being true to myself “Being true to myself means being true to my own originality, and that is something only I can articulate and discover. In articulating it I am also defining myself. … This is the background understanding to the modern ideal of authenticity, and to the goals of self- fulfilment or self-realization in which it is usually couched.” (Taylor 1991, p 29) © Julian C Hughes 2008
Origins of authenticity Moral sense – conscience: being true to oneself Nietzche/Foucault: ‘in which agents are concerned to be authors of their own lives considered as narratives, and evaluated through an aesthetics of the self’ (Ainsley J, Ashcroft RE (2005) Whither authenticity? American Journal of Bioethics 5 (3): 53) Existentialism Heidegger Sartre © Julian C Hughes 2008
Authentic Existence (Macquarrie, J. (1972) Existentialism Harmondsworth: Penguin Books) ‘Existence is authentic to the extent that the existent has taken possession of himself and, shall we say, has moulded himself in his own image…’ (p 206) Conscience is the call of the authentic self, summoning the human existent ‘from its lostness in the “they”’ (from Heidegger’s Being and Time, quoted on p 212) The basic structure of existence is being-with-others; cannot live apart from other selves. ‘Hence no image of authentic existence can lack a social dimension’ (p 209) © Julian C Hughes 2008
Authenticity as autonomy Autonomy as a right of non-interference Authenticity involves autonomy ‘On the other hand, the decision is authentic only when it is in accordance with the actor’s personal values, dispositions, attitudes, and intentions. The patient is acting in character. This, in turn, requires that the patient has reflected about his or her own values and consciously underwritten them.’ (Welie, JVM (1994) Authenticity as a foundational principle of medical ethics. Theoretical Medicine, 15 : 211-225) © Julian C Hughes 2008
The facticity of human existence ‘… the Dasein always finds itself in a situation where it has “to be”. It never begins with wide open horizons … for at any moment there are already a great many “givens”.’ (Macquarrie J (1968) Martin Heidegger, p 21) ‘The human being is “thrown” into life from the very beginning of conception. There is a particular physical and psychological constitution and health status, that are “givens” to a large extent. There is historical, geographical and social situatedness which, even if changed in the course of life, is always ex changed but never undone.’ (Welie op cit, 1994) © Julian C Hughes 2008
In summary Authenticity: As being true to one’s self (The idea of the situated self) The self located in a context © Julian C Hughes 2008
Add to this Sartre Authenticity involves awareness and acceptance of an ambiguity: seeing how things are means that one is aware one cannot win. ‘…I can become aware of the futility of, for example, my striving for perfection, for coincidence with my values, without this awareness negating my continued effort.’ (Welie, 1994) © Julian C Hughes 2008
Conclusion of Welie (1994) The existentialist concept of authenticity adds ‘one crucial insight: The essence of human life disappears out of sight if its temporal character is reduced to a series of present actions’ Clear implications of this for ethical decision-making © Julian C Hughes 2008
In summary A characterization of authenticity: As being true to one’s self (autonomy + value coincidence, stemming from ‘moral sense’) The idea of the situated self The self located in a context The nature of our striving (for unattainable perfection) The narrative perspective: our lives as a whole © Julian C Hughes 2008
Our earlier question Does this notion of authenticity help in our thinking about older people? As being true to one’s self The striving for continued independence © Julian C Hughes 2008
Authentic Ageing: Past Ottaway (2004):‘Although older people strived to remain independent, they also sought to contribute actively and significantly to the well-being of their families.’ (p 116) (e.g. Sarah Dibden) © Julian C Hughes 2008
Our earlier question Does this notion of authenticity help in our thinking about older people? As being true to one’s self The striving for continued independence The idea of the situated self The importance of this idea for people with dementia © Julian C Hughes 2008
The situated embodied agent view of the person Hughes, J. C. (2001). Views of the person with dementia. Journal of Medical Ethics, 27, 86-91. Our situatedness: Culture: traditions, norms, history Personal history: wishes, inclinations, concerns Social context: neighbours, friends, family, law Morals: virtues and values Spiritual values: religion, openness to other © Julian C Hughes 2008
Our earlier question Does this notion of authenticity help in our thinking about older people? As being true to one’s self The striving for continued independence The idea of the situated self The importance of this idea for people with dementia The self located in a context Our inevitable dependency © Julian C Hughes 2008
Dependence and Autonomy in Old Age: an ethical framework for long-term care George J Agich (2003) Cambridge: CUP ‘The agent in the everyday world is thus an essentially dependent entity, dependent on a socially derived stock-of-knowledge at hand and a repertoire of abilities and skills that comprise the background against which individual difference is manifested.’ (p 134) ‘Parentalism signals the essential interconnectedness of all human persons and is rooted in the basic response to the needy other that such relationships engender.’ (p 48) © Julian C Hughes 2008
Our earlier question Does this notion of authenticity help in our thinking about older people? As being true to one’s self The striving for continued independence The idea of the situated self The importance of this idea for people with dementia The self located in a context Our inevitable dependency The nature of our striving Our (embodied) agency: commitment to family © Julian C Hughes 2008
Our earlier question Does this notion of authenticity help in our thinking about older people? As being true to one’s self The striving for continued independence The idea of the situated self The importance of this idea for people with dementia The self located in a context Our inevitable dependency The nature of our striving Our (embodied) agency: commitment to family The narrative perspective The shape of our lives as a whole © Julian C Hughes 2008
The shape of our lives Ronald Dworkin (1993) Life’s Dominion : critical interests and the shape of our lives as a whole Critical interests and authentic existence The authentic cadence Our interest in how our lives end The significance of the ending © Julian C Hughes 2008
The final question What constitutes authentic aging (at any age)? Being your self Being true Being situated Having significance Becoming © Julian C Hughes 2008
Authentic Ageing Now? Quality of care in private sector and NHS facilities for people with dementia: cross sectional survey 10 private sector and 7 NHS care facilities. Ballard C, Fossey J, Chithramohan R, Howard R, Burns A, Thompson P, Tadros G, Fairbairn A (2001). British Medical Journal, 323, 426-427. All 7 NHS facilities and 5 of the private sector facilities needed radical improvement The remaining 5 private sector facilities needed much improvement Over the 6 hour daytime period of observation: 61 minutes asleep 108 mins socially withdrawn/not actively engaged in anything 50 minutes were spent talking/communicating < 12 minutes spent engaged in everyday constructive activities other than watching television Remainder: basic activities eg eating, going to the toilet © Julian C Hughes 2008
Authentic Ageing: Present and Future Professor Tom Kirkwood Kirkwood, T. (1999) Time of Our Lives: The Science of Human Ageing. London: Weidenfeld & Nicolson. Reith Lecture (2001): The End of Age. London: Profile Books Age Action (The Sage, 23 April 2007) http://ageaction.ncl.ac.uk/ http://ageaction.ncl.ac.uk/ ‘For a long time, medicine has been concerned chiefly with stopping people from dying. Now that we are entering an era in which most of us will survive to ages when we shall need to cope with a range of conditions requiring medical attention, it is high time to focus fresh attention on to how medicine can best address questions of maintenance of independence and quality of life in old age.’ © Julian C Hughes 2008
Authentic Ageing: Present and Future The science of ageing Assistive technology © Julian C Hughes 2008
Authenticity: Charles Taylor again ‘The general feature of human life that I want to evoke is its fundamentally dialogical character. We become full human agents, capable of understanding ourselves, and hence of defining an identity, through our acquisition of rich human languages of expression.’ ( The Ethics of Authenticity pp 32-33) © Julian C Hughes 2008
And again! Taylor on significance ‘…I can define my identity only against the background of things that matter. But to bracket out history, nature, society, the demands of solidarity, everything but what I find in myself, would be to eliminate all candidates for what matters. Only if I exist in a world in which history, or the demands of nature, or the needs of my fellow human beings, or the duties of citizenship, or the call of God, or something else of this order matters crucially, can I define an identity for myself that is not trivial.’ ( The Ethics of Authenticity pp 40-41) © Julian C Hughes 2008
Authenticity Shared language and meaning Horizons of significance What constitutes authentic aging? Being your self Being true Being situated Having significance Becoming © Julian C Hughes 2008
Counter-cultural thoughts perhaps What is the background significance of the science of ageing? What is the meaning of extra life? Will technology provide us with dialogical experiences? Or might technology disconnect us from genuinely human encounters? © Julian C Hughes 2008
Susannah Ottaway again Quintessential aspects of old age in the Enlightenment: Maintaining usefulness Avoiding isolation, engagement in family and community The denial of enjoyment © Julian C Hughes 2008
Dementia Care Partnership © Julian C Hughes 2008
Authentic Ageing Now Being with others: being dialogical Having a purpose: the significance of our lives © Julian C Hughes 2008
Thank you © Julian C Hughes 2008
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