Death in Old Age
How a Pandemic Makes Us Rethink Mortality
Table Of Contents
- About the author
- About the book
- This eBook can be cited
- FM Epigraph
- Introduction: A special time to talk about death in old age
- Part I The only normal death-age
- Chapter 1 Too old to die young: The perception and visibility of death in old age
- Chapter 2 Too old not to remind us about death
- Chapter 3 The ageing population as a threat to society
- Part II Encounters with death
- Chapter 4 Meeting death – places and occasions
- Chapter 5 Facing the death of loved ones
- Chapter 6 Public debates about the value of the end
- Part III Living towards death
- Chapter 7 In the shadow of death
- Chapter 8 Handling the last stage
- Chapter 9 Fate’s deception
- Epilogue: The afterlife of the pandemic
Why is the topic of death in old age so important and timely?
The main theme of this book is death in old age, with a focus on contemporary Western societies prior to COVID-19 and during the recent pandemic. Such a concern with a singular type of death in these specific contexts means that, while recognizing mortality as a universal human condition, the book does not meditate on death in general or abstract terms. Without delving into discussions of the timeless aspects of mortality in philosophy, theology, art history, psychology, medicine, anthropology, law and education, it views death as one of the most difficult, complex and diverse events in human life. While acknowledging that the awareness of mortality has played a different role in different societies through history, it explores the place and narratives of death in old age in ‘greying’ Western societies. By placing the discussion of death in old age in the context of the period of ‘the normality of our previous normal’ (Zizek 2020) and the very abnormal times of the COVID-19 pandemic, this book aims to prompt rethinking of societal obligations to the aged and to reflect on possible ways to handle death in old age. It looks at death in old age in normal times, when broader cultural and moral tales would ‘try to inoculate us against fear of death by banalizing and de-toxicating the sight of dying’ (Bauman 2011: 392), and compares this with death from COVID-19, which has been unpredictable, statistical, depersonalized and lonely. While accepting that attitudes towards dying and death prevalent in the present are ‘neither unalterable nor accidental’ (Elias 1985: 84) and without assuming that the impact of COVID-19 will result in a total or ←1 | 2→permanent alteration of standards, the book discusses which values and orientations towards death in old age have been reinforced and which have been challenged by the pandemic. Thus, the book offers a platform to debate society’s responsibility to old people and to explore the legacy of the pandemic in order to reflect on the quality of end-of-life care.
The topic of death in old age is very timely and important for several reasons, including that by talking about death in old age we can create a much-needed space for debates about death. In Western societies until recently, the topic of death generally was perceived to be something of a taboo. Until the beginning of this century, the sociological literature on death and dying built its theoretical paradigms upon Philippe Aries’s (1981) assumption of the taboo of death in modern society. However, from the 1970s onwards, the topic of death has gradually become less unmentionable as the ‘thanatological revolution’ animated death studies across Western Europe and the United States. Since then, the number and quality of studies dedicated to death have been growing (Broom 2015; Hockey 1990; Holloway 2007; Lawton, Julia 2000; Kellehear 2009; Neimeyer 1995; Walter 2020). Moreover, the popularity of self-help manuals about how to secure a ‘good death or ‘death with dignity’ – works ranging from Jane Feinman’s (2006) How to Have a Good Death to Lyons and Winter’s (2021) We All Know How This Ends) has increased, while images of death – especially of sudden and heroic death – have frequently been presented on TV screens and other media. With these trends making death more visible, today’s culture can no longer be described as a culture of ‘death denial’ or the ‘death taboo’ (Walter 2020). Yet, even though death is no longer always invisible, death in old age still remains a topic that is removed from the everyday experience of many people and is not explored (Gawande 2014; Zimmermann 2012). In our society, death in old age – which is often a medicalized, prolonged, lengthy and complex process – is hidden from public view (Carr and Luth 2019; Lloyd 2015).We avoid planning for it and feel awkward around old people who are grieving. However, precisely because death is now most likely to occur at the end of a long life, it is important to know how to ensure the quality of the end-of-life care for the elderly as well as to understand their views and values in relation to ‘the greatest event’ in life, as death is portrayed in Rilke’s poem ‘The Song of the Life and Death’.←2 | 3→
Death is ‘not the problem of the dead, but of the living, and that means us’ (Oz 1972: 240). Hence, by confronting mortality and by broadening our understanding of the role of death in old age in modern society, we can throw light on the cultural values that influence how we understand mortality in the West. Coming face to face with mortality not only makes life seem vulnerable and fragile; it also enhances our receptiveness to morality because the awareness of mortality can make one a more moral person (Genna 2020). The sense of mortality is the essential part of why our lives matter, why we care, why we take on responsibilities and why we value freedom, justice and dignity (Hägglund 2021). Although we need to admit that it would be disparaging to live with the continual awareness of our mortality, there is a need to acknowledge that now is a unique time to talk about death in later life. We have been led to rethink mortality in contemporary times because people who live under the protections of modern medicine, and who will be kept alive for longer than would have been conceivable even a century ago, now perceive death as not their problem, as something very distant that they know little about, and have no desire to consider (Engelhart 2022). In other words, the engagement with the issue of death in old aged has never been so important as now, when new moral dilemmas are triggered by the deferral of dying to old age and, at the same time, there is an absence of ethical attention to death in old age (Davis 2020). Because of the absence of conceptualizations of death in old age in today’s cultural narratives, and because people no longer expect to die before their old age, they feel immune from death and see it as a very distant topic. Hence the issue of death in the elderly – which is often death from disabling, chronic and degenerative diseases, which may take many months or years – tends to be kept well hidden in the background. Yet the marginalization of death in old age can impact the quality of the end-of-life care, and this means this issue requires urgent rethinking in our ageing societies.
Above all, the topic of death in old age is connected to the fact that death now increasingly occurs at the end of a long life. As the large post-war baby boomer generation is ageing, all developed nations can expect a big increase in death rates until around 2050. In the United Kingdom, as a result of the significant decline in mortality from 2001 to 2020, 18% ←3 | 4→of the population is now above 65 years of age (Spiegelhalter and Masters 2021: 136), while over the last thirty years, the number of people aged 90 years or more has increased by more than two and a half times, reaching recently 609,503 (Office of National Statistics 2020). The same trends are visible in other Western countries. For instance, 23% of the Italian population is now above 65 years old, while in Japan, the country with the highest life expectancy, 29% of people were over 65 years old in 2020 (Spiegelhalter and Masters 2021: 136). Now, with the average length of life in the developed world being above 80 years, death in old age is the most common modern type of death (Lloyd 2015). For example, in the United Kingdom between 1990 and 2017, the share of deaths in the over-seventies age cohort has increased from one-third to half of all deaths (Richie and Roser 2019), while in 2021 two-thirds of 585,412 deaths registered in England and Wales were among people aged over 75 years (Scobie and Hutchings 2022). Presently in Britain, most people die when they are over the age of eighty, with approximately 90% of deaths being of people aged over 65 years (Age UK 2015). In the United States in 2015, 2.7 million deaths – that is, 32% of all deaths – were of persons aged 85 years and older, 24% were of persons aged between 75 and 84 years and 19% were of persons aged between 65 and 74 years (Carr and Luth 2019: 517). In other words, in ‘greying’ Western societies, social and political concerns about death in old age are becoming more pressing.
Finally, the subject of death in old age is timely because the recent COVID-19 pandemic has not only made death more visible; it has also disproportionately affected the elderly. This has raised questions about how modern societies can best protect the aged. The World Health Organization (WHO 2022) has estimated that the global actual excess deaths – that is, the number of deaths that occurred beyond those expected without the pandemic – reached almost 15 million. The WHO report, released in May 2022, also found that age mattered, with 82% of the deaths occurring among people above the age of 60 (Balloux 2022: 49). The WHO figure points out that older people, especially if they suffer from chronic illnesses, have been at higher risk of death from COVID-19 than younger age groups. Already in the first year of the COVID-19 pandemic, the international data showed that once infected with the virus, the chance of death was ←4 | 5→one in 100 at age sixty-five, one in twenty-five at age 75, and one in seven at age 85, while for the youngest age groups, the risk from COVID-19 was ‘broadly comparable to those [from] everyday activities’ (Levin, Cochran and Walsh 2020: 24). The United Kingdom was also hit hard by COVID-19, with the country recording over 170,000 deaths linked to the disease and seeing the biggest rise in age-standardized mortality rates for seventy years since the major flu epidemic of 1951 (Spiegelhalter and Masters 2021). In Britain in 2020, people aged over 90 years had 35,000 times the risk of dying of COVID-19 as young children. Hence, it can be observed that ‘this virus, just, like normal life, persecutes older people’ (Spiegelhalter and Masters 2021: 125).
Because of COVID-19’s age-specific pattern of mortality – namely, that each ten-year increase in age more than doubles the risk of death for the virus (Webb 2020), since the beginning of the pandemic, there has been a need for government to take on social and public health responsibilities to protect older people from the COVID-19 risk in hospitals, homes and care settings. Yet, despite the high level of deaths in the elderly population and despite the Office of National Statistics (2021) data showing the high proportion (25.7%) of deaths of care home residents involving COVID-19, the problem of the threat posed to older people by the virus has not been addressed adequately. Fortunately, the rates of hospitalization and death for the aged have been reduced as a result of the successful vaccination programme, which in the United Kingdom began on 8 December 2020. In the following months, apart from vaccines and antiviral drugs, better treatments and greater knowledge of how the disease progresses have contributed to lowering the rates of hospitalization and to saving the lives of many elderly people. Yet through the whole pandemic, even though the vaccine uptake among the aged has been above 90%, the risk for aged people has continued because the effectiveness of the vaccines declines more quickly in older people and new variants of the virus have emerged. Moreover, with the growing public weariness and with the United Kingdom, in April 2022, passing the responsibility for everyday protective behaviour on to individuals, elderly people – especially those with underlying health conditions – and any other people with a compromised immune system have continued to face the risk in public places. Despite the evidence that the ←5 | 6→overall mortality rate has varied hugely by age through the whole pandemic, the particular risk posed by the coronavirus to the elderly did not become a key focus of British policy during the health crisis.
As many studies show, despite COVID-19’s age-specific mortality pattern, several governments – including Britain’s – have shown total disregard for social and public health responsibilities towards elderly people by not prioritizing the protection of the aged (Calasanti 2020; Calvert and Arbuthnott 2021; Clarke 2021; Dodsworth 2021; Martin and de Saille 2022). In other words, together with the pandemic, there has been ‘a parallel outbreak of ageism’ (Ayalon et al. 2020) or discrimination against older adults rooted in the acceptance of the difference between old and young as justifying the exclusion of the aged (Calasanti 2020). By neglecting its obligations to increase efforts to protect the elderly who have been at the greatest risk from the COVID-19 pandemic, and by employing the ageist rhetoric and accepting ‘the brutal fact’ that losing people in old age ‘does not cause as much economic or social disruption as losing children or people of working and childbearing age’ (MacKenzie 2020: xxv), the UK government has been relaying on and reinforcing ageist prejudices and stereotypes. The UK policy of managing the health crisis, rooted in viewing the pandemic as affecting ‘just some elderly in care homes’, and comments that people dying from COVID-19 are ‘just essentially all over 80’ have scapegoated the elderly. According to Caroline Abrahams, director of the charity Age UK, it is ageism not to be concerned about the elderly dying of COVID-19. Tedros Adhanom Ghebreyesus, director-general of the WHO goes further, describing this policy as ‘moral bankruptcy at its highest’.
The COVID-19 crisis has revealed that ageism is still embedded in British society and has exposed its application in the UK government’s handling of the recent pandemic. Because of the ageism inherent in the British government’s COVID-19 policy, the United Kingdom’s elderly people have faced a double risk. Apart from their low adaptive immunity, which puts them at risk of both catching and dying from the virus, and the waning effects of the vaccine, the aged have also faced additional risks as a result of government policy failures. For instance, aged people have been faced with the risk of being transferred from hospitals to care homes without testing for COVID-19, and have been denied access to hospitals ←6 | 7→and/or ventilators so this equipment might be reassigned to younger people who are more likely to survive (Calvert and Arbuthnott 2021; Clarke 2021; Cooper and Szreter 2021; Francis 2020, 2021; Horton 2020). The underlying ageism of the governmental policies of handling the recent pandemic has also had a negative impact on older people’s feelings of security, been detrimental to their mental health and affected their physical condition. In addition to the use of the narrative of ageism, the ‘fear-based’ policy narrative has been applied to manipulate the general public’s deep-rooted fears of contagion and death (Dodsworth 2021).
Moreover, the pandemic has revealed the faultlines in British society in terms of poverty, lower incomes and higher-risk jobs and ethnicity, as well as regional disparities in healthcare resources and access to health and care services. The COVID-19 crisis has not only exposed and supplemented the existing discrimination against older adults and fuelled many injustices, but has also revealed the structural problems that exist in the UK medical and care systems, both seen as struggling to provide palliative and hospice care. Hence, it is important to question how we should proceed in terms of the quality of end-of-life care after the current crisis has abated. To learn lessons from the COVID-19 pandemic about how older people should be protected and how the quality of the end-of-life care should be ensured, we should acknowledge that although the pandemic has disrupted daily routines, and brought tragedy and disorder to concrete human lives, the coronarius crisis, like other collective threats, has also created an opportunity to review and revise people’s priorities and to mobilize for change. A new value of solidarity, together with the inequalities connected with age, ethnicity, race, and class revealed by the pandemic, might mean that COVID-19 can contribute to enlarging the scope for social change and for much-needed reforms of the health and care systems.
While looking at government attempts to balance obligations towards the aged with other values, such as economic growth and the needs of the younger generations, this book discusses the impact of governmental policies of ‘prioritising the young over the old’ on quality of the older population’s end-of-life care (Reisz 2020: 3). By exposing the underlying tensions in handling old people’s care at the end of life both before and during the health crisis, the volume aims to reflect on the ethical dimensions ←7 | 8→revealed by the pandemic. While showing the increased visibility of death of older people during the pandemic, the book argues that the death of the old cannot be regarded simply as an untimely problem or inconvenient cost because all deaths count: with every death, an entire and irreplaceable world is lost (Derrida 1992).
The content of the book
The structure of the book reflects its two main topics: death in old age and the impact of the pandemic on the quality of elderly people’s end-of-life care, with all chapters dealing with the issues connected with death in old age in both pre-COVID and COVID times. While not dealing with death in spiritual and physical terms, this book aims to show death as the ultimate diverse and hard-to-predict event, as for ‘all the death, we die unrehearsed’, as Les Murray (2013) states in his poem ‘Corniche’. Writing about death in old age in two different contexts and writing mainly about the United Kingdom – one of the world’s less religious societies – do not just limit our possibility of tackling the universality of the mortal condition, but do not leave a space for in a detailed consideration of the role of religion in death. While recognizing the impact of secularization on attitudes towards death in modern societies, the book also acknowledges that even within multicultural contexts where secularism is a significant mode of belief and personal practice, death and dying are embedded within forms of religiosity (Broom 2015; McManus 2013). The volume does not analyse changes in the social construction and experiences of death in old age from any religious perspective, and it is not concerned with the ideas of afterlife and immortality offered by world religions. Yet, as older people are much more likely than younger people to declare that they have a religion (Woodhead 2016), and as religion still often plays a part in people’s engagement with death, the book pays attention to the role of religion and other cultural resources in negotiating death practices and following death rituals. For example, as many death ceremonies still take place in formal religious institutions, when describing funeral ←8 | 9→rituals or other death-related practices, the significance of religion cannot be overlooked.
- X, 306
- ISBN (PDF)
- ISBN (ePUB)
- ISBN (MOBI)
- ISBN (Softcover)
- Publication date
- 2023 (February)
- Societal obligations to the aged Quality of the end-of-life care Neglection of the old during the pandemic death in old age the Covid pandemic the end of life care Death in old age Barbara A. Misztal ageing societies longevity mortality death in care homes attitudes towards death
- English: Oxford, Bern, Berlin, Bruxelles, New York, Wien, 2023. X, 306 pp.