Friday, November 04, 2011

A multifaceted look at ageing issues

IF BOOKS on serious subjects like health care and dying can ever be said to be a treat, this is one of them.
By Chua Mui Hoong, Review Editor
Singapore's Ageing Population: Managing Healthcare And End-Of-Life Decisions.
Edited by Chan Wing Cheong.
Routledge Contemporary Southeast Asia Series. 222 pages, $140.

It is an intellectual treat for the sheer range of perspectives on ageing: from the medical, sociological, legal and anthropological. It also scores in offering a macro- and micro-perspective, a rare feat for academic books. The 19 contributors to the book, most of whom based their chapters on papers presented at a conference on ageing earlier, come from different academic disciplines, and quite a few are policy practitioners. So there are insights into the flesh-and-blood experience of ageing, thanks to sociologists' first-hand interviews, and policy suggestions from researchers.

One chapter describes Singapore's demographic changes in the context of an ageing Asia-Pacific, offering a macro view of ageing. (See other story.)

Yet another zooms in in some detail on the experience of ageing among men in Singapore, using its ground-up perspective to offer suggestions on ways to help elderly men age in place: go beyond health-care needs to provide meals, social support and daily assistance.

Another chapter - by Chan Wing Cheong, an associate professor at the National University of Singapore with an interest in elder law, who is also the editor of the volume - gives an insight into elder abuse victims. This is based on a study of 89 cases at TRANS SAFE Centre, a voluntary welfare organisation that handles elder abuse. This study does a useful service in confirming or overturning some commonly held assumptions about elder abuse: It is true that elderly women are more prone to being abused than elderly men. And among the different types of abuse, sons are more likely to use neglect as a form of elder abuse than other forms such as physical abuse, psychological abuse and financial abuse.

The issue of a society's rapid ageing is invariably bound up with health financing issues. The introduction of the book rightly zooms in on this Gordian knot on health financing thus: 'How can long-term medical expenses be dealt with?'

Perhaps because there are no health economists among the contributors, this important issue is not sufficiently discussed in this book. (Those who want a more thorough discussion of health-care financing can turn to another book, Social Policy In An Ageing Society: Age And Health In Singapore, by David Reisman, a professor of economics at the Nanyang Technological University, published in 2009.)

But what Chan's book on ageing lacks in economic insight, it makes up for in conceptual interest, especially when it comes to the legal and intellectual issues of end-of-life matters.

When is a person dead - when the brain has no decipherable function or must the heart also stop? How does a society represent the interests of the person at the end of life, when that person is no longer mentally capable? How much authority should a proxy carer be given to make decisions? On what basis should a proxy carer make such decisions?

Since a patient has autonomy to refuse treatment, does he also have a right to determine time and manner of death?

These difficult ethical and moral dilemmas are dealt with excellently in the last four chapters that illumine the issues with an incisive presentation of concepts.

Consider: how does one begin to make a decision for an incapacitated person? Tracey Evans Chan, an assistant professor of law at the National University of Singapore, guides the reader through the legal morass. Three usual standards apply. First, 'advance decision', which is when a patient has already indicated his or her wishes, for example via an advance medical directive or verbal instructions. Second is 'substituted judgment', which is based on one's best assessment of what the person would have chosen were he or she mentally competent. The third is 'best interests', which is making a decision based on what one thinks is in the best interest of the infirm patient.

It is interesting to know that 'the first finds clear support in the common law generally, while the second has widest support among the various US states but has been rejected by the highest courts in Britain and Canada in favour of the third'.

What of Singapore? What direction will the legal and philosophical debate here take? The chapter gives a lucid assessment of existing legal frameworks and points out their limits.

One of the most ground-breaking - and radical - proposals in the book comes towards the end, when two contributors bravely take on the sensitive issue of physician-assisted suicide (euthanasia), look at different legal models and even draft a proposed legal framework for such a law in Singapore.

This book does not claim to offer clear answers on how a society should best prepare for a rapidly ageing population. But the intelligent and varied views in this slim 222-page volume will reward both the layman and the specialist reader.

The book can be ordered online from the publisher's website It is also available at the National University of Singapore Library and the National Library.