Treatment versus care for elders: a view from China

Council Member Ann Gallagher (Professor of Ethics and Care, University of Surrey) co-authored this blog with Yonghui Ma (Associate Professor, Bioethics, Xiamen University) during Ann’s sabbatical in China.

At the time of writing this blog post, our attention was drawn to special issues of two eminent journals on the theme of ageing. The journal Bioethics explores questions relating to dignity, dementia, vulnerability and flourishing in later years. The journal Perspectives in Biology and Medicine also has a special issue, with a helpful taxonomy of ageing: ‘as a time of robust health, of dementia, of frailty, or of advanced illness that ends in death’.

These special issues contribute to an escalation in scholarship and comment on the theme of scientific and ethical aspects of ageing.The Nuffield Council on Bioethics, for example, recently published a briefing note on the theme of The search for a treatment for ageing. The briefing note introduced the idea of ‘geroscience’, – a field of research that is exploring interventions that ‘delay biological ageing and reduce the risk of age-related diseases and conditions.’ The note details potential ageing ‘treatments’ such as medicines, dietary restriction, stem cell and gene therapies and ‘young blood’ transfusions.

The briefing note helpfully scopes a range of ethical issues that relate to geroscience - for example, the potential benefits of older people living longer and having healthier lives thus reducing the demand on resources. Such interventions may also enable older people to make valuable contributions to families and societies. Potential harms could include population growth, an increased economic burden, health inequalities (access to such interventions will not be available to all) and the medicalisation of ageing, whereby ageing is no longer seen as a natural phenomenon but as a medical condition to be cured.

Writing from China, we are in sympathy with the World Health Organisation recommendation, as outlined in the Nuffield Council briefing, that policy should focus on healthy ageing, on health promotion and capacity-building strategies, and on the development of an ‘age-friendly world’.

In China, the one-child policy was first implemented in the late 1970s and resulted in a highly imbalanced population age structure for the last 4 decades. In 2013, the Chinese government revised its policy to allow a married couple to have two children if one spouse was an only child. This has had very limited impact on fertility rates as many people do not want to have a second child, partly because changed values on family size, but also because of the rising cost of raising and education children. As a result of this situation, from 2015 the one-child policy ended, and all couples are now allowed to have two children.

The one-child policy has contributed to a pattern of population aging with ‘Chinese characteristics’, which is the prevalent ‘4-2-1’ family structure (four grandparents, two parents and one child). For most families, two single children supporting and caring for four parents and one child is a reality. These factors make eldercare for China a highly challenging and pressing task.

There are currently more than 220 million elderly people in China. By 2050, more than 40% of the population will be over the age of 60. Although Chinese governmental expenditures on healthcare and eldercare has been growing, it is far from adequate and still below global averages. In China, resources are unfairly and unequally distributed among older people living in rural areas as compared with those who live in urban areas. For example, older people belonging to rural hukou (household registration) will not only encounter difficulties in accessing high quality healthcare services centred in big cities, but will also receive less reimbursement rates if they seek healthcare in cities and also receive less pension. Many older people live alone, or with their spouse, in rural areas as their children move to urban areas for work. Suicide rates among Chinese people over 65, especially in rural areas, are extremely high, accounting for 44% of all suicides. Rural male suicides were 3-5 times higher than their urban counterparts (Nie, 2016).

An important ethical consideration in China is that of ‘filial piety’. This is a Confucian value, common in East Asian societies, that sets an expectation for children to respect and care for aging parents. This value is threatened by demographic changes and the migration of younger people to cities. The meaning and implications of ‘dignity’ for Chinese elders needs to be stressed as many elders maintain that making decisions by oneself on one’s own affairs, as well as being cared for by one’s children, is the embodiment of dignity.

How to develop effective, acceptable, and ethical solutions to eldercare provision, and also to meet distinctive Chinese cultural expectations and the values of filial piety and dignity, is a challenge requiring multi-disciplinary investigation. We have a number of proposals on how to develop a sustainable response to this complex challenge.

First, eldercare is an ethical imperative. It is a human right supported by human dignity and should be viewed as a societal priority and funded accordingly. There is a need, therefore, for central government to increase investment in health care and social security (Nie 2016).

Second, a successful eldercare model in China needs to be accepted by both care-providers and care-recipients to meet the cultural values and expectations of older people. Traditionally, the preferred approach to eldercare is a cross-generational housing model, which is believed by many to be the best way to honour the Confucian ideal of filial piety towards elders. However, due to rural to urban migration and the work pressure of adult children, this model is no longer feasible for many families. We propose that those investing in care might build on this tradition by having kindergartens and eldercare facilities together so that children can gain from the wisdom of elders and elders gain from the company of children.

Third, special consideration needs to be given to older people in rural areas and to those who have lost their only child (Nie 2016). Older people whose children have left the household are called ‘kongchao laoren’. In response to the high rural suicide rate, counselling and other support programmes need to be established. The dualistic rural-urban household registration system needs to be reformed, if not abolished, to avoid structural and institutionalised discrimination against people based on residency, age, and other reasons (Nie 2016).

Our fourth, and final, proposal relates to dementia care. The Nuffield Council on Bioethics report Dementia: ethical issues outlined an ethical framework to help address problems that arise in connection with dementia care, and brought attention to some of the very many care issues. We think it is vital to have more cross-cultural sharing of good practice in the area of dementia care.

It is our view that ‘the search for a treatment for ageing’ is a future-oriented quest and one that could, in the long term, reap benefits that enable more older people globally to have longer, healthier lives.

For now, we have more urgent challenges and need to focus on enabling existing older people globally to live as well as possible. Medicalising ageing is not, in our view, a constructive strategy nor should it be the primary focus of politicians and policy-makers.

We need to shift our focus from seeking ‘a cure’ to making ‘care’ the priority. This priority is not just for governments, but for all of us, as family members and fellow citizens. As Joan Tronto writes:

"Care is difficult work, but it is the work that sustains life […]. The fact that care-givers can see an essential truth about the value, though, does not negate the fact that care is reduced to a lesser importance in society as a whole. When we look at the distribution of such rewards as money and prestige, it is clear that we value much else before care." (Tronto 1993, 117).We suggest that recognising the value of care – formal and informal – is an endeavour that all of us need to prioritise.

Reference – Nie J-B (2016) Erosion of Eldercare in China: A Socio-Ethical Inquiry in Aging, Elderly Suicide and the Government’s Responsibilities in the Context of the One-Child Policy Aging International 41: 350-365