By Chua Mui Hoong, The Straits Times, 4 Nov 2011
Singapore's Ageing Population: Managing Healthcare And End-Of-Life Decisions.
Edited by Chan Wing Cheong.
Edited by Chan Wing Cheong.
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.
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 'interim generation'
ONE chapter in the book by Professor David R. Phillips from Lingnan University in Hong Kong offers a regional perspective of the ageing issue in the Asia-Pacific. It has a critical insight worth quoting at some length:
'In many ways, today's older people in most Asia-Pacific countries form something of an 'interim generation' who have grown old before their countries have gained sufficient resources to look after them... This interim generation typically faces diversity and uncertainty. Its members have aged at a time when they had little opportunity, few resources or encouragement to invest for their futures, but there is as yet little formal support for them.
'They face increasingly uncertain family and community support, as traditional support systems may be decreasing, and many have fragmented or smaller families... They have to live on restricted incomes and usually have no pension or formal financial support other than what their work and limited savings can provide. Ultimately, in some countries, older people will be provided with more formal support but this is often some years away and not yet meaningful for this group. Meanwhile, the interim generation of today's older people, especially many older females, have to struggle on.'
Prof Phillips puts Singapore, together with Japan, Hong Kong, South Korea and Taiwan as the societies where welfare and social protection schemes are more comprehensive and mature than in the rest of the Asia-Pacific.
But his observation about the interim generation applies equally to Singapore.
Think of the group of elderly Singaporeans born around the 1940s or earlier, who had little formal education because there were few schools; benefited late from the Central Provident Fund so have little retirement savings today; and who are old at a time of falling nuclear family size, who are likely to have children who are themselves in the sandwich generation and thus hard-pressed to provide for them.
And meanwhile, as Prof Phillips put it, there is no pension or formal financial support for them.
Like other Asia-Pacific countries, Singapore has no comprehensive welfare structure to make sure its vulnerable elderly get support from the public, or at least community, purse.
What is the policy prescription?
Prof Phillips quotes a 2008 Organisation for Economic Cooperation and Development (OECD) report which advocates formal pensions for the elderly to give them a subsistence income pegged to inflation.
As he notes, in the Asia-Pacific region, only Hong Kong has such a scheme covering 5 per cent of its retirees, while Singapore's pension coverage is only 1 per cent. The book does not explain what that 1 per cent consists of, but it might be former civil servants who receive state pensions and the small number of destitute elderly on public assistance.
It is true many elderly have children, or savings. But as seen in Singapore - the old woman selling tissue paper, the old man clearing used plates in a hawker centre - and in towns and villages across Asia, there are some in this interim generation who still struggle to make ends meet.
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