The problem of paternalism in the care of older persons

Since the start of the new year, my articles for the Ageing in Society blog have moved away from the issue of boredom (about which I still have much to say, fortunately or unfortunately) to focus, momentarily, on the triangle of isms that threatens the goal of achieving dignified ageing in today's society. I am referring, in effect, to the triangle of ageism, ableism and paternalism. To the first two I dedicated the posts on the language and icons we use to refer to older people on a daily basis, proposing the solution of mutual care as a resource in the face of discrimination. This one focuses on the last element of the trigon. 

What is paternalism? 

A very clear and intuitive way of defining what paternalism is in the context of elderly care, without getting bogged down in jargon, is the following: paternalism is the authoritarian and/or overprotective attitude based on the belief that, as caregivers, we know the needs, wishes and fears of the people we accompany, care for or offer our services to better than they themselves do. In reality, it would not be very different from the definition found in any dictionary or Wikipedia: "Paternalism is the tendency to apply the standards of authority or protection traditionally assigned to the father of the family to other areas of social relations such as politics and the world of work".

Those who sin of this evil under the influence of the first meaning, authoritarianism, observe and treat the elderly from a (sometimes) unfoundedly hegemonic position that is built on the conviction that comes with disciplinary specialisation or that is based on a lack of commitment to the task of care. The former happens to health professionals who believe they are in possession of the absolute truth and qualified to diagnose and treat even against the will of the person concerned. The latter happens to formal and informal caregivers who detest the work entrusted to them and do not appreciate spending time listening to the elderly or saliva on arguing about their anxieties. Extreme cases of authoritarian paternalism often lead to repudiatory episodes of physical and psychological abuse.

Overprotectors, on the other hand, are guided by the inherent condition of parenthood which represents the constant and unavoidable fear that the people they care for and for whom they feel responsible will harm themselves or others. They do so surely out of good will, without imagining the extent to which their behaviour can have an impact. The immediate consequence is a reduction in freedom and autonomy which, over time, eventually turns life into a punishment and leads to the perpetual and destructive sense of worthlessness to which so many older people fall victim. 

Both infantilise the elderly, treating them as if they were children who not only have to be guided and taught, but also imposed and ordered not to disturb or cause harm. In the wake of paternalism, being an elderly person becomes synonymous with being a minor in the purest Kantian sense. One is reduced to a voiceless subject, or one whose voice is not worth listening to, unable to make relevant (or insignificant) decisions concerning one's own life. Paternalism, then, is the opposite of person-centred care (PCC) or, better still, person-directed care (PDC). Paternalism is the tonic of the traditional, biomedical, obsolete model of care. Paternalism, in short, is antagonistic to dignified ageing. 

How do I know if I am paternalistic?

Sometimes it can be very difficult to realise that we are adopting a paternalistic attitude towards the elderly, either because there are many to care for and it is more affordable to give them all a standardised rather than personalised treatment, or because the responsibility of care goes beyond the caregiver or because we are talking about a loved one on whose wellbeing our own wellbeing also depends. How can we judge whether we are being paternalistic? 

Surely we can create a test or a measurement scale to find out (if it doesn't already exist), but instead I want to share with you, my readers, a story that will also allow us to determine whether or not we are being paternalistic and, most likely, in a less boring and more illustrative way. It is about Kahlid the Good, created by Dr. Bill Thomas, CEO of the Eden Alternative, of which I am an ambassador in Spain, and published in his book In the Arms of Elders (2006). I came across it during my training as an Eden Associate and have asked my tutors, David Sprowl and Walter Coffey, for permission to reproduce it in its entirety in this article given its unfamiliarity and inaccessibility in Spanish and Portuguese. Let's get to it!

Kahlid, the Good

Long ago, when People were still new to this world, a man lived with his family in the southern reaches of the Great Desert, in the so-called Tum-Bak-Tee village. Like his father and grandfather, he made his living as a trader. Twice a year, in spring and autumn, the trader would take his goods, harness his camel and set out for the journey north to Mar-Kasha. As he was a very humble man and could not afford a wagon, he travelled alone. Journey after journey, year after year, all went smoothly. But there was one year when things went wrong. 

As was his custom, the merchant set out north in the spring, on his way to Mar-Kasha. For the first eight days he kept up a good pace. However, on the morning of the ninth day the wind began to pick up in the desert. At first it seemed like nothing more than a small breeze, but it was a westerly wind. The trader knew that many deadly storms had begun with such a wind. The wind grew stronger and stronger, lifting the sand into the air. The trader's fear began to grow. Soon the wind became a huge black cloud of angry sand. It rushed at the trader, scraping at his skin. It lashed his faithful camel like a thousand braided whips. The animal stopped and refused to move forward. The trader fell off the camel and crawled to a nearby dune. There he dug a hole and climbed into its depths. Above him, the wind howled its endless song of rage and pain. 

By the first rays of morning light, the storm had passed and the trader emerged from his hiding place. He searched desperately for his merchandise and his camel. They were nowhere to be found. Then he tried to find his way to Mar-Kasha. The storm had made it disappear. He crawled to the next nearest dune and looked around; all that was visible was a huge ocean of sand. Thinking that if he changed his perspective he might find hope, he left that dune and climbed up another. He found the same thing. Meanwhile, the sun rose high in the sky. Soon the trader began to feel thirsty, but he had no water. His stomach was growling with hunger, but he had no food. That night, he shivered under the cold blanket of desert stars. 

The next morning, his lips were chapped and his tongue was swollen. He thought of his family and how much they needed him to force himself to climb one more dune. After finding nothing but sand, he knew his life was coming to an end. What the poor trader did not know, what he could not know in fact, was that the Oasis of Kahlid the Good was only an hour's walk to the east. The Oasis of Kahlid had been blessed with the purest water in the desert and Kahlid was known to have the most generous heart ever seen. Kahlid scoured the dunes periodically in search of stray travellers. Just as the trader was about to close his eyes for the last time, Kahlid came upon him. He climbed down from his dune, picked up the trader in his strong arms, laid him on the back of his camel and set off for home. 

Back at the Oasis, Kahlid offered water to the traveller. He drank heavily. He drank and drank. The water quenched his thirst and allowed him to speak: "You must be Kahlid the Good," he exclaimed, "you saved me when death was clutching me by the throat. Kahlid replied, "It was God's will that I should live. Now drink, drink some more. I'm sure you haven't had enough to drink. -I thank you, but I have drunk all I need. Now I'm very hungry and tired, could I have something to eat and lie down somewhere? -"Eat? How can you be thinking of eating?" burst out Kahlid. "Not long ago I was dying of thirst. Drink!". As he said this, he raised the water-boot towards the man. The merchant turned his head away and the water spilled out onto the floor. This convinced Kahlid that the desert sun had wreaked havoc on the merchant's mind. Without missing a beat, Kahlid grabbed the trader in his arms and dragged him to the deepest part of his spring. He began to plunge the traveller's head into the water. The man tried to resist as he gasped and drowned. He swallowed a large amount of water, while Kahlid watched in delight. Again and again he forced the merchant's head into the spring water, until the merchant's strength began to fail. This alarmed Kahlid greatly, so he decided to hold the man's head under the water longer to make sure he drank. 

In the end, the merchant vanished. He died. Tears streamed down the cheeks of Kahlid the Good as he carried the traveller's body to a secluded spot in the Oasis, where Kahlid dug a grave and buried the man. He said a few prayers and covered the hole with earth and stones. It was not the first time he had buried someone. When he finished, Kahlid returned to the Oasis. There he arranged his camel and set off into the desert again, muttering to himself: "Water, they need water. 

The thing is very simple: if you identify with good Kahlid and are able to feel the anguish he was subjecting the traveller to, you are paternalistic. But don't worry, at least you've realised it! Now it's time to fix it. 

How do I avoid paternalism?

The next question is more complex: how do we maintain the balance between caring for those we are responsible for or love (ideally together) without crossing the fine line of paternalism? In addition to fostering mutual care and companionship, by always, always practising active listening. Only by establishing with the people we care for a real, personal, sincere and respectful relationship of genuine friendship, is it possible to get to know where the limits are that endanger each other's freedoms. This does not happen overnight; it takes a lot of time and effort. However, if we are not ready for this, we are better off doing something else and leaving this task to those who are prepared to commit themselves to a philosophy of care in ageing that is free of ageism, ableism and paternalism. 

I do not want to say goodbye without sharing with the readers one of my typical annoying questions/thoughts: if it is almost always women who are responsible for the care of the elderly, whether in formal or informal contexts, it is also we who develop this discriminatory attitude most often. Should we not, then, use the word maternalism instead of paternalism?