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Summary of the Opinion
The ageing of society in today’s world is an undeniable demographic fact and should incite us to review how we live together so that we can become more inclusive of our elders. Laws have been voted in the last few years to try and face up to this reality, such as a 2015 law on adapting society to ageing and one in 2016 with the aim of modernising the public health system. In this social and political context, CCNE decided to consider the ethical challenges of ageing, since the Committee feels that this subject is not sufficiently prominent in the organisation of public policy on caring for the elderly: how can society be made more inclusive for the older members of the community?
CCNE decided that its thinking on the subject should originate in the “concentration” of elderly people in special homes. This is because it cannot be denied that gathering dependent elderly people and concentrating them all together in institutions sometimes generates situations of indignity that, in turn, leads those concerned to experience feelings of disgrace. Their de facto exclusion from society, probably stemming from a collective denial of the realities of old age, end of life and death, raises some substantial ethical issues, in particular as regards the respect owed to individuals. In fact, although it is claimed that this compulsory institutionalisation is implemented in the name of benevolence and to ensure the safety of these vulnerable people, it often has actually to be enforced for want of any possible alternative to which is added the further compulsion of having to pay for accommodation they do not wish to live in.
In such a context, the Committee seeks in this Opinion to reply to the following questions: how will society cope with the growing number of people who are dependent and suffering from a loss of autonomy as a consequence of increased longevity and of medical progress in the treatment of disease? What kind of accommodation should be preferred for such people, particularly those who have lost their autonomy? What resources will we be able to mobilise to care for them?
How will we manage to satisfy these vulnerable people in their wish to choose where and how they live, without necessarily accepting the normative and frequently institutional models which are often the preferred — or even the only — option on offer?
In this resolutely “political” Opinion, CCNE is proposing several concrete approaches to reinforce awareness of this demographic reality, the ageing of the population and respect for the elderly.
Our society needs to bring into being new forms of solidarity with those among us who are the most fragile and vulnerable. In order to achieve this, CCNE proposes in particular:
- Reconsidering the creation of a "fifth section" in the social security system with the aim of ensuring better preventive healthcare and support for dependent people.
- Changing the care paradigm of our public health system with a view to a more systematic inclusion of family members and caregivers, the sine qua non condition for the existence of home care. For this purpose, a respite and support project could be launched to give carers the time and opportunity to acquire skills as required to provide assistance for elderly people still residing in their own homes.
- Fostering a change in social legislation, in particular so that a relative can help and care for a sick or disabled person. For this purpose, the possibility of enhancing the personal activity account could be explored (CPA – Compte personnel d’activité – an official ongoing training programme).
- Devising new forms of volunteer work to organise solidarity between those who are healthy and those who are ill or disabled and their relatives.
- Providing better protection for vulnerable people by the creation of a post of interdepartmental delegate for the protection of adults, as suggested in a recent report from the Court of Auditors (Cour des comptes).
CCNE is proposing that policies for the care of an ageing population should be reinforced by the following measures:
- Develop a culture of prevention so as to improve preparations for the “fourth age”, the better to plan for adapting people's homes, organise personal services and, for instance, keep in touch with caregivers.
- Develop intergenerational projects involving people in both good and ill health, young and old, actively employed, unemployed persons and pensioners, etc. with a view to promoting transfers of knowledge and experience — in particular professional — by people whose advancing age has made them economically “inactive”.
- Use digital technology as a tool to promote care for the elderly and to create new forms of solidarity.
- Improve training, assistance and recognition throughout the careers of home care providers, in particular taking better account of the arduousness of care giving and of the affective and emotional involvement inherent to these professions. Developing new professional qualifications or new professions such as case managers.
- Revisit the performance and pricing concepts for both EHPADs (Etablissements d’Hébergement pour Personnes Agées Dépendantes – Residential long-term nursing homes for dependent elderly people) and nursing care at patients’ own homes).
- At a local level, promote the regrouping of various services engaged in keeping the elderly living in their own homes. The aim would be to enable elderly people who are losing ground on their independence and autonomy to have the benefit of procedures and carers with which they are familiar regardless of which department is providing the service they need.
- Encourage and diversify alternatives to EHPADs in a given area, such as for instance intergenerational accommodation or self-managed and halfway housing for the elderly (residential autonomy and assisted living projects).
- Help to de-ghettoize the elderly, in particular by thinking about the possibility of EHPADs outside the EHPAD environment. For instance, there could be regulations for new building projects to reserve one or two levels for an EHPAD — and also for tomorrow’s alternative EHPADs — with improved integration into the urban environment. For example, EHPADs could be integrated into a single territorial scheme so that all the services engaged in caring for the elderly in their own homes could be part of one single network of closely located home care services under consolidated territorial management.
This CCNE Opinion, based on the example of the more vulnerable elderly population, is more generally offering proposals for a restructuring of the public health system, the practice of medicine and the training of healthcare providers and social workers. CCNE finds that modern medicine contributes to the emergence of complex and singular situations which, for that very reason, cannot be contained within standard definitions, averages, or evidence-based medicine, since each situation is a law unto itself thus defying any form of expertise. In such a context, CCNE suggests the following:
- Try to adopt an approach for singularity and distinctiveness as regards medical circumstances.
- Learn to reinforce a teamwork outlook the better to comprehend such complex and unpredictable situations.
- Value debate and ethical reflection despite the fact that we are in an age and context where preference is invariably given to action and achievement to the detriment of taking whatever time is needed. As part of the process of activity-based pricing we could attach more importance to interdisciplinary reflection and discussion which can be so helpful for the taking of complex decisions.
- Embark on an in-depth reform of training processes for the medical professions so that such changes can be implemented.