The Sunday Times

April 17th, 2011

The life or death decision facing the grey cuckoos in our midst

When people protest against cuts in public services, they are ignoring an enormous grey elephant in the room. The unmentionable fact is that the generous welfare systems of the rich world are doomed in their entirety. This is simply a matter of demographics. Welfare is paid for by people who work, in order (among many other requirements) to support older people who have retired.

However, the relationship in the rich world of old to young is changing so fast that by 2050 every couple will be supporting a pensioner, on top of all the payments they must make to support needy people who are younger. Clearly that will be impossible in terms of the way we live now.

We are seeing the greying of the rich world, as the baby boom generation retires. Everyone knows that, but not everyone is prepared to admit the consequences. In 1950 there were 7.2 people of working age (20-64) in the OECD member states for every person more than 64 years old. By 1980 the ratio had fallen to 5.1; now it is about 4.1 and by 2050 it will be 2.1. In the European Union (which has more generous welfare systems than most of the rest of the OECD) there will be 1.8 people and in Germany it will be 1.6.

On top of all the other requirements of the welfare state, old people’s needs are huge. Quite apart from the costs of pensions and social security, an enormous part of National Health Service annual expenditure goes on the elderly. Department of Health statistics for 2002-3 — I have found it difficult to get any comparable figures recently — show that nearly half the entire NHS budget, 46.7%, was spent on people over 64 and nearly a third of NHS spending, 30.3%, was spent on people of 75 or older. These proportions had gone up noticeably since 2000-1, when the corresponding figures were 41% and 27%.

NHS spending in England by age group in 2003 was equally startling. The average cost of healthcare per capita rises drastically once people are over 65 (for 65 to 74-year-olds the annual spending is £948; for 75 to 84-year-olds it is £1,684). That means the cost per capita of those aged 65 to 74 is almost three times the average cost of those aged 16 to 44; even the 45 to 64-year-olds cost only £459 a year each. The rapid demographic changes in this decade mean that the amount spent on the over-64s is rocketing.

One sign of this is that NHS primary care trusts are struggling with huge drugs bills. Last week it emerged they are trying to restrict the use of more expensive (often more effective) drugs even when those medicines have been approved by Nice (the National Institute for Health and Clinical Excellence). Several trusts are adding more drugs to their “red lists” of medicine that can be prescribed only by a consultant, not by a GP. Many of these drugs are used by millions of older people to treat Parkinson’s, coronary artery disease, diabetes and osteoporosis.

Baby boomers are increasingly resented for having grabbed the best of everything at the expense of the young, but far from all the baby boomers have a generous pension or capital assets. All those who don’t will become outsize grey cuckoos, crowding out the nests of the overworked young. In view of all this, the mind turns to the tradition of old people taking a walk up the snowy mountain to fall asleep and die in the snow. I associate this custom with Japanese history, but in plenty of other cultures when old people had become what the Chinese so cruelly called “useless mouths”, they voluntarily went out to meet their deaths. The Innuit took advantage of the extreme cold outdoors for this purpose.

I am not remotely recommending that anyone in a good society should be expected to take a walk up the snowy mountain, still less be obliged to. Any new laws on assisted suicide ought to be careful to protect old people from pressure. Last week it emerged that state-subsidised care homes in the Swiss canton of Vaud may well, after a poll, be given the right to help residents kill themselves. There is something chilling about that. People in such homes might come to feel assisted suicide was the decent thing to do. But old people who, entirely of their own free will, decide to take their lives without pressure from anyone else are, I think, to be admired and thanked. They are sparing themselves and their families a great deal of suffering and are relieving those around them and the welfare state of a burden. Surely that is an honourable act.

I hugely admired the right-to-die campaigner Nan Maitland, who ended her life in Switzerland on March 1. She did not have a terminal illness, although she was in great pain from arthritis and growing ever more disabled. The point she made in public was she didn’t want to suffer “a long period of decline, sometimes called a prolonged dwindling, that so many old people unfortunately experience before they die”.

For many old people — long before they become mortally ill — that prolonged dwindling is a worsening nightmare: a time of maltreatment in geriatric wards, lying on their bedsores in urine and excrement, of dependence on indifferent foreign minders in expensive care homes, a period of painful confusion, feeling ignored, unwanted and lonely. In a less rich society, such things will become more common.

Given all this, the taboo against suicide or assisted suicide seems incomprehensible. Religious people may think it wrong, although I have never quite understood why. It seems odd to me that they are not eager to meet their maker as soon as possible, if heaven is so devoutly to be desired. Perhaps it is different if one’s religion teaches that one might after death come back as a toad. But, believers apart, for everyone else there is no philosophical reason against suicide that I can see. The usual slippery slope argument is purely emotional: we are all already on the slippery slope as far as any moral decisions go and constantly have to choose between two evils.

Nor can I see any reason for restricting the right to die to people with terminal illnesses. Degenerative illnesses, constant pain and the nightmarish dwindling we all dread are excellent reasons for wanting, very rationally, to die. So I feel great admiration for all those brave people who decide to end their lives at a time of their choosing and who, for now, often face the seediness and loneliness of a Swiss clinic to do so.

We should treat them better, without disapproval but with more consideration, understanding, help and, above all, with more gratitude. We will need that if we are to be able to choose a good death in an impoverished society.