Renato Maia Guimarães
During the Paris student riots of May 1968, the slogan Il est interdit d’interdire (“It is forbidden to forbid”) made its way into the history books. Young people sought a more prominent role in society; they clamored for a new culture, one imposed by the climate of the time. Fifty years hence, with those days of collective dreams and noise now past, the young people of that time have aged, but their slogan is more alive than ever. It now applies to the relationship between the adults of today and their parents — parents who, perhaps, loved the Beatles and the Rolling Stones.
Out of an overabundance of affection or simply because they don’t know better, grown children tend to establish sets of rules for their parents which verge on prohibition. Mother shouldn’t be in the kitchen, because she has worked hard enough and for too long; father, age 90, is no longer allowed his usual shot of liquor before lunch, even if this habit may have contributed to his longevity. Is it not a gilded cage to forbid an old man from leaving home, sometimes even from leaving his own room? What is the scientific justification for keeping 80-year-olds from enjoying the taste of eggs — a taste they have known all their life — or bacon — a memory of a country childhood? Those who place the blame on cholesterol would be wrong; at this point in life, any damage is already done. Fat, like the butler in Agatha Christie’s novels, is the perennial suspect. The range of preposterous limitations is as wide as its consequences are dire.
The greatest indicator of health in old age is not the symptoms of any disease that has a predilection for the hoary-headed, but autonomy: preserving one’s ability to say “yes” or “no”, “I’ll go...” or “I won’t go...”, “I want to...” or “I don’t want to”... or even to choose which clothes one wears. As you read these words, you are exercising your autonomy; you have chosen to read this journal, and are now doing so. Abolishing the right to choose is a serious threat to well-being. This discussion can be carried to its extremes, such as the decision to end one’s life. Our conversation today will not go that far, but it bears stressing that abolition of autonomy contributes to a sense of uselessness and feelings of sorrow.
Evidently, an aging mother with arthritic knees should not be allowed to climb ladders to reach the uppermost shelves when cleaning; nor should a confused father be allowed to drive if he has developed a habit of mounting the curb or crossing the median. These are situations in which the risk of accidents is high. On the other hand, forbidding a mother whose whole life was spent tending house from drying her own dishes is an act of folly. Preventing attendance of family gatherings — even those that mean intercity travel — with the noble argument of “it wouldn’t be good for your health” implies that being locked in a room, watching television or staring at the ceiling, is somehow healthier.
There is little or no scientific evidence for treatments that might actually contribute to longevity and quality of life after age 70, except for hormone replacement therapy in its various forms and analgesics to ease the aches and pains of the body and soul. Some exceptions are welcome.
As the elderly tend to experience varied symptoms, they are often taken to various specialists, who prescribe a laundry list of medications that only a complex Excel spreadsheet can make sense of. The benefits of polypharmacy are questionable, but its drawbacks are clear: iatrogenic harm. This behavior, forbidding on the one hand while coercing on the other — such as by forcing older adults to take (often useless) medicines — is particularly common in some grown children who believe bringing jumbo-sized bottles of vitamins back home from their trips to Miami shows just how much they care for their parents.
When medications are not involved, even words can be iatrogenic. Examples include misguided advice; a dismissive “there’s nothing we can do”; confining a patient to a wheelchair without even considering the possibility of rehabilitation for gait recovery; and, worst of all, “you have to keep taking this for the rest of your life”. All of these constitute prohibitions, whether by forbidding a patient with an incurable disease from seeking alternative forms of care, from attempting rehabilitation which may be helpful, or from discontinuing a medication that does not provide any benefit or may even be downright harmful.
More subtle prohibitive behaviors involve the failure to recognize aging and the possibility of death. Sexagenarians do not have guaranteed admission to “senior citizenship”; the prime of one’s life comes at a different time for everyone, which may be in childhood, adolescence, or adulthood. Aging should neither be considered a one-way ticket to misfortune and illness, nor an unrefusable invitation to late-life happiness. No one can stop old age from coming — and bringing its sometimes unpleasant trappings with it. A failure to recognize aging leads to unduly infantilizing treatment, such as “baby talk”, which is harmful to the dignity of older adults. Forbidding the family to talk about death creates a farcical environment in which relatives think they are protecting the patient while the patient knows they are being deceived.
At a time when life has made me a transgressive physician, I propose we give out bronze medals to those who refuse to take medications that make them feel worse. Silver medals will be reserved for those who refuse therapy when no effective treatment options are available; gold, for those who break out of hospital (as Darcy Ribeiro is reputed to have done).
There is no right or wrong life; each must be free to choose their own way and make their own choices. This must be an option for the young, but is in no way forbidden to the old. The goal should be quality of life, not attempts to add years to the life of those who do not always want more time on this earth. Quality of life is a broad-ranging concept based mainly on socialization, spirituality, and freedom. Bans and prohibitions are not on the list.
Grown children have no place imposing limitations on their parents. Most do not add a single week to life. Would it not be the case, then, to ask one’s “old man” if he is truly willing to live a week longer if it means living a life of less?
It is the noble task of every geriatrician and gerontologist to oppose this pernicious conduct.
Renato Maia Guimarães