Elsevier

Journal of Aging Studies

Volume 22, Issue 4, December 2008, Pages 366-375
Journal of Aging Studies

Understanding gender differences in older people's attitudes towards life-prolonging medical technologies

https://doi.org/10.1016/j.jaging.2008.05.009Get rights and content

Abstract

The power of medical technologies to extend the final stages of life has heightened the need to understand what factors influence older people's wish to use such medical technologies. We analyse gender differences in such views, based on audio-recorded interviews with 33 men and 36 women (aged 65–93) in south-east England. Older women were twice as likely as men to oppose using medical technologies to extend life. More older women voiced ‘other-oriented’ reasons for their opposition, particularly not wanting to be a burden on others. Older men's attitudes were primarily ‘self-oriented’, reflecting a concern to stay alive for as long as possible, with fewer expressing concern about consequences for others. Women's greater life course involvement in caring and empathising with the wishes and concerns of others underlay these gender differences. Thus, women were ‘performing gender’ by putting others before themselves, even at this critical juncture in their lives.

Introduction

Hitherto there has been a separation between the concerns of writers on anti-ageing medicine (cf. Vincent, 2006, papers in this special issue), and research regarding life-prolonging medical technologies. Medical technologies are increasingly available to extend the final stages of life. However, controversies abound over using technologies, such as cardiopulmonary resuscitation, ventilation and artificial feeding, which may simultaneously extend life, but can also result in a poor quality of the end stages of life and dying with lack of dignity.

Both the anti-ageing literature and research on decision-making at the end-of-life implicitly subscribe to a rhetoric of the choices of atomised individuals about the use of anti-ageing medicines or life-prolonging medical technologies. Within the anti-ageing literature concerns are raised about social inequalities, particularly how wealth and income may facilitate or prevent access to life enhancing technologies (Vincent, 2006). Both fields have neglected to what extent the ‘choices’ of individuals may be bounded by social or cultural factors, including how gender may be associated with fundamental values and attitudes related to life extension. Since older people are the primary subjects of life-prolonging medical technologies, it is particularly salient to hear their voices and preferences, especially within a societal context of freely available health care, such as the British National Health Service (NHS). By using interviews to closely analyse the views of older people about life-prolonging medical technologies, this paper complements the papers by Settersten, Flatt, Ponsaran (2008-this issue) and Mykytyn (2008-this issue) which use qualitative interviews to examine the perspectives of scientists engaged in biogerontological research and anti-ageing practitioners respectively.

A health policy concern over recent years has been to increase control and autonomy over decision-making at the end-of-life, for example by encouraging the use of ‘Do-Not-Attempt-to-Resuscitate’ (DNAR) orders and Living Wills or Advance Directives (Duffield and Podzansky, 1996, Rodriguez and Young, 2006, Carr and Khodyakov, 2007). This medical policy development has conceptualised patients as independent and autonomous subjects, rather than as gendered persons. A neglected issue is to what extent an individual's expressed wishes about end-of-life care are influenced by their social characteristics, such as their gender and their life course experiences.

In the UK, the British Medical Association (2001) has introduced guidelines related to DNAR orders (that is, an advance decision that cardiopulmonary resuscitation (CPR) should not be attempted). Under these guidelines the ultimate responsibility for deciding whether to attempt resuscitation lies with the doctor in charge of the patient's care. The guidelines specify that the doctor should have ascertained the wishes of the patient in advance. However, this is fraught with difficulties where patients are hospitalised in a critical condition, or where the patient lacks the medical capacity to indicate their wishes. In these circumstances, the alternatives are either that the patient has previously specified their wishes through an ‘Advance Directive’ or a ‘Living Will’, or that the patient's family members are consulted and represent the ‘interests’ of the patient.

Despite the increasing importance of NHS guidelines that staff should involve patients and their families in decisions about resuscitation, there has been little sociological research in this area. Indeed, Conroy et al. (2006: 480) state ‘This area is under-researched and relatively little is known about the attitudes towards cardiopulmonary resuscitation among frail elderly people’.

Section snippets

Gender and attitudes to life-prolonging technologies

Most studies of the attitudes of older people to life-prolonging medical technologies have examined the use of CPR among hospitalised patients. Although gender has not been a focus of these studies, many have noted gender differences in attitudes. For example, a UK study of 134 patients from geriatric assessment wards (average age 81) found that 42% wanted resuscitation for themselves, with substantially more men in favour than women (67% versus 24%) (Gunasekera, Tiller, Clements, &

Methods

The paper analyses data collected as part of a larger UK study on the attitudes and values of healthy older people and their confidants regarding the use of life-sustaining medical technologies (Vandrevala et al., 2006, Garnett et al., 2008). Older men and women living in the community in south-east England were recruited from four general practices with socio-economically diverse populations. General practitioners were asked to send letters to equal numbers of male and female patients aged

Attitudes towards life-prolonging medical technologies

There was a substantial and highly significant difference in the responses of older men and women (p < .001) to the initial open question: ‘What are your thoughts about life-prolonging medical technologies that are used to increase life span at the final stages of life?’ Three-quarters of older men but only a quarter of women spontaneously indicated that they accepted the use of life-prolonging medical technologies (Table 1a). Older women were much more likely to be unequivocally opposed. In

Other-oriented reasons

The majority of older women were opposed to the use of medical technologies at the end-of-life, with most articulating ‘other-oriented’ reasons. Their opposition centred around the perceived burden on others of caring for them if they were severely incapacitated, as well as a profound sense of guilt at the thought of ever becoming a burden for their relatives.

I wouldn't want that (to be a burden)…. would prefer to live in a home and hopefully (her children) would come and visit me…. I would

Self-oriented reasons

Both women and men voiced various ‘self-oriented’ reasons for why they would not want life-prolonging technologies, most frequently mentioning lack of dignity and the resulting poor quality of life. These two reasons were often inter-related in the discourse of older people, for example:

I think these (medical technologies) are horrible. It is artificial, and at my age (70–74 years), I would not consider it. Depends what the quality of life is like after it, that is the important thing. Nobody

Discussion and conclusions

Even when considering fundamental issues, such as whether an individual wants life-prolonging medical technologies for themselves, this article has shown that older women and men ‘perform gender’. Women are much less likely to want life-prolonging medical technologies for themselves, particularly because of worries about being a burden on others and the guilt associated with this. This greater concern about being a burden is intrinsically linked to women's life course involvement in

Acknowledgements

The research was supported by a grant from the Nuffield Foundation, UK. The authors are indebted to all the participants and organisations for their interest in supporting this study.

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