1.

In March last year David Cameron announced another “national  crisis”, to go with the economy and Britain’s “broken society”. To these  crises, one real and one imaginary (because society was fixed when – No  Dogs, No Blacks, No Irish? Before the Industrial Revolution – or the  Glorious Revolution? Pre-Reformation? The escalator, as Raymond Williams  once said, just goes back and back and back… and never stops),  Cameron added a “dementia crisis”. Dementia is “one of the greatest  challenges of our time”, he said, and the low level of dementia  “diagnosis, understanding and awareness” all but a form of “collective  denial”.

For once, it would be hard to disagree with him. A recent study by Oxford University  concluded that the number of dementia sufferers in Britain, estimated  to be around eight-hundred thousand, would reach a million by the second  quarter of the century. The cost of dementia care is extremely high, at  £23bn a year, compared with £12bn for cancer and £8bn for heart  disease, and, of course, this figure will only increase. But the  seemingly endless trail of noughts also belies the fact that dementia is  as much a moral as an economic or administrative problem; we should not  forget this.

And yet, how easily it seems we forget. Pierre Bourdieu memorably  said that Watergate was not a scandal, because to be a scandal something  must be unusual – and Watergate was just one revealed instance of the  true workings of American politics. Might we not say the same of the  dementia crisis? In truth it, too, proceeds not as a series of  individual “scandals” (Mid-Staffordshire, Hilton Gardens, Kirknowe, Ash  Court, Oakfoss House…), but instead like some forgotten war, whose  continuing existence, and continuing moral horror, the general public is  reminded of only when an unusually violent reversal takes place — and  even then for no more than a few weeks at a time.

2.

All too often, “care”, as a description of what happens in  institutions, seems little more than a sordid euphemism. Take  Winterbourne View, for instance, a care home in Bristol which featured  two years ago in a Panorama investigation exposing abuse one clinical  psychologist described as “torture”. Six members of staff have since  been jailed for a total of seven years and four months, and five others  received suspended sentences. In response to the case, Mencap released  the report Out of Sight to raise awareness of neglect and abuse  in care homes for those with learning disabilities (of which  Winterbourne View was one).

The focus in such exposés rarely, if ever, falls on the experience of  being a carer; and with good reason, you might say, if it is the carers  who are doing the wrong. But should we really be so hasty in  disregarding this perspective? Are we missing out on insights that might  help us finally make care worthy of its own name? I think we are.

As a social anthropologist investigating ordinary moral experience, I  volunteered as a carer in a home for the elderly, in my native Dorset. I  had never been in a care home before, and I expected to be shocked;  duly, I was – by the lingering smells, by the silence and hopelessness  of the residents, by the sheer lack of outside interest in the place and  the people within it.

What really made me think, though, was how the residents were seen,  or came to be seen, as less-than-fully-moral human beings. By  “less-than-fully moral” I mean they ceased to be responsible at all,  that their actions, even when considered negative by the carers, ceased  to be their own. I, as a carer myself, was urged to see the residents in  this way. Troublingly for me, I found it hard not to.

What still defines social anthropology is the practice of long-term  fieldwork, though much of it no longer takes place in exotic  environments or even overseas as it once did. The assumption is that  spending large amounts of time living or working – or both – with your  informants will give you a better insight into and understanding of the  social institution or practice you are studying; volunteering in the  care home allowed me to experience some of what it’s like to be a carer.  It would be a mistake, however, to assume that this close understanding  only leads to a condoning of what you have experienced. It remains  possible, once you have tried to understand, to judge and to condemn,  but one realises that sometimes clichés persist because they are true:  that there is an expansive space where black shades into white, called  grey.

Some further provisos: as far as I could tell, the care home I  studied was a good one. It had a high rating from the Care Quality  Commission; residents and staff liked and were affectionate towards each  other; the environment seemed comfortable and secure; I never witnessed  physical or verbal abuse. Nor can I claim that my experience was  typical or representative of what goes on in every care home in Britain,  for there are many types.

Nonetheless, I do believe that my experience can tell us something  about how those in care become subjects deserving or undeserving of  certain kinds of respect and due. Whether this necessarily leads to  their abuse or mistreatment is yet another question. The recognition of  moral difference can just as surely lead to compassion as it can to  cruelty; but even this, the very opening up of such a possibility,  should give us pause to think.

3.

Ideas about responsibility are central to our understanding each  other as moral beings. Explicitly formulated or otherwise, ideas,  theories and questions of responsibility inform not only the most  complex legal and philosophical debates, but also the most mundane  social interactions. Whether we knock over a glass of wine at a friend’s  house, or stand accused in the dock, we come to dispute claims of  responsibility and blameworthiness (and sometimes agree upon them).  Responsibility is a vexed question — I didn’t mean to say that: I had been drinking… I was tired and upset… I had a bad childhood…  — and even in what seem the most basic controversies there are no  simple answers; but that doesn’t stop us from having our opinions and  defending them, often without compromise.

On first inspection, Friedrich Nietzsche, he of the “Blonde Beast” and the Übermensch,  appears hardly the most suitable philosopher to tell us anything about  care and compassion (though his tragic life might: he died mad and in  the care of his anti-Semitic sister, whom he hated and who edited his  work so that it fell in line with her proto-Nazi sympathies).

Not so, however. For part of his Genealogy of Morals, his  revealing of the non-moral origins of morality, is a quasi-historical  account of the creation of the responsible individual that can help us  to understand how different institutions create different moral  subjects, and how these different categories might make possible both  care and abuse.

Moral man, responsible man, was created, Nietzsche argues: he had to become  so. This was a social process that took place at a particular, though  indeterminate, time in history; in a radical break with the past, with a  time when man was neither moral nor responsible — was not held to  account, was not punishable. As Nietzsche says,

“The task of breeding an animal which can make promises,  includes… as its condition and preliminary, the more immediate task of  first making man to a certain extent necessitated, uniform, like among  his like, regular and constantly calculable.”

According to Nietzsche, the creation of moral subjects came with the  “slave revolt of morality”, a revaluation of dominant aristocratic  values by the weak and the oppressed, that is, the followers of Judaism  and, later, Christianity.

We need not detain ourselves with these details. What is  most important is the most general: responsible persons can be made and  unmade, permanently, and the process by which this happens is  necessarily social – these are the insights Nietzsche gave me when I  came to account for what I had experienced, and the starting-point for  an understanding of care from the carer’s perspective.

4.

Unlike a residential home, where residents can still care for  themselves, though not fully, a nursing home is for those who cannot and  so require full-time care. In the nursing home where I worked, the  average age of a resident was eighty seven. Residents were assessed  according to the Capabilities Scheme, with level 1 being the most  capable and 3 the least; over three-quarters of them were assessed as  somewhere between 2 and 3, with the rest at 3; I counted two residents  who could walk without assistance, out of a total of around forty.  Although only some of the residents had been diagnosed with dementia,  the suspicion among carers was that many more had it; but this suspicion  was never confirmed, indeed, could not be confirmed — an important  point to which I’ll return.

Learning to care consisted mainly of shadowing other more experienced  carers around the home. As I was only a volunteer, and so not qualified  to carry out certain intimate tasks, I had more time than the other  carers to spend with the residents. I went from room to room, greeting  them; I helped feed them at lunch time; I moved them from their rooms to  the lounge, where they sat for the greater part of the day, and then  back to their rooms for the evening; I sat and spoke with them or read  to them, and where that wasn’t possible I sat and held hands with them  or gave them a hug; I made endless rounds of tea and biscuits.

What’s important to note is that I had to learn to care: you  don’t just walk in off the street and start caring for the elderly,  though of course certain everyday qualities (patience, empathy) will put  a prospective carer who possesses them at an advantage from the  beginning. Being able to care, I was told by other carers, meant  learning to “turn off” my emotions, to dissociate doer from deed and not  to react to provocation from the residents, of which there was more  than enough. They could be like “naughty kids” who “don’t know what  they’re doing”; in short, they were seen as lacking the necessary stable  mental state to be judged responsible agents. Bad behaviour was still  bad behaviour, but it wasn’t blameworthy, and to react as you would  outside the home, to reproach a resident for throwing water or insulting  you, would only upset them and thus aggravate their condition.

The idea of “turning off” one’s emotions is strikingly similar to a  famous philosophical account of how we attribute responsibility and  blame. P.F. Strawson, in his paper “Freedom and Resentment”, makes the  claim that responsibility does not derive from some objective measure  “out there”, but is related to emotional stances we take towards each  other; when we identify somebody as, for whatever reason, irresponsible  or undeserving of blame, we suppress these emotions and take what  Strawson calls an “objective attitude”, making the person towards whom  we direct it no longer a full player in our moral games. This, I think,  is exactly what the other carers had asked me to do. But, in Strawson’s  account, this objective attitude is a temporary measure; there, in the  care home, it was not.

Because although the carer’s advice, that I turn off my emotional  responses to residents’ behaviour, was meant to apply only to those  known to have dementia, in reality that just wasn’t possible. Nobody  knew for certain who did or didn’t have dementia (only a minority of  residents had been diagnosed). The cause of dementia, and there are many  causes, can be confirmed by a post mortem alone, and the symptoms vary  in relation to a number of different factors – physiological,  psychological, environmental and social. Most of the residents had  “good” and “bad” days, between which their behaviour could vary  astonishingly. A number of them also regularly pleaded to be excused  from responsibility – “I’ve gone barmy”, “Where am I?”, “I really don’t  know what I’m doing”, they would plead. The Capabilities Scheme, and  with it all the other imperfect assessments that could be carried out,  brought little clarity; uncertainty was the only certainty.

And so the carers’ objective attitude became universal and permanent,  extending from the least capable to those who seemed some or most of  the time to know who they were, where they were and what they were  doing. It was the safest thing for the carers to do, because to make a  mistake might mean upsetting or confusing a resident, and so aggravating  their condition – permanently, perhaps; fatally, even.

Still, the ambiguities remained. The most ambiguous case of all was  Bill, a ninety-four year old who had run a care home with his wife  before they had both needed to live in one themselves. Bill was, for the  most part, lucid, witty and mischievous; and like the most lucid  residents, he was also among the least mobile, confined to an electric  wheelchair he could just about manoeuvre himself. Whenever I had the  chance I would sit and chat with him: his enthusiasm for intelligent  discussion was particularly striking, and we would often discuss  theology and philosophy in detail. One afternoon he declared himself a  follower of George Berkeley, the Anglo-Irish bishop and idealist  philosopher for whom “the mind produces the image”. The conversation  quite naturally turned to solipsism, and one of us, perhaps inevitably,  brought up the problem of the tree falling in the woods – does it make a  sound? A wry smile crept across Bill’s face as he countered with his  own black variation of the question, “When a resident falls in an empty  room, do they make a sound?”

Yet — Bill was not immune from suspicion. He would often rage  violently at his wife, accusing her of all kinds of unreasonable and  unpleasant things, loudly and in front of the other residents, carers  and visitors; two weeks before I had arrived in the home, I was told, he  had even tried to punch her in the face. How was one to know where  intellectual vim became existential vitriol, their precise mixture, its  volatility? The other carers were as unsure as I was.

5.

The difficult question is this, I think: Can care take place, at  least in this context, only when those being cared for are stripped of  their responsibility, of their status as fully moral?

For therein may lie the very possibility of institutional care – and yet also its danger.  “Danger” because, as even the most pat postmodernist knows, making  somebody else an “Other” is often the prelude to doing violence against  them; as in, “You’re not like us, so we can treat you differently,” or,  in this case, “You’re not fully moral, so we can treat you like a child  or an animal, or worse – a stone.”

Consider, for a moment, a recent philosophical debate. On Aristotle’s distinction between “animal” man (zoe) and “political” or “flourishing” man (bios):  is it essential for a concept of the good life which might overcome the  impasse of liberal rights-based ethics; or is it — has it been— a  foundation for totalitarianism and mass murder?

For the neo-Aristotelian Martha Nussbaum, this anthropology allows us  to conceive a good life distinct from the satisfaction of basic  “animal” needs: there is a qualitative difference between a life which  pursues political and artistic ends, and a life which can see no further  than the next meal or the mere passing on of genetic material. This  distinction also opens space for critique: by recognising certain forms  of life as allowing only the minimum of human satisfaction, we can  criticise them against the ideal of some more fulfilling political  settlement.

On the other hand, for the Italian philosopher Giorgio Agamben,  Aristotle – to put it rather bluntly – set Western history on its course  towards the gas chambers. In the Modern era, Agamben claims, a “zone of  indistinction” emerged which linked zoe and bios,  where they had once been separate, making possible an easy slippage from  one to the other; those who are fully human today are subhuman  tomorrow, fit only for slave labour, medical experimentation, and  murder. As Theodor Adorno famously asked whether there was a straight  line of development from the slingshot to the atom bomb, one might  similarly ask whether there is also a line from Aristotle to Auschwitz.

It would surely be a gross, even offensive, simplification to imagine  that Aristotle, by having certain ideas, made Auschwitz inevitable.  What this debate does show, I think, is how well-meaning moral  categories (not unrelated to our case) can be subverted and go horribly  awry. But this does not happen simply in the realm of abstract ideas,  following some kind of immanent logic; no, it takes place in particular  situations and environments — for instance, in care homes. I have  suggested that uncertainty, which is always a part of our moral and  social lives, can be a catalyst for this, especially when it becomes a  near-absolute, as it does when you are placed in the difficult position  of caring for so many frail, frightened people whom you know only  partially, if you ever know them at all; whose autonomy and  understanding are almost impossible to gauge; and this while trying your  very best to slough the accumulated burden of all the cultural and  social prejudice directed daily against the elderly and the infirm.

(And this without considering the economic uncertainty: the lack of  necessary equipment (one automatic harness to move nearly forty immobile  residents – no manual lifting – so most of the day is spent  hoisting and then wheeling residents around, going up and down in the  lift with the harness from bedroom to living room and back, not in  meaningfully interacting with them); the poor pay and long hours; the  almost untenable staff turnover rate; the staff sent straight from the  Job Centre, their (the home’s and the staff’s) last resort…)

‍

6.

In the end, perhaps it really is the case that beyond the ideas  and intentions of individuals, good or bad, the care institution itself,  as a kind of supra-individual creating moral uncertainty, should bear  the greatest responsibility for whether carers have the choice to be  anything else. So why, as when we examine the banking system, is it to  individuals that we look, time and again, when we blame for abuse and  excess? Why is the idea of personal responsibility so much more  seductive than the idea of structural responsibility?

In his famous third letter to Arnold Ruge, the young Marx explained, “the reform of consciousness consists entirely  in making the world aware of its own consciousness, in arousing it from  its dream of itself, in explaining its own actions to it”; and so might  we see our questioning why we blame who or what we blame, whether it be  individual bankers not the banking system, individual carers not the  institution of care — so might we see this, as one necessary reform of  consciousness to be made if we want, finally, to crack the most vital  question of all: What is to be done?