‘Death talk’

About two-thirds of the way into a recent debate on population ageing, its policy implications and the role biomedical scientific innovation – The Astellas Innovation Debate on the ‘Age Crunch: Facts, Fears and the Future’ – Baroness Joan Bakewell, the UK older people's champion, rather abruptly stated that, as a society, we ought to talk more about death. She did not get as far as telling us how exactly, but, in her view, this ‘death talk’ could make ‘a really major difference to our outlook’.

The context of Bakewell's injunction to talk more about death is important. It was billed as a debate on the health and social consequences of our ageing population, but it in fact ended up more like a managed conversation between well-recognised actors in academia, politics and the media than a debate as such. The invited audience was drawn from similar, what we might call, advocacy and intervention fields, and the event was chaired by broadcaster/psychologist Robert Winston and funded by the pharmaceutical company, Astellas. It proceeded by examining projections of population ageing and their health and social care implications, and then proposing possible solutions in terms of pharmaceutical, organisational and public health measures. There was some reflection on the uncertain nature of demographic projections and the extrapolation of economic consequences – the interventions of King's Fund health economist, John Appleby, in particular, looked towards a more tenuous and uncertain horizon – but, on the whole, the narrative was clear: the population is rapidly ageing. This is, on the one hand, testament to the achievements of modern science, but, on the other hand, it will have economic and social consequences which must – and, implicitly, can – be dealt with. Indeed, the brochure for the event, rather rhetorically, posed the question: ‘Scientific ingenuity has played a key role in creating today's ageing society. Can it now provide the innovative solutions needed to turn old age into a new age?’

It would be wrong to claim that the panel was unrealistic about the prospect that science could successfully meet all the challenges of ageing, but the tenor and tone of the conversation was very much in line with the dominant discourse of ‘positive ageing’, whose horizon is the elimination of the very category of old age (Estes et al. Reference Estes, Biggs and Phillipson2003; Featherstone and Wernick Reference Featherstone, Wernick, Featherstone and Wernick1995; Gilleard and Higgs Reference Gilleard and Higgs2000, Reference Gilleard and Higgs2010, Reference Gilleard and Higgs2011, Reference Gilleard and Higgs2013). In this policy and advocacy framing, biomedical science will provide the drugs, public health interventions will ensure that appropriate risk-reducing behaviours and lifestyles are adopted, and social engineering will ensure that ‘society’ adjusts its mindset to see older people as assets rather than burdens and preferably not as old at all. With certain caveats – in particular, Professor Eisen's observation that cancer associated with obesity are speeding up the ageing process not slowing it down – this ‘positive ageing’ discourse was broadly operative in the Astellas debate.

Prior to Bakewell's intervention, then, the discussion centred on demographic data, cancer drugs, the inadequacies of health and social care organisation, inappropriate cultural attitudes to housing on the part of older people themselves, inappropriate cultural attitudes to older people in the workplace, obesity and smoking cessation. All of these begged solutions that were to be explored in the second half of the debate. Then, apparently a propos of none of the above themes, came Bakewell's interjection. She stated:

Then comes the reply of the Chair, Robert Winston:

Bakewell responds:

Two things are noteworthy here. First, the sheer ambiguity of Bakewell's interjection and, second, its emotionally charged and imploring nature, which stood out on account of its stark contrast with the rather measured tone of the discussion up to that point. On the face of it, what she indexes is people's fears of dying a bad death – in institutions, in the company of strangers, in pain. Her target is, as she puts it, ‘the dying process’. More open discussion of death and one's expectations of death opens up the possibility of planning for death. This is the kind of death talk with which we are familiar, linked as it is to controversial issues around choice, autonomy, euthanasia and assisted dying. But there seems to be more at stake here. First, the opener to her insistence on the need for ‘death talk’ is fear of ‘chronic illness and incapacity and mental illness’, but there is no necessary relationship between that observation and her insistence that we should talk about death since this fear is linked not so much to death as to loss of (physical and mental) capacities. Second, while she applauds the kind of society that ‘expects death to be part of the pattern of life’, this message gets lost in statements that appear to express a desire to defer death, thereby consigning ‘death talk’ to ‘the end of very long lives’. Her intervention is heart-felt, but ambiguous and not fully formed. Even though it is clear she wants to signal something about the inadequacy of our current tendency to avoid death talk or, more accurately, to engage in ‘bad death talk’, we argue that Bakewell puts her finger on something important here. In particular, we suggest that what ‘death talk’ can offer us when confronting the prospect of physical and mental deterioration can be better appreciated through an appeal to fantasy, loss and mourning. In order to see this, we first offer a theoretical contextualisation of Bakewell's intervention in the Astellas debate, drawing on psycho-analytic theory and discussions in and around the third age/fourth age dialectic. We then show how this theoretical framework allows us to pinpoint more precisely the ambiguity and stakes of Bakewell's intervention – as well as the responses she elicits – in the Astellas debate itself. Finally, we consider how we might better capture the ethical and creative potential of the intuition informing Bakewell's intervention.

Death talk, fantasy and the third age/fourth age dialectic

Bakewell's intervention was intriguing, because it was a rather intuitive irruption that fleetingly promised to take us to another place in the debate about our ageing society, but it was quickly scotched by the assembled participants and folded back into a policy discourse of extending life and preventing diseases. Bakewell points in at least two directions with her idea of death talk. One direction, as we have discussed, concerns the possibility of securing control over the dying process. We do not deny the crucial importance of talk about end-of-life care, but it is notable how that kind of ‘death talk’ is easily assimilated to a discourse of positive ageing associated with the ‘third age’. The idea of a third age here embodies the desire to maintain, extend, even enhance, indefinitely the capacities linked to the younger more ‘productive’ period of our lives (i.e. the second age). It promises to extend the scope of our control, and since, as Bakewell implies, death is merely a distant horizon – coming at the ‘end of very long lives’ or ‘waiting at the end of a rich, healthy, prosperous old age’ – confrontation with the idea of death is itself deferred. ‘Death talk’ here works so as to avoid confronting the losses implied in old age, instead offering respite in the hope of extended control. This, we argue, is an instance of ‘bad death talk’, because it diverts us from moving in the second direction in which Bakewell appeared to point. This does not concern the final end of life but, rather, the pain and suffering and the loss of dignity, mental capacity, independence, control and agency within the flow of life itself – death, or loss, as ‘part of the pattern of life’. We might speculate that what Bakewell is indirectly referring to here is the dreaded ‘fourth age’: the disavowed excess of the non-ageing hope of the third age, which, to quote Gilleard and Higgs ‘carries with it the notion of passing beyond the social world, beyond both its comforts and its contradictions’ (Gilleard and Higgs Reference Gilleard and Higgs2010: 125).

What we are working towards here is a way to pursue Bakewell's invitation to engage in death talk, but, we argue, this requires us to be more precise about its aim and function which, in turn, demands we consider why, in general, and in the current cultural and policy context, in particular, engaging death talk is no easy matter (Butler Reference Butler2004; Glynos Reference Glynos, Carpentier and Van Brussel2014b), resulting instead in affective practices of ‘closure’. The approach we take here draws on a Lacanian understanding of the split subject: as subjects we carry with us the imaginary fullness that we suppose we experienced before entering the symbolic world of language and which we unconsciously and repeatedly seek to rediscover. Fantasies, understood in terms not of something that is unreal or fictive, but as a narrative that organises our desire and enjoyment, offers an explanation of why we lack, as well as why we are drawn to the promise of a future fullness. Fantasies can also partake of a scape-goating logic in which we are apt to blame others for our failures, or to distance ourselves from them if they remind us of our own incompleteness and precariousness.

Returning to the preceding discussion, we can understand how the third age/fourth age dialectic resonates with the fantasmatic logic of (lack of) fullness. From the point of view of the third age, the fourth age appears as a horrific apparition that dramatises lack in a rather potent way. Despite our lifestyle choices and earlier life preparations, we cannot be certain to avoid slipping into fourth age dependency. The more third age independence and age resistance are socio-culturally valorised, the stronger this dependency is resisted, repudiated and projected on to others. In Lacanian terms, what is referred to by the fourth age is ‘the Real’ – that which cannot be folded into available signifying systems, but at the same time cannot be shaken off. The fourth age is the ‘distortion in the mirror of the third age’ (Gilleard and Higgs Reference Gilleard and Higgs2010), its ‘obscene supplement’ (Žižek Reference Žižek2008a).

Of course, we are not suggesting that no discussion of the conditions and plight of those who have passed into dependency is possible. Indeed, later in the Astellas debate, Baroness Sally Greengross echoes Bakewell in talking of the fear, the dread and the loss of control associated with dementias and makes a heart-felt plea that more resources be marshalled at the upcoming G20 summit to find cures, and care appropriately for those who cannot be cured. But that is precisely the point: the fourth age is for others (Gilleard and Higgs Reference Gilleard and Higgs2010). It is the necessarily distant negative horizon that cannot be allowed to intrude upon third age positivity and control. The more we seek to ‘conjure positivity out of not being old at all’ (Wernick Reference Wernick, Featherstone and Wernick1995: 281) in biomedical, public health and social technologies, the more we ‘other’ fourth age frailty and dependence, and the more it becomes a horizon we can only dread. Moreover, to the extent that the policy response to demographic ageing has come to depend upon this active, third age framing (see Barnes, Taylor and Ward Reference Barnes, Taylor and Ward2013) – i.e. demographic ageing poses cataclysmic consequences for public finances but the way to deal with it is to invest in the prevention of age-related disease and to extend active life – our fate becomes bound up with resisting fourth age decline and dependency and, sotto voce perhaps, a certain repulsion of those who succumb to it. The relationship between the third age and the fourth is indeed, as Gilleard and Higgs (Reference Gilleard and Higgs2000) assert, dialectical. The fourth age is constituted in and by third age normality; it is the troubling excess of the positive and active third age. It cannot be assimilated to the discourse of positive ageing and the hopes, triumphs and solutions of the third age, but that does not stop its unconscious ‘return in the Real’ (Žižek Reference Žižek2008b).

So the very framing and content of the Astellas debate serves to bolster the third age, but at the same time we cannot help but be troubled by what it leaves out. It is this Real, or excess, of the third age, we argue, that circulates around Bakewell's injunction to engage in death talk. The function of this kind of death talk, then, is not just about improving our chances of ‘a good death’ at some distant point in the future, or about marshalling pharmaceutical and cognitive resources to keep death firmly on the horizon (and not any closer), but about opening up to the contingency, uncertainty and uncontrollability of ageing life that third age fantasies disavow. If ‘bad death talk’ involves an affective practice that reinforces our attachment to third age fantasies, perhaps we could say that good death talk points to an affective practice that loosens the grip such fantasies have upon us. A more appropriate label for this, we argue, is ‘loss talk’. But what happens to this fleeting thought of ‘loss talk’ in the Astellas debate?

‘Bad death talk’

Bakewell puts out her ambiguous statement about the need to engage in death talk, but the ambiguity – on the one hand, death talk as an extension of third age control, and on the other as marking the sheer contingency of ageing life – is unsettling. Winston's immediate impulse, as orchestrator of the event, is to fold this death talk back into the ‘positive ageing’ discourse of third age control:

In her first statement, the function of death talk is ambiguous, but in her response to Winston, she appears to capitulate and the Real of the fourth age slips from view. What we are unambiguously aiming at now is ‘a good death, shared with the right people with a minimum of pain’. She wants society to expect death to be ‘part of the pattern of life’, but death is for others; we can defer it until we have done all the third age living we can possibly do.

Baroness Greengross picks up this thread:

Death talk is, thereby, securely back in its third age place. Death talk comes around again intermittently in the course of the debate, but remains bound to familiar tropes that we know we can handle: what we can expect of end-of-life care; or what, to use the well-worn cliché, ‘difficult conversations’ we need to have about euthanasia and assisted dying. So, we might say there is a pattern here. First, the arousal of a deeply felt concern that there is something that is being missed in the current policy framing of the ageing population, a framing which itself feeds off, and reinforces, the cultural demands of those in the third age. Following this opening, however, there is then a ‘closing down’. All the hope, planning and research that goes into avoiding ageing leaves unaddressed the persistent worry that we will no longer be able to live up to its projected ideals. That thought is unsettling, and our impulse is to cover it over, which is precisely the effect Winston and Greengross' interventions have in the Astellas debate. Whether the focus is on death, the dying process or the ageing process more generally, death talk becomes ‘talk of a good death’ ‘at the end of very long lives’, or talk of enhanced physical and mental capacities. This, then, can be understood as a form of ‘bad death talk’, because it leaves unexamined our tendency to invest heavily in the ideal of mastery and control embodied in the image of the third age.Footnote ³ But why does this matter? We argue that it matters because these observations have ethical implications, which we will briefly illustrate with material from previous research in assisted-living environments. But we also argue that another kind of death talk is indeed possible – what we call ‘loss talk’.

Beyond ‘bad death talk’: mourning and ‘loss talk’

This fear and repulsion of the fourth age is arguably only one manifestation of a more generalised fantasy of independence and self-sufficiency that characterises ‘the culture of the new capitalism’ (Sennett 2006, quoted in Layton Reference Layton2009) and neo-liberalism (Glynos Reference Glynos2014a). As Layton has argued from a largely Freudian/Kleinian perspective, the anxiety of not living up to this ‘cultural demand’ results in a vigorous ‘repudiation of vulnerability’ (Layton Reference Layton2009: 105), which, in turn, produces both intra-psychic and inter-personal injuries (Layton Reference Layton2009: 105). The damage that we do to ourselves comes from the sheer exhaustion of upholding identities that fit this symbolic frame, and Gilleard and Higgs (Reference Gilleard and Higgs2013) similarly note the potential for pain and exhaustion in practices of age resistance. The damage that we do to others lies in the projection on to them of those repudiated, vulnerable parts of ourselves that we cannot bear (Layton Reference Layton2009). Fantasies of self-sufficiency and independence, again culturally dominant and politically reinforced, lock us into a vicious cycle of vigorous investment in the avoidance of dependency, then anxiety at the prospect of losing our physical and mental capacities. This, in turn, gives rise to the distancing and othering of those who manifestly fail (Layton Reference Layton2009). This distancing and othering, moreover, need not necessarily take outwardly aggressive forms. It can be done within modalities of kindness, compassion and care-giving as much as within modalities of unkindness and out-grouping. It takes place at the level of individual citizen-consumers as much as at the level of policy makers. What results, though, is a rigid separation between those who succeed in the independence game and those who fail, fed by anxiety at the fear of failure. (The well-worn phrase ‘successful ageing’ is indicative of the kind of boundary we are talking about here.) It is a desire for relief from this emotional carousel, we suggest, that Bakewell signals in her plea for death talk.

Having pinpointed the proper target of this death talk, we now want to discuss how we think it could change our outlook, as Bakewell suggests. Following Lacanian intuitions, we argue that good death talk is about coming to terms with transformations in how we see ourselves and others, and is thus fundamentally about processes of identification. Such transformations evoke the idea of a symbolic death in life (Žižek Reference Žižek2008c), but what is central here is the idea of loss: loss of identity and the possibility of transforming or building a new identity. More particularly, it is a matter of coming to understand the nature and strength of our investments in the fantasies that sustain our identities, and of loosening their grip (see Glynos Reference Glynos, Carpentier and Van Brussel2014b).

By way of illustration, we can turn to previous empirical work in assisted-living environments (Glynos et al. Reference Glynos, West, Hagger, Shaw, Fotaki and Kenny2014). Such environments, being an alternative to completely independent living in the community, on the one hand, and to residential care, on the other hand, are a particularly useful window on the ways in which, given the dominance of the discourse of positive and active ageing, the boundary between the third age and the fourth age is negotiated, maintained, reinforced and (potentially) relaxed. Residents are encouraged to see themselves as independent and self-sufficient and to take responsibility for their own physical and cognitive health (Glynos et al. Reference Glynos, West, Hagger, Shaw, Fotaki and Kenny2014). In short, the third age is strongly thematised and idealised. This is not to say that ‘care’ in the more traditional sense has no place; it does, and, indeed, a wide range of care needs tend to be met. What is of interest, though, is the way in which a tension between an active idealisation of independence and the far more implicit impulse to look towards a caring other for support, structured the way many subjects negotiated their experiences in these assisted-living environments (Glynos et al. Reference Glynos, West, Hagger, Shaw, Fotaki and Kenny2014). This tension is, in our view, an indication of a fantasy of self-sufficiency in operation, and, like any fantasy, this fantasy sets up an ideal – in this case, an ideal of independence – that places responsibility for our fate in ourselves as subjects. Like other fantasies, too, this fantasy draws its energy and sustenance from the production of problems and challenges that serve as obstacles to that ideal (Glynos et al. Reference Glynos, West, Hagger, Shaw, Fotaki and Kenny2014). Moreover, we expect fantasy life to play a more obviously prominent role for the subject when confronted with loss because it functions as the subject's last defence against anxiety. Moments of loss (the death of other residents, and the prospect of death, as well as chronic illness, and physical and mental deterioration) register the contingent character of the material and social support on which identities depend. These losses (dislocations) are frequent occurrences in assisted-living environments, yet (as elsewhere in life) insufficient time and space is given to processing and mourning them by means of bringing key elements of our fantasmatic life into conscious awareness. This ‘blocked mourning’, we argue, is at the root of a common pathology, involving the projection of fear of loss of independence and self-sufficiency on to others. It is by no means uncommon to find instances where residents, who are themselves physically impaired, blame the physical impairment of others for their limitations. Powerful fourth age fears of cognitive impairment are present, as is the ostracism of residents who develop the condition, in spite of the many initiatives on the part of staff to allay those fears (Glynos et al. Reference Glynos, West, Hagger, Shaw, Fotaki and Kenny2014).

This is an example in which the boundary between success and failure in upholding identities is particularly stark, and in which confrontation with loss is unusually frequent, but the tendency to avoid facing the ways in which lost objects have functioned as our identificatory supports, and mourning them appropriately, is not unusual. One of Sigmund Freud's key insights was that there is nothing ‘natural’ about engaging in a mourning process. On the contrary, there is a ‘revolt’ in our minds against mourning (Freud Reference Freud1915: 306; [Reference Freud1915] 1917: 248). In the absence of considerable effort, ‘complicated’ or ‘blocked’ mourning is a more likely pathway to follow so that instead of acknowledging and affirming loss, we might become heavily invested in blaming others for that loss. In our assisted-living example, a strong discourse of positive, active and successful ageing, and the fantasies of self-sufficiency that underpin it, offers a refuge from mourning, but it is powerfully self-perpetuating. It depends upon the establishment of a boundary, which for convenience we have chosen to label as a boundary between the third age and the fourth age; but the maintenance of that boundary depends not just upon our own investment in practices of age resistance, but also on processes of othering, distancing and blaming those who manifestly can no longer maintain independence and have slipped into the fourth age.

We are not suggesting that the scenario we outline here is an inevitable pathology to which all succumb equally. From a psycho-analytical perspective, much depends on the subject's capacity to process and creatively integrate losses. This requires two basic conditions, which we have discussed elsewhere (see Glynos Reference Glynos, Carpentier and Van Brussel2014b; Glynos et al. Reference Glynos, West, Hagger, Shaw, Fotaki and Kenny2014), but, in brief, are: (a) an event or site that enacts for an individual or collective subject a publicly shared recognition of loss; and (b) an appropriate context within which loss can be processed and creatively integrated into one's individual and collective life. Such conditions can foster ‘loss talk’, or ethical and creative affective practices. It stands in stark contrast to ‘bad death talk’, an affective practice which not only invites us to resist dwelling on our losses, but, at the same time, offers us a ready script for explaining them away: the limitations of others, failure to invest in cures and preventative measures, failure ‘to advertise what can be done to keep ourselves healthy’ (i.e. independent) and so on. Although fighting against this affective background is no easy matter, we nevertheless want to pursue Bakewell's intuition that there is something to be gained by engaging in death talk, by which we mean the kind of death talk that does not let go too quickly of the ‘opening up’ moment and its ethical potential. Such ethical potential, we suggest, lies not so much in the capacity to shift the way we approach death, but in the way we open up to the ever-present possibility of loss in life itself (deteriorating physical and mental capacity, the loss of those close to us and so on) and, crucially, what those losses imply for our identities. The Freudian category of ‘mourning’ indexes the kind of ‘good’ death talk we are aiming at here.Footnote ⁴ More active engagement in mourning or loss talk as part of life, we suggest, is the kind of affective practice that can ‘make a really major difference to our outlook’. Perhaps this is how we should understand what Bakewell was aiming at in her intervention.

Concluding remarks

Our argument is that Bakewell's plea for ‘death talk’ should be understood as a plea to adopt a more robust ethical sensibility in relation to old age and the typically person-specific physical and mental deterioration that accompanies this. However, we argue that the intuition underpinning her call to death talk should not be reduced to the idea of talking about a ‘good death’ or a ‘good long life before death’, since this often tends to partake and reinforce third age fantasies that can generate potent fourth age fears and powerful othering tendencies. Good death talk is better seen as a form of mourning – an affective practice enabling us to process loss. Our physical and mental capacities tend to function as supports for our identities and fantasies, and so the deterioration of such capacities can threaten the stability of those identities and fantasies. One response to this threat is to deny the need to process loss in the hope that medicine will find a way to re-establish our physical and mental strength. Another response is to find a way of re-asserting control through the exercise of choice, involving decisions about a good death, a good dying process or a good ageing process more generally. Both of these affective practices can be understood to embody forms of ‘bad death talk’, insofar as they do not allow the subject to countenance fully the potential loss of identity and thus the possibility of constructing a new mode of being. As Baars (Reference Baars2012: 2) has pointed out, since Cicero ‘there has been an abundance of thought about death, while questions of ageing [and the losses that accompany it] have been pushed to the margins’.Footnote ⁵ The re-assertion of control (scientific and cognitive) tends to marginalise contingency and the possibility of affirming this contingency in a different way. The extension of life now makes even death appear less proximate and central to our daily concerns, further masking life's contingency, but the fear of physical and mental deterioration and symbolic marginalisation in life persists and intensifies. Bakewell's remarks, though ambiguous, are also suggestive. They suggest that death talk has something to offer us in coping with changes linked to the ageing process. However, we argue that the intuition underpinning her call to death talk should not be reduced to the idea of talking about a ‘good death’ or a ‘good long life before death’, since this often tends to partake and reinforce third age fantasies that can generate potent fourth age fears and powerful othering tendencies. Bakewell's call to death talk is better understood to be a call to such talk in the mode of mourning – a process in which we are able to process loss.