ADVANCES IN SOCIOLOGY RESEARCH
ADVANCES IN SOCIOLOGY RESEARCH. VOLUME 8
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ADVANCES IN SOCIOLOGY RESEARCH
ADVANCES IN SOCIOLOGY RESEARCH. VOLUME 8
JARED A. JAWORSKI EDITOR
Nova Science Publishers, Inc. New York
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New York
CONTENTS Preface Chapter 1
vii Mindfulness Training: A Promising Approach for Addressing the Needs of Child Welfare System Children and Families Cynthia V. Heywood, Philip A. Fisher and Yi-Yuan Tang
Chapter 2
Overcoming Modernity: Western and Japanese Attempts Hiroshi Kaihara
Chapter 3
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker Government of Bangladesh Claudio Corradetti
Chapter 4
Democratic Failings, Successes and Prospects in the European Union: Transnational Deliberative Democracy and the Social Open Method of Coordination Stephen Elstub and Annabel Kiernan
1 31
51
71
Chapter 5
Housing Design and Safety for the Elderly Hülya Öztop and Sibel Erkal
Chapter 6
Achievements in Reducing Infant Mortality in a Newly Industrialized Country: Lessons from Taiwan Jennifer Chun-Li Wu and Tung-liang Chiang
113
Adolescents in Foster Care and Their Attachment-Security to Significant Others: A One-Year Longitudinal Study Gary R. Germo, Susan P. Farruggia, Ellen Greenberger and Chuansheng Chen
131
Personal Assistance Services (PAS) in the Workplace: Where We Are and Where We Are Going Tatiana I. Solovieva, Denetta L. Dowler and Richard T. Walls
151
What If the Embryo Is Not a Person? A. Theo Boer
169
Chapter 7
Chapter 8
Chapter 9
89
vi Chapter 10
Chapter 11
Chapter 12
Contents Mapping a Multifaceted Relationship: Political Parties and Civil Society Organizations in Turkey Emre Toros Sociality in the City: Using Biological Principles to Explore the Relationship between High Population Density and Social Behavior Daniel Tumminelli O‟Brien Angels and Saints: The Rhetorical Effects of Lay Understandings of Foster Care upon Carers Damien W. Riggs
Chapter 13
Perspectives of Home Enteral Nutrition Therapy in Brazil Ana Lúcia Ribeiro Salomon Zaban and Maria Rita Carvalho Garbi Novaes
Chapter 14
Urbanization: Causes, Economic Effects and Environmental Effects on Mental Health in Asia Norifumi Tsuno
Index
187
203
217 229
243 257
PREFACE This continuing series presents original leading edge research results in the field of sociology. Each chapter has been carefully selected in an attempt to present substantial advances across a broad spectrum. Included in this compilation are topics such as adolescents in foster care and their attachment-security to significant others; reducing infant mortality in newly industrialized countries; democratic failings, successes and challenges in the European Union; exploring high population density and social behaviors; and the causes and economic effects of urbanization in Asia. Chapter 1 - Foster children often demonstrate intensive clinical needs and evidence risk for long-term difficulties as a result of adversity and maltreatment. Addressing their diverse and intensive needs can be challenging for foster caregivers and complex for their providers. Although intervention research over the past decades has yielded a number of evidence-based treatment approaches for foster children and their caregivers, enhancement and individualization continues to be needed. As the field advances, more attention is being paid to critical skills that increase competence and resilience as protective factors versus the more traditional focus on pathology. Particularly, self-regulation and attention are becoming increasingly salient foci for scientists and practitioners seeking to improve treatment effectiveness and favorable outcomes. Mindfulness-oriented interventions pose a forum for uniquely targeting these outcomes and have the potential to (1) promote the development of self-regulation and attentional focus in foster children, (2) increase the effect of already robust therapies, (3) enhance risk prevention efforts for children whose lives are characterized by adversity, (4) address obstacles to effective and consistent implementation of therapeutic parenting strategies, and (5) increase overall well-being and quality of life for foster children and their caregivers. In this chapter, the following topics are discussed: (1) the presenting issues among foster children and their need for effective and individualized treatments, (2) the interplay of stress and neurobiology on the development critical skills, (3) current intervention trends, and (4) applications for mindfulness-oriented therapies in research and practice. Chapter 2 - We were born, raised and are living in modern society. In modern society, religion is largely confined in the private realm, sciences spectacularly develop, living conditions greatly enhance, and reason rationalizes our morality by chasing away superstitions. There is no ideological rival emerging on horizon to replace modernity. However, persistent criticisms have been rendered against modernity in highly modernized
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countries. This article is to review some of vocal critics of modernity both in the West and Japan. Chapter 3 - The actual international scenario, while urging for the elaboration of yet more refined international models of justice, it calls also for the understanding of those transitional contexts where no fully fledged democracy or rule of law of international justice can be directly applied before central institutional and legal reforms are conducted. These situations are those which can be defined in terms of non-ideal conditions of justice. Non-ideal conditions of justice, though, should not represent both at the theoretical and at the practical implementing point a defeat from the start for the progressive realization of a just scenario. Rather, non-ideal conditions of justice, should be framed as sub-optimal conditions of ideal justice requiring specific transitory steps and reforms which would eventually lead to fully working democratic systems. Along this essay the author will clarify some theoretical and methodological issues that are relevant on how non-ideal contexts of justice should be conceived, and then the author will turn my analysis on the analysis of two recent documents dealing with the role that the international community should play in transitional contexts. Finally the author will present an electoral model which the author take as being at the core of an institutional and legal renewal of transitional democracies, and present a case study which is instructive on the procedural and institutional pitfalls to be avoided when dealing within deeply divided societies. Chapter 4 - This paper considers the extent to which the social open method of coordination within the EU can be interpreted as an institutionalisation of the features of deliberative democracy at a transnational level. It argues that the experience of the social policy NGO sector in policy deliberation inside the EU provides useful illustrations of the difficulties of institutionalising such ideals, at transnational level. In spite of the limitations experienced thus far, the case offers up a tantalising example of the possible prospects for the future by furthering understanding on the barriers to institutionalisation that need to be overcome, and on where the trade-offs between theory and practice need to be made at a transnational level. More specifically the paper argues that it is the creation of open and transparent, weak and strong public spheres that must be achieved, if deliberative democracy is to be approximated at any level of governance. The OMC, which is a promising element of the ‗Lisbon‘ strategy that aims to increase stakeholder participation in EU social policy formation, goes some way to achieving this, as it generates dispered and ditributed ‗hybrid‘ public spheres that are formed through deliberation between the NGO sector, national governments, and EU institutional actors. The process is far from perfect and particularly needs to be more inclusive (especially in terms of marginal groups with challenging views), has been less responsive to the input of stakeholders than was hoped and, overall, still remains excessively elite dominated. However the commitment to improving on the dynamic between EU institutions and key stakeholders in social dialogue remains and the OMC offers a formal gauge of whether such commitments are being met. Ultimately the current OMC fails to approximate deliberative democracy sufficiently closely yet, but has had a certain degree of success, and therefore promises encouraging prospects for how this could be achieved at transnational level in the future. Chapter 5 - The number of older persons is increasing, both in actual number and as a percentage of the population. As an individual ages his or her body changes and the ability to deal with the demands of an environment usually decreases. A well designed, supportive environment may help older persons to utilize their homes more fully, more safely, and allow
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them to live independently in their homes longer. Use of kitchens and bathrooms may present the greatest challenge and the greatest safety hazard and in order to remain independent, an older person must be able to use these rooms fully and safely. Based on the concept of ‗aging in place,‘ design of houses in the past years are explored. Design features in the built environment become barriers for aging people with functional limitations. Initially, houses were designed according to the required needs of the user with the physical limitations. Later, adaptable house design was introduced that allows the house to meet the specific needs of the user, while maintaining the appearance of the house until more obvious accessibility features are needed. Today, ‗design for all‘ is recognized as a tool for ensuring physical accessibility for aging people. Housing must fulfill the needs for the daily activities of the elderly and give the feeling of satisfaction, security, comfort and independence. Chapter 6 - Infant mortality in Taiwan has dropped remarkably from 44.7 per 1000 live births in 1950 to 5.5 in 2005. By examining cause-specific mortality and the decomposition of infant deaths into neonatal and post-neonatal deaths, the decline can be largely accounted for by fewer children dying from avoidable perinatal conditions and infectious diseases. Why has Taiwan been able to reduce infant mortality in a relatively short period? The authors identified three crucial explanations. Firstly, Taiwan‘s rapid growth of economy accompanied by improved income distribution could ensure that mothers and children can enjoy a standard of living adequate for health. Secondly, gender equity and empowerment were promoted by expanding women‘s capacities through education and social participation. This is particularly relevant to planned fertility, economic rewards, and child caring practices that are conducive to child health. Thirdly, health services essential to maternal and child health were developed progressively and made universally accessible. Taiwan‘s experiences in reducing infant mortality can provide valuable lessons for developing countries seeking to secure children‘s lives and well-being from the start. Chapter 7 - A growing body of evidence suggests that older youth in foster care are at greater risk for mental health problems than youth not in foster care. Although results from community samples of adolescents indicate that a secure attachment to parents and peers is associated with youths‘ psychological well-being, there is scant information on foster care adolescents' secure attachment to parental figures and peers and their well-being. In this oneyear longitudinal study, foster-care adolescents‘ attachment-security with biological parents, foster parents, and peers was assessed in relation to adolescents‘ well-being. The sample included 184 adolescents who ranged in age from 17-20 years old. The sample was ethnically diverse (40% African American, 35% Latino, 12% Caucasian, and 13% Other), and just over half (56%) were female. At Time 2, 167 adolescents were successfully contacted and reinterviewed. Findings indicated that adolescents‘ attachment-security with biological parents, foster parents, and peers at Time 1 was positively associated with adolescents‘ concurrent well-being. Further, multiple regression analysis for a sub-sample of adolescents who reported on all three attachment figures (n = 119) indicated that adolescents‘ attachmentsecurity with biological parents uniquely contributed to adolescents‘ report of fewer depressive symptoms at Time 1, whereas adolescents‘ attachment-security with foster parents uniquely contributed to adolescents‘ greater life-satisfaction at Time 1. There were several significant effects of adolescents‘ attachment-security with foster parents and peers at Time 1 and adolescents‘ well-being at Time 2. The potential positive benefits of adolescents‘ attachment-security are discussed. In addition, the research highlights the need to provide stable, high-quality placements for adolescents in foster care.
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Chapter 8 - Workplace Personal Assistance Services (PAS) are used by individuals with severe disabilities to assist with performing job functions. PAS differs from other types of workplace accommodations in that another person (the assistant) helps with the task. For example, the employee may use an assistant to read, file, or organize work tasks. These are activities the individual would typically perform if she or he did not have a disability. Use of the personal assistant allows an otherwise qualified individual to obtain and maintain employment. Employees, employers, and service providers appear to experience confusion about the definition of workplace PAS, funding sources for PAS, and the most appropriate model for implementing PAS in the workplace. Studies were conducted to obtain the views of employees, employers, and service providers about the use of PAS in the workplace. From the perspective of employees with disabilities who use PAS, the major difficulties in using workplace PAS are: (1) defining and obtaining appropriate useful information about workplace PAS, (2) locating well-trained and reliable personal assistants, and (3) locating funds to cover the costs involved in hiring and using an assistant. From the perspective of employers, the major issues in providing PAS include: (1) defining PAS within the workplace, (2) the employer‘s fiscal responsibility relative to PAS, (3) recruiting and managing assistants, and (4) barriers such as safety, workplace disruption, scheduling, formal policies and procedures, liability, and adequate workspace for the assistant. From the perspective of service providers, the important issues identified are: (1) definitional problems concerning workplace versus community-based PAS, (2) access to PAS at the workplace, (3) availability of resources (money and trained assistants) to support PAS, and (4) other issues including establishing positive relationships with employers, employer attitudes about PAS, and transportation for the worker and the assistant. Together, this article along with the literature review will provide a broad-based description of the evolution and current reality of PAS. The synthesis of these empiricallybased findings will provide direction for future policy and practice related to workplace PAS. Chapter 9 - Discussions about the morality of research on human embryos have been dominated by the question whether or not the embryo is a person. If the answer is ―yes,‖ it deserves total protection. Otherwise, it may be used purely instrumentally, i.e., experiments may be conducted which result in the embryo‘s destruction. Following Ronald Dworkin, this paper relativizes this focus on the personhood-issue and questions the view that the absence of personhood equals a license to the purely instrumental use of prenatal life. In our attempt to find foundations for an alternative view, we explore seven considerations that could justify the position that embryos have intrinsic value and should therefore be granted some form of protection: similarity to (human) persons, continuity to (human) persons, potentiality to become (human) persons, the autonomy and the dignity of the parents/ donors, reverence for disagreements, uncertainty, and mystery, membership of the human species, and parallels to other nonpersonal values respected by humans. Chapter 10 - One of the most significant discussions on democracy today is related about the political parties, civil society organizations (CSOs) and the relationship between them. The importance of this debate is becoming difficult to ignore, since political parties and CSOs are among the most salient institutions that shape the character of the political system in most of the liberal democracies and serve as institutions that establish the primary linkages between citizens and governments. The fundamental intention of this article is to demonstrate and map this relationship within the Turkish setting.
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This study will follow a critical pattern in order to analyse the situation in Turkey, rather than accepting the concepts intrinsically as valuable. It will utilize the dimensions of the democratization framework for analysis and seeks to address three basic features of this framework: (a) the type of activity that connects a party and CSOs; (b) the strength of the connection (how close or distant and how exclusive or inclusive) and (c) the dominance or direction of influence in the relationship. Although on its own the democratization framework is not enough in explaining the problematic exhaustively, still it provides powerful empirical tools. By manipulating these dimensions with innovative tools and alternative epistemological positions, it is possible to open up new opportunities for further research and enhance the current academic debate in a critical manner. This paper, hence, by utilizing the above mentioned framework will not only focus on the relationships happening at the macro (or political system) level, but also on the relationships that take place at the micro (or organization-to-organization) level. Chapter 11 - Cities represent settlements with population densities that are unprecedented in human history. While such levels of population density can intensify competition for resources, the abundance of conspecifics also heightens their value to each other as resources. In our species, this can alter the optimal behavioral strategy for social interaction. The exploitation of cooperators provides the actor with an advantage, while damaging conspecifics, doubly enhancing one‘s relative fitness. This same model can be seen in species that have cannibal morphs that develop only in the context of high population density. The effect of population density on humans has been studied by two groups, social psychologists and sociologists. These literatures combine to demonstrate that population density causes people to be psychologically aloof, while also being socially removed from many of their neighbors. The strength of social control mechanisms rests in their ability to deter undesirable behavior, and the inclination that individuals have towards these behaviors. Population density appears to exacerbate both of these, creating a context that both harbors and breeds self-centered behavior. The authors synthesize the theories of these two disciplines, providing new evidence that shows that population density not only creates detached social behaviors, but socially aggressive ones. Chapter 12 - Analyses of the rhetorical effects of public statements and everyday conversation have long demonstrated the potentially deleterious ends to which purportedly positive statements can be put. Specifically in the context of foster care, this can occur when lay people refer to foster carers as ‗angels‘ or ‗saints‘. Drawing in this chapter on research conducted with Australian foster carers, the author suggest that referring to foster carers in this way functions rhetorically to: 1) construct foster children in particular (negative) ways, 2) deny societal responsibility for child protection agendas, 3) construct carework as outside of economic exchange, 4) implicitly question the motives of foster carers, and 5) undermine or discount the considerable challenges that foster carers face. In response to these problems associated with the construction of foster carers as ‗saints‘ or ‗angels‘, the author conclude the chapter by making suggestions for an understanding of foster care that moves away from a benevolent or ‗rosy‘ image of care provision, and instead recognises the important role that foster carers play in child protection services and the need for Australian society to better support child protection agendas. Chapter 13 - The Health Sector has been facing a huge paradox concerning the availability of its resources: the conflict between the increasing requirements of health services against the limited financial resources to support them. When analyzing the
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worldwide view, a tendency towards an integrated hospital-home model of health assistance is found, emphasizing its importance concerning the patient‘s quality of life and the humanization of health care, and also concerning the economic benefits it provides to the health sector. Home enteral nutrition favors the warranty of continuous assistance to patients that need enteral nutrition therapy, through the supply of special formulas and the reduction in complications related to nutritional status unbalance and on hospital length of stay. The present article aims at analyzing through bibliographic research the tendencies of the Enteral Nutrition Therapy and the cost-benefit of Home Enteral Nutrition establishment. Review of a range of articles published from 1996 to 2008 on databases such as: Medline, Lilacs, Proquest, Cochrane and Doyma, which adopted as key words: home enteral nutrition therapy and synonyms, in English, Portuguese and Spanish. The analyzed works (n=28) reinforced the need of setting health policies which may emphasize Home Care as a way of generating economy of health resources, of improving quality of life and of increasing the availability of hospital beds in Brazil. Chapter 14 - The ageing of populations is now a global phenomenon. The ageing of populations means that the proportion of people in the older age range increases, and the share of children and youth decreases, resulting in an ascending median age. Although it is driving the economies of most of the nations of the world, a serious concern regarding the impact of urbanization on mental health is warranted. Indeed, epidemiological studies over the last decade have supplied growing evidence of an association between urbanization and the prevalence of mental disorders. On the one hand, urbanization seems to affect the entire gamut of population especially the vulnerable sections of society - elderly, children, and women. On the other hand, urban population is heavily influenced by changing cultural dynamics leading to particular mental problems like depression, alcoholism, and dementia. In view of the increased rate of psychiatric morbidity in urban areas there is likely to be a relation between urbanization and the extent to which patients use the care services. This relation might be particularly strong in the case of long-term service-dependent patients with mental health problems. The determinants, extent and outcome of the association between urbanization and mental health would require multi-disciplinary research by social scientists, social psychiatrists and public health professionals. An appreciation of different conceptual models and associated methods would be required before effective research can begin. This article plans to review the demography and population ageing in Asia and the research literature on the relationship of urbanization and mental health, and finally to describe an example of health service and social welfare for the elderly in Japan.
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 1
MINDFULNESS TRAINING: A PROMISING APPROACH FOR ADDRESSING THE NEEDS OF CHILD WELFARE SYSTEM CHILDREN AND FAMILIES Cynthia V. Heywood, Philip A. Fisher and Yi-Yuan Tang Oregon Social Learning Center, University of Oregon, Eugene, Oregon, USA
ABSTRACT Foster children often demonstrate intensive clinical needs and evidence risk for long-term difficulties as a result of adversity and maltreatment. Addressing their diverse and intensive needs can be challenging for foster caregivers and complex for their providers. Although intervention research over the past decades has yielded a number of evidence-based treatment approaches for foster children and their caregivers, enhancement and individualization continues to be needed. As the field advances, more attention is being paid to critical skills that increase competence and resilience as protective factors versus the more traditional focus on pathology. Particularly, selfregulation and attention are becoming increasingly salient foci for scientists and practitioners seeking to improve treatment effectiveness and favorable outcomes. Mindfulness-oriented interventions pose a forum for uniquely targeting these outcomes and have the potential to (1) promote the development of self-regulation and attentional focus in foster children, (2) increase the effect of already robust therapies, (3) enhance risk prevention efforts for children whose lives are characterized by adversity, (4) address obstacles to effective and consistent implementation of therapeutic parenting strategies, and (5) increase overall well-being and quality of life for foster children and their caregivers. In this chapter, the following topics are discussed: (1) the presenting issues among foster children and their need for effective and individualized treatments, (2) the interplay of stress and neurobiology on the development critical skills, (3) current intervention trends, and (4) applications for mindfulness-oriented therapies in research and practice.
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Cynthia Valentine Heywood, A. Philip Fisher and Yi-Yuan Tang
The presence of over one-half million children in out-of-home care in the United States represents a national public health concern given that the vast majority of these placements result from abuse or neglect (Kendall, Dale, & Plakitsis, 1995; Stein, 1997). Over the past 20 years, the foster care population has grown considerably. Increases over time in the size of the foster care population, which until recently was growing by an average of 10% annually, are attributable to numerous factors. These include changes in child abuse and neglect reporting requirements, higher foster care entrance versus exit rates, and the impact of poverty, homelessness, adolescent parenthood, family violence, mental illness, and substance abuse. The issues are further exacerbated by flat or decreasing budgets for social services (Barbell, 1997; Barbell & Freundlich, 2001). In a national survey, states reported that funding for family support services has not kept pace with need, resulting in foster children languishing in care (U.S. General Accounting Office, 2007). As of 2008, there were more 463,000 foster children nationwide. Fortunately, the size of the population appears to have stabilized at around one-half million children in the past five years, and the most recent estimates indicate a decreasing trend (U.S. Department of Health & Human Services, 2009). In this chapter, the authors will explore four areas related to foster children. First, the authors review the disparities in well-being among foster children. Second, the authors explore the impact of adversity and stress on specific neurodevelopmental processes that may help to account for some of these disparities. Third, the authors discuss current trends in intervention practices with foster children and their caregivers, emphasizing evidence-based interventions designed specifically for this population. Lastly, the authors explore a new trend in emotional and behavioral health with great promise for the foster care populations: specifically, interventions designed to impact the domain of mindfulness. The authors suggest that, given the unique sequelae resulting from maltreatment and early adversity, mindfulnessoriented treatments for foster children and their caregivers pose a unique and promising approach for remediating critical deficits and addressing persistent obstacles to the implementation of more effective practices in the child welfare system.
PSYCHOSOCIAL, EMOTIONAL, AND ACADEMIC ADJUSTMENT IN FOSTER CHILDREN Foster care is intended to interrupt the experience of chaos and stress that often typifies the lives of maltreated children and to provide a context in which the impact of this adversity can be ameliorated. Frequently, however, it takes multiple reports from community members before child welfare becomes involved and/or removes a child from their home. By this point, the child may have experienced a host of adversities which cumulatively have a profound and lasting impact on his/her development and well-being. The deleterious consequences of childhood maltreatment are well-documented in the literature and have been observed during childhood as well as across the lifespan. Consequently, providing a therapeutic foster care experience proves to be challenging and complex. Despite the multitude of shared experiences that result in out-of-home placement, foster children demonstrate a wide array of outcomes with regard to psychosocial and emotional adjustment. It is important to note that there are many foster children who exhibit remarkable resilience in the face of considerable adversity. However, as a group, foster children are in
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much greater need of intervention for mental health problems than children in the general population (Chernofff, Combs-Orme, Risley-Curtis, & Heiser, 1994; McIntyre & Thomas, 1986; Pilowsky, 1995). Specifically, foster children have high rates of internalizing problems (e.g., anxiety disorders, depressive symptomotology, dissociative disorders, somatic complaints, eating disorders, and suicidal ideation), externalizing behavior disorders (e.g., aggression, delinquency, and antisocial behavior), attachment disorders, personality disorders, deficits in self-regulation, deficits in executive functioning, sexual reactivity, deficits in social competence, and difficulty forming healthy relationships with peers and adults (Ackerman et al., 1998; Bendixen, Muus, & Schei, 1994; Bolger & Patterson, 2003; Cicchetti & Toth, 1995; Hernandez, 1992; Kinard, 1999; Liem & Boudewyn, 1999; Mian, Marton, & LeBaron, 1996; Trickett & McBride-Chang, 1995; Weaver & Clum, 1993; Welch & Fairburn, 1996). Moreover, Dubowitz (1990) found that emotional, behavioral, and developmental difficulties among foster children were three to six times greater than those demonstrated among children within the general population. Trupin and colleagues found that 72% of child welfare children in their sample were not statistically unique from children participating in intensive mental health treatment programs (Trupin, Tarico, Low, Jennelka, & McClellan, 1993). Landsverk and Garland (1999) estimated that between one-half and two-thirds of all children entering the foster care system demonstrate emotional or behavioral problems significant enough to warrant mental health treatment. Clausen, Landsverk, Ganger, Chadwick, and Litrownik (1998) reported that 61% of their sample of foster children demonstrated clinically significant mental health problems as per the Child Behavior Checklist (Achenbach, 1991). Furthermore, the number of children coming into care demonstrates that these problems increased significantly over time during the 1980s and 1990s, highlighting the need for more comprehensive and effective service provision to address these concerns (U.S. General Accounting Office, 1998). The risk for school problems is also greater among maltreated children. This is not surprising, given that the early caregiving environment provides the foundation for psychosocial adjustment integral to academic preparedness and success. Children with maltreatment histories have been shown to demonstrate significantly more deficits in academic engagement, social competence, and ego resiliency, resulting in overall academic maladjustment (Shonk & Cicchetti, 2001). Additionally, these children demonstrate higher rates of academic underachievement, grade retention, poor social competence, dropout, and utilization of special education services than their same-age peers (Rowe & Eckenrode, 1999; Trickett & McBride-Chang, 1995; Wodarski, Kurtz, Gaudin, & Howing, 1990). In a study of 840 children, Eckenrode, Laird, and Doris (1993) found that children who had been maltreated were significantly more likely to repeat a grade, have lower standardized test scores and grades, and receive higher rates of office discipline referrals and suspensions. Rogosch and Cicchetti (1994) examined teachers‘ perceptions of maltreated children and found that these students were seen as less socially competent than their peers and were perceived to exhibit greater behavioral disturbances in the classroom. As noted above, problems with foster children‘s psychosocial, emotional and academic adjustment have been observed to extend well into adulthood. Skills decline over time, behavior patterns become entrenched, and ontogenic patterns become increasingly complex. For example, in a study of 900 victims of childhood abuse and neglect, Widom and Maxfield (2001) examined the effects on intellectual, behavioral, social, and psychological development into adulthood. Data revealed that, compared to a control group, the abused
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group scored significantly lower on measures of intellectual performance, completed fewer years of school, held more menial and semiskilled jobs, experienced higher rates of unemployment/underemployment, experienced higher rates of divorce and separation, engaged in higher rates of criminal behavior, and were more likely to demonstrate suicidality and personality disorders. The context often surrounding abuse, including parental criminality and substance abuse, coupled with childhood victimization increased the likelihood of later disorders.
Neurodevelopmental Deficits in Attention and Self-Regulation Two underlying commonalities in the topography of negative sequelae described above are deficits in attention and self-regulation. These highly related constructs bear influence across a number of emotional and behavioral disorders. Exploring this relationship, however, first requires definitions of the constructs. Attention is a multifaceted capacity that entails three primary brain networks that carry out the functions of alerting (i.e., acquiring and maintaining an alert state), orienting (i.e., the reception of information from sensory input), and executive control (i.e., resolving conflict among thoughts, feelings, and responses; Posner & Dehaene, 1994; Rueda, Posner, & Rothbart, 2005). Self-regulation, as defined for these purposes, is comprised of two domains: emotional regulation (i.e., modulating affective states in response to fear and anger) and behavioral regulation (i.e., self-monitoring and inhibiting impulses). Physiological regulatory processes (e.g., sleep, arousal, and digestion) function as an important counterpart to self-regulation and will be discussed in greater detail below. The emergence of self-regulation is a result of the executive function of attentional management and effortful control. When conflict between different neural networks occurs in response to a given stimulus, those neural networks compete for control, requiring the executive control system to govern the individual‘s response. For example, if an individual perceives an oncoming attack, the fight or flight response is activated. It is the executive control network that allows the individual to then determine how to respond: aggressively or in accordance with a different goal. The subsequent behavioral expression is a result of effortful control. Effortful control, defined as ―the efficiency of executive attention, including the ability to inhibit a dominant response and/or to activate a subdominant response, to plan, and to detect errors,‖ has been noted to play an integral role in the development of selfregulation (Rothbart & Bates, 2006), as it allows an individual to voluntarily shift attention, inhibit emotional responses, and modulate emotional and behavioral expression (Eisenberg et al., 2005). Many have argued that effortful control, as a component of emotion-related regulation, is an essential function of healthy emotional expression for minimizing lability and negativity (Eisenberg & Spinrad, 2006; Spinrad et al., 2006; Valiente, Lemery-Chalfant, Swanson, & Reiser, 2008). Increasing attention has been paid to the role that self-regulation plays in a host of emotional and behavioral disorders, and researchers have found that deficits in this ability are associated with a multitude of psychopathologies (Barkley, 1997; Benton, 1991; Bradley, 2000; Cicchetti, Ackerman, & Izard, 1995; Davidson, 2000; Pennington, 1997). Selfregulation is an integral facet of externalizing behaviors, as hyperactivity, defiance, and aggression are all exemplified by a lack of inhibiting inappropriate behavior and modulating
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affective states. A number of researchers have demonstrated this link. For example, children found to have diminished effortful control have been noted as being more oppositional and less prepared for the classroom (Lewis, Dozier, Ackerman, & Sepulveda-Kozakowski, 2005). Rydell, Berlin, and Bohlin (2003) found that poor emotion regulation in early childhood predicted externalizing problem behaviors and decreased prosocial skills during middle childhood. The ability to regulate expressions of anger in young children has also been found to relate to chronic levels of covert antisocial behavior. Eisenberg and colleagues (2005) found that children demonstrating externalizing behavior problems were rated as lower in effortful control and higher in impulsivity. Researchers have also indicated that young children exhibiting aggression, poor affective regulation, and poor effortful control demonstrate strained relationships with teachers and peers and poor academic performance (Birch & Ladd, 1998; Valiente et al., 2008; Wentzel & Asher, 1995). Attention has also proved to play a key role in internalizing behavior problems. Depression has been characterized by an inability to divert one‘s attention from a stressful stimulus or negative cognition (e.g., rumination), and this cognitive perseveration has been shown to predict later onset of anxiety and depression symptoms (Nolen-Hoeksema, 2000). Similarly, anxiety has been described an attentional bias to threat wherein the individual tends to allocate his/her attention to threat-relevant or emotionally negative cues (Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, & van IJzendoorn, 2007; Beck, Emery, & Greenberg, 1985; Mogg & Bradley, 2005). Although much previous research in this area was correlational, the results from a recent study confirmed that attentional bias plays a causal role in the maintenance of Generalized Anxiety Disorder (Amir, Beard, Burns, & Bomyea, 2009). This attentional bias serves to increase the overall level of arousal in an individual resulting in stress-related dysfunction over time (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002; Salovey, Rothman, Detweiler, & Steward, 2000). There have been surprisingly few studies on self-regulation or attention-related problems with specific regard to foster children. Children who are exposed to chaotic and unpredictable environments and stressors early in life, not unlike children with maltreatment histories, tend to exhibit anxiety that inhibits attentional focus because of heightened arousal and cognitive distortions (Vasey & Ollendick, 2000; Compas & Oppedisano, 2000). This is likely to be exacerbated under academic demands (Roeser & Eccles, 2000). Racusin, Maerlander, Sengupta, Straus, and Isquith (2003) found clinically significant deficits in inhibitory control, emotional modulation, and cognitive/behavioral flexibility among a considerable proportion of their sample of foster children with histories of trauma and disrupted attachment. Further, these deficits were strongly correlated with disordered attachments, behavior problems, psychiatric disorders, and diminished functioning. Slinning (2004) found that foster children exposed prenatally to substances but who were reared in low-risk care settings demonstrated significantly elevated levels of both impulsivity and attention problems, indicating a strong neurobiological basis of these behavior problems. Care settings, however, have also proved to play a role in the development of attention and self-regulation. In one study, compared to a community-based control group, children raised in substitute care (a combination of institutional and foster care) evidenced higher levels of hyperactivity and inattention continuously and beginning before 12 months of age (Roy, Rutter, & Pickles, 2000). Insufficient care and neglect appears to play a salient role in this regard. Pears and Fisher (2005) found that preschool-aged foster children with histories of neglect and emotional abuse scored significantly lower on executive functioning than foster children with other
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maltreatment subtypes (i.e., physical abuse or sexual abuse). In spite of the relatively small number of studies discussed herein, given the critical involvement that self-regulation and attention play in a host of emotional and behavioral problems, it is likely that foster children evidence more deficits in functioning in these areas than their peers in the general population. When functioning at more optimal levels, attentional focus and self-regulation can serve as protective factors that increase the likelihood of positive adaptation in the face of adversity. In their review of the development of emotion regulation, Morris, Silk, Steinberg, Myers, and Robinson (2007) argued that regulation is central to overall adjustment. The ability to modulate emotions and behavior in response to typical and novel stressors so as to respond in socially appropriate ways is integral not only to psychological adaptation but to the development of healthy relationships (Cicchetti et al., 1995; Denham et al., 2003). Additionally, the ability for a child to modulate emotional responses, behavior, and control impulses appropriately is vital to school adjustment; novel stressors and demands consistently emerge throughout childhood and adolescence (Birch & Ladd, 1998; Garon, Bryson, & Smith, 2008; Ladd, Birch, & Buhs, 1999; McClelland, Morrison, & Holmes, 2000). Dysregulation, therefore, places children at increased risk of exaggerated reactions to stressful events (Bruce, Davis, & Gunnar, 2002).
CURRENT INTERVENTION TRENDS The Context for Care The placement of a child in foster care is intended to be an intervention, and the removal of a child from their parents or primary caregivers, albeit traumatic, serves to suspend the adversity precipitating the involvement of child welfare. At the most basic level, foster caregivers shelter and protect the child for a period of time until a permanent placement plan is possible. At its best, foster care can potentiate healthy development in the child by placing them in a therapeutic context wherein foster caregivers can remediate skills on a multitude of domains. Additionally, it allows the child to experience himself/herself in the context of a normative family and to relearn a healthier caregiver–child dynamic, which can foster healthy attachment behaviors conducive to long-term care relationships. Concurrently during the child‘s placement out of home, biological parents or prior caregivers are subject to court mandates in the cases of abuse, neglect, and endangerment for the purpose of rehabilitation and skill remediation. Child welfare caseworkers monitor treatment, for both the child and the biological parents, and plan for permanency. The time afforded to the foster child to accomplish these ends varies widely. In 2008, estimates of the length of stay in foster care indicated that 5% of foster children remained in care for less than 1 month, 37% remained in care for 1–11 months, 23% remained in care for 1–2 years, and 36% remained in care for more than 2 years (U.S. Department of Health and Human Services, 2009). More than half of all foster children were placed for less than 2 years; given the breadth and complexity of their treatment needs, this is a relatively brief time allotted for remediation before returning to what is often still an environment characterized by chaos and adversity. Of the near 285,000 children who exited foster care in 2008, 52% were reunited with parents or primary caregivers, 19% were adopted, 8% were placed with other
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relatives or family, 10% were emancipated, 7% were under the care of a legal guardian, and 3% had other outcomes (e.g., transfer to another agency and runaway; U.S. Department of Health and Human Services, 2009). Instability (e.g., residential mobility, change of caregiver status, and a chaotic and unpredictable environment) is the hallmark of many of foster children‘s families of origin. This situation is not ameliorated, however, when a child enters foster care. Many foster children will move placements multiple times during out-of-home care. Researchers report that 22–56% of foster children have experienced three or more placements during their time in foster care (Newton, Litrownik, & Landsverk, 2000). Estimates for 2008 indicate the mean length of stay in foster care was 27.2 months (U.S. Department of Human Services, 2009). This is significant given that longer stays in the foster care system increase the likelihood of more placements, which decreases prospects for permanency (Barbell & Freundlich, 2001; Glisson, Bailey, & Post, 2000). Foster children with behavior problems are more likely to experience disrupted placements and to be moved frequently, sometimes throughout the entirety of their childhood years. The disruptiveness of these volatile placement patterns contributes to internalizing and externalizing behavior problems in foster children (Newton et al., 2000). Similarly, the length of time in foster care and the number of placements have been linked to behavior problems and academic underachievement with a greater number of disruptions resulting in poorer outcomes (Benbenishty, & Oyserman, 1995; Zima et al., 2000). In general, family instability is significantly related to increased rates of negative emotionality, internalizing problem behaviors, and externalizing problem behaviors (Ackerman, Brown, & Izard, 2003; Ackerman, Brown, D‘Eramo, & Izard, 2002; Ackerman, Kogos, Youngstrom, Schoff, & Izard, 1999). The risk for maladjustment due to family instability is moderated by child variables (i.e., temperamental adaptability and behavior and emotion regulation), meaning that children with lower levels of both demonstrate more adverse outcomes associated with family instability than their same-age peers (Ackerman et al., 1999). Psychosocial functioning is particularly important for young foster children because it significantly predicts the likelihood of reunification after out-of-home placements (Landsverk, Davis, Ganger, Newton, & Johnson, 1996). Similarly, volatile placement histories have also been shown to increase the risk of adoption disruption due to related problematic behavioral outcomes (Simmel, 2007). Further, instability compounds the negative consequences of abuse and neglect and significantly predicts outcomes across important areas of functioning such as school performance and self-regulation and the prevalence of internalizing and externalizing behavior problems (Ackerman et al., 2003; Ackerman et al., 2002; Newton et al., 2000). In addition to behavioral maladjustment, number of placement transitions has been found to negatively correlate with executive function in preschoolers (Pears & Fisher, 2005), a critical component of school adjustment and functioning. Similarly, children who experienced multiple placement transitions during foster care were found to have lower inhibitory control and higher oppositional behavior once in their adoptive families (Lewis et al., 2007). This is likely explained by the negative impact of transition and stress on overall development (Gunnar, Fisher, & The Early Experience, Stress, and Prevention Network, 2006). In one study, academic skill delays were significantly predicted by number of out-of-home placements in that foster children with higher rates of placement disruptions were more likely to demonstrate at least one academic skill delay than foster children with more stable placement histories (Zima et al., 2000).
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Treatment Approaches The contextual complexities discussed above highlight the need for effective and targeted intervention support for foster children, their caregivers, and their families of origin. It is critical that these interventions not only address the emergent behavioral and emotional needs of the child but also serve to increase stability and successful permanency placements. Very few evidence-based interventions have been designed specifically for the foster care population. This is problematic because the unique constellation of needs among foster children presents distinctive challenges for treatment providers. Two primary approaches have been employed for treatment in this population: (1) symptom-focused individual therapies principally targeted to the child, and (2) ecological and systems-focused interventions that address contextual factors that moderate child outcomes. Interventions with strong evidence bases that have been employed widely with this population and those specifically targeted to foster children are discussed below.
Symptom Reduction-Focused Interventions Cognitive Behavioral Therapy (CBT). Underpinning the concept of CBT is the idea that thoughts (i.e., cognitions) influence emotion and behaviors. CBT is not a specific therapeutic technique per se but a way to classify a therapeutic approach. A number of reviews and studies have indicated the use of CBT as an effective intervention approach for treating depression, anxiety, conduct problems, impulsivity, suicidal ideation, and symptoms related to Post-Traumatic Stress Disorder (PTSD) in youth (Albano & Kendall, 2002; Asarnow, Jaycox, & Tompson, 2001; Baer & Neitzel, 1991; Lewinsohn, Clark, Rohde, Hops, & Seeley, 1996; Ollendick, 1998; Rotheram-Borus, Piacentini, Miller, Graae, & CastroBlanco, 1994; Silverman, Kurtines, Ginsburg, Weems, Lumpkin, & Carmichael, 1999). CBT methods with youth encourage a constructive and problem-solving world view (Braswell & Kendall, 2003). This problem-solving orientation has also been referred to as a ―coping template‖ supporting adaptive responses to stressors (Kendall & Panichelli-Mindel, 1995). Increasing self-awareness and teaching youth how to self-monitor their affective state is a common treatment element for youth demonstrating not only affective problems but also aggression (Nelson & Finch, 1996; Kendall, 1998; Kendall, 2000). However, given the highly verbal nature of this therapeutic approach, it is not well-suited to very young children. Currently, there is much debate in the field regarding use of CBT methods with clients who have intellectual disabilities (Taylor, Lindsay, & Willner, 2008). Trauma-Focused CBT (TF-CBT). In certain cases where more severe trauma has been incurred as a result of abuse, TF-CBT may be indicated. In this approach, the basic principles of CBT as discussed above are augmented by an emphasis on gradual exposure that incrementally increases over the therapeutic relationship. Evidence for the use of TF-CBT with children is supported by a number of randomized control trials and effectiveness studies for survivors of sexual abuse, domestic violence, traumatic grief, disasters, terrorism, or multiple traumas (Celano & Rothbaum, 2002; Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen & Mannarino, 2004; Cohen, Mannarino, Perel, & Staron, 2007; Feather & Ronan, 2006; Hoagwood et al., 2006; King et al., 2000). Parent involvement in TF-CBT can be particularly effective for children as reviewing traumatic events in the therapy setting can
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retrigger a host of negative affective experiences that must then be dealt with at home. Cohen and Mannarino (2008) discussed a model for joint parent–child treatment of TF-CBT for children ages 3–17 including the following components: psychoeducation and parenting skills, relaxation skills, affective regulation skills, cognitive coping skills, trauma narrative, and cognitive processing of the traumatic event(s), in vivo mastery of trauma reminders, conjoint child–parent sessions, and enhancing safety and future developmental trajectory.
Caregiver-Based Interventions Behavioral Parent Training. U.S. federal policy indicates that all prospective foster parents receive sufficient training for meeting the needs of the child placed in their home (Foster Care Independence Act of 1999, H. R. 3443; English & Grasso, 1999). Specifications for practice, however, are determined at the state level. Generally, these include some form of parent training; however, the content, duration, and intensity of training are not standardized. Further complicating the matter, different training requirements exist for treatment foster caregivers who act as therapeutic agents and collaborate with other professionals to develop and implement treatment plans for the child (Chamberlain, 1994, 2002). In a review of current training practices and evidence for their effectiveness, Dorsey, Famer, Barth, Greene, Reid, and Landsverk (2008) noted that only 14 states require any additional preservice or annual inservice training hours for treatment foster caregivers. The guidelines set forth by the Foster Family-Based Treatment Association indicate that a central focus of training for treatment foster caregivers is parent management training (PMT; Kazdin, 1997; Patterson, 1976, 1982; Patterson, Chamberlain, & Reid, 1982). Based on principles of social learning theory and influenced by both B. F. Skinner‘s operant conditioning theories and Patterson‘s coercive family process framework, PMT coaches parents in strategies designed to increase prosocial behavior and decrease deviant or inappropriate behaviors. The ability of foster caregivers to effectively manage child behavior is central to maintaining placements (Brown & Bednar, 2006; James, 2004), and increased levels of problem behavior have been shown to relate directly to placement failure (Chamberlain, Price, Reid, Landsverk, Fisher, & Stoolmiller, 2006). Thus, effective training for foster parents in methods that decrease problem behavior is integral in not only preventing placement failure but also reducing the negative impact of subsequent placement instability as discussed above. Scores of studies have been conducted on the effectiveness of PMT for reducing problematic behaviors, and the evidence is extremely robust (see meta-analyses, Eyeburg, Nelson, & Boogs, 2008; Kaminksi, Valle, Filene, & Boyle, 2008; Lundahl, Nimer, & Parsons, 2006; Lundahl, Risser, & Lovejoy, 2006; Maughn, Christiansen, Jenson, Olympia, & Clark, 2005; Serketich & Dumas, 1996; Weisz, Weiss, Han, Granger, & Morton, 1995). Multidimensional Treatment Foster Care (MTFC). Developed at the Oregon Social Learning Center, MTFC (Chamberlain & Reid, 1991, 1998; Fisher & Chamberlain, 2000) is an evidence-based intervention model that provides comprehensive and intensive support for foster children ages 3–18. The program is designed to be an alternative to regular foster care, residential or group treatment, and incarceration for children with chronic behavior problems. Program staff work across multiple settings (i.e., home, school, and community) and with numerous adjunct providers (i.e., caseworkers, teachers, parole officers, psychiatrists, and attorneys) to increase prosocial behaviors, establish structure in daily routines, maintain high levels of supervision, implement consistent therapeutic limits for problem behavior, and
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increase placement stability. MTFC foster caregivers participate in a 20-hour preservice training focused on the principles of behavior change rooted in social learning theory and PMT (Patterson, 1976, 1982; Patterson et al., 1982). Given the chronicity and frequency of behavior problems among children living in MTFC homes, foster caregivers maintain contact with clinical staff and other foster caregivers for ongoing training and support needs several times a week, and 24/7 on-call support is provided. Keeping Foster and Kin Parents Trained and Supported (KEEP). With its roots in the MTFC model of foster caregiver training, the KEEP program was developed as an intervention for regular foster and kinship caregivers of children ages 5–11 (Chamberlain, Moreland, & Reid, 1992; Price, Chamberlain, Landsverk, & Reid, 2009). Building on the core component of foster caregiver training and support, KEEP families participate in a 16week group training that emphasizes use of positive reinforcement, effective discipline practices, and monitoring. Unlike MTFC, KEEP families do not receive intensive case management or on-call support. Findings indicate that the intervention is effective in reducing behavior problems as a result of caregiver training and increases the likelihood of a successful reunification with families of origin (Price et al., 2009).
APPLICATIONS OF MINDFULNESS-ORIENTED THERAPIES IN RESEARCH AND PRACTICE Defining the Construct In recent years, research on mindfulness and its application in the field of mental health has increased exponentially. As researchers and clinicians gain interest, conceptualizations of the mindfulness construct abound. How can the application of mindfulness-oriented therapies improve outcomes for foster children and their caregivers? In order to begin this discussion, a clear definition of mindfulness is warranted. Mindfulness primarily refers to one‘s perception of stimuli and evaluation thereof. Although mindfulness in clinical practice has been secularized, its roots in Buddhist and yogic culture lend insight to its definition as a construct. A Buddhist philosopher and scholar wrote that mindfulness can be conceptualized as follows: …pure attentiveness, an alert, impartial function of mind that simply notes whatever appears by way of the senses of sight, hearing, smell, taste, touch, and mind itself. Mindfulness does not cogitate, judge, or interpret; it only observes, neutrally and without commentary, the actual character of an object or phenomenon. (Nyanasobhano, 1998, pp. 16– 17)
In a broad definition, Kabat-Zinn (1994) wrote that mindfulness can be defined as ―paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.‖ (p. 4). Baer (2003) wrote that ―mindfulness is the nonjudgmental observation of the ongoing stream of internal and external stimuli as they arise.‖ (p. 125). As one practices mindfulness, phenomenon that enter one‘s awareness (e.g., thoughts, sensations, and emotions) are observed carefully but not evaluated in a dualistic fashion as good or bad,
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important or trivial, or true or false (Marlatt & Kristeller, 1999). What is salient across definitions is the notion of the acceptance of what is, being fully present and attentive to the moment while refraining from emotional or evaluative reaction.
Similarities and Clarification Mindfulness must be distinguished from other similar constructs. The term ―attention training‖ has been used as both a synonym to mindfulness as well as its own practice. While mindfulness does entail the application of selectively attending to a presenting stimulus, we pose that as, it is described primarily in the literature, attention training as a term subsumes this action in its entirety excluding the nonevaluative acceptance component of mindfulness. For application on a variety of mental health targets, attention training primarily addresses ruminative thinking patterns. Wells (1990), for example, developed an attention training technique that is reported to result in flexible control over attention which fosters a shift in information processing from internal cues to external cues, activating a metacognitive action, and subsequently decreasing symptoms of depression, anxiety, social phobia, panic disorder, and hypochondriasis (Papageorgiou & Wells, 1998, 2000; Wells, 1990, 2000; Wells, White, & Carter, 1997). Amir and colleagues developed an attention modification program using linguistic probes or faces displayed on a computer screen, and participants were prompted to shift their attention to neutral cues. Results indicated symptom reduction in attentional bias toward threat for participants with Generalized Anxiety Disorder (Amir, Beard, Burns, & Bomyea, 2009) and social phobia (Amir, Beard, Taylor, et al., 2009). Similarly, Schmidt, Richey, Buckner, and Timpano (2009) used attention training techniques to successfully ameliorate symptoms of social anxiety disorder compared to a control group and gains were maintained at follow-up. Mindfulness also should be distinguished from basic relaxation. While relaxation is often a byproduct of practicing mindfulness and many mindfulness training protocols include a relaxation component, the purpose of a relaxation exercise is to decrease arousal and stress, whereas the purpose of mindfulness is to cultivate a nonjudgmental awareness: two distinctly different targets. In some instances, mindfulness might actually preclude relaxation; the observer may be orienting to tension, racing thoughts, or irritation, all of which may be incompatible with relaxation. Lastly, important distinctions need be made between mindfulness and meditation. ―Meditation‖ is broadly defined and encompasses a wide variety of techniques which may or may not include mindfulness. In fact, some forms of meditation run counter to mindfulness entirely as they entail focusing attention on a single stimulus (e.g., word or mantra) and exclude observance of other present moment conditions, whereas mindfulness encourages absolute attention of the moment-to-moment flow of experiences, both internal and external. Given these distinctions, mindfulness is set apart as a state of focused awareness to the present moment without attachment or qualification; it is a state of dispassionate observance and acceptance of what is.
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Current Applications of Mindfulness Over the last two decades, numerous mindfulness training interventions and clinical applications have emerged. Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990) is among the most well-known and has been used to address a host of physical and psychological maladies. MBSR is a multicomponent training program delivered primarily in groups over several weeks and teaches participants to practice mindfulness while mentally scanning the body during seated meditation with focus on breathing and while practicing simple hatha yoga postures. Mindfulness-Based Cognitive Therapy (MBCT; Teasdale, Segal, & Williams, 1995) is a manualized 8-week group intervention based largely on Kabat-Zinn‘s MBSR protocol. The primary target of MBCT is to prevent the relapse of depression by practicing detachment from one‘s thoughts (e.g., ―I am not my thoughts‖). This decentered thinking is thought to interrupt a potential cascade of ruminative thoughts that can escalate into a more significant depressive episode. Singh, Wahler, Adkins, & Myers (2003) initially developed a mindfulness training curriculum, Soles of the Feet, for a young man with mental retardation for the purpose of decreasing aggression. Since that initial study, numerous other single subject multiple baseline studies have been conducted using this curriculum with adolescents with conduct disorder (Singh et al., 2007a) and aggressive individuals with severe mental illness (Singh et al., 2007b). The training consists of teaching the individual to focus their attention onto the soles of their feet (a neutral location), practicing mindfulness of this area until their arousal level decreases. Singh and colleagues have also trained parents of children with autism engaging in disruptive and self-injurious behavior (Singh et al., 2006) and parents of children with developmental disabilities (Singh et al., 2007c) in mindfulness practices, although the intervention components of these studies are less clearly articulated. Integrative Body–Mind Training (IBMT) is another mindfulness-based technique. Developed in the 1990s, its effects have been studied in China since 1995. IBMT achieves the desired state by first giving a brief instructional period on the method called an ―initial mind setting‖ for the purpose of preparing the individual to engage fully in the training. The IBMT method stresses no effort to control thoughts, but instead a state of restful alertness that allows a high degree of awareness (mindfulness) of body, breathing, and the recorded training instructions. The goal is a balanced state of relaxation with focused attention. Thought control is achieved gradually through the aid of a coach who guides posture and relaxation to cultivate a state of body–mind harmony. The purpose of the coach is to minimize the trainee‘s internal struggle to control thoughts in accordance with instruction. Based on the results from hundreds of adults and children ranging from 4 to 90 years old in China, IBMT has demonstrated improvements in emotional and cognitive performance as well as social behavior (Tang, 2009; Tang et al., 2007, 2009). In addition to the interventions discussed above, many well-researched and highly utilized therapies include components of mindfulness. Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999) is based in behavior analytic principles. While its treatment methods are not described as mindfulness practices per se, they are functionally comparable: namely, the nonjudgmental observation of thoughts and emotions as they arise. In contrast, Dialectical Behavior Therapy (Linehan, 1993) names mindfulness as a core
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component of its methodology. Principally, mindfulness is practiced as a method to increase acceptance and tolerate distress when it occurs.
Outcomes of Mindfulness Training Studies The aforementioned treatment models do not comprise an exhaustive list of clinical applications of mindfulness; rather, they represent some of the most notable and wellresearched interventions. Intervention studies examining the outcomes of mindfulness training programs (e.g., MBSR and MBCT) and mindfulness-oriented interventions indicate that these methods can be effective for treatment of a variety of disorders. Although critiques have been made regarding methodology (e.g., small sample sizes, lack of control group, and lack of fidelity monitoring), effect sizes for mindfulness interventions have been noted in the medium-to-large range, with the greatest effect for those participants dealing with anxiety and depression problems. In a meta-analysis of mindfulness training intervention studies, Baer (2003) reported that effect sizes at posttreatment ranged from 0.15 to 1.65, with an average weighted mean of 0.59. These were maintained at follow-up. In addition, participants have reported a great deal of satisfaction with the interventions and attribute changes in symptoms to the training they received.
Anxiety and Depression Mindfulness training has been shown to effectively reduce symptoms of depression (Biegel, Brown, Shapiro, & Schubert, 2009; Kumar, Feldman, & Hayes, 2008; Teasdale et al., 1995; Tang, 2009) and anxiety (Kabat-Zinn et al., 1992; Miller et al., 1995; Vietin & Astin, 2008; Weinstein, Brown, & Ryan, 2009). The mechanisms underlying the effectiveness of mindfulness training in reducing symptomotology are hypothesized to be the training of attention in order to decrease ruminative thinking and the promotion of acceptance (Coffey & Hartman, 2008; Teasdale et al., 1995), which leads to a decrease in avoidance behaviors (Weinstein et al., 2009). The decrease in avoidance behaviors has important implications for anxiety. In one study, individuals high on avoidance measures experienced greater panic symptoms compared to peers lower on avoidance (Karekla, Forsyth, & Kelly, 2004). Avoidance and suppression has actually been shown to result in increases in intrusive thoughts and intensification of associated negative emotions (Davies & Clark, 1998; Wegner & Zanakos, 1994), whereas more active coping (e.g., dealing directly with a stressful situation) and acceptance results in greater adaptation and overall well-being (Weinstein et al., 2009). Stress and Well-Being Mindfulness has been shown to have strong associations with stress and overall wellbeing. Weinstein and colleagues (2009) reported that mindful individuals appraised potentially stressful experiences as more benign than individuals lower in mindfulness and reported less frequent use of avoidant coping strategies. Brown and Ryan (2003) found that mindful individuals experience lower levels of stress and mood disturbance. Tang and colleagues (2007) reported finding significant decreases in stress-related cortisol levels after a short-term mindfulness meditation training.
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Improvements in well-being on both physical and mental health dimensions for those dealing with chronic illness have been noted widely. Studies have focused primiarily on the use of MBSR as a primary or adjunct therapy for a number of chronic medical conditions (e.g., chronic pain, fibromyalgia, heart disease, obesity, cancer, and psoriasis; Goldenberg et al., 1994; Kabat-Zinn, Lipworth, & Burney, 1985; Kabat-Zinn, Lipworth, Burney, & Sellars, 1986; Kaplan, Goldenberg, & Galvin-Nadeau, 1993; Ledesma & Kumano, 2009; Lush, Salmon, Floyd, Studts, Weissbecker, & Sephton, 2009). In a meta-analysis examining the effect of MBSR on stress reduction and health benefits, Grossman, Niemann, Schmidt, and Walach (2004) reported moderate effect sizes on both mental and physical health outcomes indicating improvements in quality of life, medical symptoms, and pain. This is likely due in part to the significant effect mindfulness training has on stress, thereby mediating stressrelated correlates.
Attention Discussion of how mindfulness mediates attentional focus and its effects on depression and anxiety are discussed above. Direct impact on attention as it pertains to performance, ADHD symptomotology, and basic orienting has also been demonstrated in the literature. Tang and colleagues (2007) found that even short-term training (100 minutes across 5 days) in IBMT led to better performance in conflict monitoring on the Attention Network Test. Similarly, Jha, Krompinger, and Baime (2007) found that functioning across all three attention networks (alerting, orienting, and conflict monitoring) improved after mindfulness training. Even in the presence of emotional interference, mindfulness meditation training resulted in greater attention control as compared to relaxation training (Ortner, Kilner, & Zelazo, 2007). Sustained attention has also been exhibited with greater proficiency among mindful individuals compared with controls (Schmertz, Anderson, & Robins, 2009; Valentine & Sweet, 1999). Interestingly, very little research on mindfulness applications for individuals with ADHD has been conducted. In one feasibility study, the majority of adult and adolescent participants with ADHD completed the training; although behavioral improvements were noted at posttest, the lack of randomization and a control group indicated the need for a more methodologically rigorous examination (Zylowska et al., 2007). Self-Regulation Mindfulness is not typically applied as an intervention to regulate mood and behavior per se but rather to observe emotions or thoughts in a nonjudgmental, nonreactive manner. This can result in a decrease in physiological arousal as the individual turns his/her attention to a neutral posture in response to a potentially provoking incident. This is a central construct behind emotion regulation and has neurophysiological implications as well. After administering fMRIs during an affect labeling task, Creswell and colleagues (2007) found that individuals with high levels of mindfulness exhibited increased prefrontal cortex activation and decreased amygdala activity lending credence to this relationship. Tang and colleagues (2009) observed increased activation in ventral anterior cingulate cortex, the selfregulation center in the brain (Posner et al., 2007), after only 5 days of IBMT in comparison to 5 days of relaxation training. As discussed above, the conflict monitoring component of attention (e.g., executive control) is central to self-regulation, and we have discussed how mindfulness training impacts
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this network. Another theory as to how mindfulness influences self-regulation is seen in selfdetermination theory (Ryan & Deci, 2000), which posits that open awareness, as is demonstrated in mindfulness, may be particularly facilitative in one‘s ability to select behavioral responses congruent to one‘s interest, values, or needs. Brown and Ryan (2003) found that mindfulness was actually predictive of self-regulation in day-to-day activities. In one study with adolescents demonstrating externalizing behavior problems, mindfulness training resulted in a significant decrease of both self-reported and parent-reported complaints of externalizing behaviors (Bogels, Hoogstad, van Dun, de Schutter, & Restifo, 2008). The findings from another study indicated an inverse relationship between mindfulness and aggression and hostile attribution bias and that, after mindfulness training, individuals responded to provocation with lower levels of aggression and hostile attribution bias than control groups (Heppner et al., 2008).
Children and Adolescents Applications for youth have been severely understudied to date. The mean age range of participants in published mindfulness studies has been 38–50 years. Of the few existing studies, only a handful were methodologically sound; thus, implications for treatment have been somewhat speculative. Semple, Lee, and Miller (2006) explained that, although the results from adult studies have been promising, the research with children and adolescents ―has barely begun‖ (p. 164). The bulk of the studies with youth have involved nonclinical populations, small sample feasibility studies, case studies, or measuring outcomes anecdotally or without the use of validated instruments (Thompson & Gauntlett-Gilbert, 2008). Complicating matters further, there is only one mindfulness measure validated for use with children to date, the Child and Adolescent Mindfulness Measure (Greco, Dew, & Baer, 2005). It is important to note, however, that the lack of a substantial body of rigorous research with youth does not mean that mindfulness training in this population is infeasible or without promise. A small number of studies have been conducted, indicating that not only can mindfulness be trained in children and adolescents but that training may have important implications for health and well-being. Schoeberlein and Koffler (2005) worked with the Garrison Institute to examine contemplative programs with children ages 5–18 throughout the United States. They found that, during the 2004–2005 school year, over 20 school- and community-based programs prioritizing mindfulness, attention training, emotional balance, and well-being were being implemented, indicating high feasibility for instructing children and adolescents in these methods. Although none of these programs reported empirical data, the report indicated general increases in self-awareness, self-reflection, emotional intelligence, and social skills. Other studies with children and adolescents, while not all methodologically rigorous, report training participants‘ ranging from 4–19 years old in mindfulness techniques (Biegel et al., 2009; Lee, Semple, Rosa, & Miller, 2008; Miller, Wyman, Huppert, Glassman, & Rathaus, 2000; Napoli, Krech, & Holley, 2005; Ott, 2002; Semple et al., 2006; Semple, Reid, & Miller, 2005; Singh et al., 2007a; Tang, 2005, 2007; Wall, 2005). Training methods with youth necessitate developmental considerations as attention, self-regulatory, cognitive, linguistic, and interpersonal abilities vary distinctly from adults and throughout stages of childhood.
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Potential Mindfulness Applications in Foster Care Foster caregivers and biological parents Given the prior discussion regarding the intensive needs of foster children, it bears repeating that providing responsive, nurturing care for these children can be extraordinarily difficult. In fact, clinical support for foster caregivers who serve these children has been found to be integral to maintaining placement stability and decreasing parenting stress (Fisher & Stoolmiller, 2008). Foster caregiver stress has also been shown to have a negative association on child physiological functioning (Fisher & Stoolmiller, 2008). Many foster parents of children with chronic emotional and behavioral problems describe living in a constant state of triage, which ultimately compromises their effectiveness in parenting and maintaining a therapeutic approach. Even when one has the knowledge and training needed to be effective, stress and overwhelm can dramatically interfere with the ability to access that knowledge and respond in accordance with a more goal-directed approach. To further complicate matters, foster children often experience the early parent–child relationship as chronically rejection oriented and reactive. As they enter foster care, very little may appear familiar, particularly in regard to the new parent–child framework. This results in a rather distinct dynamic. The foster child must take time to learn the norms and expectations of the foster family as well as how to appropriately initiate interactions and how to respond. During the process, they often engage in the more familiar rejection-oriented and reactive parent–child dynamic, pulling for what is familiar. In addition to what is often an already substantial constellation of emotional and behavioral needs, the best intentions of the foster caregiver to support the child is undercut by the elicitation of antagonistic exchanges. Reactivity on the part of the foster caregiver can serve to undermine therapeutic progress for the child. Given this, applications for mindfulness training for foster caregivers could result in (1) increases in goal-directed parenting, (2) improved utilization of evidence-based therapeutic parenting practices as a result of improved self-regulation and decreased arousal, (3) reductions in stress, and (4) improved well-being, all of which lead to greater placement stability and more positive child outcomes. Similarly, biological parents may benefit from mindfulness training. Fisher, Burraston, and Pears (2005) found that a significant number of permanent placements failed less than 1 year after reunification. Although the reasons for these failures still need to be fully explicated, it is often the case that, as the child begins to stabilize in the home, services and supports are likely to end. Parents may not have the long-term emotional resources to cope with the stressors of parenting a high-needs child; consequently, placements may deteriorate. The benefit of mindfulness training for these families may also serve to buffer these numerous risk factors. Foster Children Training foster children in mindfulness strategies has the potential to make a unique contribution to their treatment. We have highlighted the impact that mindfulness has on attentional focus, executive functioning, self-regulation, depression, and anxiety, all of which are well-documented needs among foster children. Important social correlates are targets for these interventions as well, namely hostile attribution bias, emotion regulation, and enhanced self-awareness. In addition, mindfulness supports coping with stressors and enhances overall
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well-being, which are important protective factors with the potential of increasing resilience in the face of adversity. Finally, mindfulness practices have been shown to support healthy neurophysiological functioning, which fosters continued adaptation to environmental demands. Outcomes from mindfulness training may extend to academic environments as well and warrant exploration in this setting given the poor academic functioning exhibited in this population. Follette, Palm, and Pearson (2006) posed that integrating mindfulness techniques into treatment for trauma may be particularly effective at supporting cognitive flexibility, focusing on the present, and supporting acceptance. In fact, in one study, mindfulness factors (i.e., accepting without judgment and acting with awareness) were predictive of PTSD symptoms in a sample of 239 adults who reported exposure to trauma but did not meet criteria for PTSD (Vujanovic, Youngwirth, Johnson, & Zvolensky, 2009). This is particularly salient as many foster children evidence posttraumatic symptomotology without a formal Axis I diagnosis.
Future Directions The study of mindfulness training and mindfulness-oriented interventions is growing exponentially as scientists and clinicians gain interest. There are a number of exciting domains yet to explore. With regard to children and adolescents, feasibility and modalities for training, mechanisms of action, impact of training on neurophysiological functioning, methods for generalization of skills, and measurement of mindfulness outcomes are just a few of the domains waiting to be explored in greater depth. As of yet, research on training mindfulness with foster children and their caregivers has yet to be conducted, but the implications of this work are exciting from both a basic science and clinical perspectives. Additionally, the feasibility and impact of mindfulness training on foster children with concurrent developmental disabilities will be an promising area to explore. Mindfulness training has the potential to increase the effectiveness of already robust methodologies by targeting the intrapersonal obstacles to effective implementation of methods. Three-prong studies that include a treatment group, treatment plus mindfulness, and matched controls may serve to illuminate the function of these obstacles and highlight strategies for eliminating them. Longitudinal follow-up after mindfulness training for foster children may also highlight the potential for mindfulness to serve as a protective factor, over time increasing favorable outcomes compared to children lower in mindfulness abilities. In fact, mindfulness studies have the potential to make a meaningful contribution to the study of resilience and risk prevention as it may be an important axis point for a number of critical risk factors. Additionally, longitudinal studies examining time-limited mindfulness training interventions, interventions with generalization protocols, interventions with and without booster sessions, caregiver involvement and training, and training across various ages and stages may illuminate critical windows and modalities for maximally beneficial outcomes. In short, we are at the beginning stages of an exciting inquiry process examining an ageold technique. With many avenues to explore, mindfulness training and its potential to impact such high-risk populations as those described here will no doubt engage researchers and clinicians for many years to come. The strength and meaning of this endeavor, however, will
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be in direct proportion to the rigors of methodology we observe during this inquiry. Indeed, mindfulness presents a ripe opportunity to marry the best of science and practice.
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In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 2
OVERCOMING MODERNITY: WESTERN AND JAPANESE ATTEMPTS Hiroshi Kaihara Brooklyn College, Brooklyn, NY, USA We were born, raised and are living in modern society. In modern society, religion is largely confined in the private realm, sciences spectacularly develop, living conditions greatly enhance, and reason rationalizes our morality by chasing away superstitions. There is no ideological rival emerging on horizon to replace modernity. However, persistent criticisms have been rendered against modernity in highly modernized countries. This article is to review some of vocal critics of modernity both in the West and Japan. By reviewing the works of major critics of modernity, I would like to delineate major themes of a project of overcoming modernity. Such a project is intended to give expressions to an ideal goal of our society. Religions sometimes play a role in providing such visions. Alasdair MacIntyre says that ―[b]y holding before them a vision of what they are denied, religion plays a progressive role in that it gives the common people some idea of what a better order would be‖ (2001, p. 103). Marxism, liberalism and progressivism are examples of ideological project to give such ideas. However, I find that these three are unsatisfactory because they are all founded on modernity. I believe that we need ―some idea of what a better order would be‖ after we have overcome modernity. This paper is a first small step for such endeavor. Western critics which I am going to discuss are Leo Strauss (1899-1973), Alasdair MacIntyre (1929 to present) and Martin Heidegger (1889-1976). Strauss accused moderns of lowering political ideals, and urged us to go back to Socrates who spent all his life to pursue the truth and the best regime. MacIntyre accused moderns of discarding telos which is indispensable element for moral theory and practice, and urge us to go back to Aristotelian Thomism in which the importance of community for moral practice was elaborated. Heidegger went on deeper to overcome Greek metaphysics which are the foundation of Western epistemology and philosophy. He seems to urge us to think about Heraclitus‘ understandings of physis, logos, or sein.
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Japanese attempts to overcome modernity are not properly dealt with in the West. It was lightly dismissed as just another example of anti-West, as Buruma and Margalit did (2004). This is understandable because some Japanese thought that the issue of overcoming modernity is irrelevant for the Japanese. They seem to think that the Japanese have not yet modernized first of all. But a discussion meeting entitled ―Overcoming Modernity‖, which was held in July 1941, showed that the problems of modernity were conceived as the demise of a unified vision of world, the death of God, the power of science, acquisitiveness and materialism bred by capitalism and the lack of morality. These were serious social issues when they discussed them and remain to be so to this day in Japan. Overcoming modernity is clearly a Japanese concern, too. Japanese critics of modernity which I am going to discuss are Kitarou Nishida (18701945), Tetsurou Watsuji (1889-1960) and Takeshi Umehara (1925 to present). Nishida tried to answer the same issue which Heidegger took of Greek metaphysics, that is, the division of the subject and the object. He urged us to think about the potentiality of pure experience. Watsuji accused Western modern ethics of becoming a matter of individual consciousness, and wanted to found ethics on inter-personal relationships. Umehara gave up Western philosophy due to its nihilism and its anthropocentrism which is destructive of nature. He tried to articulate a philosophy of the civilization of the forest in which we can believe in eternality of life. He believes that belief in eternal life is indispensable for morality. After having reviewed major theorists, I would like to ask whether we should overcome modernity. Two weakness of modernity will be discussed: one is its atheism, and the other is its neglect of virtue training. I think that the project of overcoming modernity should begin since the modern liberal project of providing an ever-expanding catalog of rights and welfare seems increasingly irrelevant for current social issue. Finally, I would like to discuss some of dilemmas which are likely to arise among major themes of overcoming modernity. I will discuss the issues of war, science and job security. These issues must be dealt with if the project of overcoming modernity is to be realistic.
LEO STRAUSS (1899-1973) It is probably true that Leo Strauss wanted to overcome modernity. Before he wrote a commentary on Carl Schmitt in his early thirties (Zuckert and Zuckert, 2006, p. 186), Strauss had presumed that ―a return to premodern philosophy is impossible‖ (1995, p. 257). But the change of orientation was first expressed in the commentary. And after the commentary, he was engaged in a number of studies and came to conclude that a turn to modern philosophy was a mistake and that a return to premodern philosophy is both desirable and possible (1997, p. x). But why on earth does Strauss desire to overcome modernity? What is wrong about modernity? Strauss talked about the crisis of the West. According to him, the ―crisis of the West consists in the West‘s having become uncertain of its purpose‖ (1964, p. 3). I am skeptical of this claim if the West narrowly means America, but let us set aside my doubt and continue to ask what is wrong with that. Strauss seems to believe that the West falls into nihilism once it has become uncertain of its purpose. Since Westerners are no longer sure about their goals, it is natural that they cannot ―acquire any genuine knowledge of what it is intrinsically good or
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right‖ (1950, p. 5). If so, it is understandable that they come to be ―tolerant of every opinion about good or right or to recognize all preferences or all ‗civilizations‘ as equally respectable‖ (Ibid.). This kind of sentiment has been fairly familiar in highly modernized societies today. Although there seems some truth in his observation, how does Strauss think the West has fallen into modern nihilism? According to my reading of his works, Strauss seems to think that there were three main disruptions in a road from the ancient world to the modern nihilism. The first disruption is the demystification of religion and done by Spinoza. Strauss wrote that ―the Bible must be studied and interpreted like any other literary document. It is only for this reason that Spinoza‘s work is of fundamental importance‖ (1997, p. 35). According to Strauss‘s Spinoza, the ―positive principle of Bible science amounts to stating: nothing may be asserted to be a teaching of the Bible which cannot be shown to be taught by the Bible by recourse to its literal sense‖ (Ibid., p. 263). Alas, according to this positive principle, many things in the Bible must be discarded; e.g., Virgin Mary, Jesus‘ resurrection, and Jesus producing four thousands out of seven breads (Holy Bible, Matthew, chapter 15, verses 36-8). Spinoza‘s positive principle made religion indefensible in modern mindset. But what is wrong about the demystification of religion in Strauss‘s discussion? Religion provides a vision of ideal state in the other world and if felicitous in this world, and make people patient about the realization of such a state. But once religion is marginalized, people come to seek a realization of ideal and rational society in this world. Then what moderns did to satisfy this demand is to lower ideals and pursue realizable goals. Strauss wrote that moderns ―deliberately lower the goal of politics; they are no longer concerned with having a clear view of the highest political possibility with regard to which all actual political orders can be judged in a responsible manner‖ (1950, p. 191). This is a second disruption in the transition to the modern world and done by Machiavelli and Hobbes. Machiavelli tried to figure out how men live rather than how they ought to live. Strauss wrote that Machiavelli ―achieves the decisive turn toward that notion of philosophy according to which its purpose is to relieve man‘s estate or to increase man‘s power or to guide man toward the rational society, the bond and the end of which is enlightened self-interest or the comfortable self-preservation of each of its members‖ (1958, p. 296). The phrase ―self-preservation‖ turned out to be a corner stone for Hobbes‘s political philosophy. Fear of death makes ―men clear-sighted‖ (Strauss, 1963, p. 132) and seek selfpreservation. And this self-preservation is a right of nature and a foundation for a rational society. Then Hobbes derives a system of natural law for a rational society solely from this natural right of self-presentation. Strauss wrote that ―there is no doubt that Hobbes is the father of the modern political philosophy. For it is he who, with a clarity never previously and never subsequently attained, made the ‗right of nature‘ the basis of political philosoph. He himself was aware that the precise subordination of Law to Right was an innovation‖ (Ibid., p. 156). Now modernists Machiavelli and Hobbes persuade us to seek realizable political goals and forget a ―best regime‖ to which an answer is not easily found. Moderns are convinced that we should seek our welfare not honor or glory, according to Strauss‘s analysis. His would be consistent with C. Taylor‘s discussion of the affirmation of ordinary life (1989, Part III) and A. O. Hirschman‘s The Passions and the Interests. In a modern society, commercial interests have replaced aristocratic virtues, and production and reproduction in ordinary life, in contradistinction to monastic life, has been revalued. Seeking a rational and affluent society became the main and sole goal of modernity.
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Finally Strauss goes on to take an issue of a distinctly modern kind of rationalism. Ancient and modern rationalisms are different: ancient rationalism is about pursuing transcendental goals, while modern one is about pursuing immanent goals. Ancient philosophers like Socrates and Plato believed that there is a best and eternal order which transcends our current society and that such an order should judge our preferences and institutions. Although they did not believe that humans can achieve the best regime in a real world due to human frailties (Strauss, 2006, p. 147), they believed that philosophy is all about pursuing the eternal order (ibid., p. 150). However, Nietzsche and Heidegger rejected this ancient rationalism, according to Strauss (1989, p. 94; 1996, p. 290). This is a third and final disruption in the road to modernity. Instead of ancient rationalism, they propagated a modern conception of rationalism which is based on historicism. Historicism is a belief that there are no immutable characters in human nature nor is there a universal and eternal norm (Strauss, 1996, p. 29). This belief is very popular, but its self-defeating nature is also clear. If all ideas and discourses are historically limited and thus should be treated relatively, then there is no reason why any historicist claim should be treated seriously. Strauss wonders ―whether the self-destruction of reason was not the inevitable outcome of modern rationalism as distinguished from premodern rationalism‖ (1995, p. 257). Now all viewpoints are equal: it‘s all about a matter of taste; de gustibus non est disputandum. It is natural under such a circumstance that we fall into a belief that there is nothing worthy of our serious discussion, analysis and defense (Strauss, 1996, p. 25). Strauss seems to believe that this is a taproot of the crisis of the West. His works on historicism and the dispute between the ancient and the modern make sense. But then where should we go? After having read several his works, I have failed to find out any concrete institutional proposals to overcome modernity. And as Catherine Zuckert and Michael Zuckert observe (2006), he did not talk of policy matter, probably except a warning against the Soviet Union. It seems that Strauss cared about our mindset rather than our institutions or public policies throughout his career. Then what kind of mindset was he talking about? Strauss seems to want to return to ancient Greek philosophy. When he talks about ancient philosophers, he mentions Socrates, Plato, Aristotle, etc. But why should we think highly of ancient Greek philosophy? Ancient Greek societies were after all slave-owning, woman-discriminating, and war-glorifying. Any philosophy which is produced in such a society should be suspect. Of course, these quips are our modern bias, but we need some reasons to think that ancient Greek philosophy presents ideals which we moderns should pursue. Which part of Greek philosophy did Strauss think highly of? It seems that what Strauss thought the most important is to live like Socrates. That is philosopher‘s life. Strauss said that ―Philosophy is quest for wisdom or quest for knowledge regarding the most important, the highest, or the most comprehensive things; such knowledge, Plato suggested, is virtue and happiness‖ (quoted by Zuckert and Zuckert, 2006, p. 46). We need not actually acquire such knowledge; we merely need to see our making progress in such a pursuit. If this much is Strauss‘s goal, we can reasonably pursue it since we can know whether we are making such a progress. We can know which theory is better when one theory can ―identify and transcend the limitations of its rival‖ (MacIntyre, 1984, p. 269; Taylor, 1989, p. 72). We have lived modern life for four or two hundred years, depending on your starting point, and by now we may be able to conclude that Strauss‘s analysis of modernity is probably correct. It is not preposterous to conclude that once we give up pursuing a best and eternal order, we are likely to degenerate. Mankind has asked the same question throughout
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its entire history; that is, what is the good. Strauss believes that this fact refutes historicism; by asking the same question, we can transcend our historical limitations. He wrote that ―the fundamental problems, such as the problems of justice, persist or retain their identity in all historical change…. In grasping these problems as problems, the human mind liberates itself from its historical limitation‖ (1950, p. 32). Of course, we disagree on what the solutions are. But that does not prove that there is no eternal and best order, nor does refute the possibility that we can overcome historical limitations by asking the same question. By ignoring this possibility, historicism has made serious discussion pointless. Once we forget serious discussion, degeneration is a likely outcome.
ALASDAIR MACINTYRE (1929 TO PRESENT) It is fairly clear that MacIntyre wants to overcome modernity. He says that ―nothing less a rejection of a large part of that ethos will provide us with a rationally and morally defensible standpoint from which to judge and to act (1984, p. x). By ―that ethos‖, he means modern liberal ethos. But why does he want to reject modernity? He seems to believe that we cannot live a morally consistent life in modern society. Our life is fragmented into several domains in our modern society. And each domain has its own system of values, and one system is not necessarily compatible with other systems. For example, you as a member of one community want to protect environment, but you as a corporate director have to make a decision which is not friendly to environment. And our life is fragmented because we moderns do not have ―the good of human life conceived as a unity‖, or a telos (MacIntyre, 1984, p. 203). Without such a commanding good, we cannot prioritize conflicting goods which we encounter daily in several domains of our life. This is very true. According MacIntyre, ancient polis or medieval kingdoms provided telos before modernity. MacIntyre observes that ―[b]oth are conceived as communities in which men in company pursue the human good‖ (1984, p. 172). With telos, the ancient and the medieval were able to live a morally consistent life. How? They had a three-pronged scheme of morality: ―untutored human nature, man-as-he-could-be-if-he-realized-his-telos and the moral precepts‖ (Ibid., p. 54). Telos told us what is ideal life, and moral precepts are a catalog of virtues which we should acquire to realize an ideal life. He goes on to argue that they pursued this moral scheme collectively. He elaborates another trilogy of moral scheme: that is, practices, narrations and tradition (Ibid., 187). Practices, such as fishing or fighting, provide them an opportunity to acquire virtues. Through practices, people worked with others, submitted themselves to authoritative standards of excellence and trained their skills and moral characters. Narrations are stories of heroes and heroines, and provide them life stories by which we can plan the whole course of life. And tradition gives content to these practices and narrations. Any viable ancient polis and medieval kingdoms had this kind of trilogy of moral practice, according to MacIntyre. However, we moderns no longer believe in such telos or old moral schemes. We tend to think that an ideal life is a matter of personal choice and that our reason can provide some kind of public morality if we need it at all. We even think that it is disgraceful for us to let anything other than our reason or will dictate our ideal life. At the beginning of the
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Enlightenment movement, moderns believed that reason, if fully developed, would bring mankind to happiness. Diderot wrote ―the finest privilege of our reason consists in not believing anything by the impulsion of a blind and mechanical instinct‖. And according to him, a philosopher, an exemplar of reason, ―trampling underfoot prejudice, tradition, venerability, universal assent, authority—in a word, everything that overawes the crowd— dares to think for himself, ascend to the clearest general principles, to examine them, to discuss them, to admit nothing save on the testimony of his own reason and experience‖ (quoted in Taylor, 1989, 323). More than two hundred years have passed since then, and we now do not have such confidence in reason. It is clear that reason has failed to provide a foundation to public morality. As MacIntyre pithily points out (1984, p. 21), it is a decisive evidence for reason‘s failure that believers of reason cannot agree on what should be a universal moral precept among themselves. Once we have reject traditional and religious authorities as superstition, there is nothing there to stop endless regression of moral inquiry. He wrote that ―the price paid for liberation from what appeared to be the external authority of traditional morality was the loss of any authoritative content from the would-be moral utterances of the newly autonomous agent. Each moral agent now spoke unconstrained by the externalities of divine law, natural teleology or hierarchical authority; but why should anyone else now listen to him‖ (Ibid., p. 68). No matter what believers of reason about morality say, one can always ask ―But why should I live like that‖ (Ibid., p. 20). There is really no reason why we should listen to what others say about morality. What is worse, believers of reason have greatly enhanced the status of autonomy. Kant wrote, ―Much as my words may startle you, you must not condemn me for saying: every man creates his God. From the moral point of view…you even have to create your God, in order to worship in Him your creator. For in whatever way…the Deity should be made known to you, and even…if He should reveal Himself to you: it is you…who must judge whether you are permitted [by your conscience] to believe in Him, and to worship Him‖ (quoted by Popper, 1976, p. 182). But once we prize autonomy like this, it will be hard for us to be open to and persuaded by others. MacIntyre observes that ―[s]eeking to protect the autonomy that we have learned to prize, we aspire ourselves not to be manipulated by others; seeking to incarnate our own principles and stand-point in the world of practice, we find no way open to us to do so except by directing towards others those very manipulative modes of relationship which each of us aspires to resist our own case‖ (Ibid., 68). It looks like that we moderns close our minds and stand bleakly in the Hobbesian field of all men‘s war against all. MacIntyre‘s works on the failure of modern moral theory is cogent, but then how does he intend to overcome modernity? He seems to want us to go back to Aristotelian-Thomist tradition (1990, p. 181; 2001, p. xxviii). Why does he highly regard of medieval Christian kingdom? There are some evidence that people were forced to confess their sexual desires and life in churches (Foucault, 1990, p. 111; Nakayama, 2004, pp. 219-24). Nobody wants to return to that practice. Which part of that tradition does he think should revive? He brings our attention to Aquinas‘s vision of a communal life (1996, p. 42). Although Aquinas‘s vision did not become hegemonic, MacIntyre believes that his vision is an excellent alternative. Probably MacIntyre believes that ―plain persons…are able to engage together in systematic reasoned debate designed to arrive at a common mind‖ in a communal life (Ibid., p. 185). And customs protect the autonomy of communal life from ―all the great wielders of power— royal, baronial, andecclesiastical‖ (Ibid., p. 51). He seems to find his ideal society in such a
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communal life. He wrote that ―The modes of social practice in some relatively small-scale and local communities—examples range from some kinds of ancient city and some kinds of medieval commune to some kinds of modern cooperative farming and fishing enterprises—in which social relationships are informed by a shared allegiance to the goods internal to communal practices, so that the uses of power and wealth are subordinated to the achievement of those goals‖ (2001, p. xvii). In MacIntyre‘s ideal community, agreed common mind is to spell out a hierarchy of goals and a standard of excellence and responsibilities assigned to each social role such as husband or hunter. In such a communal life, profit-seeking desires would be curtained by the deserts of workers. This can be known by his criticism of capitalism. He was critical of capitalism because ―[h]ard, skilled and conscientious work, if it does not generate sufficient profit, something that it is not in the power of the worker to determine, will always to apt to be rewarded by unemployment‖ (2001, p. x). He also believe that we can learn the virtues of acknowledged dependence only in a communal life (1999, p. 8). Although dependence was not part of Aristotle‘s catalog of virtues, he believes that both depending on and being relied upon by members of a family and a community are needed to actualize our virtues. If vulnerability and disability are part of human nature, dependence is also part of human nature. Unless we properly acknowledge and act on the virtue of dependence, our moral theory and practice is incomplete. The permanently disabled in a community can allow us to learn this virtue of dependence and thus deserve respect (Ibid., p. 135). And practicing such a virtue is possible only in a family and a community in which we have vital interests of daily life. It seems that MacIntyre provides us institutional guidance to overcome modernity more than Strauss does. It is a great strength that he has discussed a lot about social sciences and elaborated how moral theory and practice are possible in a real world. Although I am not sure how his idea of moral community is possible in this age of global economy, some of his institutional guidance, such as subordinating economic interests to communal interests, participation in communal affairs, or virtues of acknowledged dependence, will be part of project to overcome modernity if we start to develop policy ideas.
MARTIN HEIDEGGER MacIntyre wants to go back to Aristotelian Thomism, while Strauss wants to go back to Socrates. But Heidegger seems to want to go back further: he seems to want to overcome Greek metaphysics on which the whole Western intellectual history has been grounded. What is wrong with Greek metaphysics? He takes an issue of the division of the subject and the object. He believes this division itself is inappropriate and has ruled the interpretations of words in the West (1990, section 1). The division of the subject and the object is a subject‘s function of putting the object in front of itself (stellt es vor) (Ibid., sec. 60; 2000, p. 132). Heidegger believed that this is a fundamental stance of European thoughts and that it should be overcome (2000, p. 130). But why? This division allowed seeing nature as dead materials and led to a view of nature as mechanism (Kida, 1993, p. 139). Once the mechanistic view of nature was established, all epistemologies and technologies has led to what he called ―Gestell‖, a huge exploiting organization which reduces everything into materials (1990, p. 289; cf. Zuckert and Zuckert, 2006, p. 93). And this organization is self-operating and
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unrestrained; it will end its operations when it conquers everything existent, including humans (1990, sec. 40). For Heidegger, moderns seem to be advancing single-mindedly for a goal of technically creating themselves. And when they have done that, mankind will destroy itself (cf. Clark, 2002, p. 34). Recent developments of genetic engineering make this worry understandable. As Fukuyama (2002) and Sandel (2007) warns, we probably will lose something quintessentially human for ever when we are able to genetically design children. Moreover, Heidegger believe that humanism propagated in the West are based on Greek metaphysics as he understands it (1990, sec. 49). Such humanism cannot grasp the true nature of human existence, and it even fails to ask a question about the truth of what he calls sein (being). And humans cannot live a lively (wesen) life as long as such humanism defines human existence as a subject in terms of the division between the subject and the object, or ego cogito (1990, sec. 88). Then what does Heidegger suggest we should do? He believes that we should go back to pre-Socratic thinkers such as Heraclitus or Parmenides (1990, sec. 72). The reason is that preSocratic thinkers‘ understanding of sein is superior to that of Greek metaphysic philosophers like Plato and Aristotle. Pre-Socratic thinkers had understood sein to be something to grow and appear, while metaphysic philosophers perceived sein of presence, something present to be formed and transformed (Kida, 2007, pp. 199, 221). Heidegger believed that pre-Socratic thinkers called sein ―physis” (2000, p. 16). Physis is generally translated to ―nature‖ today, but Heidegger argued that physis meant ―to appear, stay there and rule (das aufgehendverweilende Walten)‖ (ibid., p. 17). He used an example of the flowering of a rose to explain physis. He firmly believed that tying to perceive this physis is very important because the sense of physis leads us to the wisdom of our life and world. How? First, Heidegger argued that physis is logos (2000, p. 145). He brought our attention to Heraclitus‘ fragments 1 and 2 (ibid., p. 141). There Heraclitus said that logos are ecumenical and all are engendered according to logos. Heidegger understood that this nature and function of logos are similar to those of physis, and thus linked physis with logos. Then, he went on to discuss further about logos. Logos is a noun of legain (λέγειν), and legain means to put something beneath and in front (nieder und vorlegen) or collect, store, manage and rule (Heidegger, 2000, sec. 48, pp. 137-9; 1983, pp. 12-3). Thus logos has a function of putting all together into one view. From here, Heidegger connected logos with Heraclitus‘ ἓν πάντα (1983, p. 29). ―Ἓν‖ is one, ―πάντα‖ is all, and thus together it means ―one is all‖ or ―all is one‖. He understood logos is similar to ἓν πάντα because both have the function of collecting all in one perspective. For Heidegger, ἓν πάντα is ―σουόν (wisdom)‖, the wisdom of the world (Heidegger, 1983, p. 24). It is understandable to consider something as wisdom which puts all into one perspective and allow us to see the whole. And he endorsed Heraclitus‘s motto for loving the wisdom since a life of loving the wisdom allows us to live a lively (wesen) life (2000, p. 67). Since I am not a philologist of European languages, I cannot tell whether Heidegger‘s meticulous interpretations of pre-Socratic Greek thinkers such as Heraclitus are correct or not. Nor can I find any institutional guidance by which his conceptions of sein, logos, and physis affect or transform our life and society. Nonetheless, his works which try to change our understanding of human existence or overcome anthropocentrism, i.e., humanism based on Greek metaphysics of the division of the subject and the object, is helpful for figuring out major themes of overcoming modernity. If we try to cope with negative consequences of
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modernity like the mechanization of all, overcoming anthropocentrism will become one of major themes. We need themes to change institutions. To change modern institutions, we need non-modern themes, and Heidegger‘s works provide one of such themes.
THE ISSUE OF OVERCOMING MODERNITY AND THE JAPANESE Before staring to discuss Japanese attempts to overcome modernity, I would like to make some comments on the context of the issue of overcoming modernity in Japan. The issue was clearly posed in a famous discussion meeting which was held in July 1942, seven months after Japan and America started to fight. The title of the forum was named ―Overcoming Modernity‖. In the forum, influential literature critics, artists, university professors and scientists got together, presented papers and held a roundtable discussion (Kawakami and Takeuchi 1979). Unfortunately, this discussion meeting was dismissed as anti-West in both Japan and West due to the timing of the meeting. Buruma and Margalit is the case in point (2004). But as the papers presented and lively discussions engaged in the forum clearly show, the main themes of the discussion meeting were what the nature of modernity is, what its effects are, and how the Japanese can overcome them. And the reason why this discussion meeting is still important is that discussants of the meeting indentified modernity as the demise of a unified vision of world, the death of God, the power of science, acquisitiveness and materialism bred by capitalism and the lack of morality. It is these themes that this paper is concerned with. Moreover, overcoming modernity is relevant for the current Japanese. Some leftist Japanese think that it is irrelevant for the Japanese because they have not yet achieved modernity by abolishing the imperial house (cf. Hiromatsu, 1997, p. 45). But the Japanese are struggling with the consequences of the death of God and the power of science, and for that matter the issue of overcoming modernity is relevant for them. Furthermore, some Japanese such as Yoshimi Takeuchi and Wataru Hiromatsu bring up the issue of Japan‘s relation with Asia when dealing with the issue of modernity. They seem to think that Asia has a key to overcome modernity and thus want Japan to unite with Asian countries. Although Japan‘s friendly relationships with Asian countries are important, bringing up such foreign policy issues will divert our attention from the core themes of the issue of overcoming modernity. With these general comments, I would like to turn to three Japanese philosophers who have dealt with the issue of modernity. The first is Kitarou Nishida. Nishida is probably the first modern Japanese philosopher. Before the Meiji Restoration of 1868, Japanese education had consisted of mainly poems, Shito, Buddhism and Confucianism. After the Meiji government started to hire Western scholars, what Japanese intellectuals mostly did was the translation of Western studies and sciences. But around the turn of the twentieth century, some Japanese intellectuals started to think themselves, trying to overcome Western thoughts. Nishida was a harbinger of such type of Japanese intellectuals. Nishida‘s main philosophical interest is related to what Heidegger tried to overcome, that is, the division of the subject and the object. The division is so natural for us moderns, and we are perplexed when we are told that this division should be overcome. Heidegger‘s worry that the division would lead to ―Ge-stell‖ is understandable. But what can we overcome the division? Nishida‘s answer is ―pure experience‖. Pure experience is an experience which we
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have before the subject starts to depart from the object (1950, p. 13). For example, we can have a pure experience of thunder immediately after we hear it. At the moment I hear thunder, it is like that I and thunder is one. But when I start to think that I hear it has thundered, the subject is already trying to objectify or discern my experience of thunder. In this moment, the subject has already departed from the object (Nagai, 2006, p. 14). Since there is no division between the subject and the object in pure experience, there cannot be a doubt or suspicion about the experience: such a doubt or suspicion can arise only when the subject starts to examine the object. Since it cannot be doubted, Nishida believed that pure experience can be a good starting point for philosophical inquiry. Then he tried to explain epistemology, moral theory, moral practice and religion. However, it is not clear how personal experience such as Nishida‘s pure experience can be used to explain epistemic or moral knowledge which must be shared by all. Nishida explained further (1922; 1930). For example, he argued that it is not that we acquire our thought experiences through the interactions between the subject and the object but that our thought experiences arise from pure experience which includes the subject and the object as its aspects (cf. Nitta, p. 13). Unfortunately his works are so abstract that I cannot follow. Nonetheless, his focus on pure experience is one of understandable attempts to overcome modern epistemology. Since modern epistemology is based on the division of the subject and the object, the project of overcoming modernity logically involves questioning the division; we have to be able to overcome our habit of seeing nature as a dead material. Nishida‘s pure experience and Heidegger‘s focus on physis, sein, or logos are some of such attempts. It seems to me that these attempts lead us to conclude that we need to revive non-scientific or religious ways of seeing the world to overcome modern epistemology, which has a great consequence on modern morality and political ideology. Thus reviving faith will be an indispensable element of the project of overcoming modernity.
TETSUROU WATSUJI (1889-1960) Watsuji took an issue of modern Western ethics. He believes that Western studies of ethics tend to see only the individual aspect of human nature (2007a, p. 25). He finds the beginning of this tendency in Aristotle‘s ethic. To be sure, he notes that Aristotle grasped both the individual and social aspects of human nature (1934, p. 47). In Politica, Aristotle says that polis is prior to individuals (1253a). And Aristotle seems to intend his study on ethics to be part of his much larger study on humans in which both individual and social aspects of human nature would be examined. Nonetheless, his works on ethics such as Ethica Nicomachea came to be misunderstood as a work of dealing with the goods in individual consciousness (Watsuji, 1934, p. 48). The cause of this misunderstanding is Aristotle‘s choice of method of inquiry: he decided to focus on the individual, rather than social, aspect of human nature (ibid., p. 49). Setting aside the social aspect of human nature, Aristotle asked what the human good is which distinguishes humans from other creatures. Then he tried to answer this question by elaborating the praxis of logos and other virtues. The praxis of logos was perceived as a development of individual personality, and thus ethics came to be understood as a matter of individual consciousness. Watsuji believed that modernity intensified this tendency (2007a, p. 1). In epistemology, Descartes advocated ergo cogito in
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epistemology, while Kant made will a central issue in moral practice (ibid., p. 74). Watsuji feels that these kinds of studies of ethics fail to grasp the true nature of human existence and reduce ethics to a study of individual consciousness (2007a, p. 54). Then, what is a proper way to grasp human nature in a study of ethics? Watsuji argued that human existence has both individual and social aspects. The social aspect of human existence is understood as aidagara (the relationships between individuals), such as a relationship between a husband and a wife, that between parents and a child, that with relatives, that with community neighbors, and that with one‘s nation. The individual cannot understand oneself concretely without referring to these relationships (ibid., p. 154). For him, Western studies of ethics did not appear to adequately recognize this. This does not mean Watsuji thought the social aspects are prior to the individual aspect. He said that any social relationships cannot exist without individuals (2007a, p. 150). In this sense, neither individual nor social aspect is prior to the other (ibid., p. 155). And Watsuji believed that a study of ethics which focuses on these relationships would prevent a study of ethics from degenerating into a study of individual consciousness. MacIntyre‘s works show us that we cannot have a solid foundation to morality as long as we rely on desires, sense, will or reason. For these are so fickle and amorphous. Since we are prevented from resorting to God for public reason,1 human relationships seem to be the only alternative left to give a foundation to morality. Watsuji seemed to think that we can ground morality and properly understand the right and wrong of deeds, obligations, responsibility and virtues by referring to human relationships (2007a, p. 19). But what kind of human relationships is Watsuji talking about? What is the content of them? He answered that all human relationships are based on trust. And he says that the good and bad can be derived from trust. Conducts which answer trust are good, while those which betray trust are bad (2007b, p. 48). He also rejects moral relativism which claims that the principles of the good and bad vary depending on time and place (ibid., p. 57). He believed that the principle that trust-answering is good and trust-breaking is bad is universal and eternal. He observed that basic commands such as ―don‘t kill‖, ―don‘t rape‖, ―don‘t steal‖, and ―don‘t lie‖ are universal and eternal. The reason why these acts are bad is that they betray trust. What varies according to time and place is the specific range and expressions of trust. How widely is the trust principle applied, or what conduct specifically constitutes a trustbreaking behavior? These questions cannot be answered once and for all. But that is a different matter from moral relativism, according to Watsuji: contents of trust vary according to times and places, but the principle of trust does not. Watsuji‘s discussion on trust has a merit. Trust is socially prescribed, and thus a study of ethics which is based on trust can avoid the pitfall of focusing on individual consciousness. And the focus on trust can avoid moral relativism and simultaneously accommodate the changes of time. I would like to finish this section on Watsuji by reviewing his discussion on capitalism. Like MacIntyre, Watsuji was critical of capitalism. The reason was that capitalism came to use humans for profit instead of using profit for humans (2007c, p. 267-8). He believed that economic organization should be an ethical scheme dealing with material goods. Referring to Malinowski‘s research on the Trobriand Islands, he argued that ancients did not work for profit (2009b, p. 289); they worked for social and traditional motivations. They gave most of 1
Rawls wrote that ―I propose that in public reason comprehensive doctrines of truth or right be replaced by an idea of the politically reasonable addressed to citizens as citizens‖ (1999, p. 132).
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crops for their relatives, instead of hoarding for themselves. Work was not instrument; it is a goal itself (ibid., p. 291). And work was perceived as a service for the general public (ibid., p. 312). Also in ancient time, trade had ethical and cultural meaning between communities by exchanging goods. The Kula trade among the Trobriand Islands was the case in point (ibid., pp. 346-50). Overall, Watsuji believed that economic organizations served ethical causes in ancient time. But the emergence of modern economy of industries disrupted the ethical aspect of economic activities; personal contacts between producers and consumers were severed, and the concern for efficiency eclipsed ethical considerations, such as maintaining employment, in production (ibid., pp. 323-4). Watsuji believed that ethical aspects must revive in economic organization (ibid., p. 329), although he was not specific about what to do. I am not sure how the Trobriand Islands were representative of the ancient world; it may not be representative, and that is why they survived until Malinowski visited there during W. W. I.2 Nor I am sure how widely the ancient worked for social and traditional, rather than profit, motivations. Moreover, I am more positive about modern capitalism in which information is circulated (cf. Hayek 1937) and individual ideas and initiatives are allowed. Nonetheless, Watsuji‘s discussion on capitalism is important because it seems that we need some minimum and stable economic resources to sustain an ethical life. If the whim of capitalism rewards hard work with unemployment, as MacIntyre points out above, we can hardly have healthy work ethics. And if healthy work ethics is impossible, we probably cannot have ethics. If the project of overcoming modernity has any meaning at all, the issue of capitalism and job security must be faced up and dealt with even if imperfectly.
TAKESHI UMEHARA Umehara is a victim of distorted reportage of Western media such as the New York Times.3 He is often reported as an example of nationalism, anti-West or Japanese chauvinism. So much so that he had to emphatically deny all these accusations in an interview. He says, ―I have never advocated blood purity nor the racial superiority of the Japanese people. Habitually, I take a multicultural viewpoint in considering the history and makeup of the Japanese people‖ (1995, p. 197). As a person who is familiar with his works, I am a bit sorry for him for having to say this kind of clarification. After having given up studying Western philosophy, he turned to studying Japanese history, religions and literature. All his works since then has been a pursuit for a philosophy of an eternal life. His works have nothing to do with the above characterizations. Indeed, sometimes I find his thoughts anti-state, slightly anti-Japan, and totally inadequate for Japan‘s defense. But this does not mean he approves the West or modernity. He clearly rejects modernity, saying that ―[m]odernism, born in Europe, has already played itself out in principle. Accordingly, societies that have been built on modernism are destined to collapse‖ (1995, p. 189). He even says, ―[f]ar from being the alternative to failed marxism and the reigning ideology ‗at the end of history‘, liberalism will be the next domino to fall‖ (ibid.). He rejects modernity because of two reasons. One is its 2
Gellner wrote that ―In the case of pre-agrarian societies, which leave us no written record, we have the additional problem of deciding whether the few surviving hunter/gathering societies are in any way representative of them all, or whether they are, on the contrary, highly untypical just because they have survived…in the agrarian age‖ (1988, pp. 35-6). 3 See as an example, Ian Buruma, ―A New Japanese Nationalism‖, New York Times Magazine, 12 April 1987.
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nihilistic consequence, and the other is its destructive effects on environment. He believes that these negative consequences are inevitable outcomes of anthropocentrism which modernity intensified. Like so many young Japanese, Umehara read Nietzsche and Heidegger when he was young. He wrote that ―I devoured the works of Friedrich Nietzsche and Martin Heidegger, and spent my youth filled with doubts and anxieties. Like so many others, consciously or unconsciously, I became an existentialist who could not place my faith in any claim to objective values…. Yet, as I married and became established, … I began to feel that I could not survive by a philosophy that emphasized the uncertainties of existence‖ (1995a, p. 179). Then he gave up Western philosophy and turned to Japanese culture and religions. He studied Buddhism and Shinto, and concluded that ―[t]o sum up, it seems clear that the belief in an eternal cycle of life and death is a basic element not only of Shinto, but also of Japanese Buddhism‖ (ibid., p. 187). He firmly believes that the belief in an eternal cycle of life and death is indispensable for morality. He wrote that ―Nietzsche and Dostoyevsky very seriously considered the Europe of their time to be in the ‗age of the death of God,‘ and lamented that Europe was surely courting gave danger. I believe that their concern is now realized. No matter how tenaciously humans cling as individuals to the ‗self,‘ in the end this ‗self‘ is limited and destined to die. And if there is nothing beyond death, then what is wrong with giving oneself wholly to pleasure in the short time one has left to live? The loss of faith in the ‗other world‘ has saddled modern Western society with a fatal moral problem‖ (ibid., p. 190). We usually don‘t think seriously about this. When we think at all, we think that it is wrong because we have economic incentives to live morally. But if we seriously think about it, we will find that economic incentives are not enough to motivate morality. It is probably true that all moral theories are empty and all moral practices are pointless unless we can believe in eternal life. Since atheism is one of the main features of modernity, we must face the possibility of having faith in eternal life if we are really to overcome modernity.4 Another reason why Umehara rejects modernity is its destructive effects on nature. He believes that modernity like Cartesian view is so destructive to nature. He wrote that ―The rational liberalism of the West wholly embraces the Cartesian world view that made the individual—the thinking self—absolute, endorsed man‘s total mastery over nature, and recognized only the existence of mind and matter. Nonhuman life was left entirely out of the picture. … Guided by Cartesian philosophy, the modern world is wiping out nonhuman life, and threatens to bring death to the human species‖ (ibid., p. 189). But his criticism goes beyond criticizing modernity. For Umehara, overcoming modernity is not enough for protecting nature: we need reconsider the entire historical course of mankind (1995b, p. 231). He seems to attack the invention of agriculture and urge us to recover a philosophy of forest. A civilization of city emerged five thousands years ago. One of the first cities was that of Gilgamesh5 of Sumer. And the first thing he did was to kill a god of forest called Humbaba (1995b, p. 230). This killing freed mankind of a taboo of prohibiting a destruction of forest. Since then, vegetation of wheat and stock-raising rapidly spread, causing destruction to nature. Modernity only intensified this process by propagating anthropocentrism. It is interesting to see that what Umehara says is consistent with anthropological researches on 4
I have dealt with this issue in a paper titled ―Japanese Religious Traditions in a Secular Age: the Ninth Sense as a Moral Source‖. 5 He is considered to really exist around about 2,600 B.C., according to Wikipedia (Internet dictionary).
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hunter/gatherers by Marshall Sahlins and James Woodburn.6 For them, the inception of agriculture is the biggest divide of the history of mankind. Before agriculture, there had been no hard work, no greed nor social stratification. But after that, mankind had to have all of them. For them, the emergence of modern bourgeois society is not qualitatively significant moment. Summarizing their works, Gellner wrote that ―the peasant seems to be a kind of proto-bourgeois‖ in the sense that ―agriculture involves labour with delayed return‖ (Gellner, 1988, pp. 31-3). The invention of agriculture was a great turning point, and anthropocentrism is destructive to nature. These claims may be true, but what can we do? Does Umehara therefore advocate giving up science or agriculture? No. He urges us to change the conception of technology from that of conquering nature to that of co-existing with nature (1995b, p. 43). And he admits that this will require much higher technological standards. But aren‘t our scientists working for that direction? They are working to develop efficient cars, lesspolluting factories, environment-friendly energy resources, etc. If so, what is so important to take issue of modernity to save the Earth? He seems to want to revive polytheism. He wrote that ―the polytheist sees mountains and rivers as gods‖ (1995a, p. 193). If we see gods in mountains, forests and rivers, we are more likely refrain from cutting down or remove them, thereby preserving pristine nature. Although it is a very negative way to save nature, belief in polytheism is probably the most effective way to save nature if our scientists are likely to fail to come up with technologies to save nature. Umehara probably thinks that our scientists will fail and that we had better believe in polytheism to save nature. This would be one position, although it may not convince many of us.
SHOULD MODERNITY BE OVERCOME? I have reviewed vocal advocates of overcoming modernity in the West and Japan, and now I can list up major themes of the project of overcoming modernity. (1) Strauss urged us to aim high and seek truth and the best regime. (2) MacIntyre urges us to revive communities in which we can have moral practice. Both are critical of modern liberalism‘s neglect of the importance of training virtue (Strauss, 1964, p. 33; MacIntyre, 1984, p. 162). (3) Heidegger and Nishida tried to overcome the subject-object division to understand the wholeness. (4) Watsuji urged us to answer trust in concrete human relationships. (5) Umehara urges us to have a faith in eternal life. (6) MacIntyre and Watsuji want to make economy subservient to ethical goals. Then, I would like to ask whether the project of overcoming modernity should begin. Modernity is currently hegemonic ideology in our age. It consists of secularism, preferred position of atheism, capitalism, property rights, civil-political freedoms, democracy (voting), welfare and the rule of law (courts). It is very successful in Western countries and Japan. So much so that anyone who argues against it in these countries is conceived as a ―dangerous‖ person. However, I find two major weaknesses in modernity. One is its background belief in atheism. Atheism is a view that we are nothing after death. I find that Umehara‘s conclusion that atheism is fatal to morality is probably true. Unless we can believe in eternal life, all moral talks are empty. And unless we can maintain morality, social stability might not be 6
My discussion on this topic is based on Gellner (1988, pp. 31-4).
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sustained. Gellner warns us, ―not so fast‖. He seems to think that modern society can maintain viability without public morality. He wrote that ―[i]t is not self-evident to me that societies may not also be based on fear, inertia, rational self-interest or other principle‖ (1994a, p. 63). But we see more and more social problems which modern liberal prescriptions, that is, providing more freedoms, welfare and education, cannot remedy. More and more people are losing the will to live or live cooperatively with others. Morality is not solely about social stability but firstly about individual will to live. Turning the tide would require reconsidering modern mindset. Second is that modernity ignores the importance of training of virtues. Modern liberal ideology advocates the freedom of consciousness, thereby prohibiting the state from indoctrinating or forming people‘s characters. According to this view, the only business of the state is guaranteeing security, freedoms, jobs and welfare, and letting citizens to choose their own life plan. But many of social problems in highly modern societies are relating to citizens‘ mental capabilities of writing and acting on their life plan. Mental capabilities, or virtues, must be trained; they will not grow automatically. I can understand Strauss‘ and MacIntyre‘s emphasis on the importance of training virtues. But why does the state have to do that? For many families are not functioning properly to do that. Most of troubled students come from broken or malfunctioning families. Proponents of modernity would warn that letting the state to involve in character-building leads to totalitarianism. Although this is preposterous, even a conservative note a risk involved in character-building. Sandel writes that ―[t]o accord the political community a stake in the character of its citizens is to concede the possibility that bad communities may form bad characters‖ (2005, p. 26). But voting, free press and courts would abate this risk. These institutions guarantee a ―zig-zag politics‖, Nozick‘s phrase, thereby prohibiting an extremist domination of political process for a long time. Proponents would further argue that character-building violated the freedom of consciousness. But the problem is that we have a difficulty in developing healthy consciousness or consciousness at all. A minimum amount of values must be indoctrinated. Even Rawls admits coercion to this extent. He writes ―in affirming a political conception of justice we may eventually have to assert at least certain aspects of our own comprehensive religious or philosophical doctrine‖ (1993, p. 152). Indeed, government‘s welfare program is incomprehensive unless we share a common value: that is, we all should have fair chance to develop our potentialities. Arguing that ―[e]ven the willingness to make an effort…is itself dependent upon happy family and social circumstances‖ and thus that nobody cannot automatically claim all they earn is a far-fetched argumentation to justify welfare. Modernists‘ flat rejection of the state‘s role for characterbuilding thus should be reconsidered.
DILEMMAS OF WAR, SCIENCE AND JOB SECURITY I do not claim that major themes that I have delineated above are sufficient for the project of overcoming modernity. But it is likely that they have to be dealt with if we are really to do so. I would like to postpone a task of developing institutional proposals from these themes in other papers. But in the rest of this paper, I would like to explore three dilemmas which are likely to arise among these themes.
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First is about the state. MacIntyre and Umehara seem to be critical of the state. MacIntyre wrote that ―the modern state cannot provide a political framework informed by the just generosity necessary to achieve the common goods of net works of giving and receiving‖ (1999, p. 133). Umehara criticizes that Watsuji‘s ethical scheme ended up with justifying fighting for the state (1995b, p. 208). But we cannot ignore the state because an international structure is anarchic: war could happen anytime (Waltz 1979). Although war does not happen most of times in most of places, a possibility is always there that war could happen. Different languages and history make sure mankind divided into competing political units with different values and memories. Disputes over territory, natural resources and economic rules are rampant. Where diplomacy ends war begins. A world government or a United Nations which can effectively guarantee security for all members is a dream. If we try to set up such a center of power in world politics, battle over it will be fierce. Waltz predicts that ―[t]he greater the power of the center, the stronger the incentive for states to engage in a struggle to control it‖ (1979, p. 112). Thus the state is the last resort to protect us from foreign invasion. However, if we emphasize the importance of the state and promote patriotism, our foreign policy will be jingoistic. Moreover the emphasis on the state will undermine the autonomy of regional administrative unit or communities. To that extent, one requirement for moral practice, that is, community members get together, deliberate and decide for themselves, will be compromised. Second is about science. If war could happen anytime, we have to encourage scientific developments to maintain superior weaponry. Strauss clearly noted this. He observed that ancient philosophers were distrustful of scientific developments and wanted to supervise them. But they ―had to admit the necessity of encouraging inventions pertaining to the art of war. They had to bow to the necessity of defense or of resistance. This means however that they had to admit that the moral-political supervision of inventions by the good and wise city is necessarily limited by the need of adaptation to the practices of morally inferior cities which scorn such supervision because their end is acquisition or ease. They had to admit in other words that in an important respect the good city has to take its bearings by the practice of bad cities or that the bad impose their law on the good‖ (1958, pp. 298-9). But if we continue scientific developments, it seems that we are less able to sustain faith in the ―other world‖ or eternal life. When we can copy humans like Dolly, any attempt to sustain faith or overcome the subject-object division will be Quixotic. Thus science poses a great problem for the project of overcoming modernity. Third is about job security. If war could happen anytime, we must have a viable and dynamic economy. A nation‘s military power depends on its economic power. Dynamic economy requires efficient and free distributions of scarce resources, ideas and information. According to Hayek (1937; 1994, chap. 9), only free price mechanism can achieve such free and efficient distributions. However, if we allow free distributions of economic resources and information through free price mechanism, we must accept layoffs: if workers produce products and services whose social demands are low, they will inevitably face lower remuneration or unemployment. Even today‘s invincible dominant monopolist can be reduced by rapid technological developments into an utterly miserable loser tomorrow, as Posner‘s antitrust analysis of ―dynamic monopoly‖ suggests (1999; 2005, p. 246). Job security is hardly available in such an economic environment. But MacIntyre and Watsuji believe that job security is crucial for an ethical life. Dynamic economy, which is required to defend the nation in an anarchic international politics, may not be able to provide job security.
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CONCLUSION I have tried to articulate ―some idea of what a better order would be‖ if we overcome modernity. To do so, I have delineated major themes of vocal critics of modernity in the West and Japan. Major themes are (i) higher political ideals, (ii) virtue-building, (iii) community, (iv) non-objectifying way of epistemology, (v) trust in inter-personal relationships, (vi) faith in eternal life. Then, I have discussed whether we should overcome modernity. Modernity has bred atheism and ignores the importance of virtue-building. Since modern liberal prescriptions do not seem to be effective for many of current social problems, modernity should be reconsidered and overcome where possible. Finally, I have discussed some dilemmas which are likely to arise when we are to overcome modernity. Since the anarchic structure of international politics makes war a real possibility, the state must be recognized as the last resort of our defense. But the emphasis on the state may undermine the autonomy of community which moral practices require. Also we must continue scientific developments since war is always a real possibility. But continuous scientific developments are likely to make it difficult to have faith in eternal life, which is indispensable for any moral theory and practice. Moreover, since nation‘s military power depends on its economic power, we must maintain a viable and dynamic economy. Such an economy seems possible only when scare resources and information are freely and efficiently distributed through free price mechanism. But if we allow free price mechanism, whims of the market will threaten job security which is necessary for ethical life. If the project of overcoming modernity is to be realistic, these dilemmas must be dealt with. I do not have answers to solve these dilemmas. Nor have I tried here to put major themes of overcoming modernity into concrete institutional and policy proposals. I hope I will be able to provide them when I discuss current issues in other places.
REFERENCE Buruma, I. & A. Margalit, (2004). Occidentalism: The West in the Eyes of Its Enemies. New York: Penguin Press. Clark, T. (2002). Martin Heidegger, trans. T. Takada. Tokyo: Seidosha. Foucault, M. (1990). Politics, Philosophy, Culture. New York: Routledge. Fukuyama, F. (2002). Our Posthuman Future: Consequences of the Biotechnology Revolution. New York: Farbar, Straus and Giroux. Gellner, E. (1988). Plough, Sword and Book. Chicago: University of Chicago Press. Gellner, E. (1994a). Encounters with Nationalism. Oxford: Blackwell. Gellner, E. (1994b). Conditions of Liberty. London: Hamish Hamilton. Hayek, F. (1937). Economics and Knowledge. Economica 13 (February). Hayek, F. (1994). The Road to Serfdom. Chicago: University of Chicago Press. Heidegger, M. (1983). Rogosu, Moira, Arēteia (Words, Destiny and Truth), trans. Y. Utsunomiya. Tokyo: Risousha. Heidegger, M. (1999). Hyūmanizumu ni tsuite (On Humanism), J. Watanabe (trans.). Tokyo: Chikuma Gakugei Bunko. Heidegger, M. (2000). Martin Heidegger: Die japanische Gesamtausgabe Band 40, Einführung in die Metaphysik. (Tokyo: Soubunsha).
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Hiromatsu, W. (1997). Hiromatsu Wataru Chosakushuu, 14 kan (Collected Works of Wataru Hiromatsu, vol. 14). Tokyo: Iwanami Shoten. Hirschman, A. (1997). The Passions and the Interests. Princeton: Princeton University Press. Kawakami, T. & Takeuchi, Y. (1979). Kindai no Choukoku (Overcoming Modernity). Tokyo: Fuzanbou. Kida, G. (1993). Haidegā no Shisou [Thoughts of Heidegger]. Tokyo: Iwanami Shoten. Kida, G. (2007). Han Tetsugaku Nyuumon (A Introduction to Anti-Philosophy). Tokyo: Shinchousha. Lakatos, Imre, (1979). ‗Falsification and the Methodology of Scientific Research Programme‘, in Criticism and the Growth of Knowledge Cambridge University Press. Liederbach, H. P. (2006). Haidegā to Watsuji Tetsurou [Heidegger and Tetsurou Watsuji], trans. Yukihiro Hirata. Tokyo: Shinshokan. MacIntyre, A. (1984). After Virtue, 2nd ed. Notre Dame: University of Notre Dame Press. MacIntyre, A. (1986). A Short History of Ethics, S. Shouzou (trans.). Tokyo: Ibunsha. MacIntyre, A. (1990). Three Rival Versions of Moral Enquiry. Notre Dame: University of Notre Dame Press. MacIntyre, A. (1996). Ethics and Politics. Cambridge: Cambridge University Press. MacIntyre, A. (1999). Dependent Rational Animals. Chicago: Open Court. MacIntyre, A. (2001). Marxism and Christianity, 2nd ed. London: Duckworth. Nagai, H. (2006). Nishida Kitarou: Zettaimu toha Nanika (Kitarou Nishida: What is Absolute Nothingness?). Tokyo: NHK Press. Nakayama, G. (2004). Fūkō Nyuumon [Introduction to Foucault]. Tokyo: Chikuma Shinsho. Nishida, K. (1950). Zen no Kenkyu (A Study of the Good). Tokyo: Iwanami Shoten. Nishida, K. (1922). Jikaku niokeru Chokkan to Hansei (Intuition and Reflection at SelfAwareness). Tokyo: Iwanami Shoten. Nishida, K. (1930). Ippansha no Jikaku Taikei (Self-Awareness System of the Universal). Tokyo: Iwanami Shoten. Nitta, Y. (1998). Gendai no Toi toshiteno Nishida Tetsugaku (Nishida Philosophy as a Modern Issue). Tokyo: Iwanami Shoten. Popper, K. (1976). Conjectures and Refutations. London: Routledge & Kegan Paul. Posner, R. (1999). Natural Monopoly and its Regulation. Washington, D.C.: Cato Institute. Posner, R. (2005). Law, Pragramtism, and Democracy. Cambridge, Mass.: Harvard University Press. Rawls, J. (1993). Political Liberalism. New York: Columbia University Press. Rawls, J. (1999). The Law of Peoples, with “the Idea of Public Reason Revisited”. Cambridge, Mass.: Harvard University Press. Sandel, M. (2005). Public Philosophy. Cambridge, Mass.: Harvard University Press. Sandel, M. (2007). The Case Against Perfection: Ethics in the Age of Genetic Engineering. Cambridge, Mass.: Belknap Press of Harvard University Press. Strauss, L. (1950). Natural Right and History. Chicago: University of Chicago Press. Strauss, L. (1958). Thoughts on Machiavelli. Illinois: Free Press. Strauss, L. (1963). The Political Philosophy of Hobbes. Chicago: University of Chicago Press. Strauss, L. (1964). The City and Man. Chicago: University of Chicago Press. Strauss, L. (1989). The Tree Waves of Modernity, in H. Gildin (ed.), An Introduction to Political Philosophy. Detroit: Wayne State University Press.
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Strauss, L. (1995). Liberalism Ancient and Modern. Chicago: University of Chicago Press. Strauss, L. (1996). The Rebirth of Classical Political Rationalism, T. L. Pangle, (ed.), Y. Ishizaki et al. (trans.). Kyoto: Nakanishiya Press Strauss, L. (1997). Spinoza‟s Critique of Religion, trans. E. M. Sinclair. New York: Schocken Books. Strauss, L. (2006). On Tyranny, Y. Ishizaki et al. (trans.). Tokyo: Gendai Shiso Shinsha. Tajima, T. (1990). Ekkuharuto Sekkyoshu (A Collection of Sermons of Eckhart). Tokyo: Iwanami Shoten. Taylor, C. (1989). Sources of the Self. Cambridge: Harvard University Press. Taylor, C. (2007). A Secular Age. Cambridge: Harvard University Press. Umehara, T. (1991). Mori no Shiso ga Jinrui o Sukuu (The Civilization of the Forest Saving the Mankind). Tokyo: Shougakkan. Umehara, T. (1992). Nihonjin no Tamashii (The Soul of the Japanese). Tokyo: Kobunsha. Umehara, T. (1995a). ‗The Civilization of the Forest: Ancient Japan Shows Postmodernism the Way‘, in N. P. Gardels, (ed.), At Century‟s End. California: ALTI Publishing. Umehara, T., Yoshimoto, T. & Nakazawa, S. (1995b). Nihonjin ha Shiso shitaka (Have the Japanese Thought?). Tokyo: Shinchousha. Waltz, K. (1979). Theory of International Politics. Reading, Mass.: Addison-Wesley. Watsuji, T. (1934). Ningen no Gaku toshiteno Rinrigaku (Ethics as a Study of Human Relationship). Tokyo: Iwanami Shoten. Watsuji, T. (2007a). Rinrigaku, 1 (Ethics, vol. 1). Tokyo: Iwanami Shoten. Watsuji, T. (2007b). Rinrigaku, 2 (Ethics, vol. 2). Tokyo: Iwanami Shoten. Watsuji, T. (2007c). Rinrigaku, 4 (Ethics, vol. 4). Tokyo: Iwanami Shoten. Yoshikazu I. (2008). Nihon Shugi to Toukyou Daigaku (Japanism and the University of Tokyo). Tokyo: Kashiwa Shobou).
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 3
THE NON-IDEAL CONDITIONS OF TRANSITIONAL JUSTICE WITH A CASE-STUDY ON THE CARETAKER GOVERNMENT OF BANGLADESH Claudio Corradetti Researcher at the European Academy, Bolzano, Italy Temporary Lecturer at the University of Rome ‗Tor Vergata‘
ABSTRACT The actual international scenario, while urging for the elaboration of yet more refined international models of justice, it calls also for the understanding of those transitional contexts where no fully fledged democracy or rule of law of international justice can be directly applied before central institutional and legal reforms are conducted. These situations are those which can be defined in terms of non-ideal conditions of justice. Non-ideal conditions of justice, though, should not represent both at the theoretical and at the practical implementing point a defeat from the start for the progressive realization of a just scenario. Rather, non-ideal conditions of justice, should be framed as sub-optimal conditions of ideal justice requiring specific transitory steps and reforms which would eventually lead to fully working democratic systems. Along this essay I will clarify some theoretical and methodological issues that are relevant on how non-ideal contexts of justice should be conceived, and then I will turn my analysis on the analysis of two recent documents dealing with the role that the international community should play in transitional contexts. Finally I will present an electoral model which I take as being at the core of an institutional and legal renewal of transitional democracies, and present a case study which is instructive on the procedural and institutional pitfalls to be avoided when dealing within deeply divided societies.
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1. INTRODUCTION Political theory, nowadays, is progressively exposed to the global dimension of the rule of law and justice. Just after the terrifying events of 11 September 2001, political theorists felt the need to reframe the normative patterns of a yet new approach to international politics. The core issue under debate has been that of considering whether international intervention within third states can find legitimation, as well as upon under conditions such legitimation can be found. International terrorism, indeed, represented a peculiar challenge since, differently from state organized crime, it showed itself to be capable of recruiting Islamist supporters from several western and non-western countries. Nonetheless, it was evident since then that, among Islamic states, at least few were clearly supporting and financing international terrorism. As a consequence, while considering the peculiarity of such phenomenon, state responsibility in favouring terrorism either actively or passively, was seen as part of a larger strategy characterized by several areas of intervention both domestic and international. This trend, though, was only one among the several that politics of the new millennium had to face. Indeed, it was correctly seen as part of a larger number of issues concerning a possible new role by the international community, the global investors and international tribunals; also, it questioned internal and external strategies concerning all those attempts aimed at grouping states within macro-national aggregates. The concern upon which legitimate conditions can be internationally established for the justification of intervention within third states, though, cannot anymore be separated from the duty by the international community to assist to the rebuilding of the basic structure of a post-war society and state. That a post-war phase must be followed by a long-term period of institution building under the guide of the international community is something which has become more and more clear due to the socio-political fragmentation that past actions have caused. In the past, international or unilateral state intervention in third countries, rather than contributing to the pacification of a geographical area, has prompted conflict and accrued potential threads. This second, and probably more engaging aspect of state intervention, is what appears to be absolutely new in the approach to post-war strategy. Indeed, it integrates those normative conditions of legitimacy of state intervention through a commitment to reconstruction and institution building. Along this essay, after a general overview of the dimensions of international intervention, I will address precisely the relevance of reconstructive policies. More specifically, I will sketch a normative model for the underpinning of the notion of ―transitional justice‖ in post-war contexts as it emerges from two of the most interesting documents circulating among experts. Transitional justice, differently from justice tout court, is a normative model at work in non-ideal contexts. It involves several areas of intervention running from civil society to institutions; accordingly, it places itself as a fundamental requisite for the development of a long-term strategy in post-war contexts. Some terminological clarifications are mandatory at this regards. Indeed, according to Rawls formulations (Rawls, 1999, Part Three), non-ideal justice asks itself how well-ordered peoples should behave towards those peoples which are not well-ordered. To pose such questions, means that an already clear model of (ideal) justice has been conceived, and that it guides non-ideal justice strategies to achieve normatively autonomously justified goals. Rawls, claims also that ideal justice, that is, the formulation of normative political principles of justice, should be context sensitive. For principles, to be context sensitive, mean that they
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 53 should be not impracticable or counter-intuitive. According to Rawls, the same formulation of such principles should take into account what are the actual limits that reality imposes and by doing so, they should propose how to realistically extend such limits. This double constraint of realism and, one might say of ―critical expansion‖ of presently existing institutional boundaries is what Rawls defines as a ―realistic utopia‖, that is, as a model for orienting and formulating politically grounded considerations. The realistic connotation is sensitive to two further constraints, that of confronting principles with natural standards of stability and that of valuing principles in accordance to their practicability within present institutions. On the other hand, the ―utopian‖ connotation is defined by Rawls in terms of the use of ideals, arguments, moral principles etc. oriented to the amelioration of the actual socio-institutional configurations and to the specification of a determinate theory of justice. According to Rawls, there are two senses in which non-ideal justice should be conceived: the first being that of those states unwilling to respect those international ―reasonable‖ constraints of justice which would consequently lead to a just war; the second dimension, instead, is that reconducible to those economic conditions preventing states from the allocation of goods and the development of a liberal regime. In respect to Rawlsian distinctions, I will defend a third dimension of non-ideal justice, a dimension which fits specifically into the contexts of transitional justice, and which does not fall either into the category of disrespect of international standards, nor into a condition of strict economic subsistence. As far as the condition of disrespect of international standards is concerned, the point is that it is not necessarily true that states in transition do have infringed international norms; whereas as far as economic subsistence is concerned, it is not necessarily true that such states are in principle economically dependent on third states support. Rawlsian categorization of non-ideal conditions of transitional justice into such two areas is therefore inadequate for the understanding of transitional justice context and, accordingly, my attempt will be that of delineating a specific dimension of non-ideal justice. Indeed, the main characteristic of transitional justice contexts, is that of an institutional and legal reframing of past unjust regimes, as well as of an implementation of retributive measures aimed at favouring social reconciliation. The reactivation of a condition of rule of law is thus a priority for the reconstruction of a system of justice as well as for the reactivation of a working economic system. Nevertheless, the contextual specificity of transitional domains imposes the formulation of a tailored understanding of the ambivalent role of law both in its backward-looking activity and in its foreword role of facilitating social pacification. The specificity of law is not an isolated case, but rather an indicative example of several areas in which transitional contexts calls for new categories of understanding. For this purpose, I will address later the case of the electoral model as well as of the decision making process that should be generally applied in such cases. For now, though, the theoretical point which must be defended is that non-ideal contexts of justice, and specifically non-ideal transitional contexts of justice must not necessarily be conceived purely in terms of ‗interest mediation‘ among conflicting groups, nor in terms of purely self-interested subjects whose only open option is that of finding a precarious equilibrium among conflicting interests1. 1
The present specialized literature on transitional justice that focuses on the relation between ideal and non-ideal justice takes the opposite view from the one I propose here. For instance Teitel (2000), defends the here criticised position according to which: ―The paradigm of a provisional, hyperpoliticized transitional jurisprudence is linked to a conception of non ideal justice that is imperfect and partial. What is fair and just in extraordinary political circumstances is determined not from an idealized Archimedean point but from the
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Indeed, if one wants to remain faithful to the general Rawlsian distinction between ideal and non-ideal justice, then it must admit that non-ideal justice contexts are only sub-optimal areas of ideal conditions of justice, and that far from being conceivable in a total autonomous way, they are rather logically subordinated to the instantiation, within contingent and imperfect conditions, of normatively autonomous ideals of justice and fairness. This means that nonideal conditions do indeed require parties to compromise among themselves, but the form of compromise that they are called to find is always part of an ethically justified framework which stands over and orient each specific interest trading or constitutional compromise. As said, it is a sub-optimal form of justice which nevertheless does not renounce to approximate to an ideal scenario of deliberation.
2. TRANSITIONAL JUSTICE AND ITS GLOBAL PLAYERS In what follows I will assume, without discussing the details, those philosophical secondorder meta-normative principles at the basis of liberal democracies that are reflected into those first-order principles exposed in the documents I‘m going to consider. The views that such documents present are themselves sensitive to second-order principles of justice spread throughout all liberal western democracies. Accordingly, the focus of my attention will be on the non-ideal dimension of global justice and, particularly, on the transitional justice sector of international intervention. At this regard, one of the most important attempts to reframe the approach to international relations in accordance to normative principles has been that conducted by the Independent International Commission on Intervention and State Sovereignty [ICISS], established by the Canadian government in September 2000 and recently discussed (Sept. 2009) by the UN General Assembly as a framework of action for future reshaping of international relations2. The result of the Commission amounted to the formulation of two documents published in December 2001 under the title of The Responsibility to Protect and centred, respectively, the former on the rethinking of the notion of state sovereignty, intervention and institution building, whereas the latter on an expansion of some central concepts developed in the first and followed by a large bibliography. It is important to highlight that both documents are the result of a wide process of consultation, and that especially the first one, that concerned mostly with content matters, has been conducted throughout cooperation platforms and round-tables with the experts and the representatives coming from all continents. The first and most relevant question that is addressed is on to whom it must be recognized the legitimacy for intervention in the internal affairs of third states once that the duty to protect one‘s own citizens from genocide is established as a universal and unavoidable condition of state legitimacy. Such principle implies, as a consequence, that in those states where genocide takes place, the international community is not only justified in intervening but, most importantly, has a moral duty to do so. The discussion on whether interference into third states is justified and, if so, on which conditions this can be uphold has been largely transitional position itself [...] The comparative and historical perspective pursued here compels an understanding of a non-ideal, ―compromised‖ justice that at once is informed by and constitutive of the conditions under which it is chosen‖ (Teitel, 2000, 224-227). 2 See the Report on the General Assembly Plenary Debate on the Responsibility to Protect (2009).
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 55 debated both in those cases where at the end a decision has be taken in favour of intervention (as the NATO intervention in Kosovo in 1999), as well as in those cases where no intervention has been conducted as in the case of the Rwandan genocide in 1994. As most remember, the so called ―coalition of the willing‖, bypassed the Security Council of the United Nations, that is, the only international body which can assign legitimacy to state intervention and proceed to punish those systematic human rights violations conducted by the Belgrade government. Were such violations enough systematic to require with urgency a unilateral intervention not legitimized by the UN? No clear answer can be given without the precise assessment both of the normative criteria justifying intervention and an empirical survey of the committed crimes. The opposite case, which is nevertheless indicative of the necessity to construct binding rules of state intervention, is that of Srebrenica and Rwanda, where UN troops not only were unable to protect the civilians, as in the first case, but let one of the most systematic and dreadful genocides to happen, as in the latter case. As clearly stated by the document under analysis, the central point that must be clarified concerns how to find a solution between one of the most fundamental principles international law, state sovereignty (Art. 2.1 of the UN Charter) and the moral requirement to stop genocides through armed intervention. The clash between such two principles, lead the ICISS to reformulate the notion of state sovereignty by claiming that state sovereignty cannot be defined as an unlimited power towards citizens. The principle of sovereignty implies both the requirement of respect of other‘s states sovereignty and the requirement of respect of citizens‘ dignity and fundamental rights. Sovereignty, claims ICISS, is to be reframed in terms of internal and external responsibility, from which the title of the document. The notion of responsibility, though, cannot be left unspecified but must be articulated into a specific set of parameters aimed at determining according to which criteria of legitimacy military intervention is necessary or, making sure that it remains within the agreed finalities, that it is effective, that it minimizes human casualties, and finally that it reinforces, in the long run, the possibility of a long lasting condition of peace. The new reframing of the notion of sovereignty in terms of internal and external responsibility over internal legitimate military control, according to the ICISS, involves three fundamental constraints: 1) the protection of the welfare and the security of the citizens 2) the responsibility to protect other states on the basis of the sharing of the principles of the UN Charter 3) the direct accountability for their political actions. Such constraints bring into extreme consequences a general trend that contemporary international law has developed along its documents: the centrality of the individual over the states within the international scenario. The responsibility to protect as a core mission of the states, is thus directed towards individuals, no matter of their citizenship or affiliation; it involves also the need to prevent systematic crimes through bilateral or multilateral agreements, to react to abuses and, what will be later extensively addressed, the responsibility to rebuild those basic conditions of justice. As far as prevention is concerned, the ICISS insists on the necessity to enforce all those mechanisms of prevention accompanied by political engagement aimed at detecting potential dangers at their initial stage, that is, those ―early warnings‖ that will most probably lead to conflict and mass murdering. Among those criteria for the detection of potential threads, are those oriented to the analysis of the economic conditions and wealth distribution within a society, that is, the evaluation of the condition of economic fairness characterizing a political setting. This check should be conducted in connection with a certain number of international parameters agreed before by the international community under the aegis of the UN. Further,
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such measures should be accompanied by the activity conducted by ad hoc or International Tribunals and thus by an emerging constellation of institutions aimed at giving more relevance to the role of law within international relations. Whenever preventing measures fail, the responsibility to protect implies that of reacting to abuses committed in third states. Reaction can take different forms running from sanction to military intervention. In all cases, though, it must be observed that civilians, more than politicians, are more exposed to the negative effects of sanctions and this is to be taken into account whenever strategies are to be made. For this reason, the ICISS has individuated specific sectors of intervention aimed at reducing the impact on the population but at the same way aimed at maximizing results. Such measures range from military embargos and military cooperation, to financial sanctions towards politicians and political organizations and groups of interests, as well as to the restriction of the areas dedicated to commercial activities. A second set of political sanctions foresees a restriction on diplomatic cooperation and representation, expulsion of political representatives and refusal to admit the country in all sorts of international memberships. Whenever such measures appear insufficient to convince politicians to change their strategies, then, it becomes necessary to recur to military intervention. This, according to the ICISS, has to be considered always as a sort of extreme ratio, since it is admissible only whenever state independence and legitimate sovereignty cannot be recognized anymore. The list of cases that if, once completely fulfilled, would lead to a justified military intervention are based upon: a) just authority b) just cause c) just intention d) extreme ratio e) proportional means f) reasonable perspectives. As far as the first point is concerned, that is, the problem of authority, the main problem consists in detecting those sources of authority as those contemplated in the UN Charter. First of all, the ICISS recalls art. 2.4 of the UN Charter stating the duty of abstention of the states from the use of force against territorial integrity. This point, though, is completed by the further qualification coming from art. 24 which states that the UN is called to ensure a rapid and effective action for the maintenance of peace and international order (art.41). This means that the Security Council can allow for the use of military force (art. 42) on the basis of certain parameters that differ in accordance of whether the target country is a UN member or a non-member state. The authorization to intervention is based upon Security Council member states approvals to armed pacification, so that prior consensus is to be asked before any intervention might legitimately take place. The problem, though, is that the fifthteen states can hardly be considered as representative of the entire international community, in particular if one considers also the veto power of the five permanent Security Council member states. Those contemplated reasons of intervention, the so-called just cause (point b listed before), include a large amount of loss of life, real or potential, or ethnic cleansing conducted by the state or by organizations controlled by the state. This includes all the actions defined by the Genocide Convention of 1948 as well as all the crimes against humanity contemplated by the Geneva Conventions and its Additional Protocols and, interestingly, those situations of state collapse where the population is exposed to starvation and/or civil war, as well as natural catastrophes that the state cannot manage to constrain. Coming, then, to condition c) regarding the right intention, the finality of the intervention should be addressed to the prevention of human suffering. Right intention, according to the ICISS, is to be measured as according to this criterion which involves, among different things, also the search for a multilateral intervention. Extreme ratio, in its turn, is that condition which requires that all necessary diplomatic and non-military attempts are pursued
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 57 before any military action is taken. This requires also an incisive action by the Security Council and the General Secretary for the observation and the collection of infield information. The last two constraints, that of e) proportional means and of f) reasonable perspectives, imply respectively that the military action has, in its duration and intensity, the least impact for the reaching of the humanitarian objective. Means must be proportional, indeed, to the goals and the effects limited to the objectives; on the other hand, reasonability in perspective considers that military action be justified only if it has reasonable chances of success, that is, only if it is capable of stopping massacres and human rights violations. The agreed document by the ICISS, considers also the opportunity of clarifying the operative dimension of the military intervention, that is, the procedures and constraints for the construction of a coalition, the peacekeeping activities as well as those related to deterrence and so on. In the present occasion I will skip a detailed analysis of this section, focussing instead on the section dedicated to the responsibility to rebuild. Indeed, it is within this frame that a model of transitional justice must be formulated for the re-establishment of those decent conditions allowing for long lasting peace. The section dedicated to the responsibility to rebuild is presented as part of the strategy foreseen by the responsibility to protect. Once that military operations have been successfully conducted, the legitimacy of the local state power needs to be reactivated through institutional reforms and economic interventions. This postwar phase of reconstruction is essential to the injection of new economic resources and investments, and therefore to the economic re-birth of the country, as well as to the introduction of institutional and social stabilization on the basis of the fulfilment of justice. The responsibility to rebuild, therefore, represents the validation checking of the criterion of efficacy of the intervention, since it represents the most fundamental objective for the achievement of long lasting stability. Among the areas of intervention for the operations of reconstruction are that of security through the disarmament of the local gangs and through the training of police; economic development, and most relevant for our purposes, a judicial process of justice and reconciliation. The process of reconstruction, in other words, reintroduces legitimacy to an occupied state whose sovereignty has been temporarily suspended de facto but not de jure. The goal of military intervention is not much that of substituting one illegitimate power with another illegitimate one, but rather of protecting all those processes of political self-determination of a state. This is the point of connection with the transitional justice strategy since, every state finding itself in the condition of a post-war transition, must reintroduce a condition of basic fairness within different sectors of society. Along the next section I will introduce some constraints on the typology of action that external intervention should maintain for the maximization of efficiency and the maintenance of support legitimacy. External support, though, while important is only a secondary element of a process of self-improvement by society. This process can occur only if a normative model of justice is kept as a guiding point in political choice. Nevertheless, particularly in the case of institutional change, the transitional justice strategy should confront itself with a normative but non-ideal model of justice, which consequently implies different forms of choices that must be endorsed. The role of the international community in regard to the amelioration of the conditions of a third post-war country is, today, an extremely relevant issue due to the crucial role that coherency, promptness and trustworthy of intervention has to show towards the local population. At such regard, the Security Council in a document of 2004 titled: The rule of law and transitional justice in conflict and post-conflict societies, has established a certain
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number of parameters and guidelines aimed at regulating the sectors and the modality of support to be provided to third countries. One of the core concepts developed in such document claims that ―justice, peace and democracy are not mutually exclusive objectives, but rather mutually reinforcing imperatives‖. This relaunches the relevance of an holistic approach to transitional justice as well as the necessity to approach it organically from the international perspective, so that the goal ―is not to build international substitutes for national structures, but to help build domestic justice capacities‖ (2004,1). In order to keep together such three domains of intervention, the document envisages the strengthening of a certain number of most relevant areas, such as: the promotion of the rule of law, the enforcement of international standards of assistance, the identification of the role of the United Nations in peace operations, the support to domestic reforms and in particular the contribution to the development of national justice systems and, finally, the promotion of ad hoc criminal tribunals and in particular of the International Criminal Court. As far as the promotion of the rule of law is concerned, it is made the connection between a long lasting peace promotion and the strengthening of the population conviction on the certainty of law, even if this connection does not suffice to exhaust the problem. Whereas, as far as the enforcement of the international standards of assistance is concerned, and in particular the role that the UN should occupy, it is made clear that UN operations should be targeted to the support of judicial reform, and judge and administrative training, legislative revision, and empowerment of civil society to act as an external check on institutional decision-making. All such sectors of intervention, though, must be preceded by a fundamental step consisting in facilitating reconciliation mechanisms and truth courts hearings, which only can grant a transitional process by reestablishing conditions of truth in a public dimension. This implies that national stakeholders be involved in local processes of consultation, and that the UN in this sense, would help favoring the inclusion of general excluded groups such as women, minority groups etc. A key role in the enforcement of the rule of law and the emerging of an internal process of justice, is the contribution that ad hoc criminal tribunals as well as the International Criminal Court can play. Their contribution is seen by the Security Council in tandem with other areas of intervention, that is, with integrative and complementary functions aimed at increasing the impact on institution building. The document states, clearly, that: ―To these ends, a variety of institutional models has emerged. These have included ad hoc international criminal tribunals established by the Security Council as subsidiary organs [emphasis added] for the United Nations for the Former Yugoslavia (International Criminal Tribunal for the Former Yugoslavia) and Rwanda (International Criminal Tribunal for Rwanda); a mixed tribunal for Sierra Leone, established as a treaty-based court; a mixed tribunal for Cambodia, proposed under a national law specially promulgated in accordance with a treaty; a mixed tribunal (structured as a ―court within a court‖) in the form of a Special Chamber in the State Court of Bosnia and Herzegovina; a Panel with Exclusive Jurisdiction over Serious Criminal Offences in TimorLeste, established by the United Nations Transitional Administration in East Timor; the use of international judges and prosecutors in the courts of Kosovo, pursuant to regulations of the United Nations Interim Administration Mission in Kosovo […]‖ (2004,13). In order to obtain such condition of mutual integration among the different sectors of society, it is claimed that the Security Council should help at coordinating the different subjects by acting as a coordinating entity with the international and local community. This means that the
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 59 prominence of the role of the UN should be decisive in the formalization of bilateral and multilateral agreements among donors, NGOs, and different sectors of the civil society. Thus far, I have delineated some of the major points of intervention around which a new strategy for transitional justice has been recently reformulated along the considered documents. In the remaining part of this essay, I will detail a sketchy idea for a model of elections and democracy within transitional justice contexts which should be pursued in accordance to the previous considerations. Finally it will follow the analysis of a specific case-study, the caretaker Government of Bangladesh. Indeed, I do believe that Bangladesh is still in a transitional political phase, since the Bangladesh liberation war which gave birth to it has produced in its turn a yet unreconciliated number of ethnic and political groups that are still confronting themselves nowadays.
3. ELECTIONS AND DEMOCRACY IN TRANSITIONAL SOCIETIES: DEVELOPING INTERETHNIC AND INTER-PARTY MECHANISMS OF DECISION-MEDIATION As just anticipated, this section will provide some considerations as well as propose an electoral model which is deemed as particularly suitable in the context of transitional justice societies. With this, it is not my intention to claim that the proposed model will be actually appropriate to all specific cases of post-conflict societies, but simply that it is particularly suitable in all those cases where deep cleavages among conflicting groups remain very high also after the end of the war. In his book The Third Wave: Democratization in the Late Twentieth Century (1991), Huntington advances a reconstruction of three main historical trends of democratic developments placed in between 1828-1926; 1943-1962; and from 1974 onward countervailed by two reverse trends where democracies collapsed. The even more recent request for democratization in the Asian, African and Southern American countries, is to be understood in terms of a popular reaction and struggle for liberation from oppressive dictatorships arisen in the period between 1963 and 1973. In most of these cases, further elements to keep in mind, are persistent ethnic and religious cleavages codified into deeply divergent political goals advanced by the parties and preventing, under many respects, what is generally taken as the broadest and uncontested definition of democratic ruling, that is, ―the government by the people and for the people‖. This point raises an issue of democratic representation and, more specifically, it points to the mechanisms of translation of individual preferences into seats or, to put it in other words, to the mechanisms of elections and parliamentary representation. If democratic ruling is bound to spring from and to act in favour of the people, then the crucial question becomes that of ensuring appropriate mechanisms for projecting popular will into the Parliament, and this is the task accomplished by electoral systems. Representation can be conceived of in two fundamentally different ways, that is, on the one hand in terms of representation as a ‗microcosm‘ and on the other in terms of ‗principalagent‘ representation corresponding, in their turn, to the two main divisions one can find in electoral systems, that is representative-proportional and majority-pluralist systems (Farrell, 2001, 11). According to the first understanding of representation, there must be a
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proportional ratio between population preferences and seats as if the Parliament were conceived of as a ―society microcosm‖. As far as the second understanding is concerned, instead, what counts are the decisions of the Parliament which act by replacing voters. In this second case, it is not relevant that the Parliament reflects proportionally the ratios between different ethnic or gender groups of the society. What counts is only that representatives take decisions on behalf of their voters. Decisions are the overriding element toward representation. Even from these initial reflections, one can come to see that the specific type of electoral procedure one has in mind leads necessarily to a specific type of democracy, or that any specific kind of democratic arrangement one wishes to defend cannot be detached from the specific electoral procedure which brings it about. If this is true, then, it seems that there is not a necessity nor an advantage in choosing between a methodological approach conceiving of electoral systems as dependent variables - conceptions and sociological reasons motivating the choice of an electoral system - rather than as independent variables - evaluation of the political and sociological consequences brought forth by any specific electoral system -3. Given that there is not a model which can be thought of as being right in absolute terms4, the contingency of a specific socio- political situation is a relevant factor for the determination of an appropriate democratic standard as well as of the consequences that an electoral system is going to promote. Along this writing, thus, I will address both points by trying to draw a normative measurement of electoral systems and their corresponding democratic forms as according both to the context and to the consequences they bring forth. As just stated, democratic elections play the role of determining the functioning of a democratic ruling by transferring political legitimacy to the winning party/ies. In addition, elections have the function of shaping: the specific way representation is built, the coalitions between parties and the criteria to form a government. According to which electoral system is chosen, it might be more or less likely that a specific party will rule a country, that a candidate is elected, and that a coalition is required in order to win. Electoral systems thus make a difference in the political results that might come about. One distinction can be made between the notion of electoral laws and electoral systems5. For electoral laws it is to be understood the amount of rules accompanying the process of elections, that is, the fixing of the calendar date for elections, the stages of candidate nominations, the rules for determining the requirements of potential voters, those related to political campaign and voting activities, and also the exit polls procedures as well as the counting of votes. Within these rules, a specific subclass is devoted to underpinning the same mechanism of election, that is: the type of ballot paper, the specific methodology of counting votes, the «There are many ways of studying elections and electoral systems. At the most basic level, electoral systems can be viewed as either dependent or independent variables. In other words, we can look at the way electoral systems are shaped by their political environment – for example, the reasons behind particular electoral system choices upon other parts of a political system – for example, Rae‘s (1967) seminal investigation of the effects of electoral laws on political parties» (Reilly, 2001, 12). 4 «Some disingenuous arguments about institutions and democracy do not alter the fact that institutions do make a difference. The difficulty is that there is no universally correct, most democratic electoral system, notwithstanding a variety of ―one size fits all‖ prescriptions offered by committed advocates of particular systems. Rather, the appropriateness of electoral institutions depends on three mutually contingent considerations that may be summarized as who you are, where you are, and where you want to go» (Katz, R.S., 1997, 308). 5 See Farrell, D.M. 2001, 3. 3
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 61 specific attribution of votes to seats. In general it can be said that electoral systems determine in different ways the specific relations that exist between expressed preferences and available seats. Now, if one comes to define more precisely the notion of democracy which has received so far only a provisional clarification through the notion of the ‗ruling from and to the people‘, one has to add that democracy encompasses «a meaningful competition for political power amongst individuals and organized groups; inclusive participation in the selection of leaders and policies, at least through free and fair elections; and a level of civil and political liberties sufficient to ensure the integrity of political competition and participation» (Diamond and Lipset, 1995, xvi, quoted in Reilly B., 2001, 3). Elections in a democracy of whatever form, have to take place within a scenario of consolidated fundamental liberties and rights establishing the preconditions for political legitimacy and fairness. This point adds a substantive element to the procedural one, represented by the procedure of voting, which is itself also constructed upon the respect of equality between individuals. This means that fundamental principles of human rights as recognized by international and national-constitutional charters play the function of constraining possible political claims that might be introduced within the public sphere as well as the admissibility of possible political actions that might result from government activities. Further, as observed by Huntington, democracy is to be measured also in terms of its stability, the latter guaranteed by a ―two-turnover test‖ establishing that «a democracy may be viewed as consolidated if the party or group that takes power in the initial election at the time of transition loses a subsequent election and turns over power to those election winners, and if those election winners then peacefully turn over power to the winners of a later election» (Huntington, 1991, 266-267). The ―two-turnover test‖ is a necessary requirement for defining the stability of a democratic system, and its fulfilment it is part of the obligatory requirements for speaking of a democratic system. As noted above, there is a strict relation between the typology of electoral mechanisms one is prepared to chose and the correlative form of democratic arrangement one is prepared to accept. This means that it is possible to distinguish between different forms of democratic games as according to specific ‗preference-translations into seats‘ chosen at each time. Following Lijphart (1999), one can distinguish between pluralist-majority systems matched by the so-called ―Westminster Model‖, and proportional systems determining the socalled ―Consensus Model‖. Between these two extremes there are two further systems that combine peculiarities of one or the other, that is: the majority-federal model (United States) and the consensual-unitary (Israel). One cross-cutting feature is that by fixing indicators measuring the degree of representation that popular vote receives in the Parliament, it becomes possible to conclude that proportional systems are subjected to a lower degree of dis-proportionality when confronted to majority-pluralist systems. Further comparative characteristics underpinning the specificities between these two electoral systems include the notions of district magnitude and that of ballot structure (see Farrell, 1997, 6). As far as district magnitude is concerned, such notion refers to the size of the ‗constituency‘ or ‗district‘ in terms of the seats available for election. While in pluralistmajority systems as the UK and the USA each constituency elects only one representative, in proportional systems of representation each constituency elects more than one representative, as for instance Spain, where districts elect 7 members.
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Claudio Corradetti Table 1. See Farrell, D.M., 2001, 5, tab. 1.1 Proportional and non-proportional results: two 1983 elections Vote % Britain Conservative Labour SDP/Liberal Alliance Germany Christian Democrats Social Democrats Free Democrats
Seats %
Diff. %
42.4 27.6 25.4
61.1 32.2 3.5
+18.7 +4.6 -21.9
38.2 38.2 7.0
38.4 38.8 6.8
+0.2 +0.6 -0.2
Besides the higher degree of society-representation within the Parliament maintained by proportional systems, one must admit that there is no full proportionality that a system might achieve. Every system carries some artificial ‗distorting effects‘ to the political result, in addition to natural distorting effects, by rewarding some parties more than others. The two phenomena I will discuss hereafter are not only specific to proportional systems, but can be often found also in pluralist-majority systems. The first is known as ‗malapportionment‘ and it regards an imbalance of population distribution within the constituencies (districts) in such a way that one, very often ethnicallybased, party is advantaged over the others. The redrawing of district lines as according to minority groups percentages is therefore a prerequisite for allowing parties to run on the basis of equal and fair conditions. A second phenomenon which is, instead, more typical of non-proportional systems is the so-called ―gerrymandering‖. Gerrymandering indicates the strategy adopted, generally by the ruling party, to reduce the political result of the adversaries by drawing ad hoc lines within districts, so that the opposing parties minimize the ratio between votes and seats and the ruling party, instead, maximizes such a ratio. One simple way of realizing ―gerrymandering‖ is by assigning more seats to the districts where the ruling party has a larger majority and fewer seats in districts where opposing parties have the high percentages of votes. Finally, as far as the ballot structure is concerned, there is not a clear-cut prevalence of one option over the other as according to the specific electoral system it is taken into account. One can say that the most fully-fledged pluralist-majority democracies of the world, such as the UK and the USA, make use of the so-called categorical ballot – providing an either/or option – whereas ordinal ballots – providing voters with the possibility of ranking preferences – are for instance deployed in Ireland. While district magnitude divisions can have greater influence over possible disproportional outcomes of representation, ballot structures are a less dangerous tool in terms of the effects they can bring forth. District magnitude divisions can thus lead to a problem of equality of representation when social texture is such that minority groups rest unrepresented on the basis of the specific design of the district magnitudes. If one turns then to the salient characteristics of the two polar democratic systems analyzed by Lijphart (1999), it becomes possible to observe that the Westminster Model and the Consensus Model are characterized by reciprocally opposing traits. Whereas the first is underpinned by: Concentration of executive power in one-party and bare-majority cabinets; Cabinet dominance; Two-party system; Majoritarian and disproportional system of elections
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 63 (‗first past the post‘, that is the candidate with majority vote or largest minority wins); Interest group pluralism; unitary and centralized government; Concentration of legislative power in a unicameral legislature (as for instance testified by the power asymmetries between the House of Parliament and the House of Lords in Britain); Constitutional flexibility (in the case of Britain); absence of judicial review (in Britain due to an unwritten constitution judges cannot make appeal to higher order laws); Central bank controlled by the executive. The second model (consensus model), exemplarily represented by Belgium and Switzerland, is characterized by a general attempt to ―share, disperse, and restrain power in a variety of ways‖ (Lijphart, 1999, 34ff), and by a structure of the following kind: Executive powersharing in broad coalition cabinets; Executive-legislative balance of power; Multiparty system; Proportional representation; Interest group corporatism; Federal and decentralized government; Strong bicameralism (justified especially in view of a special protection to provide to minorities that remain otherwise unrepresented under a unicameral legislature); Constitutional rigidity; Judicial review; Central bank independence. Within the Westminster model one can further distinguish between plurality systems and majority systems. The first are characterized by the already mentioned slogan ‗first past the post‘, but also by the block vote6, the latter constituting an application of the pluralist system in multi-member electoral districts (often used in Asian countries), whereas the second by a general two-rounds voting and a winner decided by an absolute majority of more than fiftypercent of the total votes (Majority systems are generally used for presidential elections, but in France it is used also in the case of legislative elections). Other types of majority systems include Alternative vote systems allowing voters with the possibility of ranking candidate preference, Supplementary Vote system which makes use of the ordinal ranking ballot as for the Alternative vote system, but redistribute all votes to the first two candidates in order to establish a one run-off winning procedure. As far as the consensus model is concerned, such model is associated generally with proportional elections even if some distinctions between different possible alternatives can be made. One first model is represented by mixed models or semi-proportional models combining features of proportional with those of majority systems. It is possible to distinguish the Single Non-Transferable Vote system from the Parallel or Mixed system. In the first, voters have only one possible preference to express, but districts are provided with many possible seats, so that the candidates receiving the relative majority of the votes gets elected. For instance, in a district with three seats a candidate to be elected would need as nearly as 33,3 % of the votes; in the second, instead, there is a combination of proportional party list and single member district, electing the Parliament in part by proportionality and in part by a pluralist or majority system. Coming now to a critical assessment of Lijphart‘s methodological analysis, one can immediately note that the classification of democratic models is to be conducted also in terms of normative criteria enforced on the basis of the specific socio-political context in which such models operate: «[…] Even if one ignores the more metaphysical values of personal development and community, there are two classes of democratic theories, one emphasizing liberalism and the other popular sovereignty, each encompassing a number of alternative models of democracy, in turn depending on alternative assumptions about the character of elites and social structure. In general terms, Ljiphart‘s two polar cases correspond to the 6
In the block vote, voters have as many votes as there are places to be filled.
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distinction between popular sovereignty and liberalism, but in particular they relate only to some popular sovereignty theories (especially the binary, Downsian, Tory, and the socialist models) and to some liberal theories (especially the concurrent majorities or consociational models)» (Katz, 1997, 279). Notwithstanding the general position defended by Lijphart who favours a consensus model both for divided and for homogeneous political contexts, the thesis I want to advance here relies on a gradual distinction between such two different idealized contexts in order to find their best possible match with electoral systems and democratic models ranked from deep disagreement/large consensus model to large political overlapping/pluralist-majority systems. As a matter of fact, if proportional systems reflect at their best the relation between votes and seats, non proportional systems, either pluralist or majority, are known to be endowed with more efficiency and thus with the capacity of increasing government stability. This provides us with an indication of how to assess the validity of the one in respect to the other and vice-versa. The general thesis defended hereafter claims that whenever one faces societies with deeply conflicting claims, then proportional representation supplied with mechanisms of political decision strict dependence between majority and minority is to be favoured, whereas in cases of broader consensus between opposing parties distinguished by few specific politics mainly restricted to the economic policy, then the advantages of efficiency provided by majority-pluralist systems are to be preferred. In the latter cases, one can satisfactorily think that democratic representation of the entire electoral body is indirectly saved for its most part by whatever coalition or party wins the elections, and that the points of difference of each political leader will be better judged as valid or not valid through the efficiency of politics implementation provided by the majority-pluralist model. In the case of profoundly ethnically and politically divided societies as those coming from a violent conflict, the case is different. The attempt to be made is that of making possible the definition of a public space which might be acceptable by all political parties. One can describe such goal in terms of the search for a convergence on the basis of a modus vivendi (Rawls, 1993) where the precise extension of the constitutional principles has not yet been defined, but where nevertheless it is crucial that each party is in the condition of achieving an agreement upon constitutional essentials guiding then within reasonable terms what is to be the normal politics of the government7. The requirement of participatory inclusiveness here is more pressing, since stability and adequate minority representation can be achieved in divided countries only through a direct participation of these same subjects within the political democratic game. It is worth considering what Kymlicka (1996) recently pointed out in a revised liberal approach regarding minority rights8. He insisted on the lack of attention to a diversification of rights due to an idealized model of society inspired by the cultural uniformity of the ancient polis that persists in recent political theories. This idealized model of society should be blamed as the main theoretical justification for a number of unjust measures against minority groups, which has led to physical elimination, expulsions, forced assimilation, segregation, and economic discrimination. Kymlicka suggests considering integrating a theory of the rights of minorities with general principles of human rights. It is understood that recognizing The reader is invited to recall the discussion in §1 on the hierarchical ordering between ideal and non-ideal justice. Also in the case of an agreement based upon a modus vivendi it must be clear that it should cohere with, even if in a more vague form than within fully fledged democracies, what Rawls defines ‗constitutional essentials‘. 8 Kymlicka (1999). 7
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 65 the rights of minorities is not without risks. Reasoning based on minority rights has been used by the Nazis and by defenders of racial segregation, therefore a liberal theory of minority rights must explain how these rights coexist with human rights in general. First, some distinctions have to be made. It is important to distinguish between multicultural states and multi-ethnic states. While these two categories are distinguished in theory, they can de facto coexist within one state. A multicultural state is characterized by a diversity derived from the absorption of local cultures, which are independent, into a state or community. A multi-ethnic state derives its diversity from actual phenomena of immigration. In the first case, smaller societies want to remain distinguished from the main culture and ask for some form of autonomy. In the second, flexible groups desire to be integrated into the dominant culture and ask for the cultural differences to be incorporated into the law. The typologies of rights recognized by these two different categories can be summarized as follows: the right to self-government (delegation of powers to national minorities through some form of federalism), multi-ethnic rights (financial and juridical support to specific ethnic groups), and the right of special representation (seats reserved for representatives of ethnic groups within the main institutions of the state). The rights falling within these three categories have traditionally been defined as collective rights9. Collective rights do not necessarily have to be seen in opposition to individual rights. It is, in fact, important to distinguish between collective rights employed as a way of internally limiting the freedom of the members of a group (i.e. for internal dissent) or as a way for a group to limit the external economic and political power of a society to guarantee its autonomy (external protection). The latter are compatible with individual freedom. Therefore, a liberal theory of minority rights must consider external protections and reject internal restrictions in the case of collective rights. When a national minority or an ethnic group asks for rights falling in one of the categories listed above, it is not possible to know a priori whether they will use recognition of those rights as an internal restriction or external protection, since it is possible to claim multi-ethnic rights in order to maintain forms of sexual discrimination. Normally, however, minority rights are claimed to obtain external protection, as for instance in the case of the rights of special representation aimed at reducing the risk that the view of a minority is ignored during decisions concerning the entire community. All these typologies of rights contribute to reducing the vulnerability of minority groups to the external pressures of the dominant society. From this perspective, there is no collision between collective and individual rights. What can be learned, instead, is the kind of relation that exists between the majority group and the minority group, and not between the minority group and its members. This means that these groups can integrate respect for fundamental freedoms with the diversity of rights in their community. It should become clear now why collective rights are an ambiguous expression, and this is because very often they do not distinguish between internal restriction and external protection. Consensus models as translated into proportional systems cannot only be understood in terms of representation. The problem to be solved is not simply that of conceiving of the Parliament, as far as possible, as a mirror of the divisions spread in society. In order to bring into political solution irresolvable conflicts permeating society, one has to seek what are the mechanisms of interethnic negotiation binding different positions to find compromises in 9
Also cultural rights can be included in a broad notion of collective rights. On this occasion though I limit myself to a restricted political notion of collective claims.
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order to come about with a viable political decision. When consensus is lacking, as it is in these cases, it becomes mandatory to develop mechanisms of interests-mediation and interests-accommodation contributing to the forging of a maximally shared political outcome leading to stability approximations. Given that in ethnically divided societies voters do not tend naturally to converge upon an idealized ‗median voter‘ (Downs, 1957), it is necessary that such a process gets institutionalized through both the creation of electoral rules offering a reward to those political parties making themselves dependent upon votes from the other ethnical groups and through the introduction of government decision making rules requiring in the same vein the necessity to look for broad coalitions in order to pass a law or a decision. Such an institutional strategy would force parties to converge at the centre, avoiding centrifugal forces represented by extremist parties which would naturally push towards ethnic conflict as a way of gaining an higher number of votes. A well established case in this sense is represented by the social and ethnic texture of the Former Yugoslavia. If this is true, then, consensus models in divided societies (Lijphart, 1977) are to be supplemented by ―centred-convergence‖, whose aim is precisely that of creating, through institutional adjustments, a convergence of the parties towards moderate positions. Centredconvergence adds to consociativism a crucial element that is that of substituting the idea of a precise representation of the ethnic groups in the Parliament with the idea of dissolving ethnic cleavages at the political level through institutional adjustments at the electoral and governmental level in such a way that political parties are forced to find interethnic alliance. This further point, though, does not delete all the normative achievements that consociativism foresees and which remain valid points also in the case of divided societies, that is: grand coalition governments representing a broad spectrum of ethnic parties, proportional representation, partial autonomy through federalism and the power of veto by minority groups, but it adds an element of decision-efficiency to that of simple representation, for the search of a maximally acceptable political solutions.
4. CASE STUDY. THE LIMITS OF INSTITUTIONAL DESIGNS FOR GRANTING DEMOCRATIC FAIRINESS: SOME CONSIDERATIONS ON THE CARETAKER GOVERNMENT OF BANGLADESH Along this concluding section, I will discuss a clear case of institutional setting of a transitional country, Bangladesh, whose malfunctioning is due not just to its specific architecture, but to the lack of compliance to ethical principles by the ruling staff. Through this further specification, it is my intention to integrate the previous paragraph focussed on institutional settings, with a clear example indicating the relevance of ethical considerations. There is a widespread belief among political and legal scholars according to which achievements in developing countries can be measured in terms of institutional reforms reflecting at their best the ‗principle of separation of powers‘ and ‗institutional accountability‘. These are certainly core features of any fully fledged democratic system, but while I take this point as a necessary one, I‘m not at all sure about its validity as a sufficient condition for the enforcement of the democratic interplay.
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 67 In order to prove this point, I will take into consideration a specific moment of ‗power vacancy‘ which is proper of any democratic state political transition before elections. More specifically, I will address the case of the caretaker government of Bangladesh10, which seems to represent a unique way of attempting to achieve neutrality during political transitory phases. The point I want to stress is that it is exactly from such ‗hybrid‘ phases that one can measure the limits of institutional transparency when not supported by a political commitment to shared democratic values. Transitory periods of ‗power vacancy‘ are part of the natural cycle of all democratic systems facing new elections and possibly a new government. This is something which does not make Bangladesh caretaker government to differ from what we are used to see in our western democracies, where it is very often the same Ministry of Interior of the outgoing government which takes care of the preparation and control of the electoral procedure and the ordinary administration of the state. What is peculiar to the caretaker government of Bangladesh is that it has been established on the basis of the conviction that only through the support of a ‗neutral‘ institution, political elections would achieve a fair and a reliable result. At its birth, the proposal of the institutionalisation of a caretaker government was seen as the only possible way in order to entrust the election process with a reliable procedure shareable by both the opposing coalitions. In the 1996 elections, indeed, B. Zia‘s government had to accept the recognition of the caretaker government through a constitutional amendment11. If the 1996 elections held under the auspices of the newly born caretaker government were perceived as a success of transparency and fairness, problems of mistrust and allegations of corruption were immediately evident during the 2001 elections. Under such transitory period, the Chief Advisor Latifur Rahman, not only clearly spoke against the Awami League, but in spite of running a routine administration of the government, accepted most of outgoing BNP government proposals which were totally unacceptable by the opposition. Coming to the situation under scrutiny, that is that connected to the 2006-7 elections, the general perception was that also the upcoming elections would have suffered from manipulation by the ruling party and mistrust by the people. Due to government‘s decision of extending the retirement age of High Court justices, the opposing party has very clearly understood that this represented a manoeuvre for opening the position as Chief Advisor to the present Chief Justice of the Supreme Court, Hasan, who has been directly involved, early in his career, into the political support of the BNP. Can one say that this is a problem of institutional design? The answer can only be partially a positive one.
10
11
The recent development of the political situation of Bangladesh tells that after an unconstitutional phase of prolongation of the care-taker government till the end of 2008 under the leadership of Fakhruddin Ahamed, a new Prime Minister has been finally elected Sheik Hasina who took the role for a second time. Before the election phase, Fakhruddin Ahamed was one of the most active persons in trying to exstirpate corruption. The result was the conviction to prison of former Prime Minister Khaleda for extorsion. Rigth after the election of the new Prime Minister, the army killed around fifthy people in order to prove their territorial control over opponents. According to the Thirteenth Amendment of the Constitution adopted in 1996, a non-party caretaker government was adopted. The President is called to select a Chief Advisor and a group of ten Advisors, by maintaining a strict neutrality in the selection criteria of the members of the caretaker government. Article 58C regulates in a very detailed way the selection process that the President has to follow, by excluding any form of discretion as that allowed for the selection of the Prime Minister.
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It is certainly true that the Election Commission is in need of reform, as for instance a full control over its budget, which is presently controlled by the office of the Prime Minister, transparency in the counting and transmission of votes, immediate publication of results, a reliable voting list, presently lacking of one third of the total official population of Bangladesh, and finally a revision of the appointments procedures still controlled by the outgoing executive. But even if all these institutional and procedural adjustments seem to be strongly desirable, as far as the caretaker government is concerned what seems mostly needed is, with few exceptions that I will shortly mention, rather an application of the existent provisions. What I mean by this is that it is recognized, in terms of a fair democratic practice, that the Chief Advisor is assisted by other ten advisors chosen in agreement with the opposition, and that this mutual agreement between the opposing coalitions should take place in the appointment of the caretaker officials. All this leads to rethink the role that democratic principles play within institutions. The 2006 pre-electoral situation of Bangladesh exhibits in a quite exemplar way how, even when the constitutional architecture is conceived in such a way as to guarantee a neutral electoral procedure, whenever the opposing coalitions are not themselves totally subordinated to democratic constitutional principles, no form of neutrality and fairness can be achieved. The problem is that concepts of ‗neutrality‘ and ‗fairness‘ are evaluative concepts, which while can receive an institutional support, cannot be seen as being exhausted by institutional adjustments: if one were to follow a popular Italian mot expressing a disaffection towards law due to parliamentary vagueness in its formulation, then one would say: ‗fatta la legge, trovato l‘inganno!‘12. Nevertheless, even though fair political behaviour is an essential element for the achievement of a decent democratic awareness both at the institutional and at the civil society level, this cannot take place in a vacuum, but has instead to be supported by institutions designed in such a way that a clear division of power is reflected. Next, I will provide some further suggestions which take into consideration both the Electoral Commission and the transparency of the caretaker government. The central tenet is that the Electoral Commission, at present, suffers from a sever control by the executive. In order to separate its functions and competences, the Electoral Commission, in addition to the already mentioned budgetary independence, must also be in control of the recruitment of its own staff in accordance to the principles of neutrality and social trust which applies, in primis, also to the selection of the Chief Election Commissioner. As far as the caretaker government is concerned, a reform should be allowed in order not to permit political interference by the executive in the selection process and its possible modification for the nomination of the Chief Advisor. The recent manoeuvre of the government to obtain the Fourteenth Amendment (2004) raising the retiring age of the Chief Justice, has shed a dark light upon the next possible caretaker Chief Advisor and elections in general. Additionally, a further modification of the Thirteenth constitutional Amendment (1996) introducing the caretaker government should be considered, and in particular, it should be possible for the caretaker government to hold control also of the command of the defence
12
The approximate translation of this maxim can be: ‗once that a law is proclaimed, the trick is found!‘
The Non-Ideal Conditions of Transitional Justice with a Case-Study on the Caretaker… 69 services which is, at present, the only sphere of power remaining under the command of the President during transitional phases. In conclusion, it might be possible to think that institutional constraints could help advancing measures of mutually dependent constraints between the opposing coalitions, and that this would help in the perception of fair and equal electoral procedures. But it must be clear that, if institutional adjustments can be effective wherever a political mistrust is widespread between the opposing coalitions, institutional adjustments become superfluous if not completed by a subordination of the parties to the fundamental rules of the democratic interplay. This is even more striking if one is ready to compare the supposed neutrality of the caretaker government of Bangladesh with other forms of transitory administration in fully fledged democracies, where no necessity of a special super partes institution is searched in order to obtain fair and transparent elections. At such regard, institutional behaviours should be checked by the civil society, and the civil society should be built on the basis of fundamental democratic values through educational activities and involvement in the future of the state.
REFERENCES J. L. Diamond, & S. M. Lipset, (Eds.), (1995). Politics in Developing Countries: Comparing Experiences with Democracy, Boulder, Lynne Rienner Publishers. Downs, A. (1957). An Economic Theory of Democracy, New York, Harper and Row. Katz, R. S. (1997). Democracy and Elections, Oxford, Oxford University Press, Oxford. Huntington, S. P. (1991). The Third Wave: Democratization in the Late Twentieth Century, Norman, University of Oklahoma Press. Farrell, D. M. (2001). Electoral Systems. A Comparative Introduction, New York, Palgrave. Katz, R. S. (1997). Democracy and Elections, Oxford, Oxford University Press. Kymlicka, W. (1996). Multicultural Citizenship: A Liberal Theory of Minority Rights, Oxford University Press. Lijphart, A. (1999). Patterns of Democracy, New Haven and London, Yale University Press. Lijphart, A. (1977). Democracy in Plural Societies: A Comparative Exploration, New Haven, Yale University Press. Rawls, J. (1993). Political Liberalism, New York, Columbia University Press. Rawls, J. (1999). The Law of Peoples, Cambridge Mass., Harvard University Press. Reilly, B. (2001). Democracy in Divided Societies, Cambridge, Cambridge University Press. Teitel, R. G. (2000). Transitional Justice, Oxford, Oxford University Press. International Commission on Intervention and State Sovereignty, (2001). The Responsibility to Protect, http://www.iciss.ca/pdf/Commission-Report.pdf United Nations Security Council, (2004). The Rule of Law and Transitional Justice in Conflict and PostConflictSocieties, http:// www. undp. org/ cpr/ documents/ jssr/ ssr/ rule%20of%20law%20and%20transitional%20justice.pdf United Nations General Assembly, (2009). Report on the General Assembly Plenary Debate on the Responsibility to Protect, http:// www. responsibilitytoprotect. org/ ICRtoP% 20Report-General_ Assembly_ Debate_ on_ the_ Responsibility_ to_ Protect% 20FINAL%209_22_09.pdf
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 4
DEMOCRATIC FAILINGS, SUCCESSES AND PROSPECTS IN THE EUROPEAN UNION: TRANSNATIONAL DELIBERATIVE DEMOCRACY AND THE SOCIAL OPEN METHOD OF COORDINATION Stephen Elstub1 and Annabel Kiernan2 1
2
University of the West of Scotland, UK Manchester Metropolitan University, UK
ABSTRACT This paper considers the extent to which the social open method of coordination within the EU can be interpreted as an institutionalisation of the features of deliberative democracy at a transnational level. It argues that the experience of the social policy NGO sector in policy deliberation inside the EU provides useful illustrations of the difficulties of institutionalising such ideals, at transnational level. In spite of the limitations experienced thus far, the case offers up a tantalising example of the possible prospects for the future by furthering understanding on the barriers to institutionalisation that need to be overcome, and on where the trade-offs between theory and practice need to be made at a transnational level. More specifically the paper argues that it is the creation of open and transparent, weak and strong public spheres that must be achieved, if deliberative democracy is to be approximated at any level of governance. The OMC, which is a promising element of the ‗Lisbon‘ strategy that aims to increase stakeholder participation in EU social policy formation, goes some way to achieving this, as it generates dispered and ditributed ‗hybrid‘ public spheres that are formed through deliberation between the NGO sector, national governments, and EU institutional actors. The process is far from perfect and particularly needs to be more inclusive (especially in terms of marginal groups with challenging views), has been less responsive to the input of stakeholders than was hoped and, overall, still remains excessively elite dominated. However the commitment to improving on the dynamic between EU institutions and key stakeholders in social dialogue remains and the OMC offers a formal gauge of whether such commitments are being met. Ultimately the current OMC fails to approximate deliberative democracy sufficiently closely yet, but has had a certain degree of success,
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INTRODUCTION One of the greatest failings of the EU is its democratic deficit. However, for Bohman this is better characterised as a ‗deliberation deficit‘ (Bohman, 2007, p. 145). The normative promise of deliberative democracy is increasingly making it the standard on which to judge ‗good‘ and ‗legitimate‘ governance, at every level of governance, including transnational governance (Bader and Bartlett, 2005; Dryzek, 2006; Bohman, 2007). However, institutionalising deliberative democracy at any level is extremely difficult due to the complex nature of modern societies (Femia, 1996; Elstub, 2007). These features of complexity are at their most acute at the transnational level. Providing more power to the European Parliament is welcome, but not sufficient, ‗rather, more direct forms public deliberation must emerge within the polyarchy‘ (Bohman, 2007, p. 147). However, through the Lisbon treaty, the EU is aiming to address this deficit. For example the European Union‘s (EU) social policy trajectory represents an attempt to give firm foundation to its claims to being a citizen focused, representative, inclusive model of democratic governance. Recent commitments to meet the ‗good governance‘ agenda, through the development of mechanisms such as the Open Method of Coordination (OMC), potentially provide a framework within which some of the ideals of deliberative democracy can be approximated (Bohman, 2007). The argument forwarded here is that the experience of the social policy Non Governmental Organisation (NGO) sector in policy deliberation, inside the EU, provides useful illustrations of the potential benefits of creating formal mechanisms which enable stakeholder participation which can provide the foundations and the tools for building truly participatory policy forums for modern, complex, and transnational societies. Ultimately we argue that the OMC has achieved only limited success in approximating the norms of deliberative democracy at transnational level. However, despite its limitations the social OMC has enabled innovation in consultative processes and, significantly, the engagement by the NGO sector, and other stakeholders, in the formal processes has better equipped those actors for utilising the OMC structures in the future. Therefore, the operation of the first round of consultations in the social OMC may provide an important template on which to build in order to take some further, concrete, steps towards embracing the deliberative model of democracy in a transnational context. In this sense, rather than providing a firm model for the approximation of deliberative democracy at transnational level, the OMC indicates that the EU does have prospects for democratisation and the approximation of deliberative democracy. Specifically it is argued that the creation of open and transparent, weak and strong public spheres, that incorporates degrees of micro and macro deliberation is essential, if deliberative democracy is to be approximated at any level of governance. The OMC goes some way to achieving this, as it generates dispersed and distributed ‗hybrid‘ public spheres that are formed through relatively inclusive deliberation between the NGO sector, national governments, and EU institutional actors fostering public reason, which is connected to decision-making arenas. The process is far from perfect and particularly needs to be more inclusive (especially in terms of marginal groups with challenging views), more transparent, has been less responsive to the input of stakeholders than was hoped and, overall, still
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remains excessively elite dominated. However the commitment to improving on the dynamic between EU institutions and key stakeholders in social dialogue remains and the OMC offers a formal gauge of whether such commitments are being met. Therefore, the current OMC does not approximate deliberative democracy sufficiently closely yet, but points the way of how this could be achieved at transnational level. The chapter is organised into five sections. The first defines deliberative democracy and discusses the need for weak and strong deliberative public spheres to institutionalise it. Section two explains the key features of the OMC, while section three discusses how the OMC creates hybrid public spheres at the transnational level, which point the way to approximating deliberative democracy in practice. The benefits of the social OMC, particularly in the UK, are highlighted in section four, before section five highlights the failings of the process, and outlines potential improvements.
TRANSNATIONAL DELIBERATIVE DEMOCRACY AND THE PUBLIC SPHERE There are two key elements of deliberative democracy; ‗democracy‘ and ‗deliberation.‘ The democratic part is collective decision-making through the participation of all relevant actors. The deliberative strand is the making of the decisions through the give-and-take of rational arguments (Elster, 1998, p. 8). Deliberative democrats believe that through deliberative interaction and communication, and therefore the consideration of those with differing preferences, existing preferences can be transformed and new preferences formed. In fact this preference transformation is thought to be the defining mark of deliberative democracy (Elster, 1998, p. 6). Therefore in order for deliberation to have taken place, communication between participants must induce ‗reflection upon preferences in a noncoercive fashion‘. This deliberation is democratic if these reflective preferences influence collective decisions and all have had an opportunity to participate equally (Dryzek, 2000, p. 2; Elstub, 2006). It is further thought that these preferences will become more rational and public after ‗running the gauntlet‘ of collective debate with participants taking on the considerations of others (Barber, 1984). Following these core beliefs, deliberative democracy has received a number of normative justifications. Included is the prudential justification which suggests that deliberative democracy enables preferences of the participants to become more autonomous by overcoming inequalities in information and rationality (Elstub, 2006; Festenstein , 2002, p. 103). There is also the epistemic justification which suggests, that deliberative democracy, by generating pubic reason, is the decision-making method most likely to lead to decisions that are true, well justified or commensurate with justice, needs or the common good (Bohman, 1998, p. 403; Festenstein, 2002, p. 99; Warren, 2002, p. 192; Elstub, 2006). A further justification is that deliberative democracy produces just decisions, as it represents a set of fair procedures in which all have been able to participate equally in debate, which encourages participants to consider the preferences of others (Elstub, 2006; Festenstein, 2002, pp.102-103; Warren, 2002, p. 193). It is these normative ideals which makes deliberative democracy increasingly the standard of good and legitimate governance at all levels of governance. Nonetheless features of complexity, namely scale, number, dispersion, diversity and inequality of citizens, and the
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need for expertise are significant barriers to achieving deliberative democracy and are all accentuated by a further feature of complexity, globalisation (Femia, 1996; Elstub, 2007), which itself creates the need for transnational democratic processes (Bader and Bartlett, 2005; Dryzek, 2006; Bohman, 2007). In order for the theory of deliberative democracy to be approximated in practice at any level of governance, and for these normative goals to be generated, there must be public debate between participants that leads to decision-making. This public debate element is present in public spheres; ‗the space in which citizens deliberate about their common affairs, and hence an institutionalised arena of discursive interaction‘ (Fraser, 1992, p. 110), that combines face-to-face and mediated communication (Bohman, 2007, p. 79). Public spheres are secured by rights of freedom of speech and assembly and are potentially open to the participation of all (Eriksen, 2000). Public spheres must meet three criteria. There needs to be a social space for communication, which must ‗manifest the commitment of participants to freedom and equality‘, and address an indefinite audience, but with an expected response (Bohman, 2007, p. 60). The resulting flows of communication can influence the opinions of the public and state sector actors and will be more likely to be based upon reason and be publicly orientated as, in order to convince others of the validity of their concerns and preferences, participants must be able to ‗employ and appeal to norms of publicity‘, limiting their potential to act as strategic actors (Habermas, 1996, p. 364). As Bohman argues ‗at the very least such public deliberation can add to, and change, the pool of reasons available to deliberation‘ (Bohman, 2007, p. 61). These public spheres can appear at local, national, transnational, international or functional level, making them vital to democracy in the global era, as institutions and modes of governance and debate increasingly occur at these multilevels. They also help overcome the scale problem as the public sphere transcends elements of time and space, potentially enabling all to participate in an anonymous discourse (Elstub, 2007). Currently throughout the EU‘s dominant closed committee system, there is a lack of public processes, so interest groups have great leeway to assert private interests and manoeuvre themselves to gain vested state powers through funding political parties, lobbying and private consultation that leads to the subversion of the formal representative institutions. When bargaining with EU and national government officials, they can use sanctions and rewards to apply pressure. However, inside public spheres the effect of interest groups is limited due to the ‗public‘ nature of these processes and these private techniques become increasingly ineffectual as convincing reasons become increasingly influential at transforming preferences and mobilising public opinion. Not only then is public opinion generated through discourse in public spheres, these opinions are also more likely to be based upon reason and be publicly orientated; essential aspects of deliberative democracy (Elstub, 2008). There are two broad types of public sphere, which reflect two types of deliberation: informal public spheres involve participation in opinion formation, where a dialogue is conducted across space and time, potentially involving a huge array of civil society actors. Here we find macro deliberative democracy which involves informal and unstructured, and spontaneous discursive communication, aimed at opinion formation, between partisan deliberators and occurs across space and time, within civil society, outside and often against the formal decision-making institutions of the state (Hendriks, 2006). This role of civil society associations, like NGOs, as communicators in the informal public sphere is an intrinsic one, as they are established through communication between individuals themselves
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and because they must try to influence the preferences of the general public and members of other associations by representing and voicing the views and interests of their members to gain influence (Elstub, 2007; Habermas, 1996, p. 369; Warren, 2001, pp. 78-80). In contrast, formal public spheres are characterised by discussion within institutionalised and decisionmaking processes, which generates micro deliberative democracy, which are more likely to resemble ideal deliberative procedures, occur within small-scale structured arenas within the state, be orientated to decision-making, and include impartial participants deliberating together in one place and at one time (Hendriks, 2006). Here we see the relevance of Fraser‘s distinction between weak and strong public spheres, with strong publics having a decisionmaking role, and weak publics involved in opinion formation (Fraser, 1992). Formal public spheres, and micro deliberation, tend to be too elitist, but strong as they result in binding decisions, laws and policy, but exclude too many participants. The informal public spheres, with macro deliberation, are more open, but there is a failure to sufficiently empower citizens and make their participation effective in terms of influencing decision-making, meaning such public spheres are weak. Consequently, if deliberative democracy is to be effectively approximated in the EU, and both the deliberative and democratic elements are to be combined, informal public spheres and its macro deliberative communication must be linked to formal public spheres and decision-making and micro deliberative venues (Hendriks, 2006; Elstub, 2008). Achieving the mediated communication required to form a public sphere at transnational level is extremely challenging given the intensification of the features of complexity at this level, and for Bohman new institutions are required to contribute to this mediation, as the same methods used at the level of the nation-state will be inadequate (Bohman, 2007, p. 79). He argues that at the transnational level public spheres contribute to democracy by forming distributed, but communicative networks that interact with dispersed institutions (Bohman, 2007, p. 61). For Dryzek the best mechanism of creating a transnational public sphere that can approximate the norms of deliberative democracy is the informal networks of communication and association of NGOs that form around and counter ‗international regimes‘ (Dryzek, 2006). Such counter-publics are then weak, informal, and at best foster macro, but not micro deliberation. Bohman is critical of this approach for these very reasons, suggesting Dryzek‘s transnational public spheres can only be ‗contestatory‘: ‗Dryzek thus ends up with a kind of institutional minimalism that also omits the dimension of active and empowered citizenship‘ (Bohman, 2007, p. 43). Although already established transnational and formal decisionmaking institutions, such as the United Nations, World Trade Organisation, and the EU, are included in Dryzek‘s theory, there is an insufficient link between the deliberation in the weak and informal public sphere that the NGOs generate and these strong and formal decisionmaking institutions. Nor are these institutions democratic or deliberative themselves. Therefore micro and macro deliberation are not linked in this approach. Dryzek is right to see the need for transnational public spheres to be embedded in a larger institutional context. As Bohman argues this embeddedness is required to ‗secure the conditions of publicity‘, and to promote the interaction that will generate deliberation (Bohman, 2007, p. 81). The argument here is that, in line with Bohman, they need to be embedded more than Dryzek suggests. However, the OMC, part of the social policy dialogue in the EU, points the way to how this balance can be achieved. The next section outlines its key features, context, and background.
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SOCIAL POLICY DIALOGUE IN THE EU & THE OPEN METHOD OF COORDINATION The nature of the policy tools and governance mechanisms, which the EU develops, are consequential for the development of democracy in the European Union. If a transparent, accessible, and a participatory social dimension can be created the public perception of the value of the EU can be transformed and thus give substance to the EU‘s articulation of its democracy, legitimacy and good governance agendas, as well as moving the EU towards the incorporation of the norms of deliberative democracy. At the Lisbon European Council meeting, in March 2000, the EU took a clear step forward in developing these themes in more meaningful ways, which was reflected in the formal commitments to a ‗good governance‘ agenda and the recognition of the need to ‗mainstream‘ the Union‘s social cohesion objectives (embed the social in all other relevant policy). The Lisbon Council effectively enabled the continuing development of new forms of more participatory, accessible and responsive governance and underlined its commitment to recognising ‗the social‘ as a distinct field of important policy activity approximating a participatory, multi-level governance policy space (Tsakatika, 2004). Specifically, the policy tools elaborated through the Lisbon strategy hold clear potential to be an influential model of deliberative democracy at the transnational level (Bohman, 2007). It is argued that the social dimension of the EU points the way for the delivery of a substantive approximation of deliberative democracy, through the elaboration of the OMC for social inclusion, which establishes a model for social dialogue enabling formal mechanisms for advancing ‗the mobilisation of all actors‘ and thus the direct input of the voice of those with direct experience of poverty and social exclusion. In fact one of the principal aims of the OMC was to increase levels of transparency and participation in decision-making (Lisbon European Council 2000 Presidency Conclusions [100/1/00], p. 7). The OMC, ―involves establishing policy guidelines, setting benchmarks, concrete targets and a monitoring system to evaluate progress through peer-review‖ (De la Porte & Pochet, 2002, p. 346). The OMC sets guidelines for the Union combined with specific timetables for achieving the goals set. As a means of promoting best practice it establishes common quantitative and qualitative indicators and benchmarks. There is periodic monitoring, evaluation and peer review, organised as exchange of experience and mutual learning (De La Porte, Pochet and Room, 2001, p. 293). Crucially, rather than ‗hard law‘, the OMC is a ‗soft‘ process of coordination. It involves agreeing common objectives, developing common indicators to measure progress, developing national plans, establishing Community action programmes and preparing European reports on the processes and the challenges (Tsakatika, 2004, p. 91). The OMC includes a transnational exchange programme, which has recently undergone reform. Additionally, there is a programme of inter-governmental ‗peer review‟ of good practice (in which a limited number of NGOs can participate). The OMC process also includes innovative developments such as the now annual ‗people experiencing poverty‟ conference organised under the relevant Presidency of the EU with secretariat provided by the European Anti Poverty Network and a sister NGO, ATD Fourth World. There is an annual ‗round table‟ of all actors also organised by the Presidency. Importantly it may be possible to argue that the requirements of deliberative democracy (deliberation, the appeal to technical expertise, addressing issues of an inequality of skills,
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creating a consensus and a genuine public space) can be met within the new governance tools developed at Lisbon. In particular the OMC lends itself to the creation of national modes of consultation which should be formative in the Commission‘s and Council‘s policy development stage. Despite the stakeholder consultations for the OMC being devolved to the member state level through the development of separate National Action Plans (NAPs), the national consultations feed in to a pan-European policy strategy (producing a Joint Report from the Commission) based on cross-national peer-review and policy-learning. Although the extent of success of these frameworks thus far is a mixed picture the established consultations within member states do have value in their own right, (in terms of creating public space for deliberation and delivering a level of expertise), but also in the way their combined pressure has produced results at the EU institutional level. This means that despite a slightly rocky start, the positives that can be drawn from the experience of these policy tools at this point, allow us to be optimistic about their continued utility and their potential to provide a clear template for more explicit attempts at a deliberative democracy type mode of governance within the EU. In line with the timing of the National Reform Programmes (strategic objectives around broad economic policy guidelines) Member states will then produce three year Plans to 2011. A social inclusion strategy was developed around a set of four objectives on the fight against poverty (access to resources, rights, goods, services and employment, preventing poverty risks, addressing situations of poverty and mobilising all actors including NGOs). The National Action Plans on Social Inclusion (NAPSI), produced by Member States, are the core mechanism for addressing the objectives. The European Commission prepares a Joint Report assessing the Plans, which is then adopted by the Spring European Council. The OMC process then implies a form of ‗policy learning‘ by policy actors in the national and European context, whilst maintaining some flexibility in the national routes to achieving the Lisbon goals. Specifically, the ‗policy learning‘ should be achieved through the reporting mechanism of NAPSI which report every two years. The conclusions of the Lisbon Council stipulate that the new OMC process is a means of spreading best practice and of achieving greater convergence of different member states and sectors. The structure and operation of NAPSI in particular, as part of the OMC mechanism, offers some potential for a genuinely consultative and deliberative policy-making process. NAPSI gave a specific role to stakeholder consultation and participation, which was a mechanism for reflecting the broader commitment to the ‗mobilisation of all actors‘. This attempted institutionalisation of consultation is potentially very important for both the development of the social policy trajectory but also for establishing a possible model of deliberative democracy in a transnational context. The ‗mobilisation of all actors‘ strategy is a response to the need for stakeholders in the social field to have some direct input into policymaking. In particular it is increasingly evident inside the EU that closing the democratic gap is urgent if the EU is to retain legitimacy in the face of falling voter turnout at European elections. Also the EU, by its very nature, has a need and a capacity for transnational alliance building. This is particularly the case in policy areas which require advocacy to achieve maximal, rather than minimal, policy responses. These tend similarly to be those areas where there is effectively a requirement for consultation with affected publics or their advocates, in order to make meaningful claims to democracy, legitimacy, and responsiveness. Consequently, in the social field, the direct insertion of the voice of those with experience of poverty, for example, is essential. In line with this, deliberative democracy aims to include all preferences and
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experiences in public dialogue. The next section will consider the relationship between the OMC and deliberative democracy in detail.
THE SOCIAL OMC AS A TEMPLATE FOR TRANSNATIONAL DELIBERATIVE DEMOCRACY The OMC, as a broad policy tool, has been equated with deliberative democracy (De la Porte and Nanz, 2004; Bohman, 2007) and been described as a decentralised, bottom-up process of public deliberation that resembles what Cohen and Sabel term ‗directly deliberative polyarchy‘, where policy debates in local settings occur; meaning normal citizens are not disenfranchised from the process completely (Cohen and Sabel, 1997). The EU social OMC, might not be a ‗full‘ or close approximation of deliberative democracy at transnational level yet, but the argument, here, is that it points to the direction transnational, and consequently EU institutions and policy processes must move towards to achieve this. Currently, the EU is limited in its generation of open inclusion and transparent public spheres as the OMC is only one aspect of decision-making institutions within the EU as a whole, and elsewhere public processes are easily avoided. Bohman (2007, pp. 44-5) argues that the OMC facilitates interactions, communication and the exchange of information between institutions and publics by fostering dispersed, collaborative, and empowered decision-making processes. Although Bohman acknowledges that the OMC could and should be more democratic, he praises it for ultimately being deliberative and reflexive, enabling EU citizens to deliberate at these dispersed locations ‗so that solutions to problems generated by other deliberators can provide alternatives or can be used as premises for the deliberation of others‘ (Bohman, 2007, p. 85). In the OMC deliberation therefore occurs at a variety of levels, amongst different actors, where local and contextual information, reasons and experiences can be shared, and yet still reflected on at higher levels, which also enables collective learning (Bohman, 2007, p. 85). Bohman‘s influential, and normative work, is an excellent starting point to discuss the relationship between the OMC and transnational deliberative democracy. However, there is still more that can be said about the OMC and its relationship to transnational, and deliberative, public spheres. In terms of informal public spheres in the EU, their absence has been one of the causes of the EU‘s democratic deficit. The key rights of freedom of speech and assembly were in place, but other factors which provide fertile ground for the development of informal public spheres were not present. For example there is an insufficient collective identity, an unsubstantial European media, no genuine European political parties and no common first language (Schlesinger and Kevin, 2000). Where informal public spheres had managed to emerge in the EU they had not been particularly deliberative (Blichner, 2000, p. 148). With its broad institutional mix and plurality of decision-making arenas, the EU potentially has many formal public spheres. However, most of these arenas are not deliberative in character, are insufficiently public and transparent, are infiltrated by private or national interests groups, are elitist and dominated by experts and bureaucrats and, consequently, there is little preference change.
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By bringing together many NGOs, national government actors, and EU representatives to discuss common social policy affairs in ‗institutionalised discursive action‘ the OMC is helping to change this by creating European, transnational public spheres; firstly through the NAPs at national level and then across transnational borders at the broader level of panEuropean policy strategy (Tsakatika, 2004, p. 93). These NGOs therefore form multiple crisscrossing networks of communication, which contribute to opinion formation at national and transnational level (Eriksen, 2000, p. 62). In particular mechanisms and frameworks for civic dialogue have been developed through the process for the Community and National Action Plans, which enable channels of access at the national level that were not previously available (of which the „Get Heard‟ programme in the UK is an excellent example); as well as offering increasing opportunities for transnational dialogue and sharing of best practice through formal mechanisms like joint reports, conferences and roundtables, which in turn have bread continuous, and less formal modes of public communication and networks, which include a range of organisations, that resemble informal public spheres. However, there are significant differences in national approaches, which mean that not all are as inclusive, public or transparent as each other. In addition it is necessary for the formal, and informal, public spheres to be linked and therefore for the macro deliberation and opinion formation generated in the informal public spheres to be connected to EU decision-making through the formal public spheres where micro deliberation is developed. The OMC does help achieve this link as it resembles what Blichner (2000) describes as a ‗hybrid‘ public sphere, not quite as weak as informal public spheres isolated in civil society, nor as strong as governmental formal public spheres, as it has no formal legislative authority, meaning they are not strong publics as they are not decisionmaking arenas themselves (Blichner, 2000, p. 150), producing soft policy decisions instead. However, the OMC‘s public spheres are not completely disenfranchised from decisionmaking arenas due to their close links to national and EU representatives. Perhaps the decision-making aspect of deliberative democracy is therefore not fully incorporated in the OMC and, as mentioned above, the national government‘s submissions to the Commission have not always reflected the NGOs‘ input. However, the evidence from social policy suggests that the decisions made by the formal EU institutions can still be, and in fact has been, influenced by the discourses emerging from the national and transnational public spheres (Dryzek, 2000, p. 132). Hybrid public spheres may then be the most effective way of approximating deliberative democracy, and combining public opinion formation, with decision-making, at transnational level, by ensuring that the dispersed public spheres are embedded in a larger institutional context, through distributed institutions as Bohman (2007) requires. In this sense the hybrid nature of the OMC avoids the weaknesses Bohman identified in Dryzek‘s approach to transnational deliberative democracy. Dryzek argues that NGOs should only deliberate in weak, informal, counter-publics, as he fears they will be co-opted if they are included in strong, decision-making publics. Consequently, Dryzek sees all projects that attempt to include civil society organisations in formal policy making processes as exclusive and unable to challenge inequalities, with these actors only ever achieving symbolic inclusion (Dryzek, 2000, p. 85). Furthermore, he suggests that having groups excluded from legislative bodies such as the EU aids democracy, as when NGOs remain excluded they are forced to engage in public protest; meaning they can provide a more potent threat to legislative bodies than if included. According to Dryzek, EU and national government policy is never completely undetermined as imperatives of
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accumulation and legitimation, must be fulfilled. Due to this Dryzek believes entry of NGOs will only occur, when the EU/ national government recognises the interest of the group as a challenge to its legitimacy or when their interest is directly related to EU/ national government imperatives, but not because it recognises the interest as legitimate in its own right. Consequently, the group is incorporated if and only if the EU/ national government is pursuing a certain public policy that overlaps with the claims of the NGO. In this sense there is not a significant transfer of power to the NGOs through processes like the OMC, and, due to the inclusion, the NGO no longer remains as a challenge to the EU‘s, or relevant national government‘s, legitimacy in the informal public sphere, leading to ‗the erosion of some existing democratic accomplishments, and a reduced likelihood of further democratisation in future‘ (Dryzek, 2000, pp. 87-8). However, the innovation of the Lisbon‘s strategy‘s social OMC is the development of hybrid public spheres at transnational level as soft policy processes, meaning that the NGOs that have participated in the NAPs and OMC gain influence and not decision-making power per se. Consequently, the NGOs are still in a good position to challenge EU decisions and might even be in a better position to do so, having been involved in the OMC and received more information throughout this process than they would otherwise have had access to. It is also worth noting the relative success of the UK NAPSI in terms of providing real leverage for the NGO sector in direct negotiations with government, notably the Treasury and the Department of Work and Pensions. In addition there does seem to be more scope for NGOs being included into the EU social policy process than Dryzek gives credit for. The state imperatives of legitimation and accumulation, although restricting, are very broad and leave plenty of scope and plenty of alternatives for EU social policy, particularly as these imperatives can be in conflict meaning trade-offs need to be made. Consequently, civil society could play a relevant role in deciding where the trade-offs between these imperatives should be made, even if it is inevitably constrained from abandoning one altogether (Elstub, 2008). Moreover, if these NGOs were not included at all in relation to decision-making in the OMC their influence on final decisions would be reduced. Once again, because the OMC generates hybrid public spheres, neither completely weak, nor strong, it enables the NGOs to influence EU social policy legislation, while still remaining in civil society where it can counter-act the EU and contribute to critical discourses. As discussed above the inclusion of NGOs in a transnational public sphere was thought essential by Dryzek (2006) and Bohman (2007) if the norms of deliberative democracy were to be approximated at a transnational level. The fact that the social policy OMC‘s hybrid public spheres are formed through the inclusion of NGO facilitates the approximation of deliberative democracy in a number of ways. A key aspect of deliberative democracy is that it aims to equally include all voices and opinions in debate. The OMC helps broaden democratic deliberation, through these hybrid public spheres, between the NGO sector and therefore helps move towards this goal. NGOs are increasingly diverse in terms of geographical location, organisational type, membership, identity, size and aims which makes them incredibly important to achieving pluralism and to representing a wide variety of preferences and beliefs in deliberative communication within the hybrid public spheres of the OMC. The more and the broader the range of NGOs the OMC can include, the more it will represent the plural nature of the EU and the closer the approximation of the ideal of deliberative democracy it will be. NGOs represent interests that are not territorially based
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which would go un(der)-represented through party politics and, therefore, can overcome the restrictions, limitations and inequalities of territorial representation. Therefore, these NGOs provide an excellent vessel for plural representation at transnational level. Although, NGOs also enable dominant groups to voice their concerns, the OMC, by incorporating NGOs, brings in new speakers to public debate, which then changes the parameters of debate. NGOs therefore enable those with similar beliefs, preferences and needs to combine their voice and therefore increase the chance that they will be heard (Elstub, 2007). This means that the EU social policy process becomes more deliberatively democratic as it includes the preferences of a broader range of citizens and not just those from dominant groups, technical experts and political elites. One of the main reasons why the EU has a democratic deficit is that it gives experts a privileged position in decision-making through its complex committee system. This has led to ‗steering without democracy and governance without government‘ (Eriksen and Fossum, 2000, p. 14) as mechanisms that link the opinions of experts with the preferences of the affected citizens are absent (De la Porte and Nanz, 2004, p. 271). The EU committee system, therefore, needs increased levels of participation and deliberation to gain legitimacy (Vos, 1999, p. 31). This is why the OMC, and Lisbon strategy as a whole, are promising processes, as they attempt to combine expertise from a range of sources, by incorporating a diversity of NGOs, making the process more democratic. NGOs are particularly useful at forming and organising information due to the fact that they specialise in certain areas which are of particular relevance to their members which they then represent to other citizens, to the state and transnational institutions like the EU. Furthermore, NGOs create a division of labour in the collection and organisation of information, achieving economies of scale that enable citizens to acquire levels of information that they would be unable to obtain by themselves (Cohen and Rogers, 1995, pp. 42-3; Hirst, 1994, pp. 34-40; Warren, 2001, pp. 71-2; Elstub 2007). Indeed a case may be made for the social policy NGO sector and the associated stakeholders to be understood as an epistemic community in their own right. In addition, due to their close involvement with their members, NGOs can provide information that would otherwise be unavailable to the distant EU committees (Cohen and Rogers, 1995, p. 43). All this information helps NGOs hold the EU officials, bureaucrats, and institutions accountable. Moreover, the more public the OMC process, the more likely preferences will be based on public reasons, which is not the case with specialists operating in private committees. Fraser argues that socio-economic inequalities cause the cultural ethos developed by socio-economic groups to be unequally valued. She further suggests that in everyday life, and within the public sphere, such powers are magnified because inequality in the political economy affects opportunities for access to participation, meaning public spheres are not and cannot be neutral and equally ‗expressive of any and every cultural ethos‘ (Fraser, 1992, p. 120). This inequality severely limits a public sphere‘s potential to fulfil both deliberative and democratic roles. The OMC helps with this problem, to some degree, by helping to form multiple public spheres around a variety of social policy issues and at various levels of governance, due to its dispersed and distributed transnational, and multilevel mechanisms. Multiple public spheres provide subordinate groups with the arenas to deliberate and form collective preferences, goals, strategies and identities away from the unequal influence of dominant groups (Fraser, 1992, p. 123). Nevertheless, they aim to disseminate their beliefs and communicate these to as broad a public as possible through networks with associations
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and between public spheres, which is the key criteria that makes them a public (Fraser, 1992, p. 124). There are, however, considerable weaknesses with the OMC process and essential improvements that need to be made, if the promise to approximate deliberative democracy at a transnational level is to be achieved. However, before considering the failings of the social OMC, the chapter will turn to the benefits that have emerged from the process, especially in the UK.
HARNESSING THE BENEFITS OF THE SOCIAL POLICY OMC PROCESS In terms of the measurable impact of these policy tools, there has been a range of experiences across the member states. However, for the OMC and the NAPSI in the UK for example, the national NGO sector has made significant use of the channels available through the OMC, and thus demonstrates what is possible to achieve if the NGO sector and other stakeholders maximise the potential of these formally instituted processes. In more general terms, creating policy discussion and interaction space between national government officials, the NGO/charitable sector in the social policy field, as well as formal EU institutional involvement through the Commission‘s Joint Report, the social OMC has been a (qualified) success. In addition, the leverage it has allowed NGOs, in their relationship with the member state governments, has, in some member states – notably the UK – also been significant. That is, in some member states the point of pressure for social policy development has shifted from applying pressure for at least minimal convergence on national governments via the EU to maintaining pressure on the EU to develop measures to protect the European Social Model (ESM) via national governments. In other words the national policy space has become, in some member states, the more important location for action to expand EU competency in the field. This is interesting for two reasons: firstly in terms of the implications it has for subsidiarity and EU integration and policy convergence; and secondly, as noted by de la Porte, Pochet & Room (2001, p. 298), the pressure for convergence is coming, not from centralised and imposed European frameworks but from the pressure to improve (be least worst) arising from the peer review, policy learning dynamic of the OMC process. ‗The soft processes involved in OMC, emphasising transparency, accountability and effectiveness, would seem to have an obvious relevance to principles of good governance. OMC also seems well attuned to the currently fashionable debates on ‗multi-level governance‘, with the actions of independent public actors at different levels articulated with each other to reach shared objectives‘ (De la Porte, Pochet and Room, 2001, p. 300)
In addition the OMC has encouraged very positive policy consultation processes. Again looking at the example of the UK, the NAPSI required the ‗feeding in‘ of expertise to government through broad consultation with stakeholders. Consequently the UK unit of the European Anti Poverty Network launched a consultation, “Get Heard”, which held open forums with 47 social and community groups in order to define targets and shape priorities in the UK NAPSI (see Cochrane, 2006). This was a very successful consultation in two key ways: Firstly it established a functioning network of stakeholders and representatives of the NGO sector which can provide a reservoir of expertise on the issues surrounding social
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inclusion both now and in the future. This has helped enhance the profile of the NGO/social policy lobby sector in terms of its relations with government, because it is accessing national government departments through the legitimacy of the stakeholder/good governance agenda established by the EU. Secondly, and of particular importance in terms of deliberative democracy which aims at preference change, the Get Heard process held the important function of ‗policy learning‘. In addition to allowing people access to genuine policy consultation, it provided the tools for skills‘ development in this area. In a practical sense the Get Heard project created a ‗toolkit‘ for those groups wanting to participate, which provided core information and context as well as methods and frameworks for getting the most out of the process. This is of utmost importance for continuing the commitment to the mobilisation of all actors and the real establishment of deliberatively democratic processes. To ensure that the ‗mobilisation of all actors‘ has real meaning it is important to give people the tools to allow their voice to be genuinely heard. This should, longer term, allow community groups and social actors to take greater ownership of the process of consultation. It is also worth noting the relative success of the UK NAPSI in terms of providing real leverage for the NGO sector in direct negotiations with government. Although there has been a certain amount of (deserved) criticism of the ‗feeding out‘ end of the process – that is the extent to which the NGO input is reflected in the government‘s NAPSI submission to the Commission – the sustained pressure and work of the social policy NGO sector in the UK has paid off in terms of further and better access to key government departments. There is a clear difference here in terms of the experience of the social policy NAP compared to that of the Employment and Pensions NAPs (see De la Porte and Nanz, 2004). Although there has been pressure to ‗roll up‘ all three NAPs into a single reporting mechanism to the Commission, the social policy NGO sector successfully argued for a separate NAP in the social field; this is in large part founded on the need to retain a distinct social dimension as the third side of the Lisbon triangle, rather than to see social inclusion measures integrated into a broad sweep of economic, specifically labour market, reforms. As a consequence there has been a different experience of the OMC in these fields. There are two clear reasons for these contrasting experiences. Firstly the transnational and domestic commitment to maintaining distinct measures for combating poverty and promoting social inclusion in the framework of the ESM can be seen in the work of network actors, as well as having some advocacy at the level of the institutions, notably through Commissioner Spidla (DGV) and in ECOSOC. Secondly the responsiveness of the relevant government department has also been a key feature. It has been the case that the Department for Work and Pensions (involved in the UK NAPSI) has been more open to consultation with lobby network actors than the Department for Trade and Industry (involved in the EES NAP) for example. In this way we may be able to start to identify something closer to the typical policy community model in the social field than has previously been the case in the EU; but one which is enhanced by having harnessed the input of a range of actors normally excluded from direct intervention in the policy process and also one that is more public and transparent than the private negotiations and bargaining than usually occurs in government consultation. Further evidence that the OMC process has ‗paid off‘ in the social field lies in the conclusions of the Spring European Council, 2006. There was criticism from within the Commission, as well as from actors in the broader policy network of the mid-term review of Lisbon in 2005. The mid-term review led by the Kok Report seemed to indicate a clear shift in priorities away from the three equal sides of the triangle, towards labour market reform
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packages to achieve the goals of the growth and competitiveness agenda. Such a drift in priorities clearly unpicked the previously established consensus on the need for separate action in the social field to tackle poverty and social inclusion on the basis that (a) there is a ESM to be defended by such measures and (b) that economic reform could not tackle all social inclusion issues, such as in-work poverty. However, the Spring European Council 2006 shows some indication of at least a partial ‗rowback‘ on the position adopted at the mid-term review. Specifically the then Commission President Barroso, in his reflections on the first round of Member State NAPSIs, noted the weak consultation in some member states and has called for greater stakeholder participation in the future. Taken together then, the initial Lisbon strategy is somewhat back on its original path and the credit for rerouting the EU institutions on this matter must, for the most part, be attributed to the policy deliberations of the network actors in the social policy NGO sector which has had greater impact as a consequence of the establishment of the OMC framework. There are then strengths of, and benefits provided by, the social OMC, suggesting it is a promising process to enhance democracy in the EU. But it is just a promise. Its success is limited. The process has significant failings, to which we now turn.
LIMITS OF THE SOCIAL OMC The social OMC was preceded by OMCs in the fields of employment and pensions (de la Porte and Nanz, 2004). It is certainly the case that the OMC varies considerably in accordance with the policy area (Tsakatika, 2004, p. 96). It seems lessons have been learnt from these, and improvements made with respect to democracy and legitimacy, but there are still significant failings of the social OMC, with plenty of scope for improvement in the future. According to recent research though, in terms of the European Employment Strategy (EES) and Pensions OMCs, the key elements of deliberative democracy have been enhanced to varying, but limited degrees. For example transparency is still poor (although this has been improved since 2003 with an EES website), but it remains one of the key areas advocated for improvement (Tsakatika, 2004; de Búrca and Zeitlin, 2003). Public debate is still partial and often ignored by the relative national governments. Social participation, although much increased (especially at the level of implementation), is still low in relation to the incentives offered, due to the lack of a formal role for the NGOs and social participants, and calls are made for it to be ‗upgraded‘ (Tsakatika, 2004, p. 95; de Búrca and Zeitlin, 2003). It is suggested this would be made easier if the process was made more transparent (Tsakatika, 2004, p. 97). Finally, both processes are being driven by the national governments with the process being centralised and top-down. Despite these factors, those who do participate in both the EES and pensions OMCs have been willing to alter their preferences, including member states, although this feature manifests itself much less when member states see the issue as particularly sensitive (de la Porte and Nanz, 2004). Nevertheless, the social policy actors have been more successful at harnessing the OMC process and particularly in terms of making the most of the potential to ‗feed in‘ from the broader community in to the national social strategy in the NAPSI, although there is plenty of evidence of the same problems of an elite-led process (specifically in relation to the extent of the ‗feeding out‘ from the national plans to the Commission Joint Report) as experienced in the in the EES and Pensions OMCs.
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The impact of the Kok Group 2004 and the mid-term review of the Lisbon strategy 2005 highlighted the fact that the Lisbon strategy can be by-passed by elites as a key constraint for the EU‘s potential to approximating deliberative democracy. The strategy only suggests the deliberations and resulting opinions of the OMC be ‗taken into account‘, which means democracy is compromised as power is not dispersed and it could lead to NGOs only being symbolically included. The public spheres that are generated through the OMC do not ‗emerge spontaneously‘ from civil society but are created by the EU institutions. This compromises their ability to form inclusive and oppositional networks (Dryzek, 2000, pp. 134-5), as a key requirement of informal public spheres is that it they are ‗not prior to or independent of decision-making agencies but created and formed in opposition to them- as a vehicle to test the legitimacy of legal provisions and as a counterweight to government power‘ (Eriksen, 2000, p. 55). We must therefore be sceptical as to whether the NGOs included in the social policy OMC have real ownership of a process established by government to serve government interests. The OMC was not formalised in the draft constitution and the strategy could consequently be more inclusive (Tsakatika, 2004). There are no specifics about who should be included in the debates within the policy process, meaning many affected are not represented and therefore remain excluded, which severely compromises deliberation and democracy. The problem lies in the absence of incentives for member states to have truly inclusive NAPs, except for morality and peer pressure (Zeitlin, 2005). Currently member states cannot fail in their NAPs, given the lack of specific targets to meet, which points to the need for considerably more stringent requirements of inclusion. We see the need for inclusion in the NAPs to be removed from the power of national governments who currently exclude from the OMC process the more critical NGOs, and therefore, to a degree, frame deliberation and decision-making in the OMC. This both undermines democracy, as there are those who are affected by the resulting social policy that are excluded, and undermines deliberation as relevant views, information and reasons are not heard. Moreover, the groups excluded from the OMC are those who are currently excluded by other EU, and national government, decision-making processes. In order to avoid this, the OMC processes must be well advertised across a diversity of media so that relevant NGOs are aware of the forums. It will also be necessary for the OMC organisers to identify and contact key stakeholders, and hopefully, with the establishment of networks between NGOs, recruitment will also be aided. A possible solution is to have targets for inclusion in the OMCs and targets not be set by the EU or national governments themselves, but perhaps the only way to ensure the OMC is not determined by the potential bias of the adversarial EU and National government political processes is if participants, in the OMC, are self-selecting (Elstub, 2008). Bohman also sees weaknesses of the OMC, again indicating that this EU process has not as yet successfully approximated transnational deliberative democracy. Firstly the OMC process is only semi-public as it is dominated by administrative agencies and private policy experts, with insufficient opportunities for citizen participation, who inevitably are in a hierarchical relationship with the officials. To make the OMC more democratic, and enable more citizen deliberation Bohman suggests integrating minipublics into the OMC process (Bohman, 2007, pp. 87-8). Minipublics are small groups of randomly selected citizens that are ‗small enough to be genuinely deliberative and representative enough to be genuinely democratic‘. These include citizens‘ juries, deliberative opinion polls, consensus conferences
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and planning cells (Goodin, 2008, p. 11). For Bohman this would help compensate for the self-selection inevitable with the participation of NGOs, due to their use of random sampling, and reduce the influence of experts. Bohman also thinks that the internet could play an important role in transnational deliberative decision-making processes like the OMC, which would extend the public sphere and make it more inclusive (Bohman, 2007, p. 89), and the ESS website has helped this but could still be a more deliberative and interactive site. Finally the employment of adjudicative and judicial institutions, which enable rights of appeal, and therefore enhances accountability, but also contribute to the public sphere by encouraging contestation of discourses within civil society, should be included (Bohman, 2007, p. 90).
CONCLUSION The EU suffers from a significant democratic deficit. As the credence of deliberative democracy continually grows it increasingly represents the criteria which must be met, by a decision-making process, to be considered legitimate. However, due to complexity, deliberative democracy is difficult to achieve in practice, and these features of complexity are even more significant at a transnational level. The social OMC approximates deliberative democracy, to a degree unprecedented at EU level, by generating distributed and dispersed hybrid public spheres that generate opinion forming debates, through which citizens can participate, that have formal links to policy making arenas, and formal public spheres. Consequently, the two essential aspects for the approximation of deliberative democracy are, to a degree at least, achieved. Macro deliberation is generated through the informal discursive public spheres and micro deliberation through the formal decision-making public sphere. The OMC leads to multiple, multilevel, public spheres, which helps to improve access to these debates for subordinate groups. The vital participants in these hybrid public spheres are NGOs which enable plural representation of expert and lay information, which also helps facilitate the approximation of deliberative democracy. However, this is not to say that the OMC cannot be improved and the norms of deliberative democracy approximated more closely. The argument here is that the Lisbon Strategy points to the type of institutional structures that are needed to institutionalise deliberative democracy at transnational level and help illuminate where the trade-off between theory and practice should be made. There are, however, considerable weaknesses with the OMC process and essential improvements that need to be made, if the promise to approximate deliberative democracy at a transnational level is to be achieved. The extent of the EU‘s leadership and various national governments‘ commitment to developing genuine deliberatively democratic policy processes is in doubt as, to date, the OMCs have only been employed in areas where the EU does not have great levels of power. The social OMC itself needs to be adapted to make it more deliberative and more democratic, most notably in terms of power of decision-making and in the inclusiveness of the process, but the generation of hybrid public spheres is nonetheless an important development in EU democracy and to the plausibility of approximating deliberative democracy at transnational level. This is still a long way from being an approximation of deliberative democracy, but the social OMC provides an important template on which to improve in order to take some further, concrete, steps towards embracing the deliberative model of democracy in a transnational context.
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Elstub, S. (2006). ‗A Double Edged Sword: The Increasing Diversity of Deliberative Democracy.‘ Contemporary Politics. 12, 3-4, 301-320. Elstub, S. (2007). ‗Overcoming Complexity: Institutionalising Deliberative Democracy through Secondary Associations.‘ The Good Society, 16, 1, 14-22. Elstub, S. (2008). ‗Weber‘s Dilemma and Dualist Model of Deliberative and Associational Democracy.‘ Contemporary Political Theory, 7, 2, 169-199. Eriksen, E. O. (2000). ‗Deliberative Supranationalism in the EU.‘ In E.O. Eriksen & J.E. Fossum (eds.), Democracy in the European Union - Integration through Deliberation? (42-64). London: Routledge. Eriksen, E. O. & Fossum, J. E. (2000). ‗Post-National Integration.‘ In E. O. Eriksen, & J. E. Fossum, (eds.), Democracy in the European Union - Integration through Deliberation? (42-64). London: Routledge. Femia, J. (1996). ‗Complexity and Deliberative Democracy.‘ Inquiry. 39, 361-97. Festenstein, M. (2002). ‗Deliberation, Citizenship and Identity.‘ In M. D ‘Entrèves, (ed.), Democracy as Public Deliberation: New Perspectives (88-111). Manchester: Manchester University Press. Fraser, N. (1992). ‗Rethinking The Public Sphere: A Contribution To The Critique Of Actually Existing Democracy.‘ In C. Calhoun, (ed.), Habermas and The Public Sphere, (107-142). Cambridge. MA: MIT Press. Goodin, R. (2008). Innovating Democracy: Democratic Theory and Practice After the Deliberative Turn. Oxford: Oxford University Press. Habermas, J. (1996). Between Facts and Norms: Contributions to a Discourse Theory on Law and Democracy. Cambridge: Polity Press. Hendriks, C. M. (2006). ‗Integrated Deliberation: Reconciling Civil Society‘s Dual Role in Deliberative Democracy.‟Political Studies, 54, 3, 486-508. Hirst, P. (1994). Associative Democracy: New Forms of Economic and social Governance. Cambridge: Polity Press. Lisbon European Council, (2000). Presidency Conclusions, March [100//00], Brussels, Council of the European Union. Parkinson, J. (2006). Deliberating in the Real World: Problems of Legitimacy in Deliberative Democracy. Oxford: Oxford University Press. Schlesinger, P. & Kevin, D. (2000). ‗Can the European Union Become a Sphere of Publics?‘ In E. O. Eriksen, & J. E. Fossum, (eds.), Democracy in the European Union - Integration through Deliberation? (206-229). London: Routledge. Tsakatika, M. (2004). ‗The Open Method of Coordination in the European Convention: An Opportunity Lost.‘ In L. Dobson, & A. Follesdal, (eds.), Political Theory and the European Constitution (91-102). Abingdon: Routledge. Vos, E. (1999). ‗EU Committees: The Evolution of Unforseen Institutional Actors in European Product Regulation.‘ In C. Joerges, & E. Vos, (eds.), EU Committees: Social Regulation, Law and Politics (19-70). Oxford: Hart Publishing. Warren, M. (2001). Democracy and Association. Princeton, NJ: Princeton University Press. Warren, M. E. (2002). ‗Deliberative Democracy.‘ In A. Carter, & G. Stokes, (eds.), Democratic Theory Today (173-202). Cambridge, UK: Polity. Zeitlin, J. (2005). „Social Europe and Experimentalist Governance: Towards a New Constitutional Compromise?‟ European Governance Papers (EUROGOV), No. C-05-04.
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 5
HOUSING DESIGN AND SAFETY FOR THE ELDERLY Hülya Öztop* and Sibel Erkal** University of Hacettepe, Faculty of Economics and Administrative Sciences, Department of Family and Consumer Sciences Ankara-Turkey
ABSTRACT The number of older persons is increasing, both in actual number and as a percentage of the population. As an individual ages his or her body changes and the ability to deal with the demands of an environment usually decreases. A well designed, supportive environment may help older persons to utilize their homes more fully, more safely, and allow them to live independently in their homes longer. Use of kitchens and bathrooms may present the greatest challenge and the greatest safety hazard and in order to remain independent, an older person must be able to use these rooms fully and safely. Based on the concept of ‗aging in place,‘ design of houses in the past years are explored. Design features in the built environment become barriers for aging people with functional limitations. Initially, houses were designed according to the required needs of the user with the physical limitations. Later, adaptable house design was introduced that allows the house to meet the specific needs of the user, while maintaining the appearance of the house until more obvious accessibility features are needed. Today, ‗design for all‘ is recognized as a tool for ensuring physical accessibility for aging people. Housing must fulfill the needs for the daily activities of the elderly and give the feeling of satisfaction, security, comfort and independence.
Key Words: Housing, elderly, home accidents, interior space design, universal design
INTRODUCTION A safe, convenient, sound and healthy living environment is prerequisite for a good house for the people with special needs. The intention of making house in such a away that it solves basic problems of fixture and fittings. However the costruction phase of a good house a
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critical to design inside and outside structures. Often the builders do not know all the factors to be considered that can maintain a safe, hygienic and healthy environment. It is believed that when housing is ergonomically furnished, then a maximum benefit will be achieved. To meet with an individual‘s specific needs, an analysis of user‘s requirement is the most importanat factors to be considered in the special houses(Ahasan et al.,2001). It is important to recognize that most people, if they live long enough, will experience a period in their lives when some functions become impaired (Lawton, 1990). A functional limitation is one that affects an individual‘s ability to function in his or her environment but does not affect the structure of body systems. Of persons over the age of 65, 45% have some type of functional limitation. This percentage increases to 72.5% for persons who live to age 75 years. It is probable that since more people are surviving to later ages, there will be more people with disabilities (Vanderheiden, 1990). Based on the concept of ‗aging in place,‘ design of houses in the past years are explored. Design features in the built environment become barriers for aging people with functional limitations (Demirkan, 2007). The elderly dealing with changed capacity, reduced ability and increased needs require the same accommodations and compensations in late life that they found in earlier years. Homes must provide solutions that address these distinctions in capacity, ability and need for daily living. (Sandhu, 2001; Scott et al., 2001; Story et al., 1998, Demirbilek & Demirkan, 2004). Initially, houses were designed according to the required needs of the user with the physical limitations. Later, adaptable house design was introduced that allows the house to meet the specific needs of the user, while maintaining the appearance of the house until more obvious accessibility features are needed. Today, ‗design for all‘ is recognised as a tool for ensuring physical accessibility for aging people (Demirkan, 2007). Accessible generally means that the dwelling meets prescribed requirements for accessible housing. Accessible features in dwellings include items such as wide doors, sufficient clear space for wheelchairs, loop-type handles on hardware, grab bars in the bathroom and knee spaces under the sink. These features are permanently fixed in place and very apparent (Demirkan1991, Demirbilek & Demirkan 2004). Accessibility should be addressed in the wider perspective of spatial planning. An accessible environment is safer and healthier, thus avoiding accidents while allowing aging people to enter. An accessible environment is more comfortable, as it is more livable. Furthermore, it is more adaptable, as it accommodates later changes. Design for all is recognised as a tool for ensuring physical accessibility for aging people, but there are many other types of accessibility, which depend on mental and physical factors. If the built environment has been designed to take into account the physical dimensions of the human being, also perceptual, motor and cognitive abilities support human activities. Therefore, the design for all is the design for human diversity, social inclusion and equality (Demirkan, 2007). A house that is inadequate for the needs of the people living in it, never becomes a home. A wide spectrum of professions is concerned with life-span design (universal design) for an ageing population, design, engineering, gerontology, ergonomics and architecture and others. All try to support ageing in place so that independence, freedom of choice and life style are promoted. Designs considering the data related to both physical and psychosocial characteristics of people can improve the quality of life by promoting independence, as well as safety, useability and attractiveness of the residence (Demirbilek & Demirkan, 1998). A universal design feature is any component of a house that can be used by everyone regardless of ability or disability. The definition also started many discussions on the issue on
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what is a design that is ‗usable by all people.‘ Consequently, many international standards on usability are published to support this issue (Bevan, 2001). Trost (2005) stated the difference between these two terms, as the universal design suggests a comprehensive philosophy, whereas the ‗design for all‘ relates to practical applications. This comprehensive philosophy is explained as the holistic approach for all users that do not include disabled people as a specialised group. Universal design is a concept that extends to a broad diversity of users who have to interact with the built environment (Sandhu, 2001; Scott et al., 2001; Story et al., 1998, Demirbilek & Demirkan, 2004). The increase in life expectancy, the resulting growth of the elderly population and the preference to age in familiar environments are the driving forces for architects to consider aging population in the design process (Demirkan, 2007). There are some studies that examined relationship between life in the home and the well-being of the elderly (Demirbilek&Demirkan 1997, Sagdic & Demirkan 1997, Sagdic and Demirkan 2000, Demirbilek & Demirkan 2000, Demirbilek & Demirkan 2004). Because there is a limitation in outside physical activities, aging people focus more on the activities in their residences. Their homes become the only places that they can maintain social bonds with individuals and their community. Researches have shown that psychological well-being is one of the most intrinsic aspects of successful aging (Carp, 1976, Schwirian1993). Housing must fulfill the needs for the daily activities of the elderly and give the feeling of satisfaction, security, comfort and independence. Previous studies for the elderly housing were mostly focused on senior housing, sheltered housing, nursing houses and community dwellings rather than privatehousing. The global aging phenomenon highlights the disparity between traditional housing and the actual standard of housing required to enable people to live in their homes as their needs change. Studies have identified various factors having impacts on the psychological wellbeing of the elderly including housing and neighborhood environments (Carp & Christensen 1986, Lawton 1985, Parmelee & Lawton 1994, ) The architecture literature sources mostly provide the requirements of elderly users for a safe and functional environment (Demirbilek & Demirkan,1998, 2000, Sagdic & Demirkan, 2000). In addition, some sources have developed a list of characteristic features of universal houses as checklists (Mace, 1998 ). Recently, a building survey is developed as a tool for evaluating the existing buildings from a human-centred perspective. Examining the checklists or building surveys, it is found that there are many universal design principles to cover, as well as one principle may comprise the others. (Ostroff & Weisman, 2004). The design professional faces a tremendous task and challenges to keep abreast of technological advances and research pertaining to many facets of human beings and the built environment (Benktzon, 1993; Dagostino, 1996; Demirkan, 1996; Pinto et al., 2000; Sagdic & Demirkan, 2000, Demirbilek & Demirkan, 2004 ). A participatory design model was proposed in order to design and develop safe and functionally appropriate housing that will promote and maintain independent living of elderly people. There is a growing recognition that the physical environment can enhance or impede the independence and mobility of the elderly. The sketches proved that involving the elderly in the design decision making process enhances the design solutions, since the experience of the users was reflected in the final design descriptions. Also, the participatory design sessions increased elderly people‘s awareness of the consequences of the decisions that were taken, as well and they gained satisfaction by having influenced the decisions (Demirbilek & Demirkan, 2004).
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Universal Design and Its Principles Although codes and standards for the benefit of people with mobility limitations specify accessible or adaptable design requirements, the universal design approach targets all people of all ages (Mace et al,1991). Universal design is ―a user-friendly approach to design in the living environment where people of any culture, age, size, weight, race, gender and ability can experience an environment that promotes their health, safety and welfare today and in the future‖ (Alliance, 2005). It essentially implies that ―universal design is the idea that everyone should have access to everything all the time‖. This definition pertains to more than just the design of interior spaces. It also relates to the appliances and products used in everyday environments such as the internet, phones that the deaf and blind can use, and a can opener with a thicker handle that is easier for an elderly person or child to grip (Nieusma, 2004). Because people are living longer and wanting to maintain a better quality of life as they age, many want to remain in their homes for as long as possible. As the population evolves, technology is also advancing and changing. Concurrently, marketing forces of industry constantly compel quality improvements and user satisfaction. Because of this, guidelines and principles of universal design have been developed to help improve technology and products so that they better serve users. This in turn lets people lead an easier, more productive lifestyle (ASID, 2000) Using universal design creates a functional, user friendly atmosphere that anyone from a child to a grandparent could use (Tenebaum, 2005). For example, creating a kitchen with multiple counter heights provides children as well as adults the ability to utilize the space. The human body changes as one ages and begins to lose its five senses. Because of this, older generations require better task lighting as well as higher contrast in certain areas. This is because degeneration of eyesight becomes a major factor with advancing age (Lanspery&Hyde, 1997). To help remedy this problem, task lighting can be implemented to help prevent eye strain for the elderly in a space. A bonus benefit of this is the same task lighting could just as easily benefit a child working on his or her homework in that same space (Clay, 2005). Overall, universal design principles and products are meant to be integrated seamlessly, simplistically, and affordably into the daily lives of people (Leibrock & Terry, 1999). By implementing these principles, better design is being created that benefits users of all ages and abilities. Beginning with the no-step entry and exits of the home, openings and doorways need to be widened, wall corners need to be rounded, and ramps may also need to be installed for wheelchair access. Installing certain devices in the home can make it a safer environment. Fire extinguishers, smoke detectors, and carbon monoxide detectors should be installed in every home. Emergency contact devices and daily calling services help to prevent prolonged periods of lying immobilized on the floor. Safety features should always be the first consideration and concern (Bishop, 2009). Aging in place reflects the desire of seniors to maintain the ability of directing their own lives, preferably in their own home. The baby boomer generation is full of individuals who will desire to maintain the independence they have enjoyed their whole lives. Our needs and wants will change as we age, and our environment will likely have to be adjusted to satisfy both of them. Universal design can offer us another housing choice as we age: allow us to
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remain in the same environment, even as our circumstances change due to reduced abilities, including the naturally-occurring process of aging ( Bishop, 2009). In contrast, this design project intends to address the needs of those who cannot remain in their current homes, cannot live independently (such as a disabled young adult), or are seeking to downsize their current residence and move closer to other members of their family. Three dwellings will be designed that provide a solution for those who have lost the ability to live fully independently, yet still desire to maintain their autonomy as possible. The design solutions will reside in the context of what many in this situation choose—to move closer to their extended families that live in a single family residence (Newbill, 2007). To accommodate these variations, three different aging-in-place dwellings will be designed that reflect the different needs and priorities of persons who might typically desire to age-in-place.
Figure A. View of Dwelling Option A, designed for a retired married couple (Newbill, 2007)
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Figüre B. Floor Plan for Dwelling Option B designed for a single active elderly person (Newbill, 2007)
Furnishing Home furnishings also play a major role in universal design (Bishop, 2009). A sick, injured or elderly person may have limited strength and energy. Even getting up and sitting down can be hard. For them, furniture must have both good support and good leverage. These requirements ensure their independence and safety. Always have the disabled or elderly person to try out chairs, sofas and beds before purchasing to be sure that they are right for the person's body. The chair seat should be as high as the length of the lower leg (14-18 inches), and as deep as the length of the upper leg (15-18 inches). When a person is seated both feet should be flat on the floor. A chair that is too high or deep puts pressure on the thighs causing aching legs, circulatory problems and numbness. A chair that is too low can cause lower back pain. It also makes getting up awkward and difficult. The seat front should be gently curved so that there is no pressure behind the knees. This, too, prevents circulation problems. There should be 2-3 inches of space between the seat front and the seated person's thigh. The cushion should be firm and resilient (Hammet, 2009).
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Figure C. Floor Plan for Dwelling Option C designed for a single elderly person (Newbill, 2007)
Like the walls in the home, the corners of home furnishings and extended countertops should be rounded. Non-skid, resilient flooring should be installed in place of carpeting, and throw rugs should be avoided. If rugs and carpets are used, they should be dense, low-pile, and should transition into other flooring with ease. Secure hand rails should be installed in stairways, and handle or lever-type controls should replace knobs on doors, windows, plumbing fixtures, and cabinets. Grab bars need to be installed in tight spaces, such as bath and shower stalls, as well as the toilet area. The installation of features such as raised toilet seats, bath stalls, and bathtub and shower chairs can be done in ways that improve the value of the home, as well as make the bathroom accessible to all in ways that allow people with disabilities to remain self-sufficient (Bishop, 2009). A room crowded with seldom-used furniture can be a hazard. Remember that a person in a wheelchair needs 60 inches x 60 inches turning area. Arrange the furniture to provide that space (Hammet, 2009).
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Principle 1: Equitable Use 1a. Provide the same means of use for all users: identical whenever possible; equivalent when not. 1b. Avoid segregating or stigmatizing any users. 1c. Make provisions for privacy, security, and safety equally available to all users. 1d. Make the design appealing to all users. Principle 2: Flexibility in Use 2a. Provide choice in methods of use. 2b. Accommodate right-or-left handed access and use. 2c. Facilitate the user's accuracy and precisions. 2d. Provide adaptability to the user's pace. Principle 3: Simple & Intuitive Use 3a. Eliminate unnecessary complexity. 3b. Be consistent with users‗ expectations and intuition. 3c. Accommodate a wide range of literacy and language skills. 3d. Arrange information consistent with its importance. 3e. Provide effective prompting and feedback during and after task completion. Principle 4: Perceptible Information 4a. Use different modes (pictorial, verbal, tactile) for redundant presentation of essential information. 4b. Maximize "legibility" of essential information. 4c. Differentiate elements in ways that can be described (i.e. make it easy to give instructions or directions). 4d. Provide compatibility with a variety of techniques or devices used by people with sensory limitations. Principle 5: Tolerance for Error 5a. Arrange elements to minimize hazards and errors: most used elements, most accessible; hazardous elements eliminated, isolated, or shielded. 5b. Provide warnings or hazards and errors. 5c. Provide fail safe features. 5d. Discourage unconscious action in tasks that require vigilance. Principle 6: Low Physical Effort 6a. Allow user to maintain a neutral body position. 6b. Use reasonable operating forces. 6c. Minimize repetitive actions. 6d. Minimize sustained physical effort. Principle 7: Size and Space for Approach and Use 7a. Provide a clear line of sight to important elements for any seated or standing user. 7b. Make reach to all components comfortable for any seated or standing user. 7c. Accommodate variations in hand and grip size. 7d. Provide adequate space for the use of assistive devices or personal assistance.
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A common misconception is that universal design is meant to meet only the needs of the disabled and elderly (Pirkl, 1994). Transgenerational design is often compared to universal design and, in fact, falls underneath the ―universal design umbrella‖. Many of the guidelines of transgenerational design could be considered subcategories of the universal design principles. Transgenerational design, however, is oriented more toward the mature consumer while still advocating design for all ages and abilities. Specifically, transgenerational design is defined as ―the practice of making products and environments compatible with those physical and sensory impairments associated with human aging and which limit major life activities. It rejects as discriminatory and stigmatizing, specialized products or devices targeted directly at older consumers. Rather, transgenerational design insists that products and environments be designed at the outset to accommodate a ―transgenerational‖ population, which includes the young, the middle-aged, and the elderly‖ (Pirkl, 1994). Transgenerational design is an approach to design that ―(1) bridges the physical and sensory changes associated with human aging; (2) responds to the widest range of ages and abilities, without penalty to any group; and, (3) preserves the individual‗s sense of dignity and self worth‖ (Netherlands, 1996). Researchers have defined the following guidelines for appropriate transgenerational design: 1. Provide cross-sensory redundant cuing for all alarms, signals and controls (combine and audio signal with a visual indicator). 2. Offer redundant modes of operation utilizing the next larger set of motor movements (finger to hand; hand to arm; arm to foot). 3. Establish consistent display/motion relationships left to right and forward/up to increase, backward, down to decrease. 4. Provide definitive feedback cues (control positions (detents) should ―snap‖ into position). 5. Reduce the complexity of all operations (minimize the number of tasks). 6. Place critical, and frequently used controls within easiest reach (cluster controls on basis of priority). 7. Prevent accidental actuation of critical controls (relocate, recess, or provide a guard). 8. Provide adjustable product/user interfaces (horizontal/incline, vertical/incline, raise/lower, push/pull). 9. Design for use by a variety of populations (male/female, young/old, weak/strong, large/small). 10. Design to facilitate physical and cognitive function (encourage user to practice and improve by making operations easy and enjoyable). 11. Design beyond the basic physical/functional need (enhance the user‗s independence, self-respect, and quality of life). 12. Compensate for a range of accommodations levels (provide for some exercise through user interaction/participations). 13. Strive to make task movements simple and understandable (clockwise for ―on‖ or ―increase‖, counterclockwise for ―off ‖ or ―decrease‖ ) (Pirkl, 1994). It is important to note that transgenerational products are those that support safety, comfort, convenience, ease of use and bodily fit (Pirkl, 1994). This type of design is notable
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because it bridges the transitions across the various life stages and is responsive to individual differences and abilities in people. These products also give all people (not just the elderly), a sense of self worth, encourages personal and social interaction, and promote close friendships between non-disabled persons and persons with disabilities (Pirkl, 1994).
Lighting Concerns Lighting is also an important aspect of the environment that must be considered for improvement. Ambient light must be increased throughout the home, but especially in dark areas such as stairways. Night time illumination also needs to be installed around and inside the home, especially on major pathways to the entry, in hallways, stairwells, and bathrooms (Bishop, 2009). The lighting levels can be increased in every room to account for diminishing eyesight. As people age, they require about three times the amount of light to see as well as those who are younger (Lawlor & Thomas, 2008). Furnishings can be arranged to optimize the use of natural light and increase levels of ambient light. The amount of light is not the only important factor. The quality of light is also important. Light rooms evenly so that there are no dark areas or glare. Here are some guidelines for planning good lighting for a person with failing eyesight: Use frosted glass globes in wall and ceiling fixtures to reduce glare. Lighting for watching TV should be relatively indirect and even in the room. Avoid contrast between a dark room and a bright TV picture. Use light-colored translucent shades on lamps to distribute light more evenly. Be sure the shade on table lamps hides the bulb. Three-way switches on lamps will allow for extra lighting when it is needed. Use night lights in bathroom, hallways, and bedrooms. Use lighted cover plates for light switches in the bedroom, hallways, stairs and bath areas. Arrange furniture in the rooms so the person does not face a large window. Cover windows with a transparent or translucent material like sheers to filter natural light and eliminate glare. All storage areas should have lights controlled by wall or easy-to-reach pull cords In kitchens, provide lighting over counters and the sink. Track lighting or fluorescent light sticks that plug into electrical outlets can be added. Switches on table lamps should be easy to use. Twisting switches may be more difficult for the arthritic hand or an accident victim. Ask you doctor about convenience devices to make a lamp easier to turn on or off (Hammet, 2009).
Safety Features Installation of sufficient safety features such as fire extinguishers and smoke detectors is important, but assistive monitoring technology should also be considered to provide
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assurance of assistance when needed. (Demiris, et al., 2008). Disabled or elderly people tend to be more concerned about personal safety because they are more vulnerable to defending themselves in an attack. Housing design should help to protect them. There is an obvious conflict between security in the home and access, which has to be carefully addressed in a successful design. People with a hearing impairment have a particular problem unless they are provided with some sort of visual or tactile alerting device. (Osman & Gibberd, 2009)
Color Color can also make a home safer and more enjoyable. Light colors reflect light back into the room. Dark colors absorb light. For example, a white wall will reflect 85 percent of the light back into the room, whereas a dark brown wall will reflect only 10 percent back into the room. By age 75, many people are not able to distinguish between shades of blue, blue green and green, and violets. Dark colors and colors of similar intensity (brightness or dullness) are more difficult to distinguish. They also may become overtiring and depressing. Light, pastel colors such as light pinks, salmon, peach, light yellows, pale greens, off whites and light blues may be difficult to distinguish from each other, too. Bright colors can help the visually handicapped "read" the environment more effectively. Dark and light color contrasts can make objects more visible. For example, a dinner plate with a colored border or a white plate on a colorful placemat can help the person see the plate better and avoid hitting the glass on the edge of the plate. Light food such as ice cream served in a dark dish can be seen easily. Contrast is also effective in signaling changes in the floor level. It can be used to show where stairs begin and end. Select light colors for walls and ceilings. Use medium colors for floors and wood finishes. Furniture that contrasts with the carpet and walls, is easier to see. Slipcover a sofa or chair or use a throw cover to save reupholstering expenses. Avoid glossy finishes on floors, wood furniture, etc., to eliminate glare. Use cloth tape in a bright contrasting color on the edge of kitchen or bath countertops that are similar to the floor color. The counter edge will be more visible. Avoid very large patterns or small "busy" wallpaper designs. They can become confusing or produce blurred vision and eye fatigue. Use light colors in areas which tend to be dark, such as hallways, closets and cupboards (Hammet, 2009).
Easy Chair For relaxing, the elderly or disabled person needs a chair that will help him sit somewhat upright. This avoids compressing internal organs and helps with proper circulation. The illustration on the bottom of this page shows the dimensions for a comfortable easy chair. Chair arms provide comfort and leverage in getting in and out of the chair. The person's arms should lie naturally and relaxed on the chair arms. Armrests that are too high strain the
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shoulders. If they are too low or not forward enough, they do not allow for leverage. The disabled or elderly person will have to lean over too much and could easily lose his balance (Hammet, 2009).
Furniture must be more than simply attractive. Here are a few more suggestions: The table beside a chair or sofa should be same height as the armrest. An inch or two higher is okay, but, for safety, it should never be lower. Table legs should be sturdy and straight. They should not stick out beyond the table edge. Pedestal and drop-leaf tables can tip if someone leans on them for support. It's too easy to trip over a low coffee table (12 inches high). They are below the line of sight of the standing person. A table 18-24 inches would be better. Bedside tables should be 2-3 inches higher than the mattress--never lower. The table should be large enough to hold necessary supplies (glasses, lamp, reading material, telephone). Beds should be sturdy, with headboard and footboard 12 inches taller than the mattress to offer support and leverage. They should be smooth and easy to grip. A footboard will also keep extra blankets off the floor. A bed should be 16-17 inches high or even with the wheelchair seat. To raise a bed, drill a hole or recessed area in heavy wooden block (2 inches x 4 inches or 4 inches x 4 inches). Place the blocks under the legs of the bed. To lower a bed, cut off the legs. Or used a 4 inch dense foam mattress instead of an innerspring mattress (Hammet, 2009).
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Floors The floor should be level and firm underfoot. Select a non-skid material with a satin or dull finish. Reflected glare from glossy finishes can give a sense of instability. Avoid waxing. The glare and the slippery surface can be a hazard. Floors in kitchen, bath, laundry area and entry should be easy to care for and slip resistant when wet. If carpet is used, select a low-level loop pile. Pile height should be no greater than ¼inch. Use thin padding underneath or no padding and glue the carpet down directly to the subfloor. Avoid patterns, strong color contrasts and sculptured carpet. Those "busy" designs can cause visual problems and thus poor balance. Use no or low thresholds between different flooring materials. Do not use area rugs. They tend to slip and can easily cause falls (Hammet, 2009).
Bathroom Areas Bathrooms are not traditionally designed to accommodate the physically challenged. The knobs on the sinks and in the showers make simple tasks such as washing one‘s hands and taking a shower extremely difficult for those with arthritis. The barrier on tubs can be strenuous for older people to step over, and often to prove to be a fall hazard. The elderly generally have limited postural control; using the toilet can require great amounts of energy for them to get on and off of it. If the doorway is not wide enough or the bathroom not big enough, wheelchair use will be impractical (Bishop, 2009). There are many alterations to a conventional bathroom that can certify it as universally accessible. In addition to changing all knobs to handles or levers, freestanding toilet paper holders provide more flexibility and convenience. Installing hand supports and raised toilets often helps those who have problems with postural control. The toilet should be at a comfortable height of seventeen to nineteen inches. Grab bars reduce the likelihood of injury in the bathroom. A recent study found that elderly people prefer to use side-support grab bars at elbow and chest height when rising from the toilet, and at buttock height when lowering (Dekker,et al.,2006). Grab bars should also be installed in the shower. Shower stalls should be step-free or ‗curb-less‘ to minimize the hazard of falling. To ease the task of bathing, a bench with an eighteen-inch seat height can be placed in the shower area. The shower head should be removable, thus enabling hand-held use. Showers can also be designed without any enclosures provided to allow for more space (Bishop, 2009) Narraow bathroom doors keep many whelchair users from entering their bathrooms, forcing them to rely on other methods of personal hygiene such as bedside commodes and sponge baths. Furthermore, narrow bathroom doors may force people using walkers to maneuver sideways through the door, increasing their risk of falling. Narrow doors may cause people who cannot walk to adopt unsafe strategies such as lowering themselves out of their wheelchair to scoot on the floor or transferring from their wheelchair to a narrower but
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dangerous alternative such as a desk chair on casters. Barriers within ahome can also increase the work and stres of caretakers who assist older and people with disabilities (Hammet, 2009).
Figure D. Tub with grab bars and bench (Luscombe, 2003)
Figure E. View of the shower illustrates universal design solutions (Luscombe, 2003)
Kitchen Areas Alterations recommended for bathrooms can also be applied to kitchens. Faucet knobs can be changed to levers. Cabinets should be lower to reduce climbing or reaching. Heavy lifting can be eliminated with things such as full-extension rollers on drawers. Kitchen cabinets should be flexible and interchangeable to allow residents to adjust cabinets to their particular needs. Careful space planning can make a major impact on the quality of life for an elderly person. Obstruction of pathways, thresholds, and throw rugs can be a threat to the elderly, as they are easy to trip over. Soundproofing rooms should be a priority too, as background noise can be frustrating and distracting for the hearing impaired. Fabric on window treatments and upholstered pieces within a room can act as an acoustical buffer. Upholstered walls, or segments of walls, and large textile hangings also absorb background noise. Seating that has arms that extend to the front edge provide more stability. Seat heights
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of eighteen to twenty inches make it easier to get in and out of chairs and sofas. The proper use of contrasting colors and patterns between floors, walls, tabletops, and countertops helps to avoid accidents. With universal design, it is important to remember that physical appeal doesn‘t need to be sacrificed for accessibility; and often, a beautiful home reduces stress and provides a happier environment for an elderly person (Bishop, 2009)
Figure F. Kitchen and dining view of ECHO addition (Hand, 2005).
Figure G. Several features are shown that illustrate transgenerational principles such as pullout storage stools placed for easy access if needed (Luscombe, 2003)
Accidents and Injuries Accidents are the sixth most common cause of death for people over age 65 and the rate increases each decade after age 65. By the time a person reaches age 85, accidents are the fifth most frequent cause of death, accounting for more deaths than diabetes mellitus (Kallman & Kallman, 1989). Every year around 14 million people are treated in Accident and Emergency Units in the UK. Home accidents account for one fifth of these casualty attendances (Gutman, 2007). Studies indicate that around 20 million home and leisure injuries occur each year in the European Union (EU) requiring medical attention (IDB,2007) Each year, many older people are injured in and around their homes (Güner& Güler, 2002). The majority accidents
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involving older people, both fatal and non-fatal, are falls (Scott and Gallogher, 1999; Gutman, 2007; Atman et al, 2007; Sattin et al, 1990; Evci et al, 2006; Alptekin et al,2008). Falls are a major cause of injury- related morbidity in the elderly, and the leading cause of accidental death in those over 75 years of age (Horan& Clague, 1999;Fallon et al, 2002).Older bones are often less dense, more brittle and break more easily. A simple fall can become a serious, disabling injury that limits independence (Tremblay, Kreul-Froseth, 2004; Koski et al, 1996). Un intentional injury, usually from falling, ranks as the sixth most common cause of death in the over 65 years age group in the US, while 10 % -15% of falls result in serious injuries (Parry et all, 2001). Although bedrooms and living rooms are the most common locations for accidents in general, the most serious accidents involving older people usually happen in the kitchen or on stairs (Gutman, 2007). Research has shown that many home accidents are preventable (Buchner et al, 1997; Province at al, 1995; Gutman, 2007). Older women had three-quarter more injuries than elderly men, and almost 82% of the injuries occurred in the home (Kelly & Kroemer, 1990). Pynoos and others (Pynoos et al., 1987) report that elderly women tend to be injured in the home more often than their male counterparts because they traditionally carry out more household duties. Older women are injured in falls around the house more often than are older men. Elderly men may be hurt outside more often by such things as lawnmowers, nails, tools, and saws. The incidence of injury in bathtubs and showers by older men and women is equal. Older persons who do not recognize their own limitations may place themselves at greater risk for an injury (Pynoos et al., 1987). Injury incurred as a result of an accident often results in an increased number of complications: increased healing time, decreased functional ability, increased dependency, and immobility. Often, after an accidental injury, there is a persistent and gradual decline in general health and function resulting in the individual becoming bed or chair bound. Immobility contributes to mortality and morbidity (Kallman & Kallman, 1989). Many older persons are so afraid of an accidental injury or fall that they restrict their activity and their socialization. Also, families are afraid of their older family members being seriously injured in an accident and statistics indicate this fear is a common reason for institutionalizing loved ones (Kallman & Kallman, 1989). Mobility aids, or prosthetic devices, are available for individuals with impaired mobility and take the form of canes, walkers, scooters, and wheelchairs. Mobility aids are very valuable assets for many individuals. However, there are problems for individuals using mobility aids since they limit the use of numerous environments. Wheelchairs and some walkers cannot get through narrow doorways or go up or down stairs. Most elderly person cannot afford to widen their doorways or to have mobility aids on every level of their home. The result is that mobility aids are helpful only within limited conditions that favor their use and do not eliminate the reality of impaired mobility. The changes that occur as a natural part of aging are normal and are happening to everyone. Most people will be relatively fit and healthy until near the end of their lives. While the natural changes of aging may not be avoidable, they should not be handicapping. It is the design of the technology, products and buildings we use which results in handicap and dependence (Andes, 2004). Risk factors in the home related injury vary. Main predictors for all kind of home accidents are associated with not only induvidual characteristics but also environmental factors.
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RISK FACTORS FOR FALLS Host-Related Factors Older age (especially > 75 years) Living alone Acute, Chronic disease Decreasing hearing etc, Foot problems Postural instability etc
Environmental Factors Poor lightings, Inadequate ventilation, Slippery floors, Unsturdy furniture, Absence of handrails in staircases Lack of grab bars or poorly located/mounted grab bars Inadequate handrails on stairs Stairs steps with different heights, Broken stairs etc. (Fuller, 2000; Tremblay & Kreul-Froseth, 2003; Erkal& Şafak, 2003;) The risk of sustaining an injury from a fall depends on the individual susceptibility and environmental hazards. Normally physical and mental changes related to aging decrease functional reserve. As a result, elderly people become more susceptible to falls when they are confronted with any challenge (Fuller, 2000). Critical steps in reducing the risk of falls in the Elderly: Eliminate environmental hazards, Improve home supports Provide opportunities for encourage Involve the family etc (Fuller,2000) Many people with severe mobility impairments risk injury from falling while being carried in and out of the home, and they may be unable to exit their homes independently carried in an emergency. In 2005, 15,800 persons aged 65 and older died from falls;1.8 million older Americans were treated in emergency rooms for their injuries, and 460,000 were hospitalized. Every year, falls among older people cost the nation more than $19 billion in direct medical costs. By 2020 the total annual cost of these injuries is expected to reach $43.8 billion (Maisel et al.,2008).
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Researchers Yardley and Smith (2002) write that seniors report fear of falling as an anxiety that exceeds even fear of robbery or financial problems and that among those who have fallen previously the fear may be as high as 50%-65%. They conducted a study of community–living residents older than 75 years of age, and attempted to identify the most commonly feared consequences of falling and to try to determine if the fear of falling motivated people to reduce their activity levels. The study concluded that the seniors in their study did indeed avoid situations in which falling could be witnessed by others, embarrass them, and pose a threat to their identity (Yardley & Smith, 2002). In the age group including those 65 years of age and older, falls are the leading cause of deaths occurring as a result of an injury. (Plautz et al., 1996). Additionally, ―fall related accidents are predisposing factors in 40% of the events leading to long-term institutional care in older people‖ (Masud & Morris, 2001, p. 5). Most (55%) of the injuries resulting from falls among seniors occur in the home. Furthermore, 28% of injuries occurring as a result of falling by older persons resulted in either short-term or long-term limitation in one or more Activities of Daily Living. Locations associated with a greater proportion of falls are stairs, street curbs, the bathroom, and the bedroom (Andes, 2004). Fires and burns among those aged 65 and older are the third leading cause of death as a result of injuries in the home(Plautz et al., 1996). The deaths that occur as a result of burns from flames are caused primarily by igniting clothing while either smoking or cooking (Christenson, 1990). Older adults who are confined to their homes have a fatality rate due to fires that is two or three times higher than the national average (Fielo & Warren, 2001). Twenty percent of all persons admitted to the hospital with burns are 65 and older, many of whom lived alone or were known to have ingested alcohol prior to their injury. Flames and scalding water from the tap, shower, or bath are the most common causes of burn injury in older adults (Kallman & Kallman, 1989). In fact, one-third of all the persons who suffered hot water burns are older persons (Christenson, 1990). The National Burn Information Exchange estimated that 50% of the burn injuries that occur in the home yearly could be prevented by education and design interventions (Pynoos et al., 1987). Main predictors for all kind of home accidents are associated with not only individual characteristics but also housing conditions. It may be difficult to overcome individual factors, but it is possible to avoid these accidents by improving the housing conditions for elderly. In order to achieve this goal, more attention should be given to home safety by implementing home control/assessment check-lists (Evci et al, 2006; Erkal, 2005) A large number of studies have been carried out on falls and hundreds of risk factors have been identified. Complex interactions between host- related factors and the environment lead to falls (Horan & Clague, 1999). The safety of individuals‘ homes is therefore of paramount importance in reducing the risk of falls (Uysal et al, 2006). Particular importance should be attached to establishing and maintaining a safe home environment for elderly people (Güner & Güler,2002; Topaç,2002). Periodic safety checks may help to identify the risk factors and thus eliminate the causes of many home accidents. Many of these injuries result from hazards that are easy to overlook, but also easy fix. By determining these hazards and taking some simple measures to correct them, many injuries might be prevented (Güner& Güler, 2002).Home accidents happen frequently at old ages and the house conditions must be arranged to prevent accident. In addition elderly individuals and those who help them with their care need to be informed about home accidents.
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Falls Prevention- Home Safety Checklist For Elderly Living Room The light switch or lamps are located near the entrance to the room Living room has adequate lights Electrical cords and telephone wires are placed out of the traffic flow and are not underneath rugs and furniture Carpets and rugs are not worn or torn Living room has non-slip surface Furniture is placed to allow free passage Chairs and couches are not too low or too deep to get in and out of easily Flooring is safe and non-slip Remove tripping hazards from walkways Bedroom Bedroom has adequate lights Light switch or lamp is within easy reach from bed A night-light illuminates bedroom or hall The telephone can be reached Smoking in bed is prohibited Gas and electric heating devices are turned off at bedtime Furniture is placed to allow clear passage between bed and door to avoid collisions in the dark Remove tripping hazards from walkways Flooring is safe and non-slip Kitchen Kitchen has good lighting over work areas Kitchen has good ventilation The range and sink areas are well lighted Work surfaces are not shiny or glaring There is enough countertop lighting for meal preperation Kitchen wall cabinet are not too high to be easily reached Hot pan holders is kept near the range Flooring is safe and non-slip Fire extinguisher is mounted near the stove BathroomBathroom has good lighting The light switch is located near the door The bathroom has good ventilation system Floor has non-slip surface Install Grab bars on both sides of toilets and bathtubs Bathroom has slip-resistant mats The bathtub or shower has non-skid mat Grab bars are installed on the walls by the bathtub and toilet The bathroom has even lighting without glare Stairways and Halls Stairways and halls have adequate lights Stairways and halls are equipped with night-lights. Steps are in good condition and are free of objects Stairways and halls are kept free boxes, toys, mops, tools, and other tripping hazards Light switches are easy to reach and near doorway Coverings on steps are in good condition Stairways should have handles on both sides Sturdy handrails are on both sides of stairways and securely fastened
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Checklist can be used to spot possible safety problems which may be present in the home. ―Yes‖ or ―No‖ system of the checklist give chance of effective use by non-qualified persons ( Güner& Güler, 2002; Tremblay& Kreul-Foresth, 2003; Erkal& Şafak,2003; Şafak et al, 2005; Rollins,2006; AGIS, 2007).
CONCLUSION As an individual ages his or her body changes and the ability to deal with the demands of an environment usually decreases. A well designed, supportive environment may help older persons to utilize their homes more fully, more safely, and allow them to live independently in their homes longer.A safe, convenient, sound and healthy living environment is prerequisite for a good house for the people with special needs. The intention of making house in such a away that it solves basic problems of fixture and fittings. However the costruction phase of a good house a critical to design inside and outside structures. Home accidents happen frequently at old ages and the house conditions must be arranged to prevent accident. In addition elderly individuals and those who help them with their care need to be informed about home accidents. The safety of individuals‘ homes is therefore of paramount importance in reducing the risk of falls. Periodic safety checks may help to identify the risk factors and thus eliminate the causes of many home accidents.
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Atman Ü. C., Dinç G., Oruçoğlu, A., Oğurlu. H. & Ecebay, A. (2007). Manisa Muradiye Sağlık Ocağı bölgesinde yaşlılarda kaza sıklığı ve kaza ile ilişkili faktörler. Türk Geriatri Dergisi, 10(2), 83-87. Benktzon, M. (1993). Designing for our future selves:the Swedish experience. Appl. Ergon, 24(1), 19-27. Bevan, N. (2001). International standards for HCI and usability. Int J Human-Comput Stud, 55, 533-552. Bishop, J. A. (2009). Booming Towards Aging in Place: ―The‖ 21st Century Specialization for Interior Designers. Retrieved December 10, 2009, from http://www. bishopinteriors. com/BDG/images. Buchner, D. M., Cress, M. E. & de Lateur, B. J. (1997). The effect of strenght and endurance training on gait, fall risk and health services use in community living older adults. J.of.Gerontology. 52A, M 218-224. Carp, F. M. (1976). Housing and living environments of older people. In: R. H. Bistock, & E. Shanas, (eds) Handbook of ageing and the social sciences. D. Van Nostrand, New York, 244-271. Carp, F. M. & Christensen, D. L. (1986). Technical environmental assessment predictors of residential satisfaction. Res Aging, 8, 269-287. Christenson, M. A. (1990). Enhancing independence in the home setting. Physical and Occupational Therapy in Geriatrics, 8, 49-65. Clay, R. (2005, Fall). Design Through The Ages: Keeping Age In Mind As You Design. ASID Icon, 37-41. Dagostino, F.R. (1996). Universal design:barrier free living. CAAR Real Estate Weekly. http://www.caar.com/REW/Edit%20Archives/ Universal. Design. Retrieved on July,27,2009. Dekker, D., Buzink, S., Molenbroek, J.& de Bruinn, R. (2006). Hand supports to assist toilet use among the elderly. In Applied Ergonomics, 38(1), 109-118. Retrieved December 10, 2009, from http://www.informedesign.umn.edu/ Demirbilek, O. & Demirka,n, H. (1997). A collaboration model in interiors involving the elderly. In: IEA‘97, International Ergonomics Association 13th Triennial Congress, vol 5, Tampere, Finland, 570-572. Demirbilek, O.& Demirkan, H. (1998). Involving the elderly in the design process. Architectural Science Review, 41, 157-164. Demirbilek, O. & Demirkan, H. (2000). Collaborating with elderly endusers in design process. In: Scrivener SAR, L. J. Ball, & A. Woodcock, (eds) Collaborative design. Springer, London, 205-212. Demirbilek, O. & Demirkan, H. (2004). Universal product design involving elderly users: a participatory design model. Appl Ergon, 35, 361-370. Demiris, G., Oliver, D. R., Hensel, B., Dickey, G., Rantz, M. & Skubic, M. (2008). Use of videophones for distant caregiving: An enriching experience for families and residents in long-term care. Journal of Gerontological Nursing, 34(7), 50-55. Demirkan, H. (1991). Some criteria for designing interiors for the turkish disabled and elderly. In: 3rd Ergonomics Congress Proceedings, MPM, Ankara, 499-509. Demirkan, H. (1996). Adaptable house design. In:Proceedin gs of XXIVth IAHS World Housing Congress. Ankara, Turkey, 27-31 May, (1), 19-29. Demirkan, H. (2007). Housing for the aging population. Eur Rev Aging Phys Act, 4, 33-38.
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Erkal, S. & Şafak, Ş. (2003). Yaşlılıkta görülen ev kazaları ve nedenleri. Nısbo Dergisi. 4(11), 32-33. Erkal, S. (2005). ―Kırıkkale ovacık mahallesinde yaşayan 65 yaş ve üzerindeki kişilerin karşılaştıkları ev kazalarının ve nedenlerinin incelenmesi‖, Türk Geriatri Dergisi, 8(1), 265-269. Evci. E. D., Ergin, F. & Beser, E. (2006). Home accidents in the elderly in Turkey. Tohoku J Exp Med, 209(4), 291-301. Gutman, G. M. (2007). Home accidents Amongst Elderly People: A Locality Study in Scotland.. Gerobilim. J. Social & Psychological Gerontology at: http:// gerobilim. Com / index . php?id=23. Güner, P. & Güler, Ç. (2002). Yaşlıların ev güvenliği ve denetim listesi. Türk Geriatri Dergisi, 4(4), 150-154. Fielo, S. B. & Warren, S. A. (2001). Home adaptation: Helping older people age in place. Geriatric Nursing, 22, 239-247. Fuller, G. F. (2000). Falls in the Elderly. Am Fam Physician,1, 1-16. Hammett, W. (2009). Lıfe-Cycle Furnishings. Cooperative Extension Service. University of Kentucky. College of Agriculture. Retrieved November 6, 2009, from www.ca.uky. edu/HES/fcs/FACTSHTS/HF-LRA.031.PDF. Hand, G. (2005). The Joys and Pitfalls of Inter-Generational Living: One Family's Success Story. Retrieved, 2007 from www.the-homestore.com/news/aarpjoys.html. Horan, M. A. & Clague, J. E. (1999). Injury in the Aging: Recovery and Rehabilitation. British Medical Bulletin, 55(4), 895-909. IDB, EU Injury Database, (2007). Injuries in the European Union. Statistics summary (ED: A., Angermann, R. Bauer, Nossek, G. & N Zimmermann,)2003-2005. Vienna, October. http://www.injuryobservatory.net/documents/Injury_stats_euro_union.pdf Kallman, H. & Kallman, S. (1989). Accidents in the elderly population. In W. Reichel, (Ed.), Clinical Aspects of Agin, 547-558. Baltimore: Williams & Wilkins. Kelly & Kroemer, K. H. E. (1990). Anthropometry of the eldelry: Status and recommendations. Human Factors, 32, 5781-595. Lanspery, S. & Hyde, J. (1997). Staying Put Adapting the Places Instead of the People. New York: Baywood Publishing Company, Inc. Lawlor, D. & Thomas, M. (2008). Residential Design for Aging in Place. Hoboken: John Wiley and Sons. Lawton, M. P. (1985). Elderly in context: perspectives from environmental psychology and gerontology. Environ Behav, 17, 501-519. Lawton, M. P. (1990). Aging and performance of home tasks. Human Factors, 32, 527-536. Leibrock, C. & Terry, J. (1999). Beautiful Universal Design: A Visual Guide. New York: John Wiley and Sons, Inc. Luscombe, B. (2003). This Bold House. Retrieved July 10, 2009 from http://www. aarpmagazine.org/lifestyle/articles/a2003-08-28-bold_ house. html? print =yes. Mace, R. L, Hardie, G. J. & Plaice, J. P. (1991). Accessible environments: toward universal design. In W., Preiser, J. Vischer, & E. White, (eds), Design interventions: toward a more human architecture. Van Nostrand Reinhold, New York. Mace, R. L. (1998). Universal design in housing. Assist Technol, 10, 21-28.
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Maisel, J. L., Smith, E., Change, C. & Steinfeld, E. (2008). Increasing Home Access: Designing for Visitability. AARP Public Policy Institute, Washington. Masud, T. & Morris, R. O. (2001). Epidemiology of falls. Age and Ageing, 30-S4, 3-7. Newbill, T. M. (2007). Inclusive Desing Close to Home :Residential Accessible Dwellings For Aging-in-Place, A Thesis Submitted to the Department of Interior Design in Partial Fulfillment of the Requirements for the Degree of Master of Fine Arts Degree Awarded: Summer Semester, 2007. The Florıda State Unıversıty College Of Vısual Arts, Theatre And Dance.
Nieusma, D. (2004). Alternative Design Scholarship: Working Toward Appropriate Design. Design Issues, 14-15.
Osman, G. & Gibberd, A. (2009). Housing for Special Needs: Physical Interior Design to Accommodate Special Needs. Retrieved September 17, 2009, from www.gauge.co.za/Accessible%20housing.pdf Ostroff, E. & Weisman, L. K. (2004). Universal design building survey: incorporating the ADA and beyond in public facilities. Available at: http://www. udeducation. org/teach/course_mods/survey/index.asp Parmelee, P. A. & Lawton, M. P. (1994). The Design Of Special Environments for the Aged. In: J. E., Birren, & K. W. Schaie, (Eds) Handbook of the Psychology of Ageing. Academic, California, 464-488. Pinto, R. M., De Medici, S., Sant, V. C., Bianchi, A., Zlotnicki, A. & Napoli, C. (2000). Ergonomics, gerontechnology, and design for the home-environment. Appl. Ergon., 31(3), 317-322. Pirkl, J. J. (1994). Transgenerational Design: Products for an Aging Population. New York: Van Nostrand Reinhold. Plautz, B., Beck, D. E., Selmar, C. & Radetsky, M. (1996). Modifying the environment: A community - based injury - reduction program for elderly residents. American Journal of Preventative Medicine, 12, 33-37. Province, M. A., Hadley, E. C. Hornbrook, & M. C. et al (1995). The effects of exercise on falls in elderly patients. A Preplanned meta-analysis of the FICSIT trials. J. of the American Medical Association, 273, 1341-1347. Pynoos, J., Cohen, E., Davis, L. & Bernhardt, S. (1987). Home modifications: Improvements that extend independence. In V. Regnier, & J. Pynoos, (Eds.), Housing the aged: Design directives and policy considerations. 277-303, New York: Elsevier. Rollins, G. (2006). Designs on building safe homes fort he elderly. http://www.nsc. org/issues/falls/falfalls.htm. Available date, 9.08.2006. Sagdic, Y. & Demirkan, H. (2000). A design decision support system model for the wet space renovation of elderly people‘s residences. Architectural Science Review, 43, 125-132. Sagdic, Y. & Demirkan, H. (1997). Different aspects of being elderly in residential wet spaces. In: IEA‟97 International Ergonomics Association 13th Triennial Congress, vol 5, Tampere, Finland, 609-611. Sandhu, J. S. (2001). An integrated approach to universal design: toward the inclusion of all ages, cultures and diversity. In: W. F. E. Preiser, & E. Ostroff, (Eds.), Universal Design Handbook. McGraw-Hill, New York, 3, 3-3.14. Sattin, R. W., Lambert Huber, D. A. & DeVito, C. A., et al. (1990). The Incidence of Fall Injury Events Among Elderly in a Defined Population. Am J. Epidemiol, 131, 1028-1037.
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In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 6
ACHIEVEMENTS IN REDUCING INFANT MORTALITY IN A NEWLY INDUSTRIALIZED COUNTRY: LESSONS FROM TAIWAN Jennifer Chun-Li Wu and Tung-liang Chiang College of Public Health, National Taiwan University, Taipei, Taiwan
ABSTRACT Infant mortality in Taiwan has dropped remarkably from 44.7 per 1000 live births in 1950 to 5.5 in 2005. By examining cause-specific mortality and the decomposition of infant deaths into neonatal and post-neonatal deaths, the decline can be largely accounted for by fewer children dying from avoidable perinatal conditions and infectious diseases. Why has Taiwan been able to reduce infant mortality in a relatively short period? We identified three crucial explanations. Firstly, Taiwan‘s rapid growth of economy accompanied by improved income distribution could ensure that mothers and children can enjoy a standard of living adequate for health. Secondly, gender equity and empowerment were promoted by expanding women‘s capacities through education and social participation. This is particularly relevant to planned fertility, economic rewards, and child caring practices that are conducive to child health. Thirdly, health services essential to maternal and child health were developed progressively and made universally accessible. Taiwan‘s experiences in reducing infant mortality can provide valuable lessons for developing countries seeking to secure children‘s lives and well-being from the start.
While most countries experienced a steady improvement in infant mortality in the last century, recent trends in some parts of the world showed stagnation of decline or went into reverse, with high mortality rates still far from acceptable [1]. Thus, global commitment and action have been called for where the reduction of infant mortality was listed as a central Millennium Development Goal [2]. Virtually, an array of potential public policies and intervening approaches may work to secure infant survival, and can offer valuable lessons for countries seeking to attain the goal.
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Taiwan‘s experiences represent such a case in which it successfully reduced infant mortality despite being a low-income country and did it within a rather short period. The infant mortality rate dropped from 44.7 per 1000 live births in 1952 to 5.4 in 2005, an eightfold decline (Figure 1). When looking into the composition of infant mortality, deaths in the post-neonatal period had consistently accounted for over 60 percent until the mid 1990s, and now close to 60 percent of infant deaths occur in the first 28 days of life. On the cause of death, infectious diseases had been the major killer of infants in Taiwan; particularly, pneumonia and gastroenteritis together accounted for half of all infant deaths in the 1950s and stayed around one-third by 1980. With the fall of infant mortality, infectious diseases gave way to congenital anomalies, accidents, and perinatal conditions such as birth injury, asphyxia and problems relating to prematurity and low birthweight. In 2005, close to one half of infant deaths were due to conditions originating in the perinatal period, and congenital anomalies accounted for one in four infant deaths (Table 1).
Figure 1. Trends in infant mortality, neonatal mortality and post-neonatal mortality.
Table 1. Leading causes of infant deaths, 1952 and 2005
1 2 3 4 5
1952 Abbreviated list of 50 causes, ICD-6 Pneumonia Gastroenteritis Diseases peculiar to early infancy and prematurity Other infectious and parasitic diseases Newborn infection
2005 Basic tabulation list, ICD-9 Mortality 1975 (1/000) Perinatal conditions 2.4 Congenital anomalies 1.4 Sudden infant death 0.7 syndrome Accidents 0.3
Mortality (1/000) 10.5 9.9 5.2
1 2 3
5.0
4
4.0
5 Nervous system
0.1
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Taiwan to date has enjoyed infant survival at a high level comparable to that in other developed countries [3]. Could this be an artifact of misreporting? By law, all births and deaths in Taiwan must be registered with the local government's household registration system. Yet, before the implementation of a new compulsory birth report system in 1995, biased data could be derived from under-registration. The under-registration was found more relevant to infant deaths occurring in the neonatal period [4], but would not affect the longterm momentum of infant mortality presented above. Then, what are the factors behind Taiwan‘s achievements in reducing infant mortality? In this chapter, we adopt Mosley and Chen‘s conceptual framework for child survival to guide our discussion on the determinants of infant mortality trends in Taiwan. The Mosley-Chen framework integrates the concerns and analytical approaches traditionally discrete between social and medical science research [5]. Central to their framework is the idea that all socioeconomic and cultural variables must operate through a set of proximate determinants that directly affect the risk of child morbidity and mortality. These socioeconomic variables are namely the focus of social science research on child mortality, and can be defined as individual, household or community-level characteristics such as individual attitude, household income, political economy and etc. Proximate determinants, on the other hand, correspond to biological mechanisms in medical science for the explanations of disease and the outcome of disease processes. Five groups of proximal determinants were identified in the Mosley-Chen framework: maternal factors, environmental contamination, nutrition deficiency, injury and personal illness control. Built on this analytical approach, this chapter is organized into three main sections. The first two sections are to give a historical overview of Taiwan‘s social context, and to depict the evolution of child and maternal health policies. In the third section, we discuss the important indication of proximate determinants that the social and policy context may have operated through to affect the trend of infant mortality in Taiwan over the past half century.
A HISTORICAL REVIEW OF THE SOCIAL CONTEXT As emphasized in Mosley-Chen framework, socioeconomic variables are the foremost group of health determinants, and can be useful for exploring the pathways to child survival. With a focus on aggregate features of infant mortality, rather than an individual-level perspective, we hereby document a historical background of Taiwan‘s economic and sociodemographic characteristic over the past five decades (Table 2).
Economic Growth with Improved Income Distribution Taiwan once earned its reputation as an ―economic miracle‖ for successful economic development during the second half of the twentieth century. As a poor country in the postwar period, Taiwan‘s gross national product (GNP) per capita was below US$150, but has dramatically increased to US$16,113 in 2005. More importantly, the economic growth was accompanied by improved income distribution. The ratio of income shared by the richest 20%
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to the poorest 20% households was 20.3 in 1952, remarkably dropped to the lowest level at 4.2 in 1980, and slightly increased thereafter. Government‘s policy making in several intertwined areas has played a crucial role behind this modern economic transition in Taiwan. In response to poverty problem and economic stagnancy under the post-war political instability, the government introduced a phase-like land reform since 1953, by making tillers into land owners or reducing their burden from high rents. These strategies successfully stimulated the growth in agricultural production, which further led to improved living standard of the farming population and a burgeoning domestic consumer‘s market. In effect, the rising income with rapidly equalizing distribution in the rural agricultural sector is believed to have played the major role in closing Taiwan‘s huge income gap during the 1950s [6]. On the other hand, aggressive economic policies came into practice that included the import-substitution phase beginning in early 1950s, followed by the phase of exportorientation since 1962. The import-substitution approach promoted industrial development characterized by labor-intensive manufacture of consumer goods for domestic demands, with funds supported by exporting agricultural commodities. The goal was to alleviate Taiwan‘s dependence on foreign assistance and high costs incurred from importing materials. As a consequence, more jobs were created, and profits earned were transformed into the expansion of production capacities, laying the ground for later export-orientation. The economic environment at the time was also observed with a surge of small and medium enterprises which have been credited with their pivotal functions in Taiwan‘s economic growth even up to today. Table 2. Basic indicators: Taiwan, 1950–2005
*
Sociodeomgraphic indicators Population size (million)a Crude death rate (1/1000) a Crude birth rate (1/1000) a Total fertility rate (1/000) b % of population aged 65+ a % of 15+ female with senior high school diploma (1/1000)b Economic indicators GNP per capita (US$) c Ratio of family income share of top 20% to bottom 20% c Health care indicators Physician per 1000 persons d Hospital beds per 1000 persons d Health spending as % of GDP d
1950
1960
1970
1980
1990
2000
2005
7.5 11.5 43.3 7.0 2.5 na
10.9 7.0 38.9 5.8 2.5 na
14.8 4.9 27.2 4.0 3.0 6.5
18.2 4.8 23.4 2.5 4.3 26.2
20.4 5.2 16.6 1.8 6.2 40.9
22.3 5.7 13.8 1.7 8.6 53.1
22.8 6.1 9.1 1.1 9.7 61.8
145 20.5*
154 11.6+
389 4.6
2344 4.2
8325 5.2
14721 5.6
16113 6.0
0.5 0.5 -
0.5 0.7 -
0.4 2.4 -
0.7 3.2 3.3
1.0 4.1 4.2
1.3 5.1 5.4
1.5 5.7 6.2
1953; + 1961; na=not available Source: a Council for Economic Planning and Development. Taiwan statistical data book (relevant years). b Ministry of Interior. Taiwan and Fukien demographic fact book (relevant years). c Directorate-General of Accounting, Budget, and Statistics. National economic statistics (relevant years). d Ministry of Health. Health and vital statistics (vol.1): general health statistics (relevant years); Chiang TL. Health care policy in Taiwan, 3rd edition. Taipei: Yuan-Liu Publisher, 2007.
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Table 3. Milestones in child and maternal health policies in Taiwan Year Event 1947 Establishment of Taiwan Provincial Health Department 1952 Establishment of Maternal and Child Health Committee, Taiwan Provincial Health Department 1959 Establishment of Provincial Research Institute of Maternal and Child Health 1964 Establishment of Family Health Committee, Taiwan Provincial Health Department 1st phase of the 5-year Expanded Family Planning Program 1965 Incentive programs for midwife practice in rural areas Universal immunization for polio 1970 1st phase of the 5-year Maternal and Child Health Improvement Program 1971 Establishment of the Department of Health 1973 Enactment of Child Welfare Law 1975 Establishment of Family Planning Research Institute 2nd phase of the 5-year Maternal and Child Health Improvement Program 1976 1st phase of the 3-year Family Planning Program Kindergarten Health Management Program 1979 2nd phase of the 3-year Family Planning Program 1980 3rd phase of the 5-year Maternal and Child Health Improvement Program 1982 1st phase of the 4-year Family Planning Program 1984 Universal screening of congenital metabolic diseases for neonates 1985 Enactment of Genetic Health Law 1986 2nd phase of the 4-year Family Planning Program 1991 1st phase of the New Family Planning Program 1993 1st Amendment of Child Welfare Law Early intervention program for developmental delay 1995 Compulsory national birth report system Implementation of National Health Insurance Program Universal well-baby clinics for preschool children Establishment of Child Welfare Bureau, Ministry of Interior Affairs 2nd phase of the New Family Planning Program 2001 Establishment of Bureau of Health Promotion, Department of Health 2003 2nd Amendment of Child and Youth Welfare Law 2005 Health care assistance for children age 3 and under
Taiwan stepped into the export-orientation phase when the domestic market became saturated, and an open foreign trade regime was encouraged by policy instruments such as tariff rebates and construction of export-processing zones. Industrial products including textiles and electronic machinery were to replace agricultural products as dominant export outputs. The drive of outwardly oriented export also brought the growth of Taiwan‘s GNP first exceeding 10% in 1964 and had remained comparably high until the last decade of the twentieth century. That is, Taiwan had moved from an agrarian economy to an industrial one in less than two decades, the fastest speed of industrialization compared to other countries [6]. On the income side, net domestic savings continued to make up an increasing proportion of the net national income, and were able to finance its investment. Because export promotion programs called for a more labor-intensive demand, this employment expansion brought in wage income at the individual worker or household level, and collectively, played a key role in the growth with increased income equity in the 1960s and 1970s [7]. Also importantly,
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with a more solid industrial structure and accountable governance, Taiwan successfully weathered the 1997 Asian financial crisis but experienced a relatively slower economic growth when entering the new century.
Demographic Transition with Declining Fertility The demographic transition in Taiwan began around 1920 [8], with a crude birth rate of 40.0 and a crude death rate of 33.2 per 1000 people. Amidst the transition in 1950, the crude birth rate remained as high as 43.3 per 1000 people, but the crude death rate had dropped to 11.5 per 1000 people. The demographic transition ended in the mid 1980s when the crude death rate was about the lowest and the total fertility rate reached the replacement level. At present, Taiwan has entered the second demographic transition, characterized by continuing decrease of the crude birth rate while and the crude death rate reversed to rise due to the aging of population (Table 2). One of the most profound demographic features in Taiwan was its fertility pattern, which has a bearing on trends in maternal and child health. The total fertility rate was 7.0 live births per woman in 1950, and started to decline all the way, especially sharper since the late 1990s. Today, Taiwan is one of the lowest fertility countries with a total fertility rate of 1.1 in 2005 (Table 2). During the transition period, the fertility decline was most evidently observed in women aged 30 and older, a pattern considered largely affected by the family planning program commencing from 1964 [9]. While for the fertility of the post-transition period, postponement of age at marriage and childbearing has become increasingly important, a phenomenon closely related to the rising educational level of women in Taiwan.
Upward Trend in Female Education and Labor Participation After the Kuomingtung (KMT, then the ruling party) retreated from mainland China to Taiwan in 1949, education had been actively expanded, as a civil right and as a political instrument. The literacy rate was less than 34.0% in 1952, but already approached 90% in late 1970s. In 1968, a nine-year compulsory education (includes 6-year primary and 3-year junior high school) was implemented, creating greater opportunities for advanced education [10]. People with a senior high school diploma have enormously increased, and the trend was not less favorable for women than men, which was of particularly significant in a paternal society like Taiwan. Among women 15 years old and over, more than half received a senior high school diploma in 2005, compared to only 5.6% in 1970 (Table 2). As the economy was oriented towards export productivity and relied immensely on labor-intensive industries, employment capacity was subsequently stimulated to include more women. For example, female labor participation rate soared from 27.5% in 1966 to 41.5% in 1973. The rate once reversed to decrease slightly because of a cohort effect where younger females extended their years of education and delayed entering the labor market. Since the early 1980s, there were steadily more than 40% of females participating in the labor force with a rate of 48.1% in 2005 [11][12].
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Public Health and Health Care System Public health and health care system is essential to infant survival and health. After the Second World War, the Taiwan government founded the Taiwan Provincial Health Department as the highest health authority to be responsible for public health administration. Importantly, by the early 1950s, the Provincial Health Department established a nationwide public health infrastructure, consisting of one health bureau for each county and city, and one health station for each township and district, to facilitate the operation of public health programs including communicable disease control, maternal and child health, family planning, and so on [13]. Yet, with government structure reforms in the late 1960s, the Department of Health, Executive Yuan, was created as part of the national cabinet in 1971 to lead health policy making and coordinate a range of public health activities at all levels. By 1970, the health care delivery system in Taiwan was not yet adequately developed [14]. The shortage of physician workforce and hospital facilities, together with their geographic disparity, represented two fundamental challenges to the goal of health care for all. In consequence, the Department of Health largely expanded the enrollment of medical students to increase the supply of physician workforce and endeavored to build and expand public hospitals. Interestingly, with the national economy taking off in the 1970s the private sector has contributed substantially to the supply of hospital facilities, particularly due to increasingly scaling up hospitals invested and operated by big enterprises. As a result, the physician density rose from 0.4 to 1.5 per 1000 people and hospital bed density from 2.4 to 5.7 per 1000 people between 1970 and 2005. Following the rapid growth of health care resources, nonetheless, came the concern of geographical mal-distribution. In response to the challenge, the Department of Health has taken several actions [13], for example, launching the ―group practice center‖ program in 1983 to provide health care services for rural communities. The implementation of the ―medical care network‖ program in 1985 was another milestone in Taiwan‘s health care industry leading to improved resources distribution and care quality. Under the Medical Care Act, the Department of Health has played a legitimate authority to certain extent to regulate the distribution of hospital capacities and physicians based on defined regions and levels of hospital accreditation. Unfortunately, improved supply and distribution of health care resources did not necessarily ensure realized utilization, with financial burden as one of the key barriers. By the early 1980s, there were only two social health insurance programs, and about 80% of the population was left uninsured [15]. With Taiwan‘s democratization where social welfare became one of the most powerful political appeals to the public, the National Health Insurance (NHI) program was born at an earlier timeline in 1995. This compulsory NHI program pertains to a single-payer scheme, and is primarily financed through payroll taxbased premiums with moderate cost-sharing rates. The NHI provides comprehensive benefits of health care such as inpatient and ambulatory care, dental services, prescription drugs, home nursing care, as well as selected preventive services including prenatal checkup and wellbaby clinic. To date, with a coverage rate of 97.8% of the total population in 2005 [16], the NHI program has been considered the most successful social policy in Taiwan. Pediatric services constitute a segment of the health care system that is most critical to child health in both preventive and therapeutic sense. Pediatric care units were already available in public hospitals during the Japanese colonial period, but some were not yet
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independent of internal medicine and pediatric specialists remained rare. With a great expansion of medical education, the number of pediatricians increased, and a range of its subspecialties were gradually developed. For example, neonatal care used to be the responsibility of the obstetric-gynecological unit, and in 1952, the National Taiwan University Hospital pioneered in shifting neonatal care to pediatrics [17]. Despite a decade of delay compared to the US, the first neonatal intensive care unit (NICU) was established in 1979, representing a big step towards high-risk infant intervention and management in Taiwan.
THE EVOLUTION OF MATERNAL AND CHILD HEALTH POLICIES The maternal and child health policies in Taiwan reflect the government‘s response to the health problems and disease patterns of children across different eras. Accordingly, we identify three periods of maternal and child policy development in Taiwan: saving maternal and child life (1950-1970), healthy growth and development (1970-1985), and healthy start in life (since 1985). It is important to note that the policy content of each period is not necessarily exclusive from each other or to replace the preceding period. Rather, more recent initiatives sometimes work to expand the population served grounded on previous efforts.
Saving Maternal and Child Life Though Taiwan‘s infant mortality at 44.7 per 1000 live births in 1952 was one third of the level during the war (e.g., 136 per 1000 live births in 1940), the rate was still high compared to other countries at the time, such as 21.0 for Sweden and 29.2 for the USA [18]. Maternal mortality showed an even greater gap, with a ratio of 196.6 per 100,000 live births in Taiwan and 60.0 for the same comparison countries. In response, the Taiwan Provincial Health Department established a special committee in 1952 to carry out the mission of ensuring childbirth safety and reducing infant/child mortality. Activities were undertaken in the form of policy planning, program demonstration, and personnel training, with financial and technical supports from international agencies such as the World Health Organization and United Nations Children‘s Fund (UNICEF) [19]. In 1959, the committee was expanded into the Maternal and Child Health Research Institute to also cover research and survey activities. Operating through the aforementioned nationwide public health infrastructure, the institute was able to successfully deliver maternal and child health services including antenatal care, postnatal care, child delivery care, universal coverage of essential child immunization, and so on. In early 1950s, close to one half of births in Taiwan were still attended by unqualified midwives or unskilled persons. Accordingly, the government initiated a series of midwifery training programs to increase the supply of qualified midwives since 1955 [19]. However, inadequate access to qualified birth attendants, particularly in disadvantaged communities, emerged as a subsequent problem. The Maternal and Child Health Research Institute hence set up midwifery stations in rural areas and provided an incentive program for qualified midwives to work at those stations. Such measures, together with the expansion in the supply
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of hospital services, have brought the rate of delivery by qualified birth attendants up to 99% by the 1980s [20]. Another important policy strategy pertains to bring public health nurses from health station into the community. This outreach approach, initiated as a pilot program in the late 1960s, allowed a broader set of maternal and child services to be delivered continuously and systematically by public health nurses in assigned communities of duty. They made regular home visits to offer antenatal and postnatal care, children‘s growth monitoring and immunization, as well as general health education and consultation. Notably, the maternal and child health policy development during this era cannot be discussed without mentioning population policy. As a result of political stability and the introduction of medical and public health measures, the natural growth rate exceeded 30‰ since the mid 1950s. With the concerns of population pressure on living standards and supply of resources, a group of local elites in their seminar papers first advocated birth control as urgent and essential. Advanced evidence was also presented by renowned demographers, alarming adverse consequences of Taiwan‘s population growth such as high dependence ratio, insufficient capacity to accommodating students under a universal education system, and that higher infant morality was associated with higher fertility in a household. However, implied from these notions, family planning as a major policy instrument for population control had drawn strong opposition from the many who feared the threat to traditional attitudes towards family size, military strength needed for recovering the Mainland China, and religious beliefs. With the support from the Joint Commission on Rural Reconstruction and their strategic appeal to key government officials, population control was eventually brought to program agenda as a health rather than economic issue [21][22]. In 1959, Taiwan Provincial Health Department officially initiated family planning programs, but in the name of ―pre-pregnancy health‖, to provide knowledge, techniques and devices on birth control. Pre-pregnancy health services were available at public hospitals to begin with, and later in selected local health stations since 1961. In order to receive official government funding to assure the extension of family planning programs, the Family Planning Regulations were executively approved and became a national policy in 1968. This line of story adds to the account that the maternal and child health policy formulation during this period was actually driven not only by health problems, but also population issues. Another major stream of public health measures concerned the high proportion of infant deaths due to infectious diseases. As a vulnerable group attacked by infectious diseases, selected vaccinations including for tuberculosis (1951), diphtheria (1955), and polio (1965) became compulsory to newborns and infants. Besides, vaccines such as tetanus toxoid were made available to pregnant or childbearing-age women for the prevention of fetus and neonate infections [19][23]. Usually, an immunization program was delivered by the local health station to monitor each child‘s vaccination schedule and respond to a report system. Public education on sanitation and personal hygiene was also offered to the community or through the school system as part of preventive measures in Taiwan.
Healthy Growth and Development By the end of 1960, infant mortality and maternal mortality in Taiwan had sharply declined to 16.9 per 1000 live births and less than 50 per 100,000 live births, respectively.
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This changing health pattern drove the maternal and child health policy from an emphasis on saving maternal and child life towards a more holistic scope of child health, and from birth to preschool. The 1973 enactment of Child Welfare Law was a timely catalyst to realizing this policy focus. By this law, the newly established Department of Health together with other government sectors declared their role in ensuring optimal physical and mental health, growth and development, as well as social welfare of their children population. During this period, three phases of 5-year maternal and child health improvement projects were conducted by the health sector. In addition to carrying on maternal and child health outreach activities by public health nurses, services attuned to the needs of special populations such as rural areas, indigenous people, and infants born preterm or with congenital anomalies were organized [19]. Another line of policy focus was nutrition. In the beginning, the priority was set for adequate diets and the intake of supplements among mothers and infants, especially in areas with high infant mortality. When the government inaugurated the national nutrition improvement program in 1980 for the general population as a whole, maternal and child nutrition remained one of the targets with services also extended to low-income family. In addition, in order to assure the validity of growth and development monitoring, the government collaborated with academic institutes to establish a sex-specific growth chart and a developmental testing, with norms applicable from infancy to preschool [24]. These became useful and essential tools for raising parents‘ general awareness of child growth, and facilitating health workers‘ inspection of potential health problems in early childhood. In considering that less policy measures were systematically designed for preschool children compared to those for infants, the preschool/kindergarten health management program was first put into practice in 1976 [24]. Literally speaking, this program targeted children‘s health per se from preschool to school age, and objectives were set for: monitoring of growth and development, early disease detection and intervention, prevention of deaths from infectious diseases and injuries, and fostering healthy behaviors and personal hygiene. Its implementation required intersectoral collaboration between health, education, and social welfare, and was based on bridging the school with family as a surveillance and management system.
Healthy Start in Life From early 1980s onward, the proportions of children under 5 who lost their lives because of congenital anomalies, and infant deaths from perinatal conditions were both increasing. Child health problems with genetic etiology or originating in preconception and during pregnancy became more salient. Promulgated in 1985, the Genetic Health Law marked a great progress of delivering genetic health services in Taiwan. In the light of the law, a national genetic health care program is organized to identify and reduce maternal and child health risks from preconception and throughout any time frame during pregnancy by providing educational information, consultation, testing, and interventions, etc [25]. Also included is the universal screening of congenital metabolic disorders for neonates as a preventive strategy for further detrimental effects among positive cases.
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―Health for All‖ through health promotion, health maintenance and preventive services was stated explicitly as a policy goal in the proposal of the National Health Promotion PlanPopulated-based Approach (1993-1997) [26]. Accordingly, universal coverage has become a key element for the promotion of population health, and maternal and child health was no exception. For example, a compulsory birth report system was established in 1995 to secure complete and accurate vital data, which in turn can improve maternal and child health service delivery to be more timely and efficient [27]. Moreover, the introduction of the NHI program in the same year catalyzed the accomplishments in making a range of maternal and child health services accessible at reasonable cost. What worth noting is that the NHI program covers preventive maternal and child health services such as prenatal examination and wellbaby clinic. Take the latter as an example. Before entering primary school, every child under NHI program is eligible for 7 well-baby care visits according to a pre-set immunization schedule. Meanwhile, growth, general health functions, developmental milestones, and dietary pattern are monitored, and health education is provided to the caregiver. Such a measure can fulfill the policy goal as to early detection and management of health and developmental problems among children in a population-oriented approach. In summary, this overview points to that the evolution of maternal and child health policies in Taiwan embraces three pivotal features related to the changing pattern of maternal and child health. First, the focus has been shifted from securing child survival to promoting a holistic view of child health. Second, intervening approaches are moving from targeting highrisk groups to universal coverage. Third, policy efforts have been made to ensure healthy start from a life-course perspective.
PROXIMATE EXPLANATIONS FOR REDUCING INFANT MORTALITY Why has Taiwan achieved to reduce infant mortality in a relatively short period? Our examination next is based on Mosley-Chen framework, emphasizing how the socioeconomic context may function as upstream factors to influence a combination of proximal determinants, and in turn contribute to the decline of infant mortality. From the preceding historical overview, we underscore three crucial aspects of Taiwan‘s socioeconomic and political context: improving standard of living, rising status and empowerment of women, and universal access to health care. How each group of these socioeconomic factors affects the trends of infant mortality is then discussed by specifying the mechanisms that Mosley and Chen considered basic and common to child survival.
Improving Standard of Living Taiwan‘s economy has grown rapidly and equally which improved the overall standard of living. The equality component is no less vital than growth, because it denotes fewer people being economically disadvantaged which consequently is associated with an average lower infant mortality [28]. A better standard of living was indicative of better nutrition, environmental sanitation, and hygiene. Surveys done in the early 1960s showed that the breastfeeding rate of the first month after delivery (including exclusive breastfeeding and
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mixed with complementary feeding) ranged from 75% to 95% in urban areas [29]. This was quite a high breastfeeding rate, compared to that in later years when more mothers participated in the workforce and formula market was quickly expanded. In times of scarceness of food appropriate for complementary feeding, however, breastfeeding alone was not enough to meet infants‘ nutritional needs. This resulted in a high prevalence of malnutrition in older infants susceptible to common conditions such as pneumonia and diarrhea. For example, for infants aged 7 to 12 months, only 40.7% and 64.8% of the ideal level of calories and proteins were consumed [30]. With the economy boosted since the early 1960s, the increasing crop production in both the amount and variety made nutritional foods much available to pregnant women and young children. Together with maternal and child health programs which incorporated nutrition education, high-quality supplements to lowincome family and widespread milk stations funded by UNICEF during the 1960s, the nutritional status of infants had greatly improved [19]. This is potentially an important contributor to the overall reduction of infant deaths from infectious diseases. Sanitary measures such as drinking-water distribution system, and sewage disposal system were a common benchmark for a nation‘s level of living standard. Access to safe drinking water is associated with the risks of diarrheal diseases in infancy, which reveals more pronounced for formula-fed infants [31][32]. In Taiwan, several drinking-water systems were already in place as early as in the Japanese colonization, yet covered less than one-fifth of the total population and were damaged badly during the war. In view of the population growth and ongoing urbanization in the postwar period, the reconstruction of these drinkingwater systems was urgently undertaken. Although convenient drinking water and irrigation systems funded by the Joint Commission on Rural Reconstruction were further extended to rural areas, it was not until 1964 when a national construction plan was proposed with partial funding from the UNICEF that this infrastructure efficiently progressed. The coverage rate was more than 40% by the end of the 1960s [33], and reached 92.2% in 2008 [34]. Public health measures through improving environmental sanitation can also be effective in reducing the incidence of infectious diseases and subsequent fatality for all age groups, including infants. Taiwan‘s experience in malaria eradication is one of such successful cases. In response to a persistently high prevalence of malaria, the Taiwan Provincial Health Department launched an eradication project to include research, prevention and treatment measures. Among them, the large-scale dichloro-diphenyl-trichloroethane indoor spray, done on a household-by-household basis, was considered the most effective means of interrupting the transmission chain. Between 1952 and 1958, the malaria parasite rate in Taiwan dropped remarkably from 9.8% to 0.01% [35]. Accordingly, the World Health Organization announced Taiwan as a malaria eradication area in 1965.
Rising Status and Empowerment of Women As described earlier, the sociopolitical context in Taiwan has substantially enhanced women‘s status reflected by better educational attainment and increased labor participation. Moreover, women were less restrained from their decision-making, particularly, in fertility behaviors. All theses point to important implications for the reduction in infant mortality. Three interrelated characteristics of fertility behaviors are well-recognized as predictors of
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adverse perinatal outcomes and infant deaths: advanced maternal age at the time of birth, high parity, and short inter-pregnancy interval [32][33][36]. Taiwan in the fifty years ago was like most low-income countries where large family size is a distinct feature. A large number of births, usually implying short inter-pregnancy interval, may exert risk effects on infant survival due to prematurity [37][38] or poor nutritional status resulting from shorter breastfeeding and limited household resources [31]. As part of industrialization where Taiwan underwent the transition of production activities and income growth, the number of children born became less of an economic concern and tended to be naturally reduced. Further with introducing an island-wide family planning program since 1964 where contraceptive practices were increasingly adopted and fertility knowledge was widely distributed, the overall fertility rate decreased in an accelerating way until the mid-1970s [9][39]. After ten years of program implementation, the total fertility rate had fallen by 40%, of which a high proportion was attributable to the decline among older married women. In 1965, a little higher than one in ten births were born to women above age 35, but the percentage dropped to 4.1% in 1975 [40]. Since the publication of Caldwell‘s findings in Nigeria [41], maternal education as a powerful determinant of child health is well accepted. Particularly in developing countries, even as little as one or two years of schooling can significantly increase the probability of child survival [42]. Based on a natural experiment over the period of 1978-1999 in Taiwan, a study also supports that maternal schooling is negatively associated with infant mortality, and of especial importance for post-neonatal infant health [43]. A number of mechanisms have been proposed and tested in different populations, showing that higher maternal education may lead to lower child mortality through economic advantages, being knowledgeable about diseases, greater access to health care, as well as life styles and hygienic practices more supportive of health [41][44]. As a sociopolitical drive in Taiwan, the enrollment rate of primary education had been quickly raised in the post-war period, with that for women already reaching 86.9% by 1955 [10]. Such an upward move in primary education for women may render itself a key upstream explanation for the sharp reduction of infant mortality in the 1960s and 1970s, through an array of above-mentioned pathways.
Universal Access to Health Care Services Equitable access to health care services matters to trends of infant mortality. It can be said that the initial impetus toward the decline of infant mortality came from the delivery of maternal and child health services. Maternal and neonatal mortality have been highly amenable to obstetric care of high-risk deliveries. Over the period of 1950-1970, the change rates of both maternal and neonatal mortality decline were quite apparent, with causes related to delivery hemorrhage and sepsis accounting for half of the decline in maternal deaths. A possible major determinant is expanding the supply of qualified birth attendants, and further having them practice in deprived and underserved areas [45]. Also, a series of maternal and child health programs were implemented successively since the mid 1960s, where prenatal and postnatal care was provided as a demonstration project to begin with, and gradually reached out to all townships through the health station network. High-risk pregnancy women such as low-income, high parity, older age and with previous history of obstetrical conditions, were specially enrolled into a case management system. Consequently, the percentage of
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pregnant women who ever received prenatal and postnatal care had reached 65% and 75% by 1970, compared to less than 10% prior to such maternal and child health measures were put into practice [46]. In essence, health policies highlighted above were directed to enhance the provision and accessibility of both preventive and therapeutic interventions necessary for safe childbearing, as well as infant survivals most associated with care practices during pregnancy to the neonatal period. As efforts were also made in a manner where health care resources were able to reach the most disadvantaged segment of the population, their benefits returned could potentially have an unignorable contribution to the overall improved status. Whereas certain health services had become more available during pregnancy and after delivery, equitable access had not been ensured in parallel. Before the 1995 NHI program, restricted utilization of needed health services in Taiwan was not uncommon mainly due to financial and geographic barriers. Only government workers were entitled to generous health benefits in relation to prenatal care, newborn delivery and children‘s health care, but not even those who were under Labors Insurance or Farmers Insurance. Moreover, as medical technologies incrementally advanced, greater differential access to both preventive services and clinical interventions was more likely to occur. Better access to both primary care and specialized perinatal or neonatal care can predict a country‘s lower level of infant mortality rate [32]. While the mechanism still holds true for Taiwan, the trend in infant mortality after having the universal health coverage was not illustrated in an anticipated pattern. The increase of infant mortality rate observed between 1990 and 1995, and following that a slight decrease but not to as low a level as previous, can be attributed to the rising neonatal mortality rates. Prior to 1995 when the amended Child Welfare Law required that all live births be reported within 10 days after birth, many infant deaths were not reported, in particular those occurring during the neonatal period. As the effect of the birth report system is partialed out, it is speculated that excess neonatal deaths came from high-risk births who were more affordable to access to specialized perinatal or neonatal care with the health coverage. Otherwise, they would have died owing to barriers to seeking for health care and not been reported to the vital system. By contrast, post-neonatal mortality was less affected by the mandatory reporting, and showed a continuing fall. After the national health insurance program which ensures a more equitably access to health care, post-neonatal mortality for infants in farmers households was significantly reduced, and among them, the more socially disadvantaged benefited to a greater extent [47].
CONCLUSION Taiwan presents a successful case in reducing infant mortality. For the study period, the reduction was much faster than several developed countries (e.g., the UK and New Zealand) whose infant mortality is currently at a corresponding rate to Taiwan, but used to be around half in 1950. As the experiences discussed above, the improvement of infant mortality in Taiwan has neither been achieved by one single key solution, nor by a social or medical approach alone. Quite in accordance with the Mosley-Chen model, there has been driving forces born from the broader socioeconomic context, in order to work through one or a combination of the various proximal determinants to affect the pattern of outcomes. In conclusion, there are at least three key lessons learned from Taiwan‘s experiences. First, the
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economy should be brought to attain growth with equity to ensure that most of the population can enjoy a decent standard of living. Second, gender equity and empowerment are promoted by means of expanding women‘s capacities, particularly through education and social participation. A third lesson is the importance of universal access to health care. For example, infant mortality in the 1950s started to decrease rapidly even when Taiwan was a low-income country. The delivery of health care essential to maternal and child health through a nationwide service network on an outreach approach, in this case, has played a major role. Besides, the success of any policies or measures also requires intersectoral coordination, as well as joint efforts from the non-government sector and the wider community. Yet, the task of ensuring maternal and child health has not come to the end. In developing countries, child survival remains a prior public health issue mainly due to poverty and lack of universal access to essential and quality health care. For their developed counterparts, changing sociodemographic features such as delayed childbearing, low fertility and increasing income inequality, similarly pose new challenges on children‘s well-being. All these warrant continuing global commitment, support and partnership for all mothers and children to achieve their optimal health and development, particularly through actions on social determinants of health [48].
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[11] Wu, RY. Female labor participation and labor supply in Taiwan. In: TS, Yu. (ed). Human resource development in Taiwan. Taipei: Institute of Economics, Academia Sinica, 1982, 698. (In Chinese) [12] Directorate-General of Budget, Accounting and Statistics. Labor statistics. Available from: http://www.dgbas.gov.tw/ct.asp?xItem=12934&ctNode=3246, accessed on 05/13/2010. [13] Chiang, TL. Health care policy in Taiwan, 3rd edition. Taipei: Yuan-Liu Publisher, 2003. (In Chinese) [14] Lu, R; Chiang, TL. Evolution of Taiwan‘s health care system. Health Economics Policy and Law, 2010, in press (doi:10.1017/S1744133109990351). [15] Chiang, TL. Taiwan‘s 1995 health care reform. Health Policy, 1997, 39, 225-239. [16] Department of Health. 2006 Health and vital statistics (Vol. 4): national health insurance statistics. Taipei: Department of Health, Executive Yuan, 2007. [17] Wei, HY. Pediatric education and practice in Taiwan: the past, present and future. Acta Paediatrica Taiwanica, 1985, 26, 479-482. (In Chinese) [18] United Nations. Demographic yearbook. New York, NY: United Nations, 1951. [19] Department of Health. Maternal and child health. In: History of Taiwan‟s public health development (Volume 2). Taipei: Health Department of Health, Executive Yuan, 1995. (In Chinese) [20] Department of Health. 1990 Health and vital statistics: general health statistics. Taipei: Department of Health, Executive Yuan, 1991. [21] Hsu, SC. From taboo to national policy: strategy in Taiwan‘s family planning. In JR. Watt, (ed.). Health care and national development in Taiwan, 1950-2000. Riverdale, NY: The ABMAC Foundation, 2008. [22] Department of Health. Family planning. In: History of Taiwan‟s public health development (Volume 2). Taipei: Health Department of Health, Executive Yuan, 1995. (In Chinese) [23] Department of Health. Communicable disease control. In: History of Taiwan‟s public health development (Volume 1). Taipei: Health Department of Health, Executive Yuan, 1995. (In Chinese) [24] Department of Health. Infant, children and maternal health care. In: History of Taiwan‟s public health development (Volume 4). Taipei: Health Department of Health, Executive Yuan, 1997. (In Chinese) [25] Department of Health. Genetic health. In: History of Taiwan‟s public health development (Volume 4). Taipei: Health Department of Health, Executive Yuan, 1997. (In Chinese) [26] Department of Health. The National Health Promotion Plan - Population-based Approach. Taipei: Department of Health, Executive Yuan, 1993. (In Chinese) [27] Bureau of Health Promotion. Development of the national birth report system. Available from: http:// www. bhp. doh. gov. tw/ BHPnet/ Portal/ Them. aspx? No= 200712250047, accessed on 05/13/2010. (In Chinese) [28] Mayer, SE; Sarin, A. Some mechanisms linking economic inequality and infant mortality. Social Science and Medicine, 2005, 60, 439-455. [29] Bureau of Health Promotion. Policy development of breast-feeding in Taiwan. Available from: http://www.bhp.doh.gov.tw/breastfeeding/index02.htmFamily Planning Institution, accessed on 05/13/2010. (In Chinese)
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[30] Chang, CK. Children‘s nutrition. In Tu, TM. (ed.). Review on advancement of public health and medical field in Taiwan. Taipei: Taiwan Medical News, 1972. (In Chinese) [31] Blair M; Steward-Brown, S; Waterson, T; Crowther, R. Child public health. Oxford, UK: Oxford University Press, 2003, 27-72. [32] Adams, MM; Alexander, GR; Kirby, RS; Wingate, MS. Perinatal epidemiology for public health practice. New York, NY: Springer Publishing Company, 2009, 155-224. [33] Department of Health. Environmental sanitation. In: History of Taiwan‟s public health development (Volume 2). Taipei: Health Department of Health, Executive Yuan, 1995. (In Chinese) [34] Ministry of Economic Affairs, Water Resources Agency. Drinking water coverage by administrative unit, 2008. Available from: http:// file. wra. gov. tw/ public/ PDF/ 892920323.pdf, accessed 05/13/2010. [35] Department of Health. Malaria eradication in Taiwan. Taipei: Center for Disease of Control, Department of Health, Executive Yuan, 1991. [36] Fretts, RC; Schmittdeil, J; McLean, FH; Usher, RH; Goldman, MB. Increased maternal age and the risk of fetal death. New England Journal of Medicine, 1995, 333, 953-957. [37] Wang, PD; Lin, RS. Perinatal mortality in Taiwan. Public Health, 1999, 113, 27-33. [38] Committee on Understanding Preterm Birth and Assuring Health Outcomes Board on Health Sciences Policy. Chapter 5: Medical and pregnancy conditions associated with preterm births. In: Behrman, RE; Bulter, AS. (Eds). Preterm birth: causes, consequences, and prevention. Washington DC: The National Academies Press, 2006. [39] Chang, MC. Demographic transition in Taiwan. Journal of Population and Social Security: Population Study, 2003, 1(suppl), 611-628. [40] Ministry of Interior. 1976 Taiwan and Fukien demographic yearbook. Taipei: Ministry of Interior, Executive Yuan. (In Chinese) [41] Caldwell, JC. Education as a factor in mortality decline: examination of Nigerian data. Population Studies, 1979, 33, 395-413. [42] Gleland, JG; van Ginneken, JK. Maternal education and child survival in developing countries: the search of pathways of influence. Social Science Medicine, 1988, 27, 1357-1368. [43] Chou, ST; Liu, JT; Grossman, M; Joyce, TJ. Parental education and child health: evidence from a natural experiment in Taiwan. National Bureau of Economic Research Working paper. MA: Cambridge, October 2007. [44] Barrett, H; Browne, A. Health, hygiene and maternal education: evidence from the Gambia. Social Science Medicine, 1996, 43, 1579-1590. [45] Yeh, CC. Examination of maternal and child health services. Public Health, 1978, 5, 11-21. (In Chinese) [46] Chang, CK. Preservation of health for children and young men in our country. In Maternal and child health. In Tu, TM; (ed.). Review on advancement of public health and medical field in Taiwan. Taipei: Taiwan Medical News, 1972. (In Chinese) [47] Chou, ST; Grossman, M; Liu, JT. The National Health Insurance on birth outcomes: a natural experiment in Taiwan. Department of Economics, National Taiwan University and National Bureau of Economic Research Working paper, October 2008. [48] Commission on the Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization, 2008.
In: Advances in Psychology Research. Volume 73 Editor: Alexandra M. Columbus
ISBN: 978-1-61761-118-6 ©2011 Nova Science Publishers, Inc.
Chapter 7
ADOLESCENTS IN FOSTER CARE AND THEIR ATTACHMENT-SECURITY TO SIGNIFICANT OTHERS: A ONE-YEAR LONGITUDINAL STUDY Gary R. Germo*, Susan P. Farruggia2, Ellen Greenberger3 and Chuansheng Chen3 1
Psychology Department, Wesleyan University School of Teaching, Learning and Development,The University of Auckland 3 Department of Psychology and Social Behavior, University of California, Irvine 2
ABSTRACT A growing body of evidence suggests that older youth in foster care are at greater risk for mental health problems than youth not in foster care. Although results from community samples of adolescents indicate that a secure attachment to parents and peers is associated with youths‘ psychological well-being, there is scant information on foster care adolescents' secure attachment to parental figures and peers and their well-being. In this one-year longitudinal study, foster-care adolescents‘ attachment-security with biological parents, foster parents, and peers was assessed in relation to adolescents‘ wellbeing. The sample included 184 adolescents who ranged in age from 17-20 years old. The sample was ethnically diverse (40% African American, 35% Latino, 12% Caucasian, and 13% Other), and just over half (56%) were female. At Time 2, 167 adolescents were successfully contacted and re-interviewed. Findings indicated that adolescents‘ attachment-security with biological parents, foster parents, and peers at Time 1 was positively associated with adolescents‘ concurrent well-being. Further, multiple regression analysis for a sub-sample of adolescents who reported on all three attachment figures (n = 119) indicated that adolescents‘ attachment-security with biological parents uniquely contributed to adolescents‘ report of fewer depressive symptoms at Time 1, whereas adolescents‘ attachment-security with foster parents uniquely contributed to adolescents‘ greater life-satisfaction at Time 1. There were several significant effects of *
Corresponding author: Visiting Assistant Professor Department of Psychology, Wesleyan University, 400A Judd Hall 207 High Street Middletown, CT 06457.
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Germo, Farruggia, Greenberger & Chen adolescents‘ attachment-security with foster parents and peers at Time 1 and adolescents‘ well-being at Time 2. The potential positive benefits of adolescents‘ attachment-security are discussed. In addition, the research highlights the need to provide stable, high-quality placements for adolescents in foster care.
As of 2008, 20% of all youth who resided in foster care in the United States were sixteen years of age or older (USDHHS, 2009). These youth are less likely to be adopted or reunified with their parents and thus are more likely to remain in state care until they ‗age out‖ or emancipate from the foster care system. This is a major concern as many older adolescents in foster care evidence significant psychosocial problems, both prior to and after the transition from care (Courtney, Piliavin, Grogan-Kaylor, & Nesmith, 2001; Farruggia & Germo, in press; Festinger, 1983). Results from a longitudinal study conducted by Courtney and Dworsky (2006) indicated that compared to adolescents not in foster care and those who remained in care, adolescents who emancipated from foster care (at age 18 or 19) exhibited more emotional and behavioral problems, had higher rates of unemployment and substance abuse, and were more likely to be evicted from their residence. Given the number of deleterious outcomes associated with some older adolescents‘ transition from care, it has been suggested that these youth represent one of the most vulnerable groups of youth in our country (Cusick & Courtney, 2007; Mendes & Moslehuddin, 2006). Importantly, then, there is a need to examine potential resources that may facilitate older youths‘ transition from foster care, and ultimately their transition to adulthood. One such potential resource is adolescents‘ relationships with significant others. Mendes and Moslehuddin (2006) argued that relationships that include strong attachments to others may promote adolescents‘ transition from foster care. Certainly, attachment relationships, both early and later in foster care youths‘ lives, may promote their well-being, as evidenced by a long line of studies on community adolescents. For example, the quality (i.e., security) of these adolescents‘ attachment relationships with biological parents and peers has been associated with their psychosocial functioning, including greater self-esteem and life satisfaction (Armsden & Greenberg, 1987; Laible, Carlo, & Roesch, 2004; Wilkinson, 2004; Wilkinson & Walford, 2001) and fewer internalizing and externalizing behaviors (Allen, Moore, Kuperminc, & Bell, 1998; Kobak, Zajac, & Smith, 2009; Raja, McKee, & Stanton, 1992). To date, however, there is scant empirical work on foster care adolescents‘ attachment to others and their psychological well-being. We address this gap in the literature by examining the association between adolescents‘ attachment-security with biological parents, foster parents, and peers and their psychological well-being among a random sample of older youth in foster care. Prior to presenting the findings, we provide a brief background on attachment theory and issues germane to attachment relationships among foster care youth.
ATTACHEMENT RELATIONSHIPS: BACKGROUND AND CONSEQUENCES According to attachment theory, infants develop a bond to their primary caregivers (usually the mother) based on the quality of these interactions (Bowlby, 1969, 1973). For example, infants who experience interactions with their mother that are warm, nurturing, and consistent are said to develop a sense of self as lovable and a sense of others as loving and
Adolescents in Foster Care and Their Attachment-Security to Significant Others… 133 trustworthy. These infants are described as having a secure bond with their mother (i.e., they are securely attached). In contrast, infants who experience interactions with their mother that are cold, insensitive, and/or inconsistent are said to develop a sense of self as unlovable and of others as unloving and rejecting. These latter infants are described as having an insecure bond with their mother (i.e., they are insecurely attached). Empirical evidence indicates that consistent caretaking that is both sensitive and responsive is associated with young children‘s development of a secure bond to their caregivers (Ainsworth, Blehar, Waters, & Wall, 1978; de Wolff & van IJzendoorn, 1997). Needless to say, maltreatment (by extension, insensitive caregiving) has been associated with the development of children‘s insecure attachments to their caregivers (Baer & Martinez, 2006; Crittenden & Ainsworth, 1989; Egeland & Sroufe, 1981; Finzi, Ram, Har-Even, Shnit, & Weizman, 2001). Bowlby (1973) placed considerable importance on an infant‘s early bond to his or her caregiver, as it results in ―internal working models‖ (i.e., cognitive representations of self and others) that can affect how children relate to others in their lives. Moreover, internal working models established in early childhood are said to exert an influence on individuals‘ later psychosocial development (Thompson, 1999). Thus, attachment in infancy has important consequences for the quality of one‘s future relationships as well as for one‘s later psychosocial functioning (Brumbaugh & Fraley, 2006). Nonetheless, research suggests that these internal working models are malleable: (Kobak, Cassidy, Lyons-Ruth, & Ziv, 2006; Weinfield, Sroufe, & Egeland, 2000). Research on young children who have experienced institutionalized care such as orphanages (O‘Connor et al., 2003) or foster care (Milan & Pinderhughes, 2000; McWey, 2004; Oosterman & Schuengel, 2008) provides evidence that young children who experience extreme neglect or abuse can nonetheless develop secure attachments to others (e.g., adoptive parents, foster parents, respectively). One of the few studies that has assessed maltreatment and adolescents‘ attachment to their biological parents found that concurrent physical abuse, but not physical abuse five years earlier, was associated with the quality of adolescents‘ attachment to mothers (Sternberg, Lamb, Guterman, Abbott, & Dawud-Noursi, 2005). The authors suggested that maltreated adolescents‘ attachment style can adapt to changes in the quality of the parent-child environment (Sternberg et al., 2005). This position is in accord with that of Bowlby (1973) and others (e.g., Kobak et al., 2006; Thompson, 1999) who consider internal working models as sensitive to perturbations in the caregiving environment. Young children in foster care who experience a sensitive caregiving environment can develop secure attachments to others. For example, in their longitudinal study, Ackerman and Dozier (2005) assessed the caregiving environment of infants entering foster care before the age of twenty months and their attachment representation (i.e., sense of self) when the children were five years old. Findings indicated that infants‘ caregiving environment that consisted of high acceptance from foster mothers was associated with children‘s more positive self-representations. The authors concluded that foster parents‘ emotional investment is integral in promoting foster children‘s ―sense of self in relation to others‖ as well as enhancing their coping behaviors (p. 517). There is much less research on foster care adolescents‘ secure attachment and their psychosocial functioning. The limited evidence, indicates that foster care adolescents with secure attachment in fewer problem behaviors (Marcus, 1991; Penzerro & Lein, 1995). Although these studies focus on problem behavior, they buttress the argument that adolescents‘ attachment to foster parents can aide in adolescents‘ psychological adjustment.
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The Present Study The present study examined attachment-security among older adolescents in foster care to their psychological well-being in relation to three significant relationship targets: foster parents, biological parents, and peers. As noted above, evidence from community samples of adolescents indicates that biological parents and peers are an important influence on adolescents‘ adjustment. Adolescents in foster care also note the importance of these relationships. For instance, in a comprehensive examination of older adolescents‘ transition from foster care, Courtney and colleagues found that many adolescents reported having close relationships with at least one member of their biological family (Courtney et al., 2001). Interestingly, although many youth reported feeling close to a parent (usually the mother), they indicated that they received lower levels of support from their parents compared to the support they received from peers. These findings suggest that peer relationships may be important for youth in foster care. Indeed, there has been a call for greater attention to foster care youths‘ peer relationships as they may serve to promote youths‘ development and functioning (Price & Brew, 1998). We assess the role of three potentially important, and previously understudied, attachment relationships (i.e., biological parents, foster parents, and peers) in the psychological well-being of older adolescents in foster care. Specifically, we examine the association between adolescents‘ attachment-security with these three target relationships and adolescents‘ depressive symptoms, self-esteem, and life satisfaction, both concurrently and over a one-year period. We focus on adolescents‘ psychological well-being for two reasons: 1) previous studies indicate that older youth in care have high rates of depression and low levels of self-esteem (e.g., Courtney et al., 2001; Farruggia, Greenberger, Chen, & Heckhausen, 2006); and 2) prior research on adolescents‘ attachment relationships has focused exclusively on adolescents‘ problem behavior (Marcus, 1991; Penzerro & Lein, 1995). In the present study, we address the following three questions: 1. Do adolescents who report greater attachment-security in their relationships with biological parents, foster parents, and peers report fewer depressive symptoms and higher levels of self-esteem and life satisfaction than adolescents who report less attachment-security in their relationships? Based on the previous literature, we expect that this will be the case. 2. How much does adolescents‘ attachment-security with biological parents, foster parents, and peers, considered together, contribute to their concurrent psychological well-being and which of the relationships, if any, make(s) unique contributions? 3. Does the recent history of attachment-security predict adolescents‘ psychological well-being one year later, and which, if any of these relationships, make(s) unique contributions?
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METHOD Participants Participants were part of a longitudinal study of adolescents‘ transition from foster care. Data for this study were from two time points, one year apart. The initial base-line interview was conducted with the adolescent prior to his or her anticipated emancipation from care (usually at age eighteen). One year later, adolescents were re-contacted, and if they agreed, were interviewed and completed a survey. Inclusion requirements at Time 1 were 1) adolescents were at least 17 years of age and 2) in protective custody of the Department of Children and Family Services (DCFS) of Los Angeles County for at least one year. The names and addresses of all adolescents who met the study requirements were provided by DCFS. A random sample was drawn from this master list. Initial consent for the adolescents‘ participation was provided by the Los Angeles County Superior Court, which has jurisdiction over these youth. The adolescents, care-providers, and social workers were then sent a letter describing the study and informing them that adolescents would be telephoned to schedule an interview. At the time of the telephone call, adolescents‘ questions were answered and, if adolescents agreed, an interview date was scheduled. At Time 1, 240 adolescents were contacted, of whom 26 (11%) declined to participate. Nine foster parents (4%) did not provide permission for the adolescent to participate, and 17 adolescents (7%) who originally consented to participate failed to appear at their scheduled interview on at least three separate occasions. The final sample included a total of 188 adolescents (78%) who provided survey and interview data. For the present study, with its focus on adolescents‘ attachment-security, data was examined only for those adolescents who provided complete data on at least one target relationship (i.e., biological parent, foster parent, peers) (n = 184). Adolescents ranged in age from 17 to 20 years (M = 17.8), and just over half (56%) were female. The sample was ethnically diverse: African Americans accounted for 39.7% of the sample, Latinos accounted for 34.8%, Caucasian, non-Hispanics accounted for 12.5%, and most of the remaining 13.0% identified as bi-racial (e.g., African American/Hispanic or Mexican/White) and were classified as ―Other.‖ At Time 2, 167 adolescents (of the 188 youth at Time 1) were successfully contacted and re-interviewed, resulting in an 89% response rate for this at-risk sample. Participants who participated at Time 2 did not differ from those who did not participate with respect to ethnicity, χ2 = 1.12, ns, or age, t(186) = .86, ns. However, males were more likely than females to participate at Time 2, t(186) = 2.05, p < .05. There were no differences between participants who participated at Time 2 compared to those who did not participate with respect to any of the Time 1 measures of depressive symptoms, self-esteem, life satisfaction, or quality of relationships with biological parents, foster parents, or peers.
Procedure Each participant met with a trained research assistant at a mutually agreed upon public location (e.g., coffee shop, bookstore). At the meeting, participants completed a survey and a short interview. If the adolescent agreed, the interview was tape-recorded and later
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transcribed to ensure accuracy of the data. Participants signed a consent form at the time of the interview and were paid $35 for their participation. Time 2 procedures were similar to Time 1 although participants were paid $45.00 at Time 2. All procedures were approved by the university‘s Institutional Review Board and the study secured a Certificate of Confidentiality from the National Institute of Health.
Measures Depressive symptoms. Adolescents‘ depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale (CES-D Scale) (Radloff, 1977), a widely used, well-validated measure of depressive symptoms. Adolescents rated, on a 4-point scale (1 = Never to 4 = Almost Every Day), how often they felt various ways (e.g., depressed, could not get going) in the last month. Responses of each participant were summed and a mean item-score was calculated. Cronbach‘s alphas were, α = .86 and α = .89, at Time 1 and Time 2, respectively. Self-esteem. Adolescents‘ self-esteem was measured using the Rosenberg Self- Esteem Scale (Rosenberg, 1965). This 10-item scale measures one‘s underlying beliefs about the self (e.g., ―At times I think I am no good at all‖ and ―I take a positive attitude toward myself‖). Adolescents rated their agreement (1 = Strongly Disagree to 6 = Strongly Agree) with each statement. A mean score was calculated for each individual. For this study, Cronbach‘s alphas were .79 and .80 at Time 1 and Time 2, respectively. Life satisfaction. The Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffin, 1985) is a 5-item scale that measures individuals‘ global evaluation of their lives (e.g., ―In most ways my life is close to my ideal‖ and ―I am satisfied with my life‖). Adolescents rated their agreement (1 = Strongly Disagree to 7 = Strongly Agree) with each statement and a mean was calculated for each individual. Cronbach‘s alphas were adequate, α = .73 at Time 1 and α = .84 at Time 2. Attachment-security. Measurement of Attachment Quality (MAQ; Carver, 1997) was used to assess participants‘ attachment-security. The MAQ, normally addressing individuals‘ quality of attachment to others more broadly, was adapted for use in this study by asking adolescents to report on several relationships in their lives. Specifically, adolescents were asked to rate their agreement on a 4-point scale, (1 = Strongly Disagree to 4 = Strongly Agree), with statements about their biological parents, foster parents, and peers. If adolescents lived with more than one foster parent, they were instructed to think of the foster parent whom they considered to be more involved in their lives. Items included, ―I find them to be reluctant to get as close as I would like‖ (reverse scored) and ―It feels relaxing and good to be close to them.‖ The MAQ provides for four attachment classifications: Secure, Avoidant, AmbivalentWorry, and Ambivalent-Merger. These typologies were derived from a factor analysis conducted by the measure‘s author. Convergent validity of the MAQ was previously demonstrated in a sample of college-age students (Carver, 1997). With the current study‘s
Adolescents in Foster Care and Their Attachment-Security to Significant Others… 137 emphasis on adolescents‘ perceived attachment-security, we summed all the MAQ items, and where necessary reverse-coded items, for each individual to create a mean score of attachment-security for each of the three target relationships (i.e., biological parent, foster parent, peers). Cronbach‘s alphas for this study were adequate, ranging from .76 to .88.
Plan of Analyses To address the first question, i.e., whether attachment-security is associated with greater well-being, partial correlations, controlling for gender (coded 0 = males, 1= females), were calculated. To examine the study‘s second question (i.e., the combined and unique contributions of attachment-security in the three relationships), we examined data for those adolescents (n = 119) who had provided information on all three attachment figures (i.e., biological parents, foster parents, and peers). Hierarchical multiple regression analyses were conducted with gender of participant entered in the first step and adolescents‘ attachmentsecurity with biological parents, foster parents, and peers entered in the second step. Entering the variables in this order allowed us to ascertain the increment in R2 beyond gender due to security in the three target relationships. To examine the study‘s third question, concerning the effects of adolescents‘ prior attachment-security on their psychological well-being at Time 2, we conducted two different sets of analyses. In the first set, we focused on information from Time 1 about each target relationship separately, resulting in the following sample sizes: biological parents, n = 122; foster parents, n = 143; and peers, n = 157. In these hierarchical multiple regression analyses (one each for Time 2 depressive symptoms, self-esteem, and life satisfaction), we entered gender in the first step, along with the Time 1 measure of the outcome variable, and the measure of Time 1 attachment-security with either biological parents, foster parents, or peers in step 2. In the second set of regression analyses, we included only those youth (n = 105) who reported on all three target relationships at Time 1. Gender and the relevant Time 1 wellbeing measure were entered in step 1, and the three Time 1 attachment-security measures were entered in step 2.
RESULTS Analyses Related to Sample Demographics Prior to addressing the main questions of the study, we conducted several analyses of demographic variables. A descriptive summary of the demographic variables is provided in Table 1, and means and standard deviations for the major study variables are shown in Table 2. In addition to participants‘ age and gender, we assessed several foster care related variables in relation to the study‘s major variables of interest. Prior evidence suggests that foster care placement history is associated with youths‘ attachment style (McWey, 2004; Stovall & Dozier, 2000); therefore, we assessed the total amount of time youth spent in foster care, the number of placements while in care, and the length of time in their current placement. First, using bivariate correlational analysis, we examined the association between participants‘ age
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and the major study variables. Participants‘ age was not significantly associated with their attachment-security with biological parents, foster parents, and peers or with adolescents‘ depressive symptoms, self-esteem, or life satisfaction at Time 1 or Time 2. Next, using independent t-tests, we examined gender differences in relation to the outcome measures and adolescents‘ attachment-security with biological parents, foster parents, and peers. There were significant differences with respect to several of the outcome variables. At Time 1, females (M = 2.02) reported more depressive symptoms than males (M = 1.76), t(181) = -3.89, p < .01, and males (M = 4.92) reported higher levels of self-esteem than females (M = 4.61), t(182) = 2.60, p < .05. There were no significant gender differences in life satisfaction at Time 1 or Time 2, and there were no significant differences between males and females with respect to their attachment-security with biological parents, foster parents, and peers. Table 1. Demographic Variables (N =184) Variable Age Gender (% female) Ethnicity (%) African American Latino Caucasian Other (e.g. bi-racial) Placement Type (%) Foster home Kin foster home Group home Other Total time in care (in months) Number of placements while in care Length of time in current placement (in months)
Mean 17.82
SD 0.78
56.0 39.7 34.8 12.5 13.0
115.65 6.38 46.04
67.50 5.62 55.55
Table 2. Means and Standard Deviations of Major Study Variables
Variable Outcome measures Depressive symptoms (CES-D) Self-esteem Life satisfaction Attachment-security Biological parents (BP) Foster parents (FP) Peers (PR)
%
Time 1 M SD
Time 2 M SD
1.91 4.75 4.20
0.48 0.80 1.35
1.79 4.97 4.30
2.91 3.04 3.05
0.66 0.48 0.43
0.46 0.74 1.49 -
Note. Attachment-security: BP (n = 137), FP (n = 160), PR (n = 177). - Used attachment-security from T1 only.
56.0 17.4 18.5 8.1
Adolescents in Foster Care and Their Attachment-Security to Significant Others… 139 To examine the association between adolescents‘ current placement (i.e., non-kin foster home, kin foster home, group-home, other) and attachment-security as well as with the wellbeing measures, we used one-way analysis of variance (ANOVA). There were no significant main effects for type of placement on adolescents‘ attachment-security or with any of the well-being measures. We also examined the association between adolescents‘ attachment-security and their total amount of time in foster care, number of placements experienced while in care, and the length of time in their current placement (see Table 3). Using partial correlations, in which gender was controlled, we found that adolescents‘ length of time in their current placement was positively correlated with their attachment-security with foster parents, r = .22, p < .01, but not with their attachment-security with biological parents, r = .10, or peers, r = .09, ns. Conversely, the number of placements adolescents experienced during their time in care was negatively correlated with adolescents‘ attachment-security: Specifically, adolescents who resided in more foster care placements reported a lower quality of attachment-security with biological parents, r = -.24, current foster parents, r = -.24, ps < .01, and peers, r = -.29, p < .001. The total amount of time youth resided in foster care was not significantly associated with adolescents‘ attachment-security. As was expected, there were significant correlations between Time 1 outcome measures and their respective Time 2 outcome measure; rs ranged from .43 to .58, ps < .001.
Adolescents’ Attachment-Security and Well-Being at Time 1 To address the first question, regarding the association between adolescents‘ attachmentsecurity and their psychological well-being, partial correlations that controlled for gender were calculated (see Table 3). Greater attachment-security was associated with fewer depressive symptoms: r = -.36 for security with biological parents; r = -.31 for security with foster parents; and r = -.35 for security with peers, all ps < .001. Adolescents‘ self-esteem also was significantly and positively correlated with attachment-security for each of the three target relationships: r = .24, p < .01 with biological parents; r = .32, p < .001 with foster parents; and r = .35, p < .001 with peers. A similar significant, positive association was found between adolescents‘ life satisfaction and greater attachment-security with foster parents, r = .27, p < .001, and peers, r = .19, p < .05. Adolescents‘ attachment-security with biological parents was not significantly associated with their life satisfaction, r = .14, ns. To address the second question, that is, the contributions of security in all three target relationships at Time 1 to concurrent psychological well-being, and to examine the unique contributions of the three target relationships to adolescents‘ well-being, regression analyses were conducted separately for depressive symptoms, self-esteem, and life satisfaction (as described under Plan of Analyses). After controlling for gender, adolescents‘ attachment-security in the three target relationships accounted for an additional 20% of the variance in adolescents‘ concurrent depressive symptoms, Δr = .20, p < .001 (see Table 4). Of the three target relationships, only attachment-security with biological parents was significantly related to adolescents‘ depressive symptoms, β = -.25, p < .01. The poorer the quality of attachment-security with
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their biological parents, the greater the frequency with which foster youth reported depressive symptoms. Turning to adolescents‘ self-esteem at Time 1, the addition of all three target relationships after gender accounted for an additional 11% of the variance, Δr = .11, p < .01. None of the three target relationships uniquely contributed to adolescents‘ self-esteem. With regard to life satisfaction, after controlling for gender in step 1, the addition of the three target relationships in step 2 explained a significant 8% of the variance, Δr = .08, p < .05. Attachment-security with foster parents was the only measure that was significantly associated with adolescents‘ concurrent life satisfaction, β = .24, p < .05.
Adolescents’ Attachment-Security and Subsequent Well-Being (T2) A second set of analyses addressed the study‘s third question; that is, whether adolescents‘ earlier-reported attachment-security with any of the three target relationships (i.e., biological parents, foster parents, and peers) was associated with their depressive symptoms, self-esteem, and life satisfaction one year later. At the bivariate level, there was evidence that adolescents‘ attachment-security was associated with their well-being, in the expected direction, one year later (see Table 3). In the following regression analyses, we assessed the relation between attachment-security at Time 1 and changes in adolescents‘ wellbeing one year later. For these analyses, we did not require that participants had completed all three attachment-security measures; thus, sample sizes for the three analyses varied. There were several significant associations between the adolescents‘ attachment-security at Time 1 and their well-being at Time 2 (see Tables 5 – 7). Results indicated that after controlling gender and initial depressive symptoms, adolescents who reported greater attachment-security with foster parents, β = -.17, or peers, β = -.16, ps < .05, reported fewer depressive symptoms one year later (see Table 5). The addition of attachment-security with foster parents explained an additional, significant 3% of variance and the addition of attachment-security with peers explained an additional, significant 2% of the variance in adolescents‘ depressive symptoms at Time 2. A similar but positive association was found with respect to adolescents‘ self-esteem. Once again, adolescents who reported greater attachment-security at Time 1 with foster parents, β = .20, or peers, β = .19, ps< .01, reported higher self-esteem one year later (see Table 6). Separately, attachment-security with foster parents and peers each accounted for an additional 3% of the variance in Time 2 self-esteem, ΔR2 = .03, ps < .01. Adolescents‘ Time 1 attachment-security with biological parents was not significantly related to their self-esteem at Time 2, β = .01, ns. Adolescents‘ life satisfaction at Time 2 was not associated with their earlier attachmentsecurity with either biological parents, β = .05, foster parents, β = .09, or peers, β = .10, ns (see Table 7).
Table 3. Partial Correlations for Major Study Variables, Controlling for Gender
1. Total time in care 2. # placements while in care 3. Length of time in current home 4. Attachment- security BP:T1 5. Attachment- security FP:T1 6. Attachment- security PR :T1 7. CES-D: T1 8. CES-D:T2 9. Self-esteem: T1
1
2
3
---
.17*
.43***
---
-.35*** ---
4
5
6
7
8
9
10
11
12
-.12
.04
-.07
-.10
.02
-.04
.02
.08
.06
-.29 ***
.13
.07
-.05
.04
-.12
-.13
-.24**
-.24**
.10
.22**
.09
-.12
.02
.05
.01
.35***
.21**
---
.30**
.40 ***
-.36 ***
-.13
.24**
.15
.14
.11
---
.58 ***
-.31 ***
-.32***
.32***
.37***
.27***
.21*
---
-.35 ***
-.31***
.35***
.38***
.19*
.19*
---
.51***
-.58***
-.43***
-.33***
-.19*
---
-.37***
-.63***
-.19*
-.37***
---
.58***
10. Self-esteem: T2 11. Life satisfaction: T1 12. Life satisfaction: T2
Note. BP = biological parents (n = 137), FP = foster parents (n = 160), PR = peers (n = 177), T1 = Time 1, T2 = Time 2. *p < .05. ** p < .01.*** p<.001.
---
.32***
.29**
.22**
.36***
---
.43*** ---
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Table 4. Hierarchical Regression Analysis of Adolescents' Psychological Well-Being on Attachment-Security with Foster Parents (FP), Biological Parents (BP), and Peers (PR) (n = 119) Depressive Symptoms B (SE) β
Self-Esteem (SE)
B
β
Life Satisfaction B (SE) β
Step 1 Gender (0 = M, 1 = F) R2
.24 .06**
(.09)
.25**
-.33 .04*
(.15)
-.20*
-.24 .01
(.25)
-.09
Step 2 Gender (0 = M, 1 = F) Attachment-security: BP Attachment-security: FP Attachment-security: PR R2 ΔR2
.22 -.12 -.08 -.08 .26*** .20***
(.08) (.04) (.05) (.05)
.22** -.25** -.16 -.16
-.29 .11 .11 .13 .15** .11**
(.14) (.07) (.09) (.09)
-.18* .14 .14 .15
-.19 .05 .33 .08 .09 .08*
(.24) (.13) (.15) (.17)
-.07 .04 .24* .06
Note: M = males, F = females *p < .05. ** p < .01. ***p < .001.
Table 5. Hierarchical Regression Analysis of Adolescents’ Depressive Symptoms (CES-D) at T2 on Attachment-Security with Biological Parents, Foster Parents, and Peers at T1 Biological Parents (n = 120) β Step 1 Gender (0 = M, 1 = F) CES-D: T1 R2 Step 2 Gender (0 = M, 1 = F) CES-D: T1 Attachment-security R2 ΔR2
Foster Parents (n = 142) β
Peers (n = 153) β
-.04 .51*** .25***
-.01 .51*** .25***
-.01 .53*** .28***
-.04 .52*** .02
-.01 .45*** -.17* .28* .03*
.01 .48*** -.16* .30* .02*
.25 .00
Note. M = males, F = females. T1 = Time 1. *p<.05. ***p<.001.
The prior set of analyses assessed the effects of each attachment relationship separately and allowed us to answer, in the affirmative, whether adolescents‘ recent history of attachment-security predicted their psychological well-being one year later. Turning to the final set of analyses, we assessed which, if any, of the three target relationships considered together had unique effects on adolescents‘ well-being one year later. These analyses were restricted to a subset of participants who reported on all three target relationships at Time 1. Results indicated that the addition of all three measures of attachment-security did not significantly increase the explained variance in adolescents‘ depressive symptoms, selfesteem, or life satisfaction at Time 2, nor did any of the three attachment relationships make unique contributions to adolescents‘ well-being one year later.
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Table 6. Hierarchical Regression Analysis of Adolescents’ Self-Esteem at T2 on Attachment-Security with Biological Parents, Foster Parents, and Peers at T1 Biological Parents (n = 122) β Step 1 Gender (0 = M, 1 = F) Self-esteem: T1 R2 Step 2 Gender (0 = M, 1 = F) Self-esteem: T1 Attachment-security R2 ΔR2
Foster Parents (n = 143) β
Peers (n = 157) β
.02 .57*** .32***
.02 .57*** .32***
.01 .61*** .37***
.01 .57*** .01
.02 .50*** .20** .36** .03**
-.01 .54*** .19** .40** .03**
.32 .00
Note. M = males, F = females. T1 = Time 1 measure. *p<.05. **p<.01. ***p<.001.
Table 7. Hierarchical Regression Analysis of Adolescents’ Life Satisfaction at T2 on Attachment-Security with Biological Parents, Foster Parents, and Peers at T1
Step 1 Gender (0 = M, 1 = F) Life satisfaction: T1 R2 Step 2 Gender (0 = M, 1 = F) Life satisfaction: T1 Attachment-security R2 ΔR2
Biological Parents (n = 121) β
Foster Parents (n = 143) β
Peers (n = 156) β
.00 .42*** .18***
-.01 .40*** .16***
-.01 .45*** .20***
.00 .42*** .05
.00 .37*** .09
-.01 .43*** .10
.18 .00
Note. M = males, F = females. T1= Time 1 measure. ***p<.001.
.17 .01
.21 .01
DISCUSSION The aim of the present study was to assess the relation between foster care adolescents‘ attachment-security to significant others and their psychological well-being, concurrently and one year later. Consistent with the literature, this study found that adolescents‘ attachmentsecurity with biological parents, foster parents, and peers was associated with higher levels of psychological well-being, although there were notable differences across relationships. In fact, our study suggests that adolescents in foster care benefit, albeit differentially, from
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significant relationships in their lives These results highlight two important issues with respect to adolescents in foster care: the continuity of adolescents‘ quality of attachment across relationships and the apparent benefits of these relationships in relation to adolescents‘ well-being. Of particular interest is the consistency of adolescents‘ security across their relationships. On the one hand, the moderate correlations among measures of adolescents‘ attachmentsecurity with others suggest an underlying, shared component, perhaps contributed by an overarching ―working model‖ of self and others. On the other hand, the independent contributions of specific attachment relationships to adolescents‘ well-being suggest that these relationships are largely distinct from each other. We discuss these issues in turn. Adolescents‘ attachment-security with foster parents, biological parents, and peers were significantly correlated, suggesting a certain degree of continuity of attachment-security across relationships. However, the strength of these associations differed. For example, adolescents‘ attachment-security with peers was more strongly associated with their attachment-security with foster parents than with security in their relationships with their biological parents. These associations are in keeping with the tenets of attachment theory such that adolescents may hold a general, overarching view of attachment relationships based on earlier caregiving experiences; however, adolescents are also capable of differentiating among these relationships (McElhaney, Allen, Stephenson, & Hare, 2009). More specifically, it has been proposed that adolescents‘ ability to reflect on the quality of prior attachment relationships, as well as the quality of their current attachment relationships, allows for adolescents to potentially seek satisfaction of their attachment needs from a variety of others (Allen & Land, 1999). Other researchers have proposed that youth in care who have foster parents who are accepting and caring are more likely to feel competent when relating to others (Ackerman & Dozier, 2005), which could facilitate the development of positive relations with peers. The participants in this study were older adolescents. Most youth enter foster care much earlier in their lives, as was the case for the majority of our sample. Thus, it is important to note that youths‘ foster care experiences were associated with their relationship with foster parents. For example, there was a significant and positive association between adolescents‘ length of time in their current placement and their attachment-security with their current foster parents. It seems reasonable that longer-lasting placements can provide an opportunity for older adolescents to establish greater attachment-security with their foster parents. In line with this finding, the number of placements adolescents experienced while in care was negatively associated with adolescents‘ attachment-security, not only with their foster parents, but with their biological parents and peers. Other factors, such as youths‘ engagement in problem behavior, have been associated with placement instability (Chamberlain et al., 2006), making it likely that the association between placement stability and attachment-security is multi-determined. Our findings on youths‘ attachment-security with others are noteworthy and give support to the call from others who advocate for enhancing adolescents‘ bonds with foster parents and biological parents (Jones & Kruk, 2005; McWey, 2004). As noted earlier, adolescents‘ attachment-security with their biological parents and foster parents was associated with higher levels of well-being. These relationships appear especially important in that they contributed to adolescents‘ well-being over and above adolescents‘ attachment-security to peers at Time 1. Adolescents‘ attachment-security with biological parents uniquely contributed to fewer concurrent depressive symptoms whereas attachment-
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security with foster parents uniquely contributed to adolescents‘ concurrent life satisfaction. These findings suggest that greater perceived security in adolescents‘ relationships with their biological parents adds to the positive effects of attachment-security with foster parents. This is important as adolescents in foster care may have a particularly difficult time with respect to their relationship with their biological parents (Levine, 1988). For instance, the distress associated with being separated from one‘s primary attachment figure likely affects adolescents‘ subsequent relationship quality with their biological parents and potentially their foster parents (McWey, 2000, 2004). Findings from the present study suggest that adolescents who are more secure in their relationships with their biological parents and foster parents also report greater levels of concurrent well-being. It is plausible, of course, that adolescents who report greater levels of well-being may also report more positive perceptions of their attachment quality. However, our findings indicated that adolescents‘ attachment-security with foster parents (and peers) was associated with adolescents‘ well-being one year later, after controlling for adolescents‘ Time 1 well-being measures, thus providing support for the interpretation that attachment-security plays a part in adolescents‘ contemporaneous wellbeing. Our results also indicated that older adolescents‘ prior attachment-security with foster parents and peers was associated with adolescents‘ well-being one year later. Perhaps older youth who had earlier, secure relationships with foster parents and peers were able to draw from these relationships over time, thus enhancing their well-being. Why this was not the case for biological parents is not clear. Interestingly, other research indicates that the effects of parental support on adolescents‘ depressive symptoms wane over time (Overbeek, Vollebergh, Rutger, Engels, & Meeus, 2003; Young, Berenson, Cohen, & Garcia, 2005). As noted above, Courtney and colleagues (Courtney et al., 2001) found that many adolescents in foster care reported feeling close to at least one of their biological parents but that they received low levels of support from their parents. Thus, receiving support and feeling close to one‘s parents may have differential effects on adolescents‘ well-being, particularly as they prepare to transition from foster care. Another possibility is that as adolescents age, they draw support from other significant relationships such as peers or romantic partners (Overbeek et al., 2003). As a means of elucidating the association between adolescents‘ attachmentsecurity with biological parents and their well-being, it would be beneficial to examine adolescents‘ continued contact with, and support from, biological parents over time. As our focus was on adolescents‘ attachment-security while in care, we did not examine the maintenance of these relationships. Future studies should explore this approach.
LIMITATIONS AND FUTURE DIRECTIONS There has been much attention to the need to promote foster adolescents‘ attachment to caregivers (foster parents, biological parents) and peers. However, the topic has received little empirical investigation. Thus, our findings provide much-needed information on adolescents in foster care, especially in understanding the association between their attachment-security in various significant relationships and their overall well-being. Several limitations of the study, however, need to be considered. One limitation was the use of a single source of data on adolescents‘ attachment-security (i.e., adolescents reporting on their attachment-security with
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others). Comparing the concordance between adolescents and adolescents‘ biological parents, foster parents, and peers on reports of attachment-security would provide a more in-depth description of adolescents‘ attachment relationships. Another limitation was that the extent of previous abuse and/or neglect that led to placement in foster care was not examined. It may be that the timing and/or duration of abuse and neglect may differentially impact the attachment-system to biological parents, foster parents, and peers. Future studies should address the specific factors that are associated with adolescents‘ quality of attachment to their foster parents. Also, in light of the fact that many older adolescents return to their families of origin after emancipating from the foster care system, it is a matter of great importance to understand those factors that promote more secure attachments to biological parents.
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U. S. Department of Health and Human Services, Administration on Children, Youth and Families. (2009). Adoption and Foster Care Analysis and Reporting System: Preliminary FY Estimates as of October, 2009. Retrieved from http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report16.htm Weinfield, N. S., Sroufe, L. A., & Egeland, B. (2000). Attachment from infancy to early adulthood in a high-risk sample: Continuity, discontinuity, and their correlates. Child Development, 71, 695-702. Wilkinson, R. B. (2004). The role of parental and peer attachment in the psychological health and self-esteem of adolescents. Journal of Youth and Adolescence, 33, 479-493. doi: 10.1023/B:JOYO.0000048063.59425.20 Wilkinson, R. B., & Walford, W. A. (2001). Attachment and personality in the psychological health of adolescents. Personality and Individual Differences, 31, 473-484. doi:10.1016/S0191-8869(00)00151-3 Young, J. F., Berenson, K., Cohen, P., & Garcia, J. (2005). The role of parent and peer support in predicting adolescent depression: A longitudinal community study. Journal of Research on Adolescence, 15, 407-423. doi: 10.1111/j.1532-7795.2005.00105
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 8
PERSONAL ASSISTANCE SERVICES (PAS) IN THE WORKPLACE: WHERE WE ARE AND WHERE WE ARE GOING Tatiana I. Solovieva, Denetta L. Dowler and Richard T. Walls International Center for Disability Information, West Virginia University, Morgantown, West Virginia, USA
ABSTRACT Workplace Personal Assistance Services (PAS) are used by individuals with severe disabilities to assist with performing job functions. PAS differs from other types of workplace accommodations in that another person (the assistant) helps with the task. For example, the employee may use an assistant to read, file, or organize work tasks. These are activities the individual would typically perform if she or he did not have a disability. Use of the personal assistant allows an otherwise qualified individual to obtain and maintain employment. Employees, employers, and service providers appear to experience confusion about the definition of workplace PAS, funding sources for PAS, and the most appropriate model for implementing PAS in the workplace. Studies were conducted to obtain the views of employees, employers, and service providers about the use of PAS in the workplace. From the perspective of employees with disabilities who use PAS, the major difficulties in using workplace PAS are: (1) defining and obtaining appropriate useful information about workplace PAS, (2) locating welltrained and reliable personal assistants, and (3) locating funds to cover the costs involved in hiring and using an assistant. From the perspective of employers, the major issues in providing PAS include: (1) defining PAS within the workplace, (2) the employer‘s fiscal responsibility relative to PAS, (3) recruiting and managing assistants, and (4) barriers such as safety, workplace disruption, scheduling, formal policies and procedures, liability, and adequate workspace for the assistant. From the perspective of service providers, the important issues identified are: (1) definitional problems concerning workplace versus community-based PAS, (2) access to PAS at the workplace, (3) availability of resources (money and trained assistants) to support PAS, and (4) other
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Tatiana I. Solovieva, Denetta L. Dowler, and Richard T. Walls issues including establishing positive relationships with employers, employer attitudes about PAS, and transportation for the worker and the assistant. Together, this article along with the literature review will provide a broad-based description of the evolution and current reality of PAS. The synthesis of these empirically-based findings will provide direction for future policy and practice related to workplace PAS.
Key Words: Accommodations, Employment, Disability, Personal Assistance Services, PAS
INTRODUCTION Personal Assistance Services (PAS) as a workplace accommodation is an evolving construct. The term PAS originally indicated the use of another person (personal assistant) to help a person with a disability to perform activities of daily living. These activities might include eating, dressing, and toileting. More recently, the term PAS has been expanded to include workplace activities such as lifting, participating in meetings, or traveling. Researchers have shed light on a variety of PAS-related issues. These issues include: How is PAS defined? How is PAS used in the workplace? Who pays for workplace PAS? How are personal assistants identified and hired? What are the attitudes about PAS at work? Together, answers to these questions provide a comprehensive view of workplace PAS. Careful examination of these findings will point to gaps in the existing knowledge base and suggest directions for future policy development and research efforts.
WHERE WE ARE NOW The definitions of PAS vary over time and across constituencies. The implementation of PAS across different disabling conditions and different job tasks can look very different. The knowledge and attitudes of stakeholders impact the relative success of workplace PAS. Policy and funding continue to compromise use of PAS as an effective accommodation. The following sections summarize what the literature tells us about where we are now.
How is PAS Defined? The 1998 Amendments to the Rehabilitation Act, Section 7(28) defined Personal Assistance Services:
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The term ―personal assistance services‖ means a range of services, provided by one or more persons, designed to assist an individual with a disability to perform daily living activities on or off the job that the individual would typically perform if the individual did not have a disability. Such services shall be designed to increase the individual's control in life and ability to perform everyday activities on or off the job.
Other Federal agencies and programs such as Social Security Administration‘s Ticket to Work and Work Incentives Improvement Act (TWWIIA) also use the definition in the Rehabilitation Act. Similarly, the Office of Disability Employment Policy in the U.S. Department of Labor (2004) defined PAS as ―services provided by people to assist individuals with disabilities with tasks that they would perform if they did not have a disability.‖ The Services Handbook (2009) of the U.S. Department of Transportation Disability Resource Center (DRC), defined PAS in the workplace as ―people or service that assist a person with a physical, sensory, mental, or cognitive disability with tasks that the person would perform for him or herself if he or she did not have a disability.‖ The DRC Services Handbook also states that the Rehabilitation Act for Federal employees and the ADA do not require the employer to provide skilled medical care. The DRC refers to the individual who provides PAS as a Personal Attendant (PA). Anyone who meets the needs of the employee without posing a liability to the U.S. Department of Transportation may serve as a PA. The PA may not perform the employee‘s job duties. The PA‘s role is to provide access to otherwise inaccessible facets of the job or personal-care tasks. Other definitions have included specific tasks or activities. The Center for Personal Assistance Services (2004) provided the following definition: Workplace personal assistance services include task-related assistance at work, such as readers, interpreters, help with lifting or reaching, reassignment of non-essential duties to coworkers, and other help related to performing work tasks and may include personal-care related assistance such as helping someone with toileting, eating, or drinking while at work.
The National Council on Independent Living (2007) defined workplace PAS as: . . . workplace task-related assistance including, but not limited to, readers, interpreters, help with lifting and reaching, and other help related to performing work tasks and may include personal care-related assistance such as toileting, eating, or drinking.
Another version of this definition was used by Kraus, Stoddard, Jans, and Ripple (2007). They defined PAS as: . . . task-related assistance at work. Such assistance may take the form of readers, interpreters, help with lifting, and reassigning non-essential tasks. Workplace PAS may also include personal care-related activities such as eating or using the restroom while at work.
Each of these three definitions identified specific types of accommodations (e.g., readers) and tasks (e.g., lifting). They also specifically included personal-care as part of workplace PAS. Glazier (2005) described three types of PAS accommodations. The PAS user may require one of these categories of assistance or some combination of types of PAS. The first category
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is personal care, including activities like eating, dressing, and toileting. The second category is job coaching, including organizing and planning work tasks, along with training the employee to perform those tasks. Job coaches generally assist the worker for a finite period of time and fade out the coaching as the employee acquires the necessary job skills. The third category is ADA-required work-specific PAS. This type of PAS must be provided by the employer to a qualified person with a disability under Title I of the ADA. The activities in this category include essential job functions. Pathways to Independence (2009) makes a distinction between personal care assistance and personal performance assistance. Personal care assistance focuses on tasks such as eating, toileting, and dressing, regardless of whether the person is at home or at work. Personal performance assistance focuses on job tasks in a work environment. The personal performance assistant completes aspects of the job task the worker cannot perform unaided. The Job Accommodation Network (JAN) defined Workplace Personal Assistance Services (WPAS) as ―work task-related assistance‖ (2006). WPAS may include, for example, a sign-language interpreter for business meetings or use of a personal care-related assistant to help the employee travel for business purposes. JAN further notes that the distinction between work task-related PAS and personal care-related PAS is driven by funding issues. When work-task PAS is a reasonable accommodation under the ADA it is most often financially covered by the employer. Personal care-related PAS is generally not the responsibility of the employer. In an early definition, Nosek (1991) broadly described PAS as ―assistance from another person with activities of daily living to compensate for functional limitations.‖ In a later definition, Turner, Barcus, West, and Revell (1999) described work-related PAS as ―services provided to an employee with a disability by a personal assistant to enable the employee to perform the essential duties of a job more efficiently.‖ Each of these definitions differentiated between a human assistant (e.g., reader) and a technological assistant (e.g., screen reading software). In research studies of PAS with employers and with service providers, confusion about the definition and use of PAS was evident. A survey of rehabilitation service providers was conducted by Misra, Orslene, and Walls (2007) to obtain their views and experiences related to PAS. The survey instrument defined PAS for these participants as: . . . accommodation includes assistance such as sign-language interpreters for persons who are deaf. PAS in the workplace may also include personal care activities such as helping someone to access the restroom. PAS may be provided formally through individuals hired to perform specific tasks or informally by having a co-worker or even a family member of the employee provide these services.
Results of this study reported apparent confusion on the part of service providers about the definition of PAS and how it is implemented in the workplace. While many service providers reported using readers, interpreters, and job coaches with their clients, they did not always consider these as personal assistance services. Many had difficulty viewing an accommodation as services provided by a person (e.g., sign-language interpreter) rather than an assistive device (e.g., TDD). Similarly, employer focus group members wanted clarity on work-related tasks versus personal care-related tasks (Misra, Orslene, & Walls, 2010). The employers also questioned
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the use of assistive devices rather than a ―live‖ assistant. These issues led employers to wonder whether or not they had actually provided PAS to their employees. The concerns about a clear definition of PAS and the distinctions between personal carerelated PAS and job-related PAS are a primary source of confusion and a major barrier to full implementation of workplace PAS. Over time, the definition of PAS has expanded from a home and community-based service and extended into the workplace. Legislation and funding, however, have not kept pace with the trend toward workplace PAS, and this lag contributes to the confusion about the definition of PAS.
How is PAS Used in the Workplace? Researchers have examined the use of PAS in the workplace to determine consistency as well as variability in the use of such services. According to the Job Accommodation Network (JAN), employers who provide PAS services reported that sign language interpreters were the most frequently requested type of PAS (2006). People with a variety of disabilities, however, may require a personal assistant. For instance, JAN provides the following scenarios: Sensory Impairment: Qualified Reader. ―A contract attorney who is blind had no difficulty accessing text material using screen reading technology, but could not read hand written correspondence. An existing legal secretary at the law firm was trained to read the hand written correspondence to the lawyer. A schedule was arranged for reading so to meet the productivity needs of the department, the lawyer, and the legal secretary.‖ Sensory Impairment: Communication Access Real-time Translation (CART). ―An employee who is deaf does not know sign language fluently, but must communicate with staff during monthly meetings. The employer hired a stenocaptioner to perform CART during the meetings.‖ Cognitive Impairment: Scribe. ―An applicant with mental retardation was having difficulty completing a job application for a bagger/cart return position at a local grocery store. To accommodate the applicant‘s limitations in writing, the store trained a current employee to be a qualified scribe. The scribe the applicant‘s responses on the job application.‖ Cognitive Impairment: Job Coach. ―A factory worker with a head injury was reassigned to a new position when the employer restructured its production department. The employee became easily frustrated by the numerous, complicated tasks in her new job. The employer accommodated her by allowing the State Vocational Rehabilitation Office to provide a job coach for the first six months of the new position. During the first two months, the job coach worked daily with the employee. For the next two months, the job coach assisted on Mondays and Fridays. During the final two months of assisting the individual, the job coach gradually faded his services until the factory worker contacted him only occasionally on an as-needed basis.‖ Mental Health Impairment: Driver. ―A public administration worker with agoraphobia had limitations in driving long distances and driving on high-traffic
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Tatiana I. Solovieva, Denetta L. Dowler, and Richard T. Walls routes. The employee had a modified work schedule that allowed her to drive to work using a quieter scenic route to avoid rush hour traffic. Twice a year the employee was required to attend a meeting in the state capital which was a three hour drive from her home. The employee‘s family member served as a driver for the biannual event. The employer, who had a policy of paying travel mileage for extended trips, reimbursed the driver for this expense.‖ Mental Health Impairment: Natural Supports in the Workplace. ―A newly hired Geography teacher with bipolar disorder had difficulty developing her work routine and at times would become very disorganized in the classroom environment. A coworker teaching in the same department agreed to serve as a natural support person. The co-worker included the new employee by encouraging conversation while taking breaks in the employee lounge and participation in school activities of interest. The natural support person served in a mentoring capacity by meeting with the new teacher at the beginning of the year and periodically throughout the semester. The meetings were used to establish a routine and organize weekly lesson plans. Together the teacher and her natural support person reviewed time and stress management techniques, discussed various organizing techniques and tools, and developed strategies for adjusting to change. As the teacher increased her confidence and skills in the classroom, her use of the natural support person decreased to an occasional, asneeded basis.‖ Motor Impairment: Personal Care Attendant. ―An employee with quadriplegia could not independently go to the toilet during working hours. The employer allowed the employee to bring his personal attendant into the workplace to perform this function at scheduled time breaks.‖ Motor Impairment: Job Assistant. ―An attorney with multiple sclerosis had difficulty manipulating files due to numbness in her fingers. Her employer provided a clerical assistant to file and retrieve the files for her.‖
Turner, Barcus, West, and Revell (1999) conducted a series of focus groups and surveys related to workplace PAS. A focus group composed of employees from Centers for Independent Living (CIL) who used PAS in the workplace and CIL managers who provided PAS to their employees developed lists of tasks done by personal assistants in the workplace. Their lists included both Job Function Duties and Personal Duties. These are shown below. Job Function Duties Make telephone calls Assist with filing Take dictation Voice interpretation Assist with making copies Enter data Take notes in meetings Read documents Get and open mail Keep work-space organized Travel on business trips
Personal Duties Assist with grooming tasks Assist with getting beverages Assist with food Assist with toileting Assist with transportation Assist with dressing and grooming tasks while on business trips
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Assistive technology has become a valuable job accommodation for some job tasks. Strobel and McDonough (2003) commented that although assistive technology would not replace the need for a personal assistant, it sometimes can reduce the hours a personal assistant is needed at the jobsite. In a study by Solovieva, Walls, Hendricks, and Dowler (2009), employers who had contacted the Job Accommodation Network (JAN) to obtain PAS-related information were asked to participate in a follow-up interview. These employers were asked to describe the outcome of PAS. Their responses included: ―. . . an employee who was losing hearing, a supervisor. When she is in a meeting with other managers, she has trouble hearing. So, she has a personal assistant who types so she can read what‘s going on. Also, when there is an appeals hearing, they can request an interpreter if they need to.‖ ―The employee with a hearing impairment used CART (Communication Access Real-time Translation) to see oral speech converted to text on the computer monitor during training. The employee said he really appreciated the help and that it allowed him to participate in the training.‖ ―We have an individual who is sight impaired. This individual is able to do the job because there is someone to read legal documents.‖ ―We had someone who needed to go out into the field and travel and needed help to do that.‖ ―We have an intern who is deaf, and we are very pleased with him. The interpreter has worked out well and allowed us to develop a good employee.‖ Thus, personal assistance services are used in a variety of circumstances. In many instances, the use of PAS is critical to the employment of that individual with a disability. Extending the use of PAS beyond the traditional readers, interpreters, and personal-care aides demonstrates creativity and commitment on the part of employers to an inclusive workforce.
Who Pays for Workplace PAS? The answer to this simple-sounding question is complex. There are a variety of funding streams and sources, each with its own rules and access points. It is typical that some combination of funding options is needed to assure on-going support for PAS in the workplace. The absence of an adequate funding tool has been identified as the primary barrier to implementation of workplace PAS (Turner, 2007). Under the Americans with Disabilities Act, some work-related PAS may be paid for by the employer as a reasonable accommodation. State and Federal funding sources include Medicaid Title XIX PCS optional state benefit and the Medicaid 1915(c) HCBS waiver program. The PAS users need to explore the options available within their own state, since availability and program requirements vary dramatically from state to state (Job Accommodation Network (2006). For example, there may be a geographically limited source that is available to a PAS user (e.g., Medicaid Infrastructure Grant (MIG) funds in various states, or the Ron Yost Personal Assistance Services Program in West Virginia). A number of
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other government programs may support PAS, including Title XX Social Security block grants, Title III Older Americans Act funds, Department of Veterans Affairs Aid and Attendants Program, Title II Section 203 of the Ticket to Work and Work Incentives Improvement Act of 1999, and State general funds. Alternatively, many PAS users solicit unpaid services from their family members or co-workers. The rules and policies for different funding options were described by Brooke (2001). The ADA describes employer responsibilities for paying for PAS as a workplace accommodation: Applicant must disclose disability during the interview process Employer must have 15 or more employees PAS must be needed for an essential job function Payment for PAS must not create an undue hardship for the employer The state Vocational Rehabilitation may pay for PAS while their client is pursuing employment. The client must be eligible for VR services and complete an Individual Plan for Employment that details how PAS will contribute to achievement of the employment goal (Brooke, 2001). State Medicaid-Funded Waiver programs are available in many states. There are statespecific eligibility criteria and guidelines for the use of Medicaid Waivers. Generally, the applicant would document limitations that require services to allow the individual to live in the community. There is also a financial needs test (Brooke, 2001). The Social Security Administration has developed work incentives that may be used to fund services such as PAS. One such incentive is the Impairment Related Work Expense (IRWE). The IRWE will reimburse costs such as PAS. The IRWE must include: Information showing the expenses are work-related Documentation of payment Expense records Indication that expenses are reasonable To be approved, an IRWE deduction must meet an additional set of criteria (e.g., cost is reasonable, items or services are required due to disability) (Brooke, 2001). A Plan for Achieving Self Support (PASS) is a second work incentive of the Social Security Administration. A person with a disability would use a PASS to set aside income or resources for a specified period of time that will help the employee achieve a vocational goal. The PASS must include: Individualized vocational goal Timeline for meeting the goal Specification of resources/income to be set aside Explanation of the how resources will be used Written plan
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In addition to these PASS components, there is a series of basic requirements for setting up a PASS (e.g., in writing, specific to the person, show what money and resources received will be used to reach the goal) and seven PASS approval requirements (e.g., feasible occupational goal, definable timelines, income/resources to be set aside) (Brooke, 2001). Misra, Orslene, and Walls (2007) noted that fiscal issues are critical concerns for implementing workplace PAS. The cumbersome regulations concerning timing and use of various funding sources are difficult to negotiate. In their study, participants reported using various combinations of Medicaid Waiver, third-party insurance, Social Security benefits, State funds, employer payment, and State Rehabilitation Agency sources. They also reported supplementing these funding sources with ―out-of-pocket‖ payment to the personal assistant. A study of employers was conducted to obtain their perspectives on workplace PAS (Misra, Orslene, & Walls, 2010). One of the themes generated by the employers was fiscal responsibility for PAS in the workplace. Employers mentioned at least 3 funding sources for PAS (Medicaid state plan personal care option program, Medicaid Home and Community Based Waiver program, and Temporary Assistance for Needy Families). Federal employers reported that the Computer/Electronic Accommodations Program (CAP), State Department, and the Army paid for PAS accommodations (Solovieva, Walls, Hendricks, & Dowler, 2009). The employers noted that even when some of the cost is borne by government programs, coordination of funding sources is a challenge. Interview data collected from employers, PAS users, and service providers were consistent with other research (Stoddard, 2006; Stoddard & Kraus, 2006). The participants in the Stoddard and Kraus (2006) study, reported a combination of personal, public, and employer resources is needed to fully fund workplace PAS. In addition, respondents used Medicaid or state health-plan funds to pay for personal-care needs that the employer was not responsible for covering at the workplace. Other PAS users (employees) worked from home in order to qualify for paid home-based assistance. One strategy employers used to reduce the cost of PAS was to share PAS among employees (e.g., on-staff interpreters or sharing an attendant). Stoddard (2006) identified an employer concern about whether accommodation costs should be covered by a unit or department within the company or from a company-wide budget. She noted that workers may hesitate to request an accommodation if they perceive that paying for the accommodation will impact the profitability of their unit or department. Consumer frustrations with the complexities of funding workplace PAS were reported in a study by Turner, Barcus, West, and Revell (1999). Quotes from consumers included: ―[VR] will only provide PAS while the consumer is in vocational training, but once the consumer is employed, their PAS funded through [VR] is stopped.‖ ―The Personal Assistance Program has a lengthy waiting list due to funding…‖ ―The individual service contract program provides financial assistance to consumers for PAS on the job; however, the consumer must meet the MR/DD eligibility to receive the [service].‖ ―We have found that home health care agencies can‘t provide PAS via Medicare or Medicaid if the consumer is working and not home-bound.‖
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Tatiana I. Solovieva, Denetta L. Dowler, and Richard T. Walls ―We have been specifically told that home services are limited to the confines of the home; PAS at work is the employer‘s responsibility.‖ ―Agencies that provide home health care in our area do not provide services outside of the home because Medicare/Medicaid do not pay for such services.‖ ―Agencies insist that they are not allowed to provide personal assistance services at the job site.‖
As noted by Solovieva, Walls, and Dowler (in press), the critical problem of funding PAS at work still needs resolution. The complex interactions of funding streams, lack of clarity in definitions for what is and is not a reasonable PAS accommodation, coupled with confusion of roles and responsibilities in acquiring and paying for PAS, are barriers to effective implementation of a nation-wide system of workplace PAS.
How Are Personal Assistants Identified and Hired? The consumer, the employer, the rehabilitation service provider, or a combination will be responsible for identifying and hiring the personal assistant. Employers who participated in a focus group reported using a variety of methods to recruit personal assistants (Misra, Orslene, & Walls, 2010). These strategies included contacting local Centers for Independent Living, advertising in newspaper and local publications, contacting community organizations, and working with the state Vocational Rehabilitation agency. The employers discussed issues such as the short-term nature of the work, needing security clearances or background checks, and confidentiality in the workplace. Rehabilitation professionals reported in a focus group that they used community groups and colleges to find trained personal assistants (Misra, Orslene, & Walls, 2007). The rehabilitation professionals also noted that families usually help locate and train personal assistants. Issues included low-wages for the personal assistants, sporadic work schedules, and responsibility for training the personal assistant. The focus group participants suggested that people with disabilities should conduct a self-assessment to determine their PAS-related needs, translate these needs into job functions, and use that information to develop a job description for the personal assistant they want to hire. Turner (2003) described a self-assessment process and tools to facilitate self-assessment. He also provided tips for recruiting and hiring personal assistants, including advertising, screening and interviewing applicants, and making a job offer. He noted that the advertisement should include explanation of the required skills, but it is not important to describe the consumer‘s disability in the ad. When screening applicants, the consumer should involve the company‘s human resources department to the extent required by the company. When interviewing, at least one question should focus on the applicant‘s attitudes about working for a person with a disability. Turner (2003) noted that it is easier to teach new skills than to teach new attitudes. When making a job offer, the consumer should consult with the supervisor. Since the supervisor will be interacting with the personal assistant, it is good practice to obtain the supervisor‘s input before the job offer is made. According to a trend analysis by Hewitt and Larson (2007), the demand for PAS is likely to increase while availability of personal assistants may decline. People may be unwilling to
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serve as personal assistants due to low wages, lack of medical/other benefits, burn-out, lack of training, and limited opportunity for career advancement. Variables that effect positive experiences with workplace PAS include the relationship of the personal assistant to the consumer with a disability. Many people with disabilities choose a family member or friend to serve as their personal assistant in the workplace. Consumers who have a close relationship with the assistant report higher satisfaction, and they feel safer than those who receive assistance from a non-family member. Ironically, many states in the U.S. will not pay for PAS when it is provided by a family member or spouse (Hagglund, Clark, Mokelke, & Stout, 2004). Matthias and Benjamin (2008) also found higher levels of satisfaction with PAS services when the personal assistant was a friend or family member. An evaluation of the Employment Personal Assistance Services (EPAS) program described issues related to workplace PAS (Holt, Chambless, & Hammond, 2006). EPAS allowed the consumer to select and hire an assistant or to work with a licensed agency that employed and managed the personal assistant. The participants with disabilities in the evaluation study noted the need for a pool of qualified personal assistants. This pool would relieve the difficulties in locating back-up support when the personal assistant is ill or unavailable. It would also allow a personal assistant to take a day off without creating a hardship for the consumer. The shortage of qualified personal assistants is widely recognized. ―The best employment PAS programs and policies in the world have little impact on a person being successfully employed if there is an inadequate PAS workforce‖ (National Consortium for Health Systems Development, 2008). Thus, recruitment of trained personal assistants is a universal stumbling block to full implementation of PAS in the workplace. There is recognition of the problem on the part of relevant constituents, and there is some movement toward potential solutions. A means of reducing the need to recruit a full-time personal assistant often has involved the use of assistive technology (Strobel & McDonough, 2003). Such technology has included screen readers, print readers, and voice dictation software (Barcus & Targett, 2003). It is likely that as technology continues to evolve many new devices will be of service to workers with disabilities. Such devices, however, are unlikely to eliminate the need for identifying and hiring human workplace assistants.
What Are the Attitudes about PAS at Work? Attitudes about PAS are impacted by experience with and knowledge of such services. A focus group of service providers discussed the lack of knowledge and the fear of liability that contributed to employer skepticism about PAS (Misra, Orslene, & Walls, 2007). The service providers indicated that employers had little understanding of PAS and thought that using PAS meant hiring a second person to do the same job. These misperceptions put PAS in a negative light. On the other hand, the service providers reported that employers have a generally positive attitude about hiring people with disabilities. Their attitudes seemed most positive when the employer had first-hand experience with disabilities (e.g., had a relative with a disability, retained a valued employee with a disability, had a co-worker with a disability).
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Employer attitudes may be based on a lack of information or on misinformation. Misra, Orslene, and Walls (2010) conducted focus groups with employers who expressed their concerns about PAS. They noted a number of barriers to the provision of workplace PAS including safety issues. Does a personal assistant need to be certified? What is the employer‘s liability if the PA is injured at the workplace? Another issue was workplace disruption. Employers feared that the PA may lack knowledge of traditional workplace etiquette and distract co-workers. Also, scheduling must include the employee with a disability, the attendant, and/or co-workers for specific tasks. The additional layer of scheduling can pose hardship for the employer. Even mundane issues such as adequate workspace for the employee and his or her personal assistant must be considered. In addition, first-hand experience with PAS can influence employer attitudes. Employers (N=69) were interviewed about their use of PAS as a job accommodation in the workplace. They were asked about indirect benefits their company accrued as a result of having made a PAS accommodation. More than half of these employers said that use of PAS (1) improved interactions with co-workers, (2) increased overall company morale, and (3) increased overall company productivity (Solovieva, Walls, Hendricks, & Dowler, 2009). Outcomes such as these tend to increase positive attitudes toward the use of PAS. Telephone interviews conducted with 40 employers and employees who are PAS users yielded information about co-worker and supervisor attitudes. Many of the interviewees noted barriers to workplace PAS that result from co-worker attitudes. A PAS user felt the need to demonstrate that he can ―pull his own weight‖ or be a ―team player‖ (Stoddard & Kraus, 2006). One employer noted that from a union perspective, ―…if the person cannot do the job, they should not be there.‖ The interviewees suggested that negative co-worker attitudes could be mitigated through disability-awareness training. The National Consortium for Health Systems Development (2008) noted employer attitudes and concerns as a challenge to incorporating PAS in the workplace. They reported that PAS-related liability or confidentiality concerns may limit employer willingness to hire people with disabilities who require PAS. Information and training resources, along with business-to-business organizations might provide technical assistance to negate these concerns and improve employer attitudes. When the personal assistant demonstrates reliability, punctuality, loyalty, honesty, and a commitment to effective communication, this complement of attributes will increase the value of the personal assistance to the employee with a disability and to the employer (Barrett, 2003). A personal assistant whose performance is an asset to the consumer is more likely to be viewed in a positive light by the overall organization. Even though employers generally have positive attitudes about hiring people with disabilities, lack of knowledge about PAS (e.g., misunderstanding of the nature of PAS) and lack of experience with PAS (e.g., unfounded liability concerns) tend to compromise employer willingness to work with an employee who requires PAS. Employers who have used PAS reported an improved organizational climate and an increase to the ―bottom line‖ that resulted from using workplace PAS. Additional information and training can also improve co-worker attitudes and increase company morale.
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CONCLUSION: WHERE WE ARE GOING The most widely accepted definition of personal assistant services comes from the Rehabilitation Act. Other Federal legislation (e.g., the ADA) relies on this definition. . . . a range of services, provided by one or more persons, designed to assist an individual with a disability to perform daily living activities on or off the job that the individual would typically perform if the individual did not have a disability. Such services shall be designed to increase the individual's control in life and ability to perform everyday activities on or off the job.
Agencies and programs have adapted this definition, or created their own, to more explicitly include the activities the assistant would perform. Others have created definitions to make a distinction between personal care-relation assistance and work-related assistance. The reason these distinctions are necessary is tied to the issue of funding for personal assistance services. For instance, (1) Medicaid can only pay for personal-care related assistance, but (2) Vocational Rehabilitation can only pay for employment supports. Funding continues to plague potential PAS use. Various convoluted combinations of funding sources, each with their own rules and timelines, were described previously. Each potential PAS funder developed a set of guidelines in isolation. From the perspective of a person with a disability who needs PAS, accessing these disparate options can be a logistical nightmare. Employers have attempted to circumnavigate the cost issue by sharing attendant services across employees or by facilitating volunteer co-workers as attendants. Some states have responded to this funding challenge by making legislative changes that define where PAS services can be delivered. The traditional definition of PAS included such services in the home and community. Use of PAS in the workplace traditionally was not covered. California‘s changes only expanded where PAS could be provided. Neither the number of hours nor the reimbursement rate was changed. This simple modification to California‘s law will drastically reduce the complexity of funding PAS accommodations (National Consortium for Health Systems Development, 2008). Another funding issue is the confusion over Medicaid funding versus Vocational Rehabilitation (VR) funding of PAS. Arkansas addressed this issue by creating a Memorandum of Understanding between Medicaid and VR to clarify the role of each agency in funding PAS accommodations. They hoped that this clarification would encourage more VR counselors to put PAS accommodations in place (National Consortium for Health Systems Development, 2008). There is a concern that expanding traditional home-based personal assistance services to the workplace will greatly increase program costs for Medicaid. Pilot programs, however, in several states have demonstrated only modest increases in program growth and expenditure. This seems reasonable given the low percentage of Medicaid recipients who are working and the low percentage of those workers who require workplace PAS (National Consortium for Health Systems Development, 2008). It is tempting to denigrate the value of PAS in light of this low demand, but PAS can make the difference between productive employment and unemployment for those who need personal assistance services at work. A study of disability as part of ―diversity‖ policy with the Fortune 100 companies was undertaken by examining publically available diversity policies from the companys‘ websites
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(Ball, Monaco, Schmeling, Schartz, & Blanck, 2005). Those authors identified three types of diversity policy with respect to employment of people with disabilities. (1) Inclusive policies explicitly include people with disabilities. (2) Non-committal policies do not define diversity in terms of specific groups that would be considered diverse. (3) Disability-absent policies may include gender, race, and/or sexual orientation, but seem to exclude people with disabilities. Less than half (42%) of the Fortune 100 companies posted ―inclusive‖ policies on their website, 47% had non-committal policies, and 11% had policies that were ―disabilityabsent.‖ While it would be important to consider how the policies are put into practice in hiring and retention of employees with disabilities, this cursory examination demonstrates the need for development of explicitly inclusive policies, even among these top-performing companies. Successful provision of PAS in the workplace has been tied to strong positive relationships between service providers and employers. These relationships facilitate establishing supports employees with disabilities need to do their job. Also, when there is good rapport, the service provider may foster the development of strong company policy on workplace PAS (Misra, Orslene, & Walls, 2007). As disability legislation has evolved in the United States, it has clearly set the stage for the use of workplace PAS as a reasonable accommodation. Section 504 of the 1976 Reauthorized Rehabilitation Act, Title I of the Americans with Disabilities Act, and Titles II and XVI of the Social Security Act each establishes a part of the foundation for personal assistance services in the workplace. In 2009, new legislation was introduced to set up a mechanism for providing personal assistance services that will lead to increased community participation, education, and employment. The proposed Community Living Assistance Services and Supports (CLASS) Act would amend the Public Health Service Act to establish an Independence Fund to pay for personal care services (CLASS Act, 2009). At this writing, the future of the CLASS Act is uncertain. It demonstrates, however, progress toward a clearer solution to a serious funding dilemma. A person with a disability is the best judge of the type of personal assistant support needed as an accommodation on the job. Typical uses are sign-language interpreters to accommodate workers with hearing impairments, job coaches to accommodation workers with cognitive impairments, and clerical assistants to help workers with motor impairments. Some PAS users incorporate technologies to reduce their need for a personal assistant. Blending ―live‖ assistance and ―technological‖ assistance may be an optimal scenario for some workers. The day-to-day tasks that are supported by the personal assistant might include telephone use, filing, dictation, work-related travel, and reading documents, but it is important to understand that the one-size-fits-all strategy is not an efficient way to approach PAS. An individual assessment that includes the requirements of the job, in light of the abilities of the worker with a disability, is more likely to result in an effective complement of PAS services. Serving as a personal assistant, while rewarding, is not a high-status job. The pay is low. The hours are sporadic. The burn-out rate is high. There are rarely benefits such as insurance. Developing a pool of people who are willing to be trained and enter this employment arena is a daunting task. Yet, development of a pool of qualified personal assistants is critical to the overall success of PAS. Even though a family member or friend often serves as a personal assistant for the employee, in other cases, finding an appropriate personal assistant and being able to hire that personal assistant are crucial parts of the PAS puzzle.
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An attitude embodies beliefs and feelings about a concept. An attitude influences behavior. Negative attitudes about PAS in the workplace generally are fostered by a lack of information or by misinformation. Employers and co-workers who have experience with disability and disability issues are more receptive to workplace PAS. A systematic program of education (e.g., disability awareness workshop) or technical assistance (e.g., business-tobusiness resources) can shift attitudes in a more positive direction. The debate continues on the appropriate use of personal care-related PAS versus workrelated PAS. Even though PAS related to the essential functions of the job tend to be more accepted in the workplace, either type of PAS (personal care-related or task-related) can contribute to a qualified individual becoming a productive worker. Paying for PAS is perhaps the greatest hurdle to overcome. The employer is viewed as a prime funder of PAS as a reasonable accommodation but the issue is cloudy when personal-care tasks are involved. Development of clear company policy that embraces the concept of disability as diversity can foster the productive employment of qualified workers with disabilities.
REFERENCES Ball, P., Monaco, G., Schmeling, J., Schartz, H. A. & Blanck, P. (2005). Disability as diversity in Fortune 100 companies. Behavioral Sciences and the Law, 23, 97-121. Barcus, J. M. & Targett, P. (2003). Maximizing employee effectiveness through use of Personal Assistance Services at the workplace. Journal of Vocational Rehabilitation, 18, 99-106. Barrett, J. C. (2003). Being an effective workplace personal assistant. Journal of Vocational Rehabilitation, 18(2), 93-97. Brooke, V. (2001). Funding options and opportunities for personal assistance services at the workplace. In E., Turner, G. Revell, & V. Brooke, (Eds.), Personal assistance in the workplace: A consumer-directed guide manual, (62-82). Richmond, VA: VCU RRTC on Workplace Supports and Job Retention. Center for Personal Assistance Services. (2004). Retrieved May 27, 2008 from http://www.pascenter.org/home/index.php CLASS Act. (2009). Community Living Assistance Services and Supports Act. Retrieved January 28, 2010 from http://www.passtheclassact.org Glazier, R. E. (2005). Personal assistance services in the workplace. Disability Issues, 25(3). Retrieved October 28, 2009 from http:// www. masschec. org/ uploadedfiles/ DISABILITYISSUESFALL05.pdf Hagglund, K. J., Clark, M. J., Mokelke, E. K. & Stout, B. J. (2004). The current state of personal assistance services: Implications for policy and future research. NeuroRehabilitation, 19, 115-120. Hewitt, A. & Larson, S. (2007). The direct support workforce in community supports to individuals with developmental disabilities: Issues, implications, and promising practices. Mental Retardation and Developmental Disabilities Research Reviews, 13, 178-187. Holt, J. M., Chambless, C. E. & Hammond, M. (2006). Employment personal assistance services (EPAS): A Medicaid work support. Journal of Vocational Rehabilitation, 24, 165-175.
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Job Accommodation Network. (2006). Personal assistance services (WPAS) in the workplace. Accommodation and Compliance Series, Morgantown, WV. Kraus, L. E., Stoddard, S., Jans, L. & Ripple, J. (2007). The ADA and Beyond: Reducing barriers to PAS at work. Proceedings of PAS Center State of the Science Conference, Washington, DC. Matthias, R. E. & Benjamin, A. E. (2008). Paying friends, family members, or strangers to be home-based personal assistants. Journal of Disability Policy Studies, 18(4), 205-218. Misra, S., Orslene, L. E. & Walls, R. T. (2007). Personal Assistance Services (PAS) for workers with disabilities: Views and experiences of rehabilitation service providers. Disability Studies Quarterly, 27(3). Retrieved October 28, 2009 from http://www.dsqsds.org/article/view/31/31 Misra, S., Orslene, L. E. & Walls, R. T. (2010). Personal Assistance Services (PAS) for workers with disabilities: Views and experiences of employers. Journal of Rehabilitation, 76(1), 22-27. National Consortium for Health Systems Development. (2008). The role of Personal Assistance Services in the workforce delivery system. Retrieved October 28, 2009 from http://www.nchsd.org/libraryfiles/PAS/NCHSD_PAS_Brief_April2008.pdf National Council on Independent Living, (2007). Position on PAS. Retrieved October 28, 2009 from http://www.ncil.org/news/PASPosition.html Nosek, M. A. (1991). Relationships between personal assistance and productivity among Japanese adults with severe physical disabilities. Rehabilitation Counseling Bulletin, 35, (2), 105-118. Office of Disability Employment Policy in the U.S. Department of Labor. (2004). Retrieved October 28, 2009 from http://www.dol.gov/odep/pubs/ek97/personal.htm Pathways to Independence. (2009). Evolving the role of PAS in the Workplace: Applying PAS as a cost-effective form of long-term support in supported employment. Wisconsin Department of Health Services, Division of Long-Term Care. Services Handbook. (2009). U.S. Department of Transportation Disability Resource Center (DRC). Retrieved October 29, 2009 from http://www.drc.dot.gov/ Solovieva, T. I., Walls, R. T, Hendricks, D. J. & Dowler, D. L. (2009). Cost of workplace accommodations for individuals with disabilities: With or without Personal Assistance Services (PAS). Disability and Health, 2(4), 196-205. Solovieva, T., Walls, R. T. & Dowler, D. L., (in press). Personal assistance services (PAS) for individuals with disabilities: Self-care at the workplace. WORK: A Journal of Prevention, Assessment & Rehabilitation. Strobel, W. & McDonough, J. T. (2003). Workplace personal assistance service and assistive technology. Journal of Vocational Rehabilitation, 18, 107-112. Stoddard, S. (2006). Personal assistance services as a workplace accommodation. Work, 27, 363-369. Stoddard, S. & Kraus, L. (2006). Arranging for personal assistance services and assistive technology at work. A report of the Rehabilitation Research and Training Center on personal assistance services. Disability and Rehabilitation: Assistive Technology, 1(1-2), 89-95.
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Turner, E. (2003). Using a personal assistant in the workplace. Journal of Vocational Rehabilitation, 18, 81-85. Turner, E. (2007). Personal assistance services: Emerging from community support to employment support. PAS Facts. Virginia Commonwealth University, RRTC on Workplace Supports and Retention. Turner, E., Barcus, J. M., West, M. & Revell, G. (1999). Personal assistance services: A vital workplace support. In G., Revell, K., Inge, D. Mank, & P. Wehman, (Eds.) The impact of supported employment for people with significant disabilities: Preliminary findings from the National Supported Employment Consortium. Richmond, VA: Virginia Commonwealth University, RRTC on Workplace Supports and Job Retention.
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 9
WHAT IF THE EMBRYO IS NOT A PERSON?
*
A. Theo Boer Protestant Theological University, Utrecht, The Netherlands
ABSTRACT Discussions about the morality of research on human embryos have been dominated by the question whether or not the embryo is a person. If the answer is ―yes,‖ it deserves total protection. Otherwise, it may be used purely instrumentally, i.e., experiments may be conducted which result in the embryo‘s destruction. Following Ronald Dworkin, this paper relativizes this focus on the personhood-issue and questions the view that the absence of personhood equals a license to the purely instrumental use of prenatal life. In our attempt to find foundations for an alternative view, we explore seven considerations that could justify the position that embryos have intrinsic value and should therefore be granted some form of protection: similarity to (human) persons, continuity to (human) persons, potentiality to become (human) persons, the autonomy and the dignity of the parents/ donors, reverence for disagreements, uncertainty, and mystery, membership of the human species, and parallels to other nonpersonal values respected by humans.
INTRODUCTION Discussions about the morality of the use and destruction of human embryonic cells (hES-cells) have been dominated by the question whether or not an embryo is a person. If the answer is ―yes,‖ it deserves total protection. Advocates of hES-cell research tend to describe an embryo in terms of potential human life, whereas many of those who reject this kind of *
The author wishes to thank the Project Group, ―The Moral Status of Human Embryos with Special Regard to Stem Cell Research and Therapy‖ at the Norwegian School for Lutheran Theology and Oslo University, esp. professor Øyvind Baune of Oslo University, professor Dan Callahan of the Hastings Center, professor Dagfinn Føllesdal of Oslo University and Stanford University, professor Egbert Schroten of Utrecht University and the Protestant Theological University, and professor LeRoy Walters of the Kennedy Institute, for valuable comments on earlier drafts of this paper.
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research prefer to speak of embryos as persons. There seem to be two camps, the first of which is often described as ―pro choice,‖ the other as ―pro life.‖ Not every participant in the debate is satisfied with this polarization. In his study Life's Dominion, the philosopher of law Ronald Dworkin argues that the alleged antagonists may have more in common than they want to admit.[1] Although they disagree on whether or not unborn life is personal life, they agree that personhood is a core value in our culture. Dworkin calls this high esteem of personhood a ―derivative‖ approach, since our obligations derive from the subjective interests and rights of persons. And there is a second point of agreement: most parties recognize an intrinsic value in human life which is not derived from the rights and interests of persons. Dworkin calls this the ―detached‖ view. Wittingly or unwittingly, most people have some equivalent to ―detached‖ concepts such as ―intrinsic value‖ and ―sanctity of life.‖ In fact, although the conviction that human embryos are persons is fading (if it was ever generally held), the use of human embryos continues to bother the minds of researchers, politicians, and the public. There is little doubt that stem cell research which does not involve the destruction of human embryos helps to circumvent important ethical concerns and is therefore to be preferred. Dworkin argues that those who deny human embryos the status of a person still have their reasons to be protective about embryos. But which reasons? Dworkin focuses on legal rather than moral issues and only tentatively works out the reasons why human life can be ―sacred.‖ In this chapter we identify a number of arguments which could justify a detached reverence for embryonic human life.
PART I. PERSONHOOD 1.1. Two Notions of Personhood Before exploring such justifications, we first make some observations about the important role of personhood in discussions about the morality of embryonic research. The term persona as a reference to what is specifically human is a relatively modern concept. In classical antiquity, it meant a ―character in a play.‖ Closer to our modern understanding of a person comes the term anima, usually translated as ―soul‖.[2] Aristotle and St. Augustine use the term ―rational soul‖ for what is specifically human in a human being. In early Christian tradition the term ―soul‖ is used in the sense of an entity created by God which, though in need of a physical substrate, is spiritual in essence. The first to use the term in a modern sense is Boethius. In Against Eutyches and Nestorius he defines personhood as ―the individual substance of a rational nature‖ (naturae rationabilis individua subtantia).[3] Boethius thereby sets the trend by using the characteristics of rationality and individuality. Since then, other criteria have been suggested: self-awareness, self-control, a sense of time, the capability to relate to others, responsibility, and free will.[4] In all these criteria some more or less empirically observable features serve as indicators of personhood. Hence, these concepts can be called descriptive notions. Others, like Dworkin, use the term ―personhood‖ in a predominantly moral sense.[5] Moral notions of personhood tell us how we ought to behave rather than being descriptive of those we conceive to be persons. Ascribing moral personhood is tantamount to saying, ―We
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have certain moral obligations to this individual which are basically identical to obligations other people have to us‖.[6] Here, the term ―personhood‖ identifies who belong to the human moral community and enjoy the associated rights. The moral and the descriptive interpretations of personhood are not mutually exclusive. Rather, they constitute the subvenient and the supervenient aspects of one and the same matter. Ascribing moral personhood to an entity implies that some minimal descriptive criteria can identify members of the category of persons; conversely, using the term ―person‖ descriptively serves more than descriptive purposes: it commonly implies that the entity concerned has a moral value. For Dworkin, this value is linked to an entity's rights and interests. In this chapter, I use the term ―personhood‖ mainly in a moral sense. Remaining deliberately vague about the descriptive features of personhood, allows us, mutatis mutandis, to include other terms with essentially the same moral function, such as ―soul,‖ ―human life,‖ ―humanity,‖ ―human dignity,‖ ―hominization,‖ or ―full personal status.‖ Any of these terms may play an important role when it comes to ascribing an embryo and a fetus rights similar to those of children and adults whose personhood is beyond doubt.[7]
1.2. Increasing Value –– Increasing Personhood? It is often suggested that the value of unborn human life increases in the course of its development. Speaking of such a, as Engelhardt calls it, ―spectrum of increasing value to life‖ has some advantages.[8] In the course of a pregnancy, many people become increasingly attached to their unborn child—emotionally, socially, and physically. Concepts of increasing value also feature in other moral settings. Value may increase or decrease with the age of an object, or may go up under conditions of scarcity. Concepts of increasing value also have a methodological advantage: they stay clear from moral absolutes, yet they help to settle conflicts between competing values. A problem arises, however, when the concept of ―increasing value‖ presupposes a corresponding gradual development of the human person. Many Western modern moral and legal conceptions of personhood include the (originally Aristotelian) view that personhood is an indivisible feature. Likewise, Oriental religions assume that human beings at some point in their development receive a soul. These views support the full equality of all human beings. But if ―personhood‖ loses its ―all or nothing‖ character, and if, e.g., new categories, such as ―beginning persons,‖ ―half-way persons,‖ or ―deficient persons‖ were introduced, we might have a hard time arguing for the full personhood of comatose patients or patients in an advanced stage of dementia. The view that personhood cannot be held partly has come under pressure in modern times. Since the Enlightenment, rationality and free will are broadly conceived to be essential features of personhood—and it can hardly be contested that these capacities develop gradually. If we nevertheless insist that personhood cannot be held partially, we have two options. The first is that personhood is present only when free will and rationality have become fully developed in a human being. In this option, free will and rationality are necessary conditions for the existence of personhood. This view may have consequences for our attitudes towards toddlers, people with a mental handicap, and comatose patients. Peter Singer‘s contention that personhood enters into a human biography at some point after birth
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implies a position with regard to the rights of young children which most people will not be ready to accept.[9] The alternative is to return to Aristotelianism and reverse the logic: rather than constituting personhood, free will and rationality disclose its presence.[10] In this option, personhood is a necessary condition for the existence of free will and rationality. The absence of these qualities is not enough to justify the conclusion that there is no personhood.
1.3. The Dominant Role of Personhood If we assume that personhood is indivisible, i.e., that it is either fully absent or fully present, the next question is whether we can sustain the view that the value of an embryo increases gradually. After all: if embryos and fetuses are persons, does that not mean that their purely instrumental use equals homicide? And if they are not, does that not mean that the purely instrumental use of embryos and fetuses is unproblematic, if not altogether justified? In 1973, the US-Supreme Court ruled that a fetus is not a person in the context of constitutionally protected rights. By implication, the Court argued, this meant freedom of choice for the parents (Roe vs. Wade). A similar point is made by Engelhardt when he contends that ―[h]uman embryos lack the dignity of persons. They can therefore be used as means merely‖.[11] Likewise, Mertes et al contend that once we adopt a gradualistic view on the value of embryo, ―embryo research is not immoral per se‖.[12] The literature is replete with examples of this line of reasoning. The reasons for stressing the value of personhood are compelling: from the conviction that humans have an immortal soul created in the image of God, via Kant's categorical imperative, to Dworkin's characterization of persons as individual bearers of rights and interests. This stress on the value of personhood has put other values in its shadow. The lower the relative value of other values in comparison to personhood, the harder it is to make a case for their protection when they collide with person-related interests and rights. Only personhood suffices to withstand the weight of personhood. In the context of the embryo-discussion, this equation of personhood and the right to full protection may explain why some may be tempted to ascribe personhood to embryos for strategic purposes rather than from true conviction: the strongest—perhaps even the only— way to argue for the inviolability of embryos is to claim that they are persons. If other arguments fall short of granting full protection, attributing personhood to an embryo may serve as a last resort.[13] The reverse may also occur: an effective way to justify the instrumental use of embryos is to argue that they lack personhood. In absence of other ways to affect the outcome of a moral argument, changing one of the descriptive premises becomes tempting.[14] Literature is thus replete with examples of how personhood has become a shibboleth with an undisputed status and priority. And for good reason. In a complex reality, there may be conflicts of interests of, e.g., humans and animals. In order to settle such value collisions, a hierarchy of values with personhood at the top is an effective, unambiguous, and uncontested tool. Moreover, this hierarchy may be objectively just, e.g., because we believe it reflects the way things are (including the way humans are), or the way God created things; and it may be subjectively true, namely, from the perspective of human beings who are the only moral
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agents in the universe as we know it. After all, humans ―make‖ morality, so why not give preference to persons? Value collisions between ―higher‖ and ―lower‖ values may be settled in different ways. The first is discrimination, which means prioritizing one value when we cannot safeguard all values at once. An example is a decision to save humans first and cattle later in a flooding disaster. The second option is threat removal and implies the active and intentional destruction of a value which threats the existence of another value. An example in case is the termination of a pregnancy in order to save a woman's life. The third possibility is sacrificing. It implies the destruction of a value which does not present a threat to the existence of the other value. Its destruction serves the other value's protection or flourishing in a relevant way. Animal experimentation is a case in point. Although many people agree that it is sometimes necessary to sacrifice a value, it clearly is the most problematic of solutions and thus carries a heavy burden of proof. If the embryo is not a person, does the life and wellbeing of existing persons automatically justify its instrumental use? The answer to this question is not an automatic ―yes,‖ but depends on the kind of deontology we adopt.[15]
PART II –– OTHER NOTIONS Questions about personhood have thus been very important in the debate about the morality of human embryo research. This focus on personhood may have diverted our attention from other values which could be found in prenatal human life. According to Dworkin, the value of life needs to be distinguished from the value of personhood. Our duty to protect human life may be compared to duties to respect species, the natural environment, or works of art.[16] The inviolability of humans can be defended detached from notions of personal interests and personal rights. Dworkin is not alone: many of those who do not ascribe personhood to embryos are convinced that human life in its pre-personal stage should still be treated with some form of respect. Consider what warrants us taking such a detached view. We start with a proposal by the American philosopher Jane English. In her paper on the morality of abortion, English starts from the observation that it can be successfully argued that some persons should not be protected: for example when they are a threat to the lives of other persons. From this follows that ―personhood‖ and ―inviolability‖ are not equivalent terms. Moreover, English argues that some non-persons, like animals, in fact do have a right to protection: ―Some opponents to abortion seem worried that if a fetus is not a full-fledged person, then we are justified in treating it in any way at all. This is not true. Non-persons do get some consideration in our moral code, though of course they do not have the same rights as persons have [ ] We cannot treat them in any way at all‖.[17] English suggests two major grounds for treating nonpersons with respect: similarity to persons, and continuity to persons.
2.1. Similarity to Personhood Humans can hold obligations towards non-persons if these are in one or more relevant aspects similar to persons.[18] The way we treat fetuses, English argues, may influence our
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respect for human persons: there is a connection between the way we treat persons and the way we treat ―person-like non-persons‖: ―For our ethical theory to work, it must prohibit certain ways of treating non-persons that are significantly person-like‖.[19] An ethical theory, English argues, must operate by generating a set of sympathies and attitudes toward others which reinforce the functioning of that set of moral principles. We need a coherence of attitudes. Some animals are so much like humans that permission to abuse them would weaken our moral resolve to protect humans: ―People who torture dogs are not to be trusted with people‖.[20] Neither can we expect a nurse to dispose of viable 24-week aborted fetuses while at the same time caring for six-week premature infants.[21] English understands similarity in predominantly morphological terms: ―[I]n the early weeks after conception, a fetus is very much unlike a person. It is hard to develop [positive] feelings for a set of genes which does not have a head, hands, beating heart, response to touch or the ability to move by itself‖.[22] Given the absence of these visible features in embryos, it can be asked whether English's similarity argument has relevance for the discussion about the use of embryos. We may solve this problem by pointing to the fact that English considers morphological features essential only insofar as they reveal the presence of personhood. Human hands are meaningful because we see them as the hands of a person, not because we see a body part in the shape of a hand. It could thus be worthwhile to identify other—perhaps even more essential—similarities between persons and embryos, such as membership in the human species, genetic similarities, and individuality. But even if we could succeed in finding such similarities, would they be convincing? Can there be a duty to respect an entity only because it resembles a person, without reference to its intrinsic value? An example from the field of psychology may illustrate the case. Research has shown that caring for a pet stimulates the development of social skills in children.[23] Some psychologists advise parents to purchase a pet so that their children may develop a more caring attitude towards other people. Does that reduce the value of a pet to its usefulness for the purpose of rearing virtue? It may, but could well be the other way around: the intrinsic value of a pet comes first, and through discerning and affirming this value, children will learn how to respect the similar but higher value in fellow human beings. Their conviction that animals deserve attention, that they should not be suffering, that they should live according to their nature and be able to realize their potential, precedes considerations of a more instrumental character. The argument that unborn human life resembles personal life is therefore in itself insufficient to undergird a duty to respect unborn life. There can only be such a duty when pre-personal unborn life not only looks like a person, but also shares some of its intrinsic values.
2.2. Continuity to Future Personhood English identifies a second reason for protecting non-persons: the bodily continuity between a fetus and an adult. She draws a parallel with the way we treat human corpses: ―Bodies play a surprisingly central role in our attitudes toward persons. [ ] Even after death, when all agree the body is no longer a person, we still observe elaborate customs of respect for the human body‖.[24]
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The strength of this argument depends on whether the continuity between living persons and their dead bodies is in relevant ways similar to the continuity between unborn life and full-fledged persons on the other. When we treat a dead body in a way respectful to the deceased person, why not treat prenatal life in a way respectful to the future person? Let us first look at the differences. Biologically, the continuity is stronger at life‘s beginning than at its end. Before and after birth, it is one and the same life, the same beating heart, the same genetic identity, the same individuality. When a person dies, most of the biological continuity is disrupted and what is left of it, will soon decay. In another sense, however, the continuity at life's end is stronger than at its beginning. At the beginning of life, people may make guesses or have hopes as to what the future child will be and how it will develop, but its biography is imaginary rather than real. If the fetus dies at an early stage of the pregnancy, there may be grief, but part of the grief is caused by the shattering of dreams, not by the loss of a real person. However, when someone dies, his or her remains represent a concrete person, a somebody who has been part of a network of relatives, friends, colleagues, and others. This asymmetry unveils a logical problem: whereas the continuity between a living person and his dead body is real and final, the continuity between prenatal life and a future person is imaginary and conditional. If human actors decide that an embryo will be destroyed, this embryo is not a future person and there can be no duty to protect or respect it. The claim that we should protect an embryo because it is a future human being equals the claim that we should vote for a presidential candidate because he will be our future president. Only if there is a duty to respect the life of an embryo or a fetus apart from the continuity argument, does the continuity argument provide a reason to pay this future person proper respect and care. We have to protect future persons, but the question whether embryos should be treated as future human persons cannot be answered on the basis of the continuity argument.[25]
2.3. Potential Personhood Speaking of the value of an embryo only in terms of similarity to personhood and of future personhood is thus insufficient to undergird a duty to protect it. It is here that we leave English and proceed to an argument which boasts of a long tradition: embryos and fetuses have the potential to become persons.[26] Edward A. Langerak describes this argument as follows: ―If, in the normal course of its development, a being will acquire a person's claim to life, then by virtue of that fact it already has some claim to life‖.[27] The circularity which is typical of the continuity argument does not apply to the argument from potentiality. Embryos may not be future persons (they may be destroyed, nature may not grant them the conditions for further development), but they may still be potential persons.[28] The potential to become a person is there, irrespective of its future actualization. Moreover, this inner developmental ―drive‖ is, in Langerak's definition, in some way normative, ―normal.‖ This potentiality to develop into a human person, even if it will never be actualized, is a capacity which lends the embryo a special value when compared to both lifeless matter and other, nonhuman life forms. The distinction between potential and future personhood may prove relevant for the status of the many embryos in laboratories worldwide which will never get a chance to develop into human beings. It is sometimes argued that these surplus or excess embryos constitute a
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special category of embryos. Their destruction does not does not scatter the dreams of a parent in spe since most of them were never intended to be placed in utero. Still, they have the potential to become a person.[29] The more this potentiality is seen as a good—and no doubt the potency to become a person represents some kind of value—, the more likely it is to have consequences for the way surplus embryos are dealt with: should they be destroyed, stored for future use, offered for adoption, or used for research purposes? And, in the latter case: in what way and for what purposes? All these choices should be as congruent as possible with the embryo‘s status as potential person.[30]
2.4. Parental Consent and Parental Dignity Almost any regulation regarding the use of human embryos contains the requirement for parental (or donor) consent. This condition is hard: without consent, an embryo may not be used under any condition.[31] We begin this section by observing that parental consent in the context of embryo research is not consent by proxy. The latter refers to the right of one person to decide on behalf of another—and the duty to do so in his or her best interests. A person appointed to give consent by proxy should never condone actions which seriously threaten the wellbeing of the other person, unless these are necessary to protect him or her from more harm. The object of concern, in other words, is a person and has interests. Use of the term, ―consent by proxy‖ implies the conviction that the embryo is a person and this, in turn, would rule out any form of research which would lead to the destruction of the embryo, even if its parents would give their consent. Those who are convinced that an embryo is a person, yet deny it the possibility to develop into a healthy baby, have an inconsistency in their human rights convictions. So if the criterion of parental consent is not consent by proxy, what is it? First, we should note that the position of the embryo is relatively weak: its protection can be overridden and its existence sacrificed when its parents give their consent. Not the life of the embryo is inviolable but the autonomy of the donors: their objections overrule even the strongest consequentalist arguments in favor of research. This requirement resembles the role of consent to organ donation by living donors. Human organs have a low intrinsic value, if any at all, and the value which is at stake here is the autonomy and the dignity of the person from whom they originate. Similarly, the requirement for parental consent in the context of embryo research does not concentrate on embryos for what they are but for the persons they represent—the ―parents.‖ Taken by itself, the requirement for parental consent will no doubt be too weak for those who argue that embryos are persons. They may press for stronger safeguards for the protection of the embryo, safeguards which overrule the subjective views of the embryo's biological parents. Still, even within the requirement for parental consent embryos are more than mere property. In most Western countries, research on embryos is forbidden unless it meets the standards of relevance, safety, effectiveness, and chances of success. One reason for such standards may be the financial costs involved, another the status of the embryo itself: ―life,‖ ―person,‖ ―potential person,‖ ―future person,‖ as well as other considerations explored
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here. Part of this reverence for embryos may not be related to what embryos are but to whom they represent. What happens to an embryo in a certain way happens to its biological parents. Decisions with regard to an embryo are not only related to parents‘ autonomy but also to their dignity. A comparison may illustrate the point. Several countries have seen debates about the morality of media programs in which people act in a manner embarrassing and harmful to their interests, self-esteem, and good name. But what if these people are competent and consenting adults who enjoy rather than suffer from the effects of such an appearance, e.g., because it yields income or fame? Some may want to solve the issue by pointing to the fact that these people may have the legal right to such participation. But this leaves the moral question unattended, nor does it address the general public's pity, contempt, or vicarious embarrassment for such choices. Human dignity may transcend the individual autonomy and interests of a person. In a similar way, one of the reasons why donation of embryos is bound to rules may be that research should be compatible not only with the autonomy but also with the dignity of the donors.[32] What if, for example, embryos would be used for improving the life conditions of animals, or for testing in the cosmetic or food industry? What if a couple sells their embryos in order to finance a new kitchen? Even if there are no objections based on the embryo‘s intrinsic value, and even if the donors cooperate, using embryos may still be morally offensive. Just like media appearances can be embarrassing for those involved, certain ways to use embryos can be shameful to the parents. In an embryo the lives and the dignity of two human persons come together. The origins of individual human life are closely associated with intimacy, and even an embryo in vitro will be associated with this personal notion (although to a lesser extent than in the case of a natural pregnancy). Not without reason many couples keep their visits to a fertility clinic a secret. The genetic and biographical identity of the gamete donors not only has consequences for the identity of the embryo, but the formation of this new organism may in turn influence the self-understanding and relationship of its parents. More than human somatic cells an embryo is associated with intimacy, privacy and personal and genetic identity. Paradoxically, the delicacy of human sexuality and procreation may be an important reason why the argument from parental dignity hardly features on an institutional and political level. But that does not render the argument irrelevant. Concern for privacy and respect for human reproduction may play an all the more important role in individual and private decisions whether or not to consent to research. The requirement for parental consent may be a much underestimated indicator of the presence of some kind of value in an embryo.
2.5. Sense of Mystery, Uncertainty, Lack of Consensus Many debates about the use of human embryos suffer from a Babylonian confusion. Different parties do not even come near to understanding the other party‘s perspective. Scientific methods fail to explain what happens at the origins of human personhood. Concepts such as ―personhood‖ and ―identity,‖ which are pivotal in our self-understanding, stretch beyond the vocabularies and methods of empirical science. Views differ about the relation spirit-matter, about what happens after conception and in the first months of a pregnancy, and
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about the relevance of these convictions for our actions, attitudes, and policies. And not only is what happens at the beginning of an individual human life hard to access, but many people doubt whether we should even want to explore it. For religious and nonreligious people alike, the term ―playing God‖ reflects the intuition that humans must know and respect their limits.[33] In the words of an experienced scholar in hES-cell research: ―I do not believe the human embryo is a person, but when I look at it through the microscope, I feel a hundred times more reverence than if I look at another living cell‖.[34] Some would argue that given these competing views, policies with regard to the use of embryos are neither possible nor desirable. But the existence of deep and lasting disagreements may also be reason for a certain kind of policy. Tutorianism, which is based on Aristotle's uncertainty theorem, is the view that uncertainty about the possible harmful effects of our actions justifies extra caution.[35] When, for example, a major accident has occurred and there is disagreement whether or not there are survivors, rescuers are expected to act as if there are survivors. Expensive and risky rescue efforts are made. Some may want to advocate a similar policy with regard to embryos: since we do not agree on the moral and ontological status of the embryo, let us take a safe course and take strict precautions. Embryos may be given the benefit of the doubt, even if this entails the risk of erring on the side of caution. There are of course individuals and groups who claim to have sufficient certainty about the status of the embryo. But they live in a world in which other people, groups, and traditions are not so sure or hold different views. The mere existence of deep disagreements should strike us as morally relevant. Lack of consensus about crucial moral issues is in some way similar to an individual's doubts or afterthoughts when faced with important decisions— ―What if?‖ ―Could I be mistaken?‖ ―Does the other party see values or truths which I have missed?‖ Tutorianism, needless to say, should not be pursued ad absurdum. If we want to rule out any risk of harming an unknown human person, biomedical science may have to stop experimenting altogether. Neither does Tutorianism mean that ―conservatives should always win.‖ What it does mean is this: any institutional or political policy on an issue in which essential values are believed to be at stake, and in which there is no consensus, should be solved in a way that is as respectful as possible to the different fractions who disagree. It means that political and institutional majorities should not only strive to ―get as much as they can,‖ but to attain their goals, or part of them, with due respect for the opinions of minorities. By accepting constraints on the use of embryos and by consenting to the funding of alternative research methods, a ―liberal‖ majority may give ―conservatives‖ this signal: ―We understand your objections and respect your conscience.‖ ―Conservative‖ majorities may indicate a similar attitude by not vetoing embryonic research, and instead pressing for strict conditions.[36]
2.6. Membership of the Human Species If an embryo is not a person, what is it? Clearly, it is not vegetative or animal life—it is human life. And unlike a human body part or a somatic cell, an embryo is not taken from an organism but is an organism in its own right. It lives independently, aided by favorable circumstances, it has a unique genetic identity, and it has the potential to become a fullfledged person. What it shares with persons is not personhood but membership of the human
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species—―humanhood.‖ Embryos, fetuses until a certain phase of their development, anencephalic babies, people who are brain dead and full-fledged persons together form the human species. Not all of them are persons, some may not even be future persons and others may lack the potency to become persons. Together they constitute a category of related organisms.[37] The distinction between humanhood and personhood has an appeal to two different and largely irreconcilable positions. Some argue that a life may lack personhood or the potency to it, yet insist that it may have some value based on the fact that it is individual human life. They don‘t deny personhood its important status but argue that membership of the human species constitutes another, independent reason for protecting an organism. To others this distinction serves an opposite function. Some human beings or organisms may look like persons and share much of their genetic and organic identity, yet this does not justify the duty to protect them: it is personhood alone, not humanhood, which justifies such a duty. The assumption that membership of the human species equals inviolability witnesses an ―is-ought‖ fallacy and is a form of speciesism.[38] And indeed: if we could rule out personhood or the potency to it in embryos, why would we have the duty to respect these human nonpersons? One option would be to argue that even these members of the human species were ―meant‖ to be or to become persons. Their value is not found in their future or their potential but in their membership of a species of which the members have the telos to become persons. This telos exists irrespective of both inner deficiencies in this organism and outer circumstances which hinder its development.[39] Thus understood, membership of the human species has a primarily detached meaning. The core value is not personhood, nor potential personhood, but a telos.
2.7. Respect for Nonhuman Entities We come back to the suggestion made by Susan Wolf that respect for prenatal life may rest on the similarity between fetuses and human persons. We argued that this line of thought is only convincing if fetuses not only look like people, but also share some of their intrinsic values—without being persons. One parallel between fetuses, animals, and born humans is that they share the capacity to experience pain. However, in the context of embryo research this argument will fail: as far as we know, embryos can sense no pleasure or pain. Neither will a parallel with our duty to respect the potential of animals to develop and evolve provide any new perspective: the potentiality of the human embryo to become a person stands for itself and does not need the help of parallels with animals. Arguing that we should protect an embryo because we also protect the potentiality of animals is no more convincing than arguing that we should protect the Mona Lisa because it resembles another valuable painting. Another possible option is to follow Dworkin and to compare our duty to respect unborn life with obligations to preserve biodiversity, the natural environment, works of art, and human cultures. All these categories are not incrementally valuable: there is no duty to aggregate these values, but once they have come into existence, they deserve our respect. What works of art, biodiversity, the natural environment, and human cultures may have in common with embryos is that all these entities are not persons, yet they all deserve some form of respect.
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Some may argue that even this respect for nonpersonal entities is derivative in disguise. After all, does the protection of the natural environment not serve the aesthetic and recreational needs of human persons? Does not the preservation of biodiversity serve the wellbeing of future generations? Does respect for works of art and human cultures not originate from respect for the efforts and intentions of their individual or collective makers? And is, in the end, respect for the natural environment not another way to honor a Divine personal creator? Indeed, insofar as our respect for all these entities envisages the satisfaction of human needs, or insofar as it originates from respect for their makers, the approach is derivative rather than detached. Perhaps there is a way out. To begin with, the fact that the preservation of the natural environment serves human needs does not rule out the presence of intrinsic values in those entities. It may well be the other way around: we feel the need for recreation and enjoy the beauty of nature not because of our interests or rights but because these natural things strike us as valuable. Perhaps one of the reasons why human persons feel attracted to being in the woods, the mountains, or at the beach, is precisely because these environments represent values which surpass our interests, rights, and aesthetics. Some of those who engage in extreme outdoor sports may do so because they seek to be challenged by factors and powers beyond their control. Our personhood which so often forms the center of our value system may need an axiological Gegenüber. Nature provides conditions for human life and thus has instrumental value to us. But that does not rule out the existence of intrinsic values which do not derive from the rights and interests of persons. But even if works of art or human cultures are the result of the activities of persons, and even if biodiversity and the natural environment would be the result of Divine creative activity, there is no reason to claim that personhood is the only reason we value them. Needless to say, the fact that something is the result of personal activity does not make that something a person with interests or rights. Moreover, it is very well possible to have a duty to respect such a nonpersonal entity without reference to its origins in the mind of their makers. In the case of a painting, the approach would be derivative if we would argue that the destruction of the painting violates the rights of the painter. But the duty to protect a created work is not necessarily a derived duty. A painter may have no rights—he may have passed away or he may have forfeited or lost his rights—but it may still be wrong to destroy a painting. Likewise, protecting the natural environment may be derivative if it is out of concern for the interests of future generations of human persons, out of respect for a Divine creator, or out of fear for Divine wrath. But that does not rule out reverence for the intrinsic values of these entities. Only few will visit the Van Gogh Museum out of respect for the great painter: most people will want to enjoy the unprecedented artistic value of Van Gogh‘s paintings. Likewise, we may want to preserve biodiversity out of reverence for its creator, but we may also act respectfully out of reverence for the unique, complex, and beautiful configuration of living and dead matter. Dworkin points to another detached reason for respect. Many of the nonpersonal things we value are the result of a long and complex process of development: ―We consider it a kind of cosmic shame when a species that nature has developed ceases, through human actions, to exist‖.[40] For secular people, ―even unconscious natural processes of creation should be treated as investments worthy of respect‖.[41]
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CONCLUSION In a way similar to all these notions we may also explain our sense of duty towards embryos. After all, why should we have to explain all values in terms of their origins from personal activity, their compatibility with personal preferences, or their effects on the wellbeing of persons? If all our duties in some way derive from the value of personhood, we may in the end have to concede that the concept of ―value‖ is synonymous with that of ―person.‖ If personhood were the only value within human morality, and if an entity is only valuable insofar as it affirms personhood, promotes its interests, or obeys its commands, the concepts of ―value‖ and ―personhood‖ would refer to one and the same thing. The question is not only whether we like to adopt such a radical anthropocentrism, but it is also whether it is realistic to do so. There are good arguments in assuming that personhood may be an important, perhaps the most important value in human morality, but that leaves open the possibility that the concept of ―value‖ transcends that of ―person.‖ Dworkin‘s concept of ―sanctity of life,‖ as any other detached concept of value, goes back to the intuition that there are things which have neither interests nor rights or preferences, but which we nevertheless ought to respect. In a similar way, the theologian and ethicist James M. Gustafson criticizes the anthropocentrism of contemporary theology, philosophy, and science.[42] In conclusion, one thing seems beyond doubt: if human embryos are persons, research that involves their destruction is problematic if not unacceptable. But what if we are convinced that they are not persons, or at least cannot affirm that they are? In this chapter I have argued that the stress on the value of personhood in present day western morality can be criticized. Although there are good reasons why personhood is a core value in private and public morality, it remains to be seen whether this licenses a liberty to sacrifice embryos. Much depends on whether or not we find other values in embryos that we may want to protect. In this chapter we have therefore explored seven considerations: embryos are similar to persons; their existence is linked to the biography of future persons; they are potential persons; they represent the autonomy and dignity of the donors; the status of the embryo is uncertain, mysterious, and disputed; embryos are members of the human species with a specific telos; and respect for human embryos equals respect for animals, the natural environment, species, and works of art. Not all of these considerations are equally plausible, nor have we presented them as such. We have seen that many of these considerations are somehow related to respect for personhood. The question is thus legitimate whether we will ever be able to get the embryo-discussion out of the shadow of personhood-issues. But what I hope to have made clear is that even those who cannot affirm the presence of personhood in embryos, and who still insist that the purely instrumental use of embryos should be avoided as much as possible, are not devoid of good arguments—arguments that reach beyond the limits of particularistic convictions, and that deserve to be heard in the context of a pluralistic discussion.
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REFERENCES [1]
Dworkin, R. Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom (London: Harper Collins, 1993). [2] Its counterpart, animus, is normally translated as ―spirit.‖ For the parallels between humanistic and religious notions of what is specifically human, cf. J. T. Noonan, Jr., ―An Almost Absolute Value in History,‖ in: Bioethics, ed. R.B. Edwards and G.C. Graber (Orlando FL: Harcourt Brace Jovanovich, 1988), 598-603, here 599. [3] Campbell, A. V. ―Persons and Personality,‖ in The Westminster Dictionary of Christian Ethics, ed. J. F. Childress and J. Macquarrie (Philadelphia: Westminster, 1986), 470472, here 470. [4] Joseph Fletcher uses the term ―indicators of humanhood,‖ J. Fletcher, ―Indicators of Humanhood: A Tentative Profile of Man,‖ in Contemporary Issues in Bioethics, 2nd ed., ed. T. L. Beauchamp, & L. R. Walters, (Belmont, CA: Wadsworth, 1978), 90-93. [5] For the distinction between ontological (descriptive) and moral notions of personhood see L. R. Walters, ―Concepts of Personhood,‖ in Contemporary Issues in Bioethics, 2nd ed., ed. T. L. Beauchamp, & L. R. Walters, (Belmont, CA: Wadsworth, 1978), 87-89. A different way to describe this distinction–descriptive versus normative personhood–is found in Joel Feinberg, ―The Problem of Personhood,‖ in Contemporary Issues in Bioethics, 2nd ed., ed. T.L. Beauchamp and L.R. Walters (Belmont, CA: Wadsworth, 1978). [6] See Walters, ―Concepts of Personhood.‖ [7] For some, even the simple term ―life‖ (as in ―when do you think life begins?‖) is used as a moral equivalent to ―person.‖ [8] Engelhardt, H. T. ―Medicine and the Concept of Person,‖ in Contemporary Issues in Bioethics, 2nd ed., ed. T. L. Beauchamp, & L. R. Walters, (Belmont, CA: Wadsworth, 1978), 94-101, here 94. [9] Singer, P. Animal Liberation, new revised ed. (New York: Avon Books, 1990). [10] This is an allusion to a view of Oliver O'Donovan: ―Personality discloses personhood. It does not constitute it,‖ O. O'Donovan, ―Again: Who Is a Person?‖, in: On Moral Medicine, 2nd ed., ed. S. Lammers and A. Verhey (Grand Rapids: Eerdmans, 1998), 380-386, here 382. [11] The full text of this strongly shortened quotation: ―Human sperm, human ova, human cell cultures, human zygotes, embryos, and fetuses can have value, but they lack the dignity of persons. They are thus, all else being equal, open to socially justifiable experimentation in a way persons in either the strict or the social sense should never be. That is, they can be used as means merely,‖ Engelhardt, ―Medicine and the Concept of a Person,‖ 99. Cf. ―[If] the moral status of the embryo is not that of a person, [...] its use for certain kinds of research can be justified,‖ M.A. Farley, ―Roman Catholic Views on hES Cell Research,‖ in: The Human Embryonic Stem Cell Debate: Science, Ethics, and Public Policy, ed. S. Holland, K. Lebacqz, & L. Zoloth, (Cambridge, MA and London: Bradford and MIT, 2001), 113-118, here 116. [12] Mertes, H., Pennings, G. & VanSteirteghem, A. (2006). ―An Ethical Analysis of Alternative Methods to Obtain Pluripotent Stem Cells without Destroying Embryos,‖ Human Reproduction, 21, 11, 2749-2755.
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[13] According to Dunstan, ―[i]t is to be expected [ ] that those who feel most strongly that the sacredness of human life is under new threat should stake their claim at the highest conceivable point; and, indeed, that despairing of any ―half-way house‖ or defensible intermediate point, should claim ―absolute‖ protection for the human embryo from the moment ―when life begins.‖ Unless a stand is made, no life is safe; whatever experiment or disposal is thought to be expedient will somehow be justified.‖ G.R. Dunstan, ―The Human Embryo in the Western Moral Tradition,‖ in: The Status of the Human Embryo: Perspectives from Moral Tradition, ed. G. R. Dunstan, & M. J. Seller, (London: Oxford University Press, 1988), 39. [14] White, M. What is and Ought to be Done: An Essay on Ethics and Epistemology (New York/ Oxford: Oxford University Press, 1981). [15] Perhaps the second part of Kant's categorical imperative–no mere instrumental use of humans–could be applied to more than persons alone. Making such an extension of Kant is not unproblematic. The most successful arguments in line with Kantianism would probably be that embryos belong to the human species, or that the use of embryos would be bad for our own morality (the argument from pedagogy). To both we will return under the head of the Similarity argument in Section 2.1. [16] Dworkin, Life's Dominion, 76. [17] English, J. ―Abortion and the Concept of a Person,‖ in: Bioethics, ed. R. B. Edwards, & G. C. Graber, (Orlando FL: Harcourt Brace Jovanovich, 1988), 620-627, here 624. English tragically died on the Matterhorn at age 31. [18] English basis this argument partially on John Rawls' Theory of Justice. However, there are doubts as to whether Rawls' construal would support her argument. [19] English, ―Abortion,‖ 625. This argument is essentially a Kantian way to justify the protection of animals. Kant does not argue anywhere that animals should be respected for their own sake. [20] English, ―Abortion,‖ 626. [21] English's account comes close to the ―slippery-slope‖ argument, which holds that doing A is wrong because it will lead to B (which is unacceptable). In the literature, two versions of the slippery slope argument are distinguished: the logical (or conceptual) and the empirical (or factual, or psychological) version. The logical version of the argument holds that once we accept A, rejecting B implies logically contradicting ourselves. The empirical version holds that accepting (or doing) A will (or is likely to) result in the acceptance (or doing) of B, and C, etc., but not by logical implication. English's similarity argument resembles the empirical version. For an analysis of the concept of the slippery slope, cf. D. Lamb, Down the Slippery Slope (London: Croom Helm, 1988), 3. [22] English, ―Abortion,‖ 625. [23] Endenburg, N.(1991). Animals as Companions: Demographic, Motivational, and Ethical Aspects of Companion Animal Ownership (Utrecht: Rijksuniversiteit Utrecht,). [24] English, ―Abortion,‖ 626. She continues: ―This is a degree of resemblance to persons that animals cannot rival.‖ [25] An example of how this may work can be found in the biblical story of Samson. Samson was destined to be a Nazarite; his life was to be fully dedicated to serving Jahwe (Judges 13). Thus, the future destiny of Samson is presented as a given fact.
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[26]
[27]
[28]
[29] [30]
[31] [32]
[33]
[34] [35]
A. Theo Boer Based on this, Samson's mother is commanded not to drink alcohol from the beginning of her pregnancy. Engelhardt rightly makes the following observation: ―[I]f one succeeds in arguing that a fetus or infant has the potentiality to become a person, one has conceded the point that the fetus or infant is not a person,‖ Engelhardt, ―Medicine and the Concept of Person,‖ 96. Langerak, E. A. ―Abortion: Listening to the Middle,‖ in: Bioethics, ed. R. B. Edwards, & G. C. Graber, (Orlando FL: Harcourt Brace Jovanovich, 1988), 591-598, here 593. Margaret Farley, in my opinion, blurs the concepts of actual and potential personhood by defining a person as ―an individualized human entity with the settled inherent potential to become a human being,‖ Farley, “Roman Catholic Views,” 115. An important stage in the development of views on potentiality and continuity was Tertullian's contention: homo est qui est futurus: even a human who is yet to be is a human. The crucial question is: did this ―futurus‖ point to continuity to a future person or to the potentiality to become a person? Despite that he uses the term ―futurus‖ it seems that what he referred to was potentiality. This can be inferred from a parallel that he draws between humans and a seed: ―every fruit is already present in seed.‖ It is the presence of the fruit in the seed rather than the future of the fruit in the seed (Apologia, 9.8). This corresponds to his view called ―transducianism,‖ the belief that the soul derived from the parental seed. Dunstan, ―The Human Embryo,‖ 44. Two lines of argument may be found plausible here. The first is: since these embryos (unfortunately) will never develop into persons, the most respectful thing is to use them for the purpose of enhancing the life prospects for those who do: future persons and existing persons. The second line is: since all these surplus embryos are part of a tragedy or even the result of an outright moral wrong (some may want to use these terms with regard to the intentional creation of considerable numbers of potential but not future persons), destruction is the most respectful thing to do: destruction this does not imply the problematic notion of purely instrumental use. Catholic World News, ―British Cardinal Says Allow Embryos to Die,‖ Catholic World News (31 July 1996). Edwards, R. G. & Puxon, M. (1984). ―Parental Consent over Embryos,‖ Nature, Jul 1925, 310(5974), 179. Sheryl de Lacey argues that altruism and money can very well go together, as can money and informed consent. Procedural requirements may be developed which can prevent involuntary cooperation. S. DeLacey, ―Embryo Research: Is Disclosing Commercial Intent Enough?‖, Human Reproduction, 21, 7, 2006, 1662-1667. Lacey is not alone in favoring a lifting of the ban on commercial trade. Cf. A. Verhey, ―Playing God‖ and Invoking a Perspective, in: On Moral Medicine, 2nd ed., ed. S. Lammers and A. Verhey (Grand Rapids: Eerdmans, 1998), 287-296, esp. 289 about ―playing God etsi deus non daretur.‖ . The Dutch-British professor of Molecular Biology Christine Mummery in a radio discussion with the author. Pope John Paul writes: ―The mere probability that a human person is involved would suffice to justify an absolutely clear prohibition of an intervention aimed at killing a human embryo,‖ John Paul II, Evangelium Vitae [The Gospel of Life] (Vatican City:
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[36] [37]
[38]
[39] [40] [41]
[42]
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The Vatican Press, 1995). Cf. J. Porter, ―Is the Embryo a Person?‖ Commonweal 129 (8 February 2002), 8-10. Cf. Theo A. (2008). Boer, ―Stem Cells, Pluralism, and Moral Empathy,‖ in Ethics and Embryos: Interdisciplinary Perspectives, ed. L. Östnor (Dordrecht: Springer,), 121-34. Some may want to reject the distinction between personhood and humanhood on epistemic grounds. It is hard, if not futile, to define humanhood without reference to personhood. To them, membership of the human species suffices for assuming personhood. For an outstanding analysis of the argument from species, see Der moralische Status menschlicher Embryonen: Pro und contra Spezies-, Kontinuums-, Identitäts- und Potentialitätsargument, ed. G. Damschen, & D. Schönecker, (Berlin: Walter de Gruyter, 2002), 35ff. Perhaps a lack of prospect provides an extra reason for respect, just like we may be especially compassionate with young persons who face a premature death. . Dworkin, Life's Dominion, 75. Dworkin, Life's Dominion, 79. Poplawski and Gillen have identified this feature as ―the concept of longitudinal form‖: apart from the presence or absence of personhood, they argue, development is ―a process whose overall nature may have distinct moral significance.‖ N. Poplawski and G. Gillen, ―Ethics and Embryos,‖ Journal of Medical Ethics, 17, 1991, 62-69, here 63. James, M. (1984). Gustafson, Ethics from a Theocentric Perspective, vol. 1, Ethics and Theology. Chicago: University of Chicago Press, 1981. Vol. 2, Ethics and Theology, Chicago: University of Chicago Press.
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 10
MAPPING A MULTIFACETED RELATIONSHIP: POLITICAL PARTIES AND CIVIL SOCIETY ORGANIZATIONS IN TURKEY Emre Toros Atılım University, Ankara, Turkey
ABSTRACT One of the most significant discussions on democracy today is related about the political parties, civil society organizations (CSOs) and the relationship between them. The importance of this debate is becoming difficult to ignore, since political parties and CSOs are among the most salient institutions that shape the character of the political system in most of the liberal democracies and serve as institutions that establish the primary linkages between citizens and governments. The fundamental intention of this article is to demonstrate and map this relationship within the Turkish setting. This study will follow a critical pattern in order to analyse the situation in Turkey, rather than accepting the concepts intrinsically as valuable. It will utilize the dimensions of the democratization framework for analysis and seeks to address three basic features of this framework: (a) the type of activity that connects a party and CSOs; (b) the strength of the connection (how close or distant and how exclusive or inclusive) and (c) the dominance or direction of influence in the relationship. Although on its own the democratization framework is not enough in explaining the problematic exhaustively, still it provides powerful empirical tools. By manipulating these dimensions with innovative tools and alternative epistemological positions, it is possible to open up new opportunities for further research and enhance the current academic debate in a critical manner. This paper, hence, by utilizing the above mentioned framework will not only focus on the relationships happening at the macro (or political system) level, but also on the relationships that take place at the micro (or organization-to-organization) level.
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INTRODUCTION One of the most significant discussions on democracy today is related about the political parties, civil society organizations (CSOs) and the relationship between them. The importance of this debate is becoming difficult to ignore, since political parties and CSOs are among the most salient institutions that shape the character of the political system in most of the liberal democracies and serve as institutions that establish the primary linkages between citizens and governments. The fundamental intention of this article is to demonstrate and map this relationship within the Turkish setting. The current literature on political parties and civil society display a wide array of conceptualizations. To start with, there is a towering literature on the decline of political parties. Especially among the established democracies, it is argued that political parties are in short of abilities that they commended three of four decades ago (like ideological representation, depth of involvement etc.) (Linz, 1992). Moreover, it is proven that in both developed and underdeveloped countries, the party membership is shrinking (Mair & van Biezen, 2001); parties, as intermediary institutions between the society and the state, cannot handle a decisive role in political socialisation as they used to; and less able to attach the masses to the democratic processes. This ―unfortunate‖ pattern on political parties contrasts with the ―fortunate‖ character of the concept of civil society. As an obese concept, civil society is more and more used as a readymade solution for the problems of democracy. As the ―big idea‖ in democratic politics (Edwards, 2004), the free, active and diverse civil society fosters the communicative interaction (Young, 2002); opens up the ways for new kinds of democratic representation via social movements (Ibarra, 2003); and has the power to create a diverse public sphere which re-legitimates the principles of democracy, based on a rational and dialogic discussion in the decent society (Benhabib, 1996). Predominantly built on this literature, there is another category which tries to formulate relationship between political parties and civil society especially within the framework of democratization (Diamond, 1999; Diamond & Gunther, 2001; Morlino, 1998; Thomas, 2001). However, mainly based on the above-mentioned literature, scholars also provided some alternative options for understanding these concepts. For example, when political parties are in question Daalder (2002) aptly argues that the current developments related to political parties are better understood as one of change than one of unconditional decline. Pointing the same issue nearly one decade before Katz and Mair (1995) suggested that the decline and/or failure of parties is ―largely misconceived‖ and formulated the cartel party description. This description was formularized for the parties that operate in established democracies, where parties have been able to compensate this loss through a retrenchment in the state and increasing reliance on its resources. For civil society, similarly, questioning the assumed democratizing qualities of the concept, there is an alternative line. During the last four or five decades civil society produced a diversified set of organizations and political positions. This should be perceived as normal since civil society is a multilayered ground populated by national, cultural, ethnic, religious and gender groups. However the ideas and interactions produced both within and among these diverge groups immigrants‘ and foreign workers‘ communities, fundamentalist associations, new age groups, neo-fascist and anti-immigrant organizations among the it would be misleading to assume that only democratic values will take root within this ground. It is a multilayered arena – inhabited by new social movements,
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nongovernmental organizations, international bodies and local communities, encompassing new political styles and building new institutions. This study will follow the latter critical pattern in order to analyse the situation in Turkey, rather than accepting the concepts intrinsically as valuable. It will utilize the dimensions of the democratization framework for analysis and seeks to address three basic features of this framework: (a) the type of activity that connects a party and CSOs; (b) the strength of the connection (how close or distant and how exclusive or inclusive) and (c) the dominance or direction of influence in the relationship. Although on its own the democratization framework is not enough in explaining the problematic exhaustively, still it provides powerful empirical tools. By manipulating these dimensions with innovative tools and alternative epistemological positions, it is possible to open up new opportunities for further research and enhance the current academic debate in a critical manner. This paper, hence, by utilizing the above mentioned framework will not only focus on the relationships happening at the macro (or political system) level, but also on the relationships that take place at the micro (or organization-to-organization) level.
DEFINITIONS AND PLACING THE DISCUSSION IN THE TURKISH SETTING Although a variety of definitions of political parties and CSOs have been provided by the academic literature, a comprehensive discussion of these definitions is not within the scope of this study. What is needed here, rather, is an operational definition of the concepts in question which will provide basis for empirical research. Hence, this study will utilize the following definition of civil society: an intermediate associational realm between state and family populated by organizations which are separate from the state, enjoy autonomy in relation to the state, and are formed voluntarily by members of society to protect or extend their interests or values (White G. , 1994, p. 379). Similarly a political party is understood as an ―organization that pursues the goal of placing its avowed representatives in government positions‖ (Janda, 1993, p. 166).
On Civil Society in Turkey A number of students on Turkish political structure persuasively argued that there is an ―omnipotent state‖ that shapes both the society and the political system within the OttomanTurkish continuum (Toros, 2007; Heper, 1985; Özbudun, 2000). However with the help of historical developments that took place especially after the transition to multiparty politics in 1946, spaces for associational activity and pluralist politics expanded against the Turkish state. According to Toprak (1996, pp. 90-91) the thirty year period between 1950 and 1980 was characterized by the struggles to set the systems for party politics and democratic procedures, guarantee the civil rights and legitimize the civil associations. Following these decades especially during 1980s, the relatively free environment created by economic liberal policies, affected the state society relationship in Turkey. The policies of economic liberalism first reduced the role of state within the economic sphere and following that these effects
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were spilled over to the cultural and social spheres and hence helped to the reformation of civil society in Turkey. In consequence, discussions on civil society during 1990s revolved around notion‘s relationship with other concepts like citizenship, secularism, liberal economic policies, voluntarism, consensus vs. conflict, and ethnicity and democratic maturation. Authors like Keyman and İçduygu (2003), focused on the formulation of citizenship in the Turkish context and underlined its characteristics as a product of the Kemalist modernization project. Since the Kemalist reforms foresaw a) a societal model based on homogeneity and uniformity and b) a citizenship model based on duties rather than rights, the citizen as a subject of political inquiry evolved in a different way. Hence this approach highlights the defective character of citizenship in Turkey by referring to the connection of the citizen with the state. Since democracy and democratic amelioration necessitates autonomous individuals organized under civil societal organizations, this situation affected the development of civil society in Turkey in an atypical way. Then again, the post 1980 era anatomized in an alternative way by a number of scholars. For example Navaro-Yasin (1998, p. 59) argues that the above-described developments took place only at the discourse level. According to him, after 1980 coup there was a need for a ―space‖ which should ―demonstrate‖ independent features from the state and accordingly state ―discovered‖ the idea of civil society. By this way, state managed to produce and reproduce the official ideology outside of its own boundaries. Unquestionably, organizations that are concerned only with the fabrication of official ideology of state, might have limited chance for the development of democracy. With a different perspective, Sarıbay explains the expanded interest in civil society in Turkey with a rising demand for the establishment of western institutions for the sake of protection of the individual against state. Thus, civil society as one of these western institutions was perceived as a magic tool for democratization by every political formulation. Sarıbay argues that this situation resulted in a new political attitude in Turkey that may be called as ―civil societism‖ since the notion was practised without giving priority to the social and/or political reality depicted by it (Sarıbay, 1998, p. 96). Hence the lip service paid to the civil society was not helpful at all for creating values like democracy, tolerance etc. under the dominance of Islamic social structures and/or dominant political ideologies. Ersin Kalaycıoğlu focuses on another dimension of the subject in question and elaborates the ―quality‖ of civil society organizations in Turkey. According to Kalaycıoğlu (1998, p. 121) since traditional orientations and unwritten practices became dominant during the post 1980 period, religious organizations like tarikats were accepted and diffused on a wider scale. Author labels this structure as ―neopatrimonalism‖ which is a new form of patrimonialism, referring to a situation where strong primordial values triumphs over modern political structures with a strong state and weak civil society. Furthermore he refers to the rate of memberships to associations in Turkey and states that the 10 percent rate in Turkey is well under the levels of developed countries an concludes his arguments by referring to the problems related to the existence of independent judiciary and neo-patrimonial political culture that hinders the development of strong civil society (Kalaycıoğlu, 1998, p. 133). From the expostulations above one may conclude that the formation of civil society in the Turkish context initiated on incongruous grounds resulting from both political and social systems. Nonetheless, this situation started to evolve intermittently especially with the modernization movement that took place in the late Ottoman and early republican period. The
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augmentation related to civil society continued and accelerated especially during the last two decades and civil society became an area of investigation. So the whole picture displays a duality where traditional structures and pressures on these structures co-exist together when civil society in Turkey is concerned.
On Turkish Political Parties and Party System It would not be wrong to argue that since from the early years of the republic, Turkish politics is heavily under the influence of political parties. Frey, while analysing the Turkish political structure during 1950s wrote that the Turkish politics, then being anything else, is party politics (Frey, 1965, pp. 301-303). One point to mention here is at its developmental phase, the dominant elitist character of Turkish politics started to influence the party formation and politics (Sayarı, 1978, p. 41). During this initial stage, through the clientelist mechanisms the Turkish political parties were heavily shaped by the elite conflicts (Özbudun, Turkey: The Politics of Political Clientelism, 1981, pp. 258-265). When accompanied by continuous social change and unstable economic conditions, this tight grip of elites over the party politics endured and clientelism has become a prominent structural feature of Turkish party politics (Özbudun, 2001, p. 246). Military interventions also influenced the developmental pattern of party politics in a great deal (Çarkoğlu, 1998, p. 546). Since habitual coups muddled the processes of political socialization of Turkish citizens, when party politics concerned, they resulted in high level of volatility among voters. Instead of stable and consistent party choices, short term interest based party preferences dominated the electoral history of Turkish politics (Kalaycıoğlu, Ersin; Çarkoğlu, Ali;, 2006, pp. 23-42). Besides volatility two other dominant characteristics is visible about the Turkish party politics: fragmentation and ideological polarization (Özbudun, 2001; Çarkoğlu, 1998; Özbudun, 1981). Moreover, the Turkish political system displays a vivid ideological variety which affects the political parties of the country. Combined with the high degree of volatility central parties were swept away by voters in favour of more extremist parties with Islamic and nationalist agendas during the last two decades. Such kind of developments proves that the structural features of Turkish political parties reproduce themselves and continue to be salient. One important comment on the Turkish party system beyond these characteristics came from Özbudun (2001, p. 260) stating that in Turkey, different than the European parties, political parties leaped from elite-based cadre party model to catch-all model without passing through a mass party phase. This seems quite important since, as I will discuss in detail below, the structural features of elite based clientelistic model is endured and became the main feature of Turkish political parties. This feature, while shaping the functioning of the political parties in Turkey today, also contours their relationship with civil society.
METHOD AND SAMPLE Based on the above theoretical framework, qualitative research strategy was employed for the analysis of the problematic. Although a pre-defined framework was utilized, this
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skeleton was also used for the improvement of the frameworks mentioned within the literature. Hence, the research was still open to form an inductive view of the relationship between theory and research, whereby the former is generated by the latter. Additionally interpretivist epistemology meaning in the sense that the problematic was studied through an analysis of the interpretation of that world by its participants; and a constructionist ontological position was utilized which implies that social properties are outcomes of the interactions between individuals. The data for this study was collected by semi-structured interviews that were carried out with party and CSO representatives. The field work was carried out during October, November and December 2008. The sample was a convenient one and consisted of 4 political party and 8 CSO representatives. As the sample for political parties, the ones that have more than 20 seats in Turkish Grand National Assembly were chosen (Justice and Development Party, Republican Peoples Party, Nationalist Action Party, and Democratic Society Party). According to the Turkish laws the parties that have more than 20 seats are allowed to form groups and send representatives to the legislative committees. Additionally the respondents within these political parties were chosen among the MPs and executives who are responsible for party‘s relations with CSOs. The sample for CSOs, on the other hand, looked for diversity and popularity. Accordingly 8 CSOs were chosen including business associations, human right organizations, labour unions, occupational groups, religious umbrella organizations and issue oriented associations. 6 out of 8 respondents of CSOs were chairpersons and the other two were members of the executive committees. Each interview took around one hour. Although the interviews were guided by questions prepared in advance, the respondents were let free to add their opinions and additional comments. All interviews were recorded with the permission of the respondents and recordings were transcribed into computerized text files. All of the interview transcripts were read by the researcher and coded to the pre defined categories of (a) the type of activity that connects a party and a CSO; (b) the strength of the connection (how close or distant and how exclusive or inclusive) (c) the dominance or direction of influence in the relationship. (Occasional Paper Series, 2004) Nvivo software package were used for coding and analysis.
FINDINGS a. Type of Activity Connecting Political Parties and CSOs Below I will comment on the types of activities that connect political parties and CSOs in the Turkish setting. These activities were grouped under the headings of lobbying, information providing, training, CSOs as springboards, providing resources and voter mobilization.
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Lobbying: One common activity of a CSO is to carry lobbying activities on political parties in order to raise its specific policy demands. While most of the CSOs advocate particular substantive issues only a few has the power to press on for legislation that directly affects political parties. The activities of CSOs mainly take place within the areas of electoral regulations, campaign finance reform, and decentralization. When lobbying is concerned the respondents from political parties stated that frequently they face lobbying activities from CSOs. However they also state that distinct kind of CSOs, like business organizations, are more powerful in these activities. When the reasons for this situation were asked they put forward the organizational capabilities of these business organizations. At the same time, however, respondents also admitted that they have an inclination to refuse these group-specific activities since as political parties they tend to catch all interest rather than a specific group. Additionally if the lobbying activity spills out to the political sphere, rather than concentrating on specific policy areas, political parties usually do not take these demands into consideration. CSOs, on the other hand, display diversity on lobbying activities. Although all of the respondents accepted lobbying as one of the crucial mechanism for affecting policies, most of the time they perceive lobbying as an inefficient way to influence the political mechanism. Information providing: Commonly CSOs, where suitable grounds available, provide information on issues and even policy position. Among the political parties researched, only respondent from Justice and Development Party stated that they have a policy to check the information provided by CSOs. This situation was also ratified by CSOs interviewed: 7 of 8 respondents complained about the apathy of political parties to their reports. (Only the CSO which is a business association stated that their opinions were frequently asked by governmental bodies). Another two important points appears up to be important from the findings. First one is related to the international dimension. The CSOs that work on the issues of human rights stated that their reports are taken more seriously at the international area than in Turkey. More interestingly, when their reports find place among the international publications, they add, suddenly the officials change their attitudes and try to refer to these reports in their policies. The second one is related to reports that focus on issues on micro administrative levels, like municipalities. The CSOs interviewed stated that local governments seem to be more respondent than the central government to the reports provided by CSOs. Other findings also support the idea that CSOs are more effective at local level than they are at the centre. Training: During their contacts with political parties CSOs may provide training to political party members, candidates and activists on a variety of topics ranging from campaigning to legislative procedures. From the research data it is possible to conclude that the CSOs which, provide such kind of training, focus on the youth and women members of political parties rather than the executives. Additionally during the interviews none of the political parties refer to any kind training activities provided by CSOs. CSOs as springboards: Sometimes, CSOs may produce opportunities for individuals who want to become party candidates, or vice-versa they may provide a temporary home for out-of-office politicians. In countries like Turkey where political parties are hierarchically organized or advancement through political parties is limited, CSOs may serve as centres for
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―mobility formation‖ for politically ambitious candidates. When asked, all of the respondents from political parties approved ―utilizing‖ the CSOs as springboards. Indeed, in Turkey it is quite common to see the former CSO representatives as MPs. The CSO representatives interviewed, on the other hand, disapprove this attitude and complained about the former CSO executives who were elected as MPs. They blamed the former CSO executives for forgetting the place that once they were and ignoring the demands of civil society after the elections. This point seems quite important and will be dealt in detail in the discussion section below. Resources: CSOs may provide direct and indirect resources to a party behind the closed doors and beyond exposure, in exchange for a promise of party support. These include endorsement, money, and materials and alike. The party representatives interviewed, confessed that they use the resources of civil society organizations but they neither detailed the quality nor quantity of the help they receive. CSO representatives displayed a similar attitude and stated that their organization does not provide support to political parties in that sense but some others do. So although accepting such kind of a connection CSO representatives tend to externalize this connection. Voter mobilization: CSOs may mobilize voters for political parties. Once a CSO has backed a political party, it may, for example, hold internal meetings at which members are encouraged to get out the vote for that party. Groups can also maintain and mobilize voters between elections by providing services to constituents on behalf of political parties. It seems that this function is important for political parties. All of the party representatives mentioned that, they especially concentrate on women and youth for voter mobilization and gave special importance to this connection. CSOs, on the other hand, declared different positions on this issue. Although some of them ban their members to be active in that sense within the CSOs, some openly declare the support for a particular political party.
b. The Closeness and Exclusiveness of Relationships The closeness of the relationship between CSOs and political parties and its density also seems to be an important variable for the issue in question. Some CSOs may choose not to be involved in politics. This may be due to the activity area of CSOs which does not require any kind of political action. However, some others although engage in political activities, may still refrain from setting close contact with political parties. By this way they will be freed from being marked as ―partisan groups‖ and accordingly avoid from acting within the area of ―dirty politics.‖ When political parties concerned it seems that although they want to utilize the sources of CSOs, they have a tendency to keep them away from the decision making processes. CSOs seem more demanding on this issue. Although they want to keep their independence, at the same time they want to be more effective in policy making. They perceive the issue of independence as the vital characteristic of a CSO. This position is valid for all CSOs interviewed regardless of their organizational types and issues.
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c. The Course of Influence Not but not least the direction/course of influence appears up to be an important variable within the relationship in question. Political parties may be more under the influence of some CSOs than others depending mainly on the political setting. Thus business or farmers groups may be more influential than women‘s, consumers‘ or environmentalist groups. Similarly, within one type of CSO, like unions, some groups may be more autonomous of political parties than others, even within one country. The party may also be more powerful than any interest group. The Turkish case suggests the latter position. It seems that political parties in Turkey have an inclination to have a ―pressure-free‖ environment, where they can utilize the civil society organizations but not be affected by them. Instead of perceiving CSOs as partners in the decision making process political parties in Turkey try to dominate and exploit the resources produced by the CSOs. CSO representatives produced similar comments and underlined the desire of political parties to influence the internal mechanisms of CSOs, especially the election processes. However, CSO representatives also mentioned nowadays this desire of political parties is not welcomed by the CSOs, and most of them prefer to establish a distant relationship with all of the political parties. By this way, they hope, the established course of relationship from political parties will be reversed.
DISCUSSION The recent literature puts an emphasis on parties‘ tendency to dominate civil society when their relationship is concerned. Accordingly, political parties‘ strategies include penetration (Schmitter, 1993), bonding (Yishai, 2001) and even occupying (Farrel, Ignazi, & Römmele, 2005, p. 26) civil society. Yet, it is hard to label these strategies as participatory and/or policy responsive. The connections take place in a different level, which is based on remuneration and where civil society provides electoral benefits (Farrel, Ignazi, & Römmele, 2005). Surely that is far from the more organic participatory nature of the mass party idealtype (Lawson, 1980). More interestingly CSOs may absorb and digest such kind of strategies, on the condition that they enjoy access to state resources and become more visible in policymaking mechanisms. The findings suggest that, the relationship between political parties and CSOs in Turkey falls into the above categorization. As referred in the introduction, among others, one of the key concepts that is useful for understanding the Turkish party politics, has always been clientelism. Basically, clientelism is a form of two-way exchange, which is typically characterized by a sense of ―uncomfortable responsibility‖, and asymmetrical power relations between the ones involved (Roniger, 1994; Piattoni, 2001). The basics of this asymmetric relationship rest on both client and patron, where client reciprocates the support of patron with a combination of economic goods and services and social acts of deference and loyalty (Mason, 1986, p. 489). Since the concept of clientelism is widely used and referred to in very different contexts, it is open to conceptual stretching (Piattoni, 2001). Based on these definitions studies after 1960s have suggested the emergence of a ‗new clientelism‘ (Weingrod, 1968), in which political behaviour is still
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characterized by patterns of exchange, but in an alternative way. Geographical mobility, rapid urbanization, increased levels of education, industrial development weakened traditional patron-client ties, which opened up the way for new forms of exchange. As a result organized political parties, with their bureaucratized mechanisms, replaced the traditional structure. For explaining this change in the Turkish context, an illuminating case study was provided by Güneş-Ayata (1994, pp. 49-63) where author focuses on the evolution of the traditional dyadic form of patron client relationship to clientelistic brokerage type carried by political parties. Grasping the discussion from this point, I would suggest a new term, civil clientelism, as the new form of the concept, which, I think, may be useful for understanding the relations of political parties with civil society in Turkey. Contemporary clientelistic exchange is not limited to face-to-face contacts but may also be based on group relations (Hopkin, 2006). Below I will try to formulize the components of the term civil clientelism. Above-mentioned findings suggest that political parties in Turkey, when their relationship with CSOs concerned, mainly prioritize the issues that are related to electoral activities. As mentioned above, approval and common usage of CSOs as springboards and utilizing their resources for reaching to segments of society by political parties supports this argument. Interestingly, however, political parties in Turkey prefer to carry such kind of partnership in informal/traditional manners. When their relationship with CSOs questioned on electoral matters, one party representative stated that: ―I cannot openly answer that question but I can say that there is no political party in Turkey which do not receive such kind of support. However it will not be appropriate to reveal the names of the organizations here...‖
In Turkey during the 1970s party organizations worked among the new ethnic, occupational and neighbourhood communities that were formed in the cities in order to reproduce the previously created patron-client links. (Güneş-Ayata, 1994, p. 55). As these communities organized in alternative ways and transferred themselves into CSOs during the years, they have become the new vote-banks and/or brokerage agents of political parties. Currently CSOs seems as a fruitful arena for political parties for the establishment and reproduction of these new patron client links. This is due to a number of structural factors of political parties and civil society in Turkey. As mentioned in the introduction, in Turkey political parties during their evolution from cadre party model to catch-all party model did not experience the mass party phase (Özbudun, 2001, p. 250). The mass parties that are characterized by large base of members which are both active during and intra-election periods try to penetrate a number of spheres of social life mainly through organized interests (Diamond & Gunther, 2001, p. 16). The absence of this phase contributed to the lingering of vertical clientelistic networks and machine-type politics which explains the lack of horizontal loyalties of political parties in Turkey (Özbudun, 2001, p. 246). Political parties instead of trying to establish the horizontal ties with civil society, preferred to stay autonomous from civil society. Research findings also confirm this stance. Political party representatives responded to the related questions as follows: ―CSOs may only be manipulative in politics, but not decisive.... Acting completely together with CSOs will lead us to the chaos that Turkey has experienced during 1970s.‖
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―Today CSOs in Turkey have problems related to reliability... Cooperation is possible but it has to be in a limited manner‖ ―CSOs in Turkey have a tendency to involve in politics more than the desired level. Surely this is not acceptable. Although they are important in producing ideas about their expertise area, they should remain within this sphere instead of involving in politics.‖
At this point it may be fruitful to check the features of civil society in Turkey in order to search its linkages with civil clientelism and support my argument. One argument on civil society in Turkey aptly states that CSOs in Turkey based themselves on mutual trust and interpersonal obligation rather than on individualistic contractual memberships (White J. , 2002). Thus the structure of civil society in Turkey does not reflect the ―ideal type‖ civil society which is an active stakeholder of politics based on group interests. On the contrary, because of this structural feature, CSOs have always been among the arenas suitable for producing and reproducing the clientelistic features. Within that framework, not surprisingly for CSOs connections with political parties are perceived as valuable chances to reach and control the state resources. Thus, CSOs‘ leaders and/or candidates do not hesitate to display their connection with political parties, especially when these parties are represented at the national assembly. CSO representatives interviewed stated the following ideas related to this point: ―All of the political parties directly involve in the electoral processes of CSOs. They do lobbying within CSOs and spend money where necessary‖ ―They (political parties) attend to the meetings of CSOs when it is related with elections. Usually they don‘t. But when it is related to election they attend to the meetings for displaying their support to particular candidates so that in return they can reach to the members of the CSOs.
The connection mentioned above, however, rarely works in favour of the CSOs as political clients. Once these resources are under control, parties and ―adopted leaders‖ of CSOs have a tendency to neglect the interests of their clientele. This practice was also vocalized by the CSO representatives interviewed: ―We have MPs who were once members of CSOs, both from right and left. But once they are elected, they think that their responsibility, as a CSO representative, ends. But this has to be reversed: Since this MP knows the problems and solutions better than anyone else, s/he has to work harder.‖
Moreover, when this new form of clientelism starts to function, political parties have a tendency to perceive all of the CSOs on a common ground, regardless of their foci and organizational capabilities. Although political party representatives accept the fact that some CSOs are more powerful than others when the components of civil clientelism are functioning, findings do not display significant differences among the attitudes to CSOs. Hence from the discussion above it will not be wrong to conclude that political parties in Turkey today have a tendency to sustain their established clientelist tradition by utilizing the channels that are offered by CSOs. This disposition may be categorized under the term civil clientelism, where political parties perceive CSOs as by-organizations in order to reach the voters and prioritize only the electoral activities CSOs‟. At the same time they are reluctant to
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establish horizontal ties with CSOs where CSOs are perceived as shareholders of democratic process. However above conclusion does not reflect the whole picture. Beyond the findings mentioned in the previous paragraphs related to political parties, this research also highlighted a number of interesting points about CSOs in Turkey. Although surrounded by traditional structural features, it seems that Turkish CSOs at the same time search alternative ways of being more effective within the decision making processes. This search seems in accord with the project of ―critical scepticism‖ of post-modern era where the central, state-centred and one-dimensional solutions for global problems are criticized (Keyman, 2000). In accordance with that, starting especially by late 1990s, CSOs are being active especially in a number of areas in Turkey. To start with, by acting as agenda-setters and by trying to initiate policies, civil society organizations in Turkey raise the issues that the governing elites try to avoid. Especially during 1990s, civil society in Turkey was clearly successful in raising issues such as human rights problems onto the political agenda by publishing reports. On this subject one CSO representative stated that: ―Rather than local authorities our reports are taken seriously especially by international organizations like the EU.‖
Indeed, in Turkey CSOs became more and more visible through their reports. This is quite important since based on this proposition it may be argued that, although indirectly, CSOs in Turkey started to act as agenda setters. Moreover, by working as a government counterpart, civil society injects its experience into policy areas such as health, education, and housing. Civil society organizations, compared to state bodies, have a greater chance of being more efficient; have more knowledge; and have better local contacts. Additionally, by being a source of education, a number of civil society organizations in Turkey are involved in the project of educating the citizens in different areas. The educational function of civil society is especially significant since through this channel, democratic values and ideas find ways to establish themselves among the citizens. Last but not least, by being a source for new political alternatives, civil society organizations that have the aim of triggering new political movements and identifying the potential leaders have become increasingly visible in Turkey (Toros, 2007).
CONCLUSION This article tried to display the relationship of political parties with CSOs within the Turkish setting by utilizing the democratization framework. One common fact is after 1990s although Turkey started to have a comparatively strong and independent civil society than it previously enjoyed, CSOs in Turkey still remain relatively weak and has developed far less than hoped or expected when compared to European counterparts. Although it is argued that the stability for a democratic system is dependent on the existence of a vibrant civil society, as this study show, civil society can play only a limited role in the process democratic functioning for the Turkish case. Although, civil society can contribute to democratic development by being a countervailing power it is important to note that only as long as civil
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society organizations have a commitment to democracy will they advocate a democratic orientation of the reforms. One particularly challenging feature, as this empirical study illustrates, is in practice, the formal structures can co-exist with authoritarian traditions, e.g. clientelism. Hence, it would not wrong to argue that for the Turkish case there is a gap between formal democratic structures and informal practices. This problem clearly needs to be examined, and one challenge is to develop the appropriate methodological tools which this study tried to do. It may be concluded that in the Turkish context the political parties have an important responsibility within the existing situation. Political parties instead of perceiving CSOs as equals within the sphere of politics, tend to sustain and reproduce their traditional structures based on clientelism. While doing so they adopt themselves to new tools and mechanisms which may be conceptualized under the term of civil-clientelism. The question of whether this situation is typical to Turkish context with its a-typical civil society tradition and/or the employment of the term civil clientelism in different contexts needs further research. However there is still room to be optimistic about the civil society in Turkey. Although in a limited manner they manage to influence the sphere of politics by a number of activities including publication of reports and education providing. Additionally by acting as agendasetters and by trying to initiate policies, civil society organizations in Turkey raise the issues that the governing elites try to avoid, including the political parties. Moreover CSOs especially after 1990s started to inject their experience into policy areas such as health, education, and housing. Last but not least, by being a source for new political alternatives, civil society organizations that have the aim of triggering new political movements. As a final point, for this particular case, even though there is a very long way to go, it seems that the enthusiastic attitudes on the side of CSOs in Turkey will open up the channels for a more pluralistic democracy, which will stipulate a more institutionalized democratic system.
ACKNOWLEDGMENTS Author is grateful to Ergun Özbudun and Ayşe Ayata for their valuable comments.
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Diamond, L. & Gunther, R. (2001). Political Parties and Democracy. (L. Diamond, & R. Gunther, Eds.) Baltimore and London: The Johns Hopkins University Press. Edwards, M. (2004). Civil Society. Cambridge: Polity. Farrel, D., Ignazi, P. & Römmele, A. (2005). The Prevalence of Linkage by Reward in Contemporary Parties. In D., Farrel, P. Ignazi, & A. Roemmele, (Eds.), Political Parties and Political Systems: The concept of linkage revisited (17-36). New York: Praeger Publications. Frey, F. W. (1965). The Turkish Political Elite. Cambridge: The MIT Press. Güneş-Ayata, A. (1994). Roots and Trends of Clientelism in Turkey. In L. Roniger, & A. Güneş-Ayata, (Eds.), Democracy, Clientelism and Civil Society, (49-63). London: Lynne Reinner. Heper, M. (1985). The State Tradition in Turkey. Walkington: The Eothen Press. Hopkin, J. (2006). Clientelism and Party Politics. In R. S. Katz, & B. Crotty, (Eds.), Handbook of Party Politics, (406-421). London: Sage. Ibarra, P. (2003). Social Movements and Democracy. New York: Palgrave. Janda, K. (1993). Comparative Political Parties: Research and Theory. In A. W. Finifter, (Ed.), Political Science: The State of the Discipline II (163-191). Washington, DC: American Political Science Association. Kalaycıoğlu, E. (1998). Sivil Toplum ve Neopatrimonyal Siyaset. In A. Y. Saribay, & F. Keyman, (Eds.), Kuresellesme, Sivil Toplum ve Islam (111-135). Ankara: Vadi Yayınları. Kalaycıoğlu, Ersin; Çarkoğlu, Ali;. (2006). Turkish Democracy Today: Elections, Protest and Stability in an Islamic Society. London: I. B. Tauris. Katz, R. & Mair, P. (1995). Changing Models of Party Organisation: The Emergence of the Cartel Party. Party Politics, 5-28. Keyman, F. (2000). Türkiye ve Radikal Demokrasi: Geç Modern Zamanlarda Siyaset ve Demokratik Yönetim. İstanbul: Alfa Yayınları. Keyman, F. & İçduygu, A. (2003). Globalization, Civil Society and Citizenship in Turkey: Actors, Boundaries and Discourses. Citizenship Studies, 7(2), 217-232. Lawson, K. (1980). Political parties and linkage: a comparative perspective. New Haven: Yale University Press. Linz, J. (1992). Change and Continuity in the Nature of Contemporary Democracies. In G. Marks, & L. Diamond, (Eds.), Reexamining Democracy: Essays in Honor of Seymour Martin Lipset, (182-190). Newbury Park: Sage. Mair, P. & van Biezen, I. (2001). Party Membership in Twenty European Democracies, 19802000. Party Politics, 5-21. Mason, D. (1986). The Breakdown of Clientelism in El Salvador. Comparative Political Studies, 18, 487-518. Morlino, L. (1998). Democracy Between Consolidation and Crises. New York: Oxford University Press. Navaro-Yasin, Y. (1998). Bir İktidar Söylemi Olarak ‗Sivil Toplum‘. Birikim, 57-62. Occasional Paper Series. (2004, March). Civil Society Groups and Political Parties- U.S. Agency for International Development - U.S. Agency for International Development. Özbudun, E. (2000). Contemporary Turkish Poltics. London: Lynne Rienner Publishers. Özbudun, E. (2001). The Institutional Decline of Parties in Turkey. In L. Diamond, & R. Gunther, (Eds.), Political Parties and Democracy, (239-265). London: The Johns Hopkins University Press.
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Özbudun, E. (1981). The Turkish Party Sysytem: Institutionalization, Polarization, and Fragmentation. Middle Eastern Studies, 17 (April 1981), 228-240. Özbudun, E. (1981). Turkey: The Politics of Political Clientelism. In S. Eisenstadt, & R. Lemarchand, (Eds.), Political Clientelism, Patronage and Development (249-268). London: Sage Publications. Piattoni, S. (2001). Clientelism in Historical and Comparative Perspective. In S. Piattoni, (Ed.), Clientelism, Interests, and Democratic Representation (1-30). Cambridge: Cambridge University Press. Roniger, L. (1994). The Comperative Study of Clientelism and the Changing Nature of Civil Societyin the Contemporary World. In L. Roniger, & A. Güneş-Ayata, (Eds.), Democracy, Clientelism and Civil Society (1-17). London: Lynne Reinner. Sarıbay, A. Y. (1998). Türkiye‘de Demokrasi ve Sivil Toplum. In A. Y. Sarıbay, & F. Keyman, (Eds.), Küreselleşme, Sivil Toplum ve İslam (88-110). Istanbul: Vadi Yayınlar. Sayarı, S. (1978). The Turkish party system in transition. Government and Opposition, 12, 39-57. Schmitter, P. (1993, September). Some Propositions about Civil Society and the Consolidation of Democracy. Forschungsberichte/Research Memoranda Reihe Politikwissenschaft/Political Science Series, 14. Thomas, C. S. (2001). Political Parties and Interest Groups: Shaping Democratic Governance. (C. S. Thomas, Ed.) Boulder: Lynne Rienner. Toprak, B. (1996). Civil Society in Turkey In . In R. A. Norton, (Ed.), Civil Society in the Middle East. (87-118). Leiden: E. J. Brill. Toros, E. (2007). Understanding the Role of Civil Society as an Agent for Democratic Consolidation: The Turkish Case. Turkish Studies, 8(3), 395-415. Weingrod, A. (1968). Patrons, Patronage and Political Parties. Comparative Studies in Society and History, 377-400. White, G. (1994). Civil Society, Democratization and Development (I): Clearing the Analytical Ground. Democratization, 1(3), 375-390. White, J. (2002). Islamist Mobilization in Turkey. London: University of Washington Press. Yishai, Y. (2001). Bringing Society Back in: Post-Cartel Parties in Israel. Party Politics, 7(6), 667-687. Young, I. M. (2002). Inclusion and Democracy. Oxford, p. 188-9. Oxford: Oxford University Press.
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 11
SOCIALITY IN THE CITY: USING BIOLOGICAL PRINCIPLES TO EXPLORE THE RELATIONSHIP BETWEEN HIGH POPULATION DENSITY AND SOCIAL BEHAVIOR Daniel Tumminelli O’Brien* Department of Biology, Binghamton University, Binghamton, New York, USA
ABSTRACT Cities represent settlements with population densities that are unprecedented in human history. While such levels of population density can intensify competition for resources, the abundance of conspecifics also heightens their value to each other as resources. In our species, this can alter the optimal behavioral strategy for social interaction. The exploitation of cooperators provides the actor with an advantage, while damaging conspecifics, doubly enhancing one‘s relative fitness. This same model can be seen in species that have cannibal morphs that develop only in the context of high population density. The effect of population density on humans has been studied by two groups, social psychologists and sociologists. These literatures combine to demonstrate that population density causes people to be psychologically aloof, while also being socially removed from many of their neighbors. The strength of social control mechanisms rests in their ability to deter undesirable behavior, and the inclination that individuals have towards these behaviors. Population density appears to exacerbate both of these, creating a context that both harbors and breeds self-centered behavior. We synthesize the theories of these two disciplines, providing new evidence that shows that population density not only creates detached social behaviors, but socially aggressive ones.
Keywords: Urban social behavior; Prosociality; Population Density; Social disorganization theory; Systems overload hypothesis * Corresponding author: Email:
[email protected]
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Cities are currently home to over 50% of the world‘s population. This may seem high, but not overly surprising to most people reading this chapter, as they will predominantly hail from North America or Europe, where over 70% of the population is clustered in urban areas (defined as settlements of 50,000 inhabitants or more; United Nations 2007). What should be more striking is the speed at which this transition is occurring. As of 1800, only 3% of the world‘s population lived in cities, with the majority of the rest residing in agricultural societies. The technological advances that enabled the industrial revolution, however, have catalyzed a marked shift towards urbanization since the 19th century. Although this process is seemingly ―complete‖ in those countries that were the first to experience this transition, like the United States and Britain, it is continuing at full speed (some argue faster, in fact; see Moreno and Warah 2007) on the more rural continents of Asia and Africa. In turn, the United Nations believes that by 2050 the proportion of human beings living in urban areas will rise from around 50% to 70%. With cities rapidly becoming our native ecology, it is important to consider how our evolved psychology may be interacting with this unfamiliar setting. In particular, elevated population density may make competition for resources more apparent. Even if resources are ample, it does not seem unreasonable to believe that consistent interaction with unrelated conspecifics will activate one‘s focus on outcompeting one‘s neighbors. There are crossspecies variations in ―natural‖ population densities, and a species‘ social adaptations are appropriately calibrated with this. There is no reason to believe this is the case for urban living, however, being that our social adaptations probably arose in a very different context. Moreover, the rural-to-urban transition has occurred so quickly and recently that natural selection has probably had little opportunity to adjust individual psychology to these modern conditions. If this assumption stands, the majority of the world‘s population is living in settings that have the potential to promote aggressive, self-oriented behaviors. Ironically, a region with high population density is only functionally sustainable if such behaviors are limited, and interactions are characterized by civility, if not outright prosociality. This paradox proposes a sizable challenge to a city like New York, whose neighborhoods are anywhere from 10 to 25 times as dense as the rural areas that lie beyond its suburbs. Researchers have explored the relationship between social behavior and population density in multiple species, including our own, and the conclusion has been unanimous: as density increases, individuals are indeed less likely to exhibit prosociality and more likely to be antisocial (i.e. aggressive). These results come from independent work in the disciplines of biology, social psychology, and sociology, and there has been little to no cross-talk between them. Each of these research traditions has been interested in a slightly different question, pursuing how population density is relevant to the foci of the parent discipline. For example, social psychologists are most interested in the effect of immediate context on human behavior and, thus, have only probed how the presence of many others may encourage an individual to not help others. In this chapter, the goal will be to turn this approach on its head, using the methodologies and findings of these diverse disciplines to answer the question in its broadest sense. As others have argued before (Gintis 2007, Wilson 2007), such a synthesis will require an evolutionary perspective. While most often credited with its elegant ability to reduce a complex question to one of cost-benefit, this framework is also special in that it simultaneously considers components of the physical environment, social environment, and individual adaptation in order to elucidate the emergent properties of these. This is especially
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important in human studies as these seemingly separable aspects of our species have been divvied among the behavioral disciplines. To these ends, the first section will formulate a model for how population density can influence the adaptive landscape for social behaviors using empirical research from nonhuman species. The second section turns to existing theories on population density offered by social psychologists and sociologists, which discuss, respectively, its effect on individual attitudes and group processes. These theories complement each other, but neither fully considers the impact of the other. The last section will present an interdisciplinary synthesis along with new evidence that suggests that residents of densely populated regions are not only more self-oriented, but also more sensitive to such threats from others. This last insight can be used in future urban planning decisions, leading to city neighborhoods characterized by prosociality, despite their high density.
RESEARCH ON NON-HUMAN SPECIES In a seminal paper, Calhoun (1962) described an experiment in which he turned a rat cage into a veritable distopia. He permitted an existing population to continue growing without granting them more living space, inducing behaviors that escalated from basic stress, to aggression, to outright cannibalism. As one might logically do, Calhoun extrapolated these results to humans, asserting that they validated the worst fears of pessimistic philosophers who had decried urbanization since its beginning (e.g. Thomas Malthus). There has been much criticism of this research and its implications, the most important being that humans are not rodents, and a lengthy evolutionary history as a social species may have created a distinct psychological structure that would have a more sophisticated response for high population density (de Waal 1989). Another main critique has been to address the difference between crowding and density (Stokols 1972). While crowding is a physical setting to which an individual is not habituated, density is a demographic feature. In this way, density is a prerequisite for crowding, but does not guarantee it. Firstly, individuals who live at high density may have a greater threshold for the immediate presence of conspecifics than those accustomed to lower density. Secondly, even when living in high density, congregations that are discomfiting to individuals may rarely arise. The literature is not always specific about this distinction, but this section will do its best to focus specifically on population density, avoiding some of the more dramatic results and conclusions that can be drawn from experiments that raise density to a level that makes crowding a constant stressor.
How Density Can Encourage Aggressive Strategies Simply put, the presence of many conspecifics makes the importance of relative fitness (i.e. one‘s success in comparison to others) more salient. Whether the issue is access to food, territory, or mates, individuals are under more pressure to gather and defend the resources necessary to pass on their genes. Such being the case, individuals are likely to be exceedingly intolerant of each other, especially when conflict may yield greater access to resources. It may be claimed, then, that the truly proximate factor is resource availability, not population
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density, though it may easily create a situation in which resources are limited. However, picture a species in which conspecifics themselves represent a resource. In this case, exploitation of the resource would benefit one‘s own absolute fitness and damage (or eliminate) the absolute fitness of a competitor, effectively giving one‘s relative fitness a double boost. The most apparent example of this is cannibalism, and the following paragraphs summarize two clades in which cannibal morphs appear in response to high population density: amphibians and crickets. In amphibians, larva-larva cannibalism is relatively common across species (Elgar and Crespi 1992). Research on the tiger salamander, Ambystoma tigrinum tigrinum, has demonstrated that this is a genetic polyphenism (West-Eberhard 1989), meaning that the same genotype can use environmental inputs to produce the most adaptive phenotype from two or more options. One of these morphs is a tadpole that feeds primarily on plankton, the other a cannibal with an enlarged head and jaw, permitting the consumption of other tadpoles. Laboratory experiments have demonstrated that these cannibal morphs develop given two main requisites: consistent tactile interaction with other tadpoles; and being larger than the vast majority of these conspecifics (Hoffman and Pfennig 1999). This adaptation for high population density is quite sophisticated, as cannibals preferentially feed on non-kin (except when starved by experimenters for multiple days before exposure to a non-cannibalistic sibling) (Pfennig et al. 1999). In a related species, Hynobius retardatus, development into a cannibal is fully inhibited in aquaria where the population, though dense, is from a single set of siblings (Michimae and Wakahara 2001). Similar dynamics arise in cricket swarms, with research focusing particularly on desert locusts, Schistocerca gregaria, owing to the devastating impact they can have on agriculture (Burrows 1996). Uvarov (1921) first described a polyphenism in desert locusts, with a ―solitary‖ and ―gregarious‖ morph. He found that the gregarious form is a response to population density during larval stages. Being that the gregarious morph is more adept at flying, the reigning opinion was that it arose to address the issue of rapidly exhausting resources, and that the airborne swarms were able to seek out and exploit new patches. It has recently been suggested that the resource scarcity associated with population density also promotes cannibalism. In a field experiment using the related Mormon cricket (Anabrus simplex), it was found that the crickets themselves contain a high concentration of two nutrients—protein and salt—that are difficult to find during a march (Simpson et al. 2006), making conspecifics a valuable option as a food source. For this reason, it is necessary for these individuals to march away from individuals behind them, and towards individuals ahead of them, which is precisely what occurs in a swarm. In a laboratory experiment, Bazazi et al. (2008) clipped the hind nerves of some crickets, preventing them from sensing contact from behind. In turn, these individuals were more likely to fall out of formation and to be cannibalized by others. Unlike in salamander populations, cannibalism is a universal trait within a locust or cricket swarm, thus individuals are as much at risk from others as they are a danger to them. From this unique environmental pressure we see a co-evolution of cannibalistic and anti-cannibal traits. The crickets are acutely sensitive to attacks from behind, while simultaneously waiting for this sensitivity to fail in others. In sum, it is an extreme example of a species-specific response to population density, treating its own kind as both a resource and exploitative threat.
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Primate Literature While the life histories of some species lend themselves to the evolution of cannibalism, others do not, and primates do not appear to be one of these groups. Instead, the general results of population density studies in primates are more in line with the rodent research mentioned above, though not quite as drastic. Population density, especially when elevated in such a way that crowding becomes a near constant, is stressful. However, while elevated population density is always accompanied by indicators of anxiety (e.g. scratching oneself), aggression does not necessarily increase (de Waal 1989). Instead, when placed in this uncomfortable situation, there‘s nearly an even chance that the population will erupt in aggression, or will use other behaviors to diffuse stress before it escalates to violence. Whether this latter process is successful or not seems to be a result of other factors specific to the context. Research on macaques and chimpanzees have exposed two approaches to dealing with individual stress and subsequent group tension. In one macaque study, after population density was artificially elevated, intrasexual aggressive behavior did increase for females, but it was accompanied by a rise in intrasexual grooming for both sexes (Judge and de Waal 1997). Presumably, these prosocial actions, which themselves can counteract stress hormones, prevent aggression from getting out of hand. Chimpanzees, though, demonstrate an even more complex individual sociality as they seem to intentionally repress their stress without reliance on allogrooming. In an experiment placing chimpanzees in high population density, aggression in fact decreased, but self-scratching, an indicator of anxiety, increased, particularly when individuals were made aware of the presence of other troops (e.g. by hearing their vocalizations) (Aureli and de Waal 1997). Such self-control was interpreted as a deliberate avoidance of unnecessary conflict. Being that strangers on city buses regularly opt to avoid each other rather than groom each other, the seeming aloofness and social repression of chimpanzees may be more informative when considering humans. The implications of this are borne out in greater detail by social psychologists (see below). Either way, our tendency for cooperative living is a hallmark of human society, and is more fully elaborated than that of even our closest phylogenetic relatives. At this extreme of sociality, conspecifics become a resource that can be utilized and exploited for personal gain. With a powerful ability to disguise our internal thoughts and intentions, humans may be able to go beyond the instrumental asociality (i.e. social abstention) seen in chimpanzees, expanding to subtle forms of antisociality, like deception. While not cannibalism in a classical sense, we may expect to see a suite of adaptations that enhance social exploitation and its avoidance, analogous to the systems seen in salamanders and locusts.
PERSPECTIVES FROM HUMAN-ORIENTED DISCIPLINES Human behavioral scientists have also been concerned with the effect of population density on social decisions, and from this effort two main schools of thought have arisen. The first hails from the tradition of social psychology, which focuses on the relationship between environmental factors and individual behavior, while spending little time on the operation of
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groups given the same settings. On the other hand, sociologists have been primarily concerned with the influence of population density on group function, while not exploring its potential to have a direct effect on the social decisions of individuals. This sort of split is common in human studies, and is an artifact of the way our diverse behaviors and institutions have been divided into separate disciplines. While this permits greater focus on each, the communication between these fields is infrequent, and often inhibited by cultural differences in assumptions, methodologies, or terminology (Wilson 2007). As will be seen, both social psychologists and sociologists are offering a valuable perspective, but each would gain strength if expanded to consider the implications of the other, a synthesis that can be facilitated by an evolutionary approach.
Social Psychological Perspectives: The Bystander and Systems Overload Hypotheses The earliest treatments of population density by social psychologists were primarily inspired by an event in New York City that occurred in 1964. While walking to her home in Queens after working a night shift, Catherine Genovese was stabbed repeatedly in the early morning hours. In the ensuing murder investigation, 38 individuals admitted to witnessing the event—and potentially more actually did—but not a single one chose to intervene on the woman‘s behalf. The outrage at this event was not towards the murder itself, but towards the lack of action by witnesses. In response, Latané and Darley (1968) performed a clever experiment to test the effect of bystanders on one‘s tendency to help individuals in need. Subjects were placed in a cubicle and asked to partake in a conversation with other subjects about the problems faced by college students. The conversation was to take place over intercom and individuals were placed in groups of different sizes. Each subject was appraised of the size of their group, but was not told that all other members were in fact tape recordings, and that she was the only live person partaking in the conversation. At a certain point, one of the recorded voices reported that he or she was suffering from a seizure and needed help. Results showed that as perceived group size increased, individuals waited longer to leave the room for help. More alarmingly, nearly 40% of individuals placed in groups of six (the largest treatment) never even went for help! In light of these and other empirical results, Latané and Darley (1970) proposed that the presence of others allows an individual to diffuse responsibility for prosocial action. Notably, this formulation of human social behavior is very similar to the tragedy of the commons model (Hardin 1968), in which self-interested strategies are the most locally adaptive, despite undermining the function of the group as a whole. This ―bystander effect,‖ as it was termed, was incorporated by Milgram (1970) into his ―systems overload theory,‖ which described urbanites as similar to Aureli and de Waal's (1997) chimpanzees: aloof, but not particularly aggressive. He argued that high population density acts upon adaptive psychology in a variety of ways, including the tendency to assume that others will help someone in need, thus releasing them from any obligation. In addition, he states that the anonymity of urban life will promote a sense of vulnerability, leading to higher levels of distrust and avoidance of strangers. Finally, he proposed that social norms for not helping have evolved in response to population density. An urbanite who felt compelled to
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offer civilities and small acts of kindness to all passer-bys would be crushed either by the task itself, or the guilt of not being able to fulfill it. Thus, an unspoken agreement to be aloof insulates all individuals from feeling imposed upon by the needs of the uncountable others they meet on a daily basis. Since then, numerous researches have tested these ideas, primarily comparing helping behavior in urban and rural areas. These studies use a variety of protocols in which a confederate prompts prosociality while blending in with daily life; for example, an experimenter requesting change from a pedestrian, or posing as a blind person who needs help crossing the street. In a meta-analysis of such studies, helping behavior was indeed lower in larger municipalities, particularly those with populations greater than 300,000 (Steblay 1987). In an ambitious experiment including 36 American cities with populations above this threshold, Levine et al. (1994) found that population density was an important, negative predictor of a variety of helping behaviors. As fruitful as this research tradition has been, its broad application to social behavior is problematic. Most apparently, the focus has been on abstention from prosocial acts, and does not consider the fact that population density may also encourage antisocial behavior. Secondly, it is oriented almost exclusively on proximate mechanisms and their external triggers, meaning that adaptationist and byproduct hypotheses are not finely distinguished, precluding any testing between them. For example, Latané and Darley's (1970) bystander effect can be interpreted as an adaptation that is beneficial to the actor (although they do not do so), while the other forms of system overload are more likely to be byproducts of a system‘s functional limits (though, again, they are not discussed as such). Thirdly, all interest is on the immediate effect of context, and not on long-lasting influences. It seems plausible that the social strategies of individuals habituated to high population density will bear the imprint of this experience across contexts. Finally, these results only discuss the effect of population density on individual interactions, and fail to address the challenges this might pose for specific aspects of group function. Social norms, by their very definition, are not located in individuals, but in the cultures that enforce them, and the discussion of social behavior is incomplete without considering a society‘s capacity for informal governance. This is a primary interest of the field of sociology, and the focus of the next section.
Sociological Perspectives: Social Disorganization Theory One of the easiest ways to describe the quality of a community is to measure the strength of the ties shared by neighbors. Within these interpersonal relationships lie a variety of resources (i.e. social capital; Coleman 1990, Putnam 2000), including the ability to enforce social norms through informal governance (known as collective efficacy; see Sampson et al. 1997). The strength of collective efficacy is visible in a variety of ways. At the most basic level, the houses are better cared for, the lawns and bushes are trimmed, the open spaces cleared of garbage (Kawachi et al. 1999, Markowitz et al. 2001, Sampson and Raudenbush 1999). More importantly, when collective efficacy is weak, undesirable behaviors like disorderly conduct and public drunkenness go unpunished and are likely to rise. Further, the neighborhood becomes an unsafe area that harbors crime and its perpetuators, all because the community members have failed to defend their territory. This is the essence of Shaw and
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McKay's (1942/1969) social disorganization theory, which states that the prevention of crime in a neighborhood lies with the residents and their ability to use local relationships to exert social control. Since then, a considerable amount of research has validated this hypothesis, demonstrating that collective efficacy is integral in keeping local crime rates low (Kawachi et al. 1999, Rosenfeld et al. 2001, Sampson and Raudenbush 1999, Sampson et al. 1997), and discouraging delinquent behavior in resident adolescents (Sampson et al. 1999). This latter relationship is more germane to the interests of this chapter because it demonstrates the effect that one‘s home environment may have on the development of social behavior. Shaw and McKay theorize that three demographic factors can undermine the ability of a neighborhood‘s residents to establish an effective system of social control: economic disadvantage, ethnic heterogeneity, and residential mobility (i.e. large population turnover). In a paper presenting the first true empirical test of this hypothesis, Sampson and Groves (1989) added to the list the prevalence of family disruption (e.g. divorce), and urbanization. Along with these measures, they asked members of 238 British communities to describe the strength of their friendship ties within walking distance of their home, their participation in local social organizations, and the extent to which truant and delinquent behavior was visible in their neighborhoods, each of which was considered a measure of social organization (note that at this time the more specific construct of collective efficacy had not yet been proposed). In models controlling for the four other predictors, individuals from urban communities reported weaker friendship networks and adolescent supervision in their neighborhoods. In a later study concentrating on collective efficacy across Chicago neighborhoods, Sampson and Raudenbush (1999) replaced ―urbanization‖ with a measure of population density, and found that it too had a strong, negative effect on a neighborhood‘s collective efficacy. The argument made for the negative effect of population density on community function is not dissimilar from Milgram‘s system overload theory, although in this case the focus is on the limited capacities of the group, not the individual. They point out that it‘s only feasible to maintain relationships with so many people, and that unknown neighbors are further accompanied by unknown visitors. Thus, one may come into direct contact with a variety of strangers in a given day. The anonymity that results can create a sense of disempowerment for those who would govern, and a sense of freedom for those pursuing mischief. Thus, selforiented or aggressive strategies will be more successful. For upstanding citizens who are less inclined toward such tactics, one might expect to see aloofness or wariness, being that outright prosociality is more at risk in an environment harboring individuals who might exploit such overtures. Further research suggests that cues of social disorganization do, in fact, exert a cognitive effect that discourages helping behavior (Wilson et al. 2009) and cooperative attitudes in general (O'Brien and Wilson Under Review). Though initially focused specifically on crime outcomes, social disorganization theory and the ensuing research highlight the importance of group-level processes to social behavior more broadly defined. Of particular importance is the impact the native environment can have on individual differences in behavioral strategies, depicting a long-term developmental effect rather than the short-term cognitive one described in the previous section. However, the model only describes a single chain of effects, with the demographic environment influencing the social environment, which, in turn, determines individual behaviors. It does not consider the effects the demographic environment alone can have on individual psychology.
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AN EVOLUTIONARY SYNTHESIS As stated, these two bodies of work each address distinct implications of high population density for social interactions. Though one focuses on the individual, the other on group-level processes, a synthesis is not as simple as fitting them together like ready-made puzzle pieces. Instead, there is a consistent feedback loop between the individual and the group, being that the group, which consists of individuals, creates a social environment within which those same individuals live. Thus, a formal ecological relationship requires four steps (represented in Figure 1): a) how does population density influence individual behaviors?; b) how do these resultant behaviors come to bear on the interpersonal interactions that create collective efficacy?; c) what direct effects does population density have on the nature of these interactions?; d) to what extent can the emergent level of collective efficacy serve to govern individual social strategies, which themselves may be partially attributed to the adaptive landscape provided by high population density (as noted in a))? Some argue that the evolution of cooperation is dependent on the processes of informal governance, like gossip, reputation, and shunning (Boyd et al. 2005). Such mechanisms are vital components of collective efficacy, and are functional only if the community members share an established set of social norms, and actively enforce them. As characterized by the studies of social psychologists, high population density erodes the interactions necessary for both of these steps; individuals tend to be aloof, avoiding the interpersonal relationships necessary to communicate norms, and, following the anecdotal case of the Genovese murder, tend to shirk active participation in neighborhood governance. Thus, Milgram‘s overload hypothesis alone could account for the shortfall in neighborhood governance seen in areas of higher population density (Sampson and Groves 1989, Sampson and Raudenbush 1999). However, we have not accounted for the anonymity that population density brings with it. Even if people were actively enforcing social norms, they may routinely encounter numerous individuals who are not socially beholden to them, making informal mechanisms of governance ineffective. The deterrence of antisocial behavior then faces a double challenge: an environment that is difficult to govern, and residents who are disinterested in doing so. What is the nature of the individuals being governed, though? If neighbors are merely aloof strangers, as the systems overload hypothesis suggests, the problem is simply the absence of conspicuous prosociality and a weakened capacity for norm maintenance. However, there is the possibility that high population density may activate people‘s focus on relative fitness, promoting selfish strategies that manipulate social exchange for personal gain. If high density does this while also undermining the system for the punishment of such behavior, the result will be even more severe. This hypothesis can only be tested by measuring behaviors, population density, and collective efficacy simultaneously, as has been done in the criminological research. If the issue were merely failures at the group level, then any measure of neighborhood governance should mediate the relationship between population density and crime. Although this is the case for all other factors predicted to diminish social control (e.g. ethnic heterogeneity), population density independently predicts higher rates of property crime, like burglary and robbery, when controlling for collective efficacy or related constructs (Sampson and Groves 1989, Sampson and Raudenbush 1999). Such observational results suggest that high population density not only has the capacity to harbor antisocial behavior, but to breed it.
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Figure 1. The Causative Relationships Between Population Density, Individual Behavior, and GroupLevel Processes. The letters denote the links described in the text
Studies using a children‘s game called the Madsen Cooperation Board (Madsen 1967) have provided good evidence that areas of higher population density train individuals in selforiented behavior. The game can either be played competitively or cooperatively, with a cooperative strategy being the only one that ―wins.‖ When played with children from rural areas and urban areas, those from urban areas consistently employ the competitive, noncooperative strategy. These results are cross-culturally robust, replicated in Mexico (Madsen 1967), South Korea (Madsen and Yi 1975), Colombia (Marin et al. 1975), and Papua New Guinea (Thomas 1975). Not only does this go beyond the indifference suggested by the systems overload hypothesis, its standardized scenario precludes a cognitive explanation. Instead, the game appears to have uncovered differences in social strategy that individuals from areas of high population density carry with them into the game. Unfortunately, these studies do not control for collective efficacy or related constructs. More recently, protocols developed by experimental economists have arisen as tools for estimating social behavior. These ―games,‖ which can be played with either adults or children, place participants in social situations in which their decisions impact monetary payoffs for themselves and partners. Like the Madsen Cooperation Board, they reduce social interactions to easily interpreted, standardized measures that can be used cross-culturally. The simplest of these are based on the model of the prisoner‘s dilemma. Two players are paired together (often anonymously) and are given the opportunity to either cooperate or defect. Two cooperators receive a higher payout than two defectors, but in a mixed interaction, the defector receives the highest possible payout (the ―temptation‖) and the cooperator the lowest (the ―sucker‘s payoff‖). A more informative variant of this game is played in sequential form (the sequential prisoner‘s dilemma, or SPD), in which the first player acts blindly while the second player responds to the first player‘s decision (modeled, with example payoffs, in Figure 2). Whether a participant will be the first or second mover is not known at first, thus participants report how they would behave in each of three situations: as a first-mover (―trust‖); as a second mover with a cooperator (―reciprocation‖); as a second mover with a non-cooperator (―self-sacrifice‖). The author recently utilized the SPD to measure variation in social attitudes between subcultures in New York State, with a particular focus on population density. Manuscripts from these studies are currently being reviewed for publication elsewhere, but their importance will be summarized here. In the first such study, high school students from Binghamton, NY, a small city about three hours northwest of New York City, played the SPD. Individuals‘ responses were mapped across the city and neighborhood descriptors, including social cohesion between neighbors (a component of collective efficacy) and
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population density, were used to predict behavior. In general, a non-cooperative strategy, including the tendency to exploit other cooperators, was more common in areas of higher population density, an effect that was independent of social cohesion, which itself did not significantly predict behavioral decisions. In the second study, a sample of college students from across New York State and surrounding areas played the SPD. Subjects reported their home town or zip code, and Census data was used to estimate a variety of demographic variables, including population density. Again, the probability of employing a non-cooperative strategy increased with the population density of a subject‘s native environment. Although the nature of this study made a measure of collective efficacy impossible to access, the results again supported the hypothesis that population density has a more insidious effect than either the social psychological or sociological literatures suspected. It doesn‘t just encourage aloof behavior, nor does it simply create a setting where governance is difficult, permitting antisocial behavior in the case that it does arise. It actively promotes antisocial behavior while simultaneously compromising the governance system. There is a silver lining to these results, however, whose interpretation requires briefly referring back to the social interactions in locust swarms. Recall that, while members of the swarm were inclined towards cannibalism, their marching formation was an emergent adaptation for avoiding this threat in others. In the college sample, subjects also played a form of the SPD that permitted punishment of non-cooperators. For every $1 invested by a player, her non-cooperative partner would receive $5 less than the original payoff. In this version of the game, individuals from areas of higher population density were more likely to invest their winnings in punishment. In doing so, these individuals placed a particular emphasis on punishing people who had not offered cooperation. Upon reading comments as to why people played the way they did, it became clear that this arose from a focus on relative fitness. When a first player does not offer cooperation, it is easy enough to also not cooperate and accept an equal, albeit lower, payoff. People from areas of higher population density were not so easily appeased, however, insisting that anyone who ―took their chance to make money‖ (quotation from actual subject) deserved to receive less money, and not an equal share. Much like the locusts, these individuals are aware that they are surrounded by others who (maybe even like themselves) are prepared to exploit prosociality when given the opportunity. To combat this, they have a heightened sensitivity to norm violation, and are comfortable with directly confronting it. 1 C
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Figure 2. Payoff Matrix and Possible Strategies for the Sequential Prisoner‘s Dilemma. ‗C‘ = Cooperator, ‗D‘ = Defector
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CONCLUSION Here we have the outline of a relationship between an environmental input, and a phenotype that responds to it adaptively. Integrating the previous literatures, the new model is more comprehensive, and the assumptions necessary to construct these new connections are borne out by existing empirical results. There are still many questions to be answered. Little work has explored the extent to which population density exerts a short-term cognitive effect, or a long-term developmental effect, and the potential linkage between these two. It is also unclear if this correlation between environment and adaptive behavior is the result of a subconscious genetic program, or if it is transmitted through social learning. Most importantly, potential applications of this research need to be elaborated. Big metropolises do not habitually disintegrate into chaotic infighting, but one could easily argue that improvements are possible. In particular, although we see a weakened group-level tendency to enforce social norms, the recent evidence suggests that individuals are quicker to punish their violation when acting alone. By fully understanding the proximate mechanisms at work here, it may be possible to plan new neighborhoods and urban areas that permit such behavior to have greater impact on the neighborhood, in turn dampening the negative effects that population density can have.
REFERENCES Aureli, F., de Waal FBM. (1997). Inhibition of social behavior in chimpanzees under highdensity conditions. American Journal of Primatology, 11, 213-228. Bazazi, S., Buhl, J., Hale, J. J., Anstey, M. L., Sword, G. A., Simpson, S. J. & Couzin, I. D. (2008). Collective motion and cannibalism in locust migratory bands. Current Biology, 18, 735-739. Boyd, R., Gintis, H., Bowles, S. & Richerson, P. J. (2005). The evolution of altruistic punishment in H., Gintis, S., Bowles, R. Boyd, & E. Fehr, eds. Moral Sentiments and Material Interests. Cambridge, MA: The MIT Press. Burrows, M. (1996). The nerobiology of an insect brain. Oxford: Oxford University Press. Calhoun, J. B. (1962). Population density and social pathology. Scientific American, 206, 139-148. Coleman, J. (1990). The foundations of social theory. Cambridge, MA: Harvard University Press. de Waal FBM. (1989). The myth of a simple relation between space and aggression in caprive primates. Zoo Biology Supplement, 1, 141-148. Elgar, M. A. & Crespi, B. J. (1992). Cannibalism: Ecology and evolution among diverse taxa. Oxford: Oxford University Press. Gintis, H. (2007). Five principles for the unification of the behavioral sciences. Brain and Behavioral Sciences, 30, 1-61. Hardin, G. (1968). The tragedy of the commons. Science, 162, 1243-1248. Hoffman, E. A. & Pfennig, D. W. (1999). Proximate causes of cannibalistic polyphenism in larval tiger salamanders. Ecology, 80, 1076-1080.
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Judge, P. G. & de Waal, F. B. M. (1997). Rhesus monkey behaviour under diverse population densities: Coping with long-term crowding. Animal Behaviour, 54, 643-662. Kawachi, I., Kennedy, B. P. & Wilkinson, R. G. (1999). Crime: Social disorganization and relative deprivation. Social Science and Medicine, 48, 719-731. Latané, B. & Darley, J. M. (1968). Group inhibition of bystander intervention. Journal of Personality and Social Psychology, 10, 215-221. —. 1970. The Unresponsive Bystander. New York: Appleton-Century-Crofts. Levine, R. V., Martinez, T. S., Brase, G. & Sorenson, K. (1994). Helping in 36 U.S. cities. Journal of Personality and Social Psychology, 67, 69-82. Madsen, M. C. (1967). Cooperative and competitive motivation of children in three Mexican sub-cultures. Psychological Reports, 20, 1307-1320. Madsen, M. C. & Yi, S. (1975). Cooperation and competition of urban and rural children in the Republic of South Korea. International Journal of Psychology, 10, 269-274. Marin, G., Mejia, B. & de Oberle, C. (1975). Cooperation as a function of place of residence in Colombian children. The Journal of Social Psychology, 95, 127-128. Markowitz, F. E., Bellair, P. E., Liska, A. E. & Liu, J. (2001). Extending social disorganization theory: Modeling the relationships between cohesion, disorder, and fear. Criminology, 39, 293-320. Michimae, H. & Wakahara, M. (2001). Factors which affect the occurrence of cannibalism and the broad-headed "cannibal" morph in larvae of the salamander Hynobius retardatus. Behavioral Ecology and Sociobiology, 50, 339-345. Milgram, S. (1970). The experience of living in cities. Science, 167, 1461-1468. Moreno, E. L. & Warah, R. (2007). Urban and slum trends in the 21st century. The UN Chronicle, 43, 24-29. Nations, U. (2007). World Urbanization Prospects: The 2007 Revision. Report no. O'Brien, D. T., Wilson, D. S. Under Review. Community Perception: Using the physical structures of unfamiliar urban neighborhoods to accurately assess safety and formulate adaptive social responses. Journal of Personality and Social Psychology. Pfennig, D. W., Collins, J. P. & Ziemba, R. E. (1999). A test of alternative hypotheses for kin recognition in cannibalistic tiger salamanders. Behavioral Ecology, 10, 436-443. Putnam, R. (2000). Bowling Alone: The collapse and revival of American community. New York: Simon nd Schuster. Rosenfeld, R., Messner, S. F. & Baumer, E. P. (2001). Social capital and homicide. Social Forces, 80, 283-310. Sampson, R. J. & Groves, W. B. (1989). Community structure and crime: Testing social disorganization theory. The American Journal of Sociology, 94, 774-802. Sampson, R. J. & Raudenbush, S. W. (1999). Systematic social observation of public spaces: A new look at disorder in urban neighborhoods. American Journal of Sociology, 105, 603-651. Sampson, R. J., Raudenbush, S. W. & Earls, F. (1997). Neighborhoods and violent crime: A multilevel study of collective efficacy. Science, 277, 918-924. —. 1999. Beyond social capital: Spatial dynamics of collective efficacy for children. American Sociological Review, 64, 633-660. Shaw, C. & McKay, H. (1942/1969). Juvenile Delinquency and Urban Areas. Chicago: University of Chicago Press.
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Simpson, S. J., Sword, G. A., Lorch, P. D. & Couzin, I. D. (2006). Cannibal crickets on a forced march for protein and salt. Proceedings of the National Academy of Sciences of the United States of America, 103, 4152-4156. Steblay, N. M. (1987). Helping behavior in urban and rural environments: A meta-analysis. Psychological Bulletin, 102, 346-356. Stokols, D. (1972). On the distinction between density and crowding: Some implications for future research. Psychological Review, 79, 275-277. Thomas, D. R. (1975). Cooperation and competition among Polynesian and European children. Child Development, 46, 948-953. Uvarov, B. P. (1921). A revision of the genus Locusta (L.) (=Patchytylus Fieb.), with a new theory as to the periodicity and migrations of locusts. Bulletin of Entomological Research, 12, 135-163. West-Eberhard, M. J. (1989). Phenotypic plasticity and the origins of diversity. Annual Review of Ecology and Systematics, 20, 249-278. Wilson, D. S. (2007). Evolution for Everyone. New York: Bantam Dell. Wilson, D. S., O'Brien, D. T. & Sesma, A. (2009). Human prosociality from an evolutionary perspective: Variation and correlations at a city-wide scale. Evolution and Human Behavior, 30, 190-200.
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 12
ANGELS AND SAINTS: THE RHETORICAL EFFECTS OF LAY UNDERSTANDINGS OF FOSTER CARE UPON CARERS Damien W. Riggs Department of Social Work and Social Policy, Flinders University, South Australia
ABSTRACT Analyses of the rhetorical effects of public statements and everyday conversation have long demonstrated the potentially deleterious ends to which purportedly positive statements can be put. Specifically in the context of foster care, this can occur when lay people refer to foster carers as ‗angels‘ or ‗saints‘. Drawing in this chapter on research conducted with Australian foster carers, I suggest that referring to foster carers in this way functions rhetorically to: 1) construct foster children in particular (negative) ways, 2) deny societal responsibility for child protection agendas, 3) construct carework as outside of economic exchange, 4) implicitly question the motives of foster carers, and 5) undermine or discount the considerable challenges that foster carers face. In response to these problems associated with the construction of foster carers as ‗saints‘ or ‗angels‘, I conclude the chapter by making suggestions for an understanding of foster care that moves away from a benevolent or ‗rosy‘ image of care provision, and instead recognises the important role that foster carers play in child protection services and the need for Australian society to better support child protection agendas.
INTRODUCTION Contrary to popular sentiment, words can indeed hurt. Furthermore, and as analyses of rhetoric have long identified, words intended to hurt can fail in their intent, just as words intended to help can actually harm. Certainly this is the argument so cogently made by Judith Butler (1997) in her book Excitable Speech, in which she argues that ‗hate speech‘ is typically only recognised as such on very limited terms arbitrated by the State. As a result, Butler
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suggests that only certain claims to harm are rendered intelligible, and furthermore, that precedent for one claim to harm can be (mis)used to argue a claim of harm that is oppositional to the original claim (e.g., such as those who make recourse to the right to freedom of speech in order to legitimate hate speech). Words thus have performative effects, though these are not necessarily always consistent (referring here either to words not having a consistent meaning over time or the response not necessarily being consistent with the intent of the speaker). As such, rhetorical analyses have much to tell us about the effects of particular words within a given context, and their power to hurt, marginalise or otherwise control particular individuals or groups. In the context of foster care, the performative effects of language are evident in the terms typically used to describe foster carers. Primary amongst these is reference to foster carers as ‗angels‘ or ‗saints‘. In the context of Australian foster care (which is the focus of this chapter), the imagery of angels is often used in representations of foster care in general, and has been used specifically by some agencies in recruitment campaigns. Members of parliament often make reference in public statements to foster carers being ‗angels‘ whose role it is to ‗save‘ children who have experienced abuse. And media reporting of foster care often utilises the language of ‗angels‘ and ‗saints‘ to describe the majority of foster carers (though this description is often contrasted with an image of ‗failed‘ or ‗bad‘ foster carers who have abused children in their care). Whilst the intention behind most uses of the imagery of foster carers as angels or saints can be fairly presumed to be positive toward foster carers, it is not necessarily the case that this is how foster carers will perceive the deployment of these terms, nor can we assume that the performative effects of referring to foster carers as ‗angels‘ or ‗saints‘ are always positive. Importantly in this regard, then, studying the performative effects of referring to foster carers as angels or saints does not require imputing intention on behalf of the speaker. Rather, the point of rhetorical analysis is to examine the potential effects of certain words, and the very real world impact they can have. With the above points about rhetorical analysis in mind, my interest in this chapter is to closely examine how a group of Australian foster carers reported experiencing the deployment of the words ‗angels‘ and ‗saints‘ in reference to their role as foster carers. In so doing, my interest is not in the rhetoric of the foster carers themselves, but rather the rhetorical effects of references to them as angels or saints in their everyday lives. Specifically, I identify five rhetorical effects of the use of the words ‗angels‘ or ‗saints‘ to refer to foster carers, these being the ways in which such references 1) implicitly construct foster children in particular (negative) ways, 2) deny the responsibility of individuals in relation to child protection, 3) construct carework as outside of economic exchange, 4) implicitly question the motives of foster carers, and 5) undermine or discount the considerable challenges that foster carers face. In order to illustrate these five rhetorical effects I analyse extracts from interviews and focus groups I conducted with Australian foster carers in 2006. I then conclude the chapter by presenting an alternate approach to understanding and representing foster carers, namely one that moves away from representations of foster carers as ‗benevolent angels‘, and towards one where child protection is seen as the responsibility of all individuals.
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METHOD Participants The data analysed here are drawn from a broad corpus of individual interviews and focus groups conducted as part of a national research project examining why people choose to become foster carers and how to best attract new foster carers. Ethical approval was sought and granted from both the University of Adelaide and the foster care organisations with whom the foster carers were registered. Ten interviews with couples and fifteen focus groups were conducted with men (n=31) and women (n=49) from a range of cultural backgrounds and with a broad range of care experiences across four Australian states using a semistructured interview schedule. Interviews and focus groups were audio taped and transcribed orthographically, and all participants were allocated a pseudonym following transcription to ensure anonymity.
Analytic Approach In response to one question in the interview schedule (‗What do you think other people in your community and friends and family think about foster carers in general?‘), the majority of participants orientated in some way to a perception of foster carers being seen as ‗angels‘, ‗martyrs‘, ‗saints‘ or more generally spoke about a perception of benevolence in regards to foster carers amongst the wider community. Often this occurred in focus groups where one individual noted the perception and then others in the group reported similar perceptions. Nonetheless, in individual interviews participants also commented on the imagery of angels and saints and often spoke at length about what this means in their lives as carers. As such, this theme of other people‘s perceptions of carers as angels or saints was predominant in the broader context of the data set. Having identified this theme of lay (i.e., non foster carers‘) perceptions of foster carers as angels or saints, I then preceded to highlight all instances of this within the data set (55 in total), and then fairly grouped the instances into distinct categories. Categories were distinguished not by the content of the individual speaker‘s words per se, but rather by the potential rhetorical effects of each reporting of the perception that foster carers are angels or saints. In other words, upon repeated rereading of the 55 instances it was possible to discern five distinct rhetorical effects that may arise from the particular construction of foster carers identified. Whilst there was some overlap between the categories of rhetoric I identified, most instances were clearly identifiable as producing one primary rhetorical effect (even if there were other potential effects evident in each individual extract). Having identified five categories, I then selected extracts from within each category for closer analysis. The extracts and analysis are presented below.
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ANALYSIS Before I present my analysis, it is important to reiterate two things: First, my focus in the following analysis is on the potential rhetorical effects of statements that foster carers reported being made to them or general opinions about foster carers that they perceive from the communities they live in. As such, my focus is not on the rhetorical devices deployed by the carers themselves, nor on the veracity of their claims. Rather, I take as given the fact that a large proportion of carers spoke of the perception that foster carers are seen as ‗angels‘ or ‗saints‘ (albeit in a range of different ways), and that whilst this can tell us nothing per se about what is actually said by lay people about foster carers, it nonetheless represents a persistent pattern of perceptions that warrants attention. The second point is related to the first, in that whilst I treat as valid the perceptions that foster carers report, I am not interested in imputing intent to either foster carers or those in their communities who are reported as seeing foster carers as angels or saints. In other words, and as per rhetorical analysis more broadly, my interest is not to prove that any individual meant to make a particular moral judgement or attribution about foster carers by referring to them as angels or saints. Rather, my interest is on the potential rhetorical effects of such statements in the lives of foster carers.
Rhetorical Effect 1: Depicting Foster Children in Negative Ways The first rhetorical effect identified here is one in which the statement ‗oh you must be an angel‘ serves to construct foster children as undeserving or as damaged, the implication being that it would take a saint to care for them. In an analysis of Australian media representations of foster care conducted by myself and colleagues (Riggs, King, Delfabbro & Augoustinos, 2009), we found similarly that foster children are almost exclusively constructed as ‗damaged goods‘, and that foster carers are by implication ‗angels‘ who are the only ones willing to meet their care needs. In the extract below Meg, who at the time was caring for one child with her husband, talks about this association between foster carers being ‗angels‘ and children as being ‗lucky‘ to have them: Meg: We are always being told be professionals and family members that we are saints for taking on this child. And people tell him that too. We had a massage therapist here last night and she has been coming to us for 12 months and she said to the child ‗oh you are such a lucky boy. Do you know how lucky you are to be with these people?‘. And I just want to smack her; he has the same rights to a family environment as any other kid. My mother came to visit in the holidays too and she kept saying ‗oh you are such a lucky boy‘. I told her to shut up; he is entitled to a bedroom just like any kid.
Notions of ‗luck‘ function rhetorically to construct the purportedly lucky person as only in their present situation by virtue of fate: they are not seen as intrinsically deserving of whatever it is they have received, but rather their receipt of whatever makes them ‗lucky‘ is relatively unrelated to them as a person. When we apply this to foster children, as Meg does, the construction of children in care as ‗lucky‘ not only ignores the reasons why they are in care (i.e., significant abuse and/or neglect), but also treats foster placements as something children should be grateful for. Of course my suggestion here is not that foster children (like
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all children) should not be appreciative of the work undertaken by those who parent them. Rather, my suggestion is that constructing foster children as lucky recipients of the care provided by ‗saints‘ fails to recognise that foster children have the right to adequate care, as Meg suggests. The category ‗saint‘ exacerbates this negative construction of foster children as potentially undeserving by constructing the category as one in which only foster carers (and thus not foster children) belong. Elsewhere I have suggested (Riggs, 2009) in relation to transnational adoption that such a focus on gratitude and the presumed generosity of adoptive parents produces an injunction upon adopted children to first recognise themselves as damaged goods, and then to display gratitude to the welfare systems and individuals who made possible their removal from their birth parents and birth cultures. My point here is not that adoption or foster care may not, in some instances, be the best outcome for children, but rather to suggest that the implicit construction of a sole causal link between bad birth families and/or bad children and removal into care fails to recognise the broader social contexts in which child protection services operate, a point I will elaborate in discussing the next rhetorical effect.
Rhetorical Effect 2: Denying Societal Responsibility Part of the problem with constructing foster children as ‗lucky‘ recipients of the ‗care of saints‘ is that it individualises care provision. What this means in practice is that only certain children and birth families are seen as the cause of child protection concerns (i.e., ‗bad‘ birth families and ‗bad‘ foster children), and only certain people are seen as rightly engaged in child protection practice (i.e., ‗good‘ social workers and ‗saintly‘ foster carers). An alternate reading of child protection (and one I elaborate in the conclusion to this chapter) would see child protection as a social justice issue that is a responsibility of all individuals. Certainly it could be suggested that the individualising of child protection through the statement ‗you must be a saint‘ absolves the speaker of any requirement to themselves engage in the work of child protection (whether that be to care for children themselves or to find other ways to support children and their families). In the following extract Sam, a single lesbian carer with three children in her care, raises precisely this point about the rhetorical effects of referring to foster carers as saints or angels: Sam: I find a lot of people are sort of taken aback, ‗oh you must be a saint‘ and all this sort of thing. But no, I am just a normal person. They say ‗it must be so difficult, how do you do it. I could never do that‘. All these sort of phrases that I get from a lot of people and I just heard recently that my sister in law who was never very friendly with me in the past, now she is being very nice to me and somebody said that is because my sister had told her that I was like the salt of the earth and had a heart of gold and I think it is because of that, the fostering. They make it like you are something other worldly, so then it is okay for them to say ‗I couldn‘t do it because I am not a saint‘.
As Sam suggests, the individualising of care provision to individual ‗saints‘ absolves other people of any requirement to care. Furthermore, this type of statement functions as an illocutionary act by requiring a response from the listener (in this instance a foster carer). In other words, by stating ‗I couldn‘t do it because I am not a saint‘, the speaker places an
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expectation upon the listener to refute the statement either by denying that they are a saint, or by finding ways to demonstrate that the speaker is also a saint (or at the very least a ‗good‘ person). Again, this functions rhetorically to individualise care provision so that the foster carer being addressed in the statement acts as an individual in the good things they do, just as the speaker acts as an individual in the good things they do. This in effect flattens out ‗good‘ into a singular and simplistic category that doesn‘t discern between individual good and good for the society. Of course, as I argue in my examination of the following rhetorical effect, the two are closely intertwined. But nonetheless, the individualising effects of the claim that foster carers are saints functions to deny societal responsibility for child protection both by focusing solely on individual ‗saints‘, and by requiring such individuals potentially to recognise a wide range of individual ‗good‘ in other people, thus reducing foster care to being just one instance of (individualised) good.
Rhetorical Effect 3: Constructing Carework as a Generous Gift My discussion above of the construction of foster care as but one of many ‗good things‘ that people do is closely related to the construction of care provision as outside of economic exchange. Public commentary on the topic of remuneration for foster carers in Australia typically draws a clear line between love and money. Yet research on the topic (e.g., Kirton, 2001; McHugh, 2006; Smith, 1988) suggests that the line is much blurrier, and importantly, that foster carers cannot adequately care for children (who often have very challenging behaviours) if they must undertake full-time work at the same time. Another rhetorical effect of the statement that foster carers are angels or saints, then, is to reinforce the separation of carework from economic exchange, in the sense that ‗angels‘ (unlike workers) are not paid for their good deeds – they do good things because they are good people, not because they expect payment. In the following extract Mark, who cares for two children with his wife, illustrates well how the construction of foster carers as angels implicitly overwrites the need for adequate remuneration: Mark: People say to us we are angels because we foster. They carry on like you are some kind of altruistic angel and that they couldn‘t possibly do it themselves, or they would love to but they can‘t afford to or don‘t have a big enough house. Well we can‘t afford to, and our old house wasn‘t big enough when we decided to care for a second child. But this is something we believe in, that children have the right to a fair chance in life. So we wear the responsibility of that. But other people don‘t seem willing to front up to that, or to recognise the costs that come with it for us.
Many of the carers I spoke to within the project from which these extracts are taken elaborated the bind they find themselves in where they undertake care provision because, for the majority, they are committed to caring for children, but this often leaves them in debt due to the often high costs of caring for children with considerable needs or challenging behaviours. Carers, for example, spoke of feeling treated as though they are mercenary when making requests for reimbursement for damages caused by children. Others spoke of remuneration as allowing them the space to care for children properly and with the right facilities to do so, but that this was often viewed negatively by others (see Riggs & Delfabbro,
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2008, for a summary of these findings). As such, the rhetorical effect of referring to foster carers as angels in the same breath as referring to monetary concerns implicitly constructs foster carers as either justifiably poor (in that they accept the financial impact of care provision), or as mercenary (for those carers who make expense claims, who are depicted as doing it for money, not love). One implication of this complex and oft-discussed relationship between remuneration and carework is that carers in general are treated as having questionable motives, a point demonstrated by the following rhetorical effect.
Rhetorical Effect 4: Questioning the Motives of Foster Carers The central aim of the research project from which the data in this chapter are taken was to identify what motivates people to become foster carers. Of the 80 carers I spoke to from across Australia, many spoke of undertaking care provision through a sense of social justice, a significant number spoke of becoming carers as a way of having a family or extending their own family, and some carers spoke of care provision as something they had always wanted to do since they were young (i.e., be a foster carer). None of the people I spoke to mentioned monetary motivations (and most laughed at the possibility of money being a motivating factor due to the high costs and low remuneration of foster care). Whilst there may have been monetary or other potentially less positive motivations that were not reported to me, it is fair to suggest that, in general, the sample of carers I spoke with reported positive motivations to care provision. Yet most participants also reported that they felt their motivations constantly questioned by others, including social workers. Perceptions of negative motivations included the aforementioned financial motivation, in addition to the presumption that because it has been identified that abuse of children does occur in care, that some carers might be motivated to care to gain access to children. In particular, male foster carers spoke of feeling hyper scrutinised in regard to their motivations, and that at times the statement ‗you must be an angel‘ was perceived as an implicit slight against their potential motivations, as Paul, a gay man who provided care to two children with his partner reports in the following extract: Paul: One of my friends said to me recently, ‗I just don‘t get why you do it, what do you get out of it? It seems so challenging. You must be an angel‘. What they don‘t get is the reciprocity of caring for kids. Sure it can be hard work, bloody hard work. But it is also rewarding, and it also gives my life meaning. I am not an angel by any stretch of the imagination. I have done as many good things in my life as I have done bad things. But I do know that I am motivated by a desire to care for another human being, and it is great to sometimes feel cared for in return. I sometimes wonder, with all the allegations about abuse in care, if people question why we do it or are suspicious of our motives that they think surely can‘t be good.
Here Paul suggests that a friend had said they couldn‘t understand why he would be a carer – what could potentially motivate him to take on children who, for Paul and his partner, had been immensely challenging. One rhetorical effect of this type of statement, and particularly when followed up with the ‗you must be an angel‘ comment, is to suggest that perhaps Paul and his partner are not actually angels at all, but rather have other motives. In other words, either Paul is expected to agree and say ‗yes, it is hard, but yes we are angels so
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we don‘t mind‘, or to deny that he is an angel. Either way, he is caught in a bind: if he agrees that he is an angel then he would likely be seen at best as immodest, and at worst as delusional, both of which would throw into question not only his motives, but also his appropriateness as a carer (i.e., if he were delusional or conceited then he wouldn‘t really be there ‗for the children‘). And if he denies being an angel, and in the face of the challenges identified by his friend, his motivations are again rendered suspect – why would anyone want to do something that is so consistently challenging and unrewarding? Of course Paul‘s response to me during the interview highlights a motivation that was, presumptively, not intelligible to his friend, namely that care provision is as rewarding as it is challenging. Certainly this was a statement made consistently by many participants, particularly in relation to the kinship bonds that many carers felt had developed with the children in their care (see Riggs, Delfabbro & Augoustinos, 2008, for a summary of these findings). To be motivated by care for another human being, and to engage in reciprocal and mutually recognising relationships with children, was the primary motivation for many carers in the sample. The carers I spoke to were adept at both recounting the challenges they face, whilst also honouring the relationships they have to children in their care. Yet despite this capacity of carers to see both sides of the coin, most carers, such as Paul, reported that other people were unable to see the positives as well as the benefits, and thus reference to carers as ‗angels‘ or ‗saints‘ functioned rhetorically to manage other people‘s lack of understanding, rather than to actually recognise the important work that carers undertake. And this is a point that I make in examining the following and final rhetorical effect, in which reference to carers as ‗angels‘ can ignore the challenges that carers face as much as it can focus only on the challenges, as I argued above.
Rhetorical Effect 5: Discounting Challenges Faced by Carers Many of the carers I spoke to reported that they felt unprepared for the challenges of care provision after the completion of their training. They felt that they were given a relatively ‗rosy‘ image of foster care and that the reality of carework was much harder and much less supported. Obviously there will always be a certain spin in foster care training, partly because trainers most often are not carers and thus will not have a complete picture of the challenges, and partly because it would likely be counter productive to training to present an entirely negative image. Nonetheless, many carers reported feeling a pressure to be a ‗good‘ carer once they started caring (i.e., one who coped, or who didn‘t complain, or who didn‘t ask for support), and many reported a fear that if they weren‘t a good carer then children would be removed from them. Certainly this expectation is evident in Australian foster care systems, where carers are expected to provide the highest level of parental care, whilst birth parents are required only to prove they can provide ‗good enough‘ parenting in order for reunification to occur. This injunction upon foster carers to be ‗perfect angels‘ can thus negatively impact carers in multiple ways, as Dee, a single heterosexual carer, suggests in the following and final extract: Dee: I remember in training that carers were always made out to be martyrs, and so that is what I thought I had to be. That I had to expect no thanks or support as martyrs just get on with the job and do it. For me that turned out really bad, because I care for children with
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disabilities, and you really do need a lot of help, and with the last boy I was caring for he had a major operation and I should have asked for more help before, because I was suffering so much from sleep depravation after a week of not sleeping and him crying the whole time from pain, but I didn‘t because I thought I had to be a martyr.. I have learnt not to be the martyr. That is really important. I fell asleep and didn‘t hear him crying and the girl next door came and tapped on my window because she knew it was unusual to hear him crying and I didn‘t ask for help when I should have. So when people say ‗you are amazing, you are an angel‘, I actually find that is an alienating statement, not one that helps me to be a good carer.
This is a perfect example of how the injunction experienced by carers to be ‗martyrs‘ can work to the disservice both of carers and children. Indeed, the expectation that carers who are not martyrs will fail functions as a self-fulfilling prophecy: carers are expected to cope, and when they don‘t (and typically this is for legitimate reasons), they are seen to have failed, and thus to have been flawed or imperfect martyrs or angels to start with. What this type of logic fails to comprehend is that no parent is perfect, and no one, no matter how good their parenting skills are, can succeed every time if they are faced with considerable challenges and no support (and this includes birth parents). The expectation for carers to be martyrs, then, sets carers, children and indeed the foster care system up to fail, in that it doesn‘t adequately recognise the challenges of care provision, nor does it put in place adequate support for foster carers and children. Furthermore, and as Dee suggests, the statement that carers are ‗amazing angels‘ serves to ignore the very real challenges that carers face. Certainly, I would endorse the fact that, in the face of considerable pressures and a lack of resources, foster carers, on the whole, succeed in caring for children in positive and productive ways. And certainly, this is something to be recognised and indeed celebrated. Nonetheless, if the only response to the experiences that carers have is to say ‗you must be an angel‘, then there is again an injunction upon carers simply to accept this title (and thus not speak of the challenges), or to deny the title and thus be seen as having questionable motives or as having poor judgement in continuing in the face of challenges. In this final rhetorical effect, then, the statement ‗you are an angel‘ (and further the expectation of foster carers to be selfless angels) sets foster carers up to potentially fail by schooling them in the belief that a) they must be perfect, b) if they are not then they have failed, and c) if they find care provision challenging then they must just take this in their stride and not complain. None of these are approaches that we would advocate with birth parents, and it thus seems illogical to advocate this type of logic when it comes to foster carers.
CONCLUSION Throughout this chapter I have emphasised the ways in which the statement ‗you must be an angel‘ in relation to foster carers functions to control, marginalise or otherwise disempower foster carers and to potentially discredit their experiences. Importantly, many of the rhetorical effects I have identified function contrarily and in competing and overlapping ways with one another. So, in one instance, a claim that foster carers are angels can serve to discredit the costs and challenges of carework, whilst in another instance it can construct foster children as unfathomably hard work (which, it would be expected, should be
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adequately supported and remunerated). And that is precisely why identifying the statement that foster carers are ‗angels‘ or ‗saints‘ as having rhetorical effects is so important: otherwise, the effects will continue (primarily in negative ways for foster carers and children), and nothing will actually be put in place that could more usefully support or recognise foster carers. One approach that could actually shift how we see foster care away from one of rosy benevolence on the part of foster carers would be to recognise the responsibility of all individuals as part of a broader society to engage in the work of care provision. Beasley and Bacchi (2005), drawing on the work of Levinas, suggest that understandings of ‗care‘ may be reconceptualised through an approach of ‗non-indifference‘ towards those other than ourselves. Whilst they provide an important critique of the limitations of Levinas‘ work (and in particular the ways in which he relies too heavily on a particularly narrow account of care), Beasley and Bacchi‘s work nonetheless signals the importance of adopting a ‗non-indifferent‘ approach to caring for others that takes as its starting point the contingency of the self upon the other. They suggest that considering the need for care of those other than ourselves must be a product of an acknowledgement of the ways in which our own identity as ‗cared for‘ individuals is intimately enmeshed with those for whom we may not typically consider a duty of care over. They suggest that moral indifference towards the other is only possible if we deny how reliant we are upon those other than ourselves for our sense of self and location within the world. Taking up this understanding of care as a ‗non-indifferent‘ approach to others, and particularly in regards to foster carer, it is important to recognise that normative discourses of ‗the family‘ are premised largely upon the juxtaposition of ‗good families‘ with ‗bad families‘. In other words, not only are differing families placed in explicitly adversarial relationships with one another (such as birth families and foster families), but those of us who are identified as ‗good parents‘ or as living in ‗good families‘ are implicitly reliant upon those who are identified as ‗bad parents‘ living in ‗bad families‘. Recognising the contingency of the former category upon the latter would be central to a ‗non-indifferent‘ account of foster care provision that pays close attention to the ongoing politics of child placements. In relation to child protection, then, an understanding of the responsibility that comes from a ‗non-indifferent‘ approach that refuses or challenges moral binaries of worth as they pertain to families is one that focuses on a child‘s right to care that is the result of living in a social context whereby care is disproportionately distributed according to factors such as the socio-economic status, gender and race of their parents (Roberts, 2003). Again, such an approach would refuse a paternalistic engagement with children in need of care (and their families) that centres upon ‗pity for the other‘ (which holds the potential to reify indifference towards those other than ourselves – ‗I have done my duty and that is enough‘), and instead focuses on how the privileges held by those of us who occupy dominant or privileged social locations are always already contingent upon the aforementioned differential distribution of social resources (Riggs, 2008). Further in regards to foster parents, an engagement with the concept of ‗non-indifference‘ may help to engender forms of recognition that emphasise foster carers locatedness within a broader social context that at the very least promotes a concern about child protection. In other words, if foster carers are seen as engaged in the actual work of caring for children in a context of protection, then it is likely that this will result in forms of recognition that extend beyond the sanctioning of foster carers by the State. To acknowledge foster carers, at a
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national level, as engaged in the work of child protection, would be to shift attention away from a focus on individual instances of child abuse or the individual carework that carers take (which is often depicted as the individual ‗good‘ of specific ‗angels‘, as I discussed earlier), and towards a focus on the rights and needs of children to a safe living environment, and the important role that foster carers (amongst others) play in meeting this need. Recognition that emphasises the meeting of children‘s needs may help to counter the dichotimisation of families into categories of ‗good‘ and ‗bad‘, and the role this plays in perpetuating disparities in family outcomes across Australia, whereby a failure to achieve particular normative family standards is typically marked as deviant. Whilst it is obviously the case that child removal will continue to be primarily considered the product of ‗bad parenting‘, the promotion of non-indifference as a framework for understanding child protection may help to engender an understanding of the contexts within which a range of families live, the hardships that some families face, and the role of foster carers as one facet of a commitment to meeting the needs of children, some of which will also be met by the ongoing role of birth parents and potential reunification with birth families. A focus on non-indifference would of course also hold important implications not only for foster carers as family members, but also for social workers. A non-indifferent approach to social work may entail the elaboration of a praxis that views a commitment to social justice as a significant component of the paid work of child protection. Certainly many social workers may already engage in such a praxis, but an educational and workplace commitment to ensuring ongoing awareness amongst social workers of current and changing factors that impact upon families (both biological and foster) may help to ensure this focus. This may involve encouraging social workers to understand their work practice as occurring in contexts where issues of child protection primarily result from a lack of social support and a failure to meet the needs of particular families, parents and children, rather than primarily resulting from the pathology of individual people. Examining the often implicit comparison of ‗good‘ and ‗bad‘ families may enable an approach to social work practice that not only appreciates a more diverse range of family forms, but which is also committed to institutional change that enables families to achieve supportive relationships. In conclusion, and as I have briefly elaborated here, engaging in a ‗non-indifferent‘ approach to understanding child protection may help to move away from the need to see foster carers as ‗angels‘ and ‗saints‘ (and the rhetorical effects of these claims), whilst still acknowledging the vital role that foster carers play in national child protection agendas. Seeing care provision as a social responsibility, and foster carers as key players in this work, doesn‘t undermine recognition of foster carers, but it does put that recognition in context, and thus refuses the individualisation of ‗good‘ in the context of foster care (whilst nonetheless recognising the challenges that foster carers face as individuals). Seeing child protection as a form of social good and thus a responsibility of all individuals is no less a rhetorical device with performative effects than is referring to foster carers as angels or saints. Nonetheless, it may be somewhat more productive in its effects in that it may broaden out societal understandings of care provision, and indeed encourage more people, in a range of ways, to engage in supporting children and families who are in crisis by seeing care (and the reasons for why it is necessary) as everyone‘s responsibility, rather than seeing crises as solely the product of ‗bad families‘ who are positioned as other to the norm of the ‗good family‘
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ACKNOWLEDGMENTS I begin by acknowledging the sovereignty of the Kaurna people, the First Nations people upon whose land I live in Adelaide, South Australia. The research reported in this chapter was supported by an Australian Research Council grant, DP0666189.
REFERENCES Beasley, C. & Bacchi, C. (2005). The political limits of ‗care‘ in re-imagining interconnection/community and an ethical future. Australian Feminist Studies, 20, 49-64. Butler, J. (1997). Excitable speech: A politics of the performative. New York: Routledge. Kirton, D. (2001). Love and money: Payment, motivation and the fostering task. Child and Family Social Work, 6, 199-208. McHugh, M. (2006). Indirect costs of fostering and their impact on carers. Communities, Children and Families Australia, 2, 73-85. Riggs, D. W. (2008). Towards a ‗non-indifferent‘ account of child protection. Australian Feminist Studies, 23, 375-388. Riggs, D. W. (2009). Race privilege and its role in the ‗disappearance‘ of birth families and adoptive children in debates over adoption by non-heterosexual people in Australia. In D. Cuthbert, & C. Spark, (Eds.) Adoption in Australia. Melbourne: Australian Scholarly Publishing. Riggs, D. W. & Delfabbro, P. H. (2008). Economics of care: Recognition and remuneration of foster carers. Journal of the Association for Research on Mothering, 10, 94-104. Riggs, D. W., Delfabbro, P. H. & Augoustinos, M. (2008). Negotiating foster families: Identification and desire. British Journal of Social Work, 38, 1-47. Riggs, D. W., King, D., Delfabbro, P. H. & Augoustinos, M. (2009). 'Children out of place': Representations of foster care in the Australia news media. Journal of Children and Media, 3, 234-248. Roberts, D. (2003). Shattered bonds: The color of child welfare. New York: Basic Books. Smith, B. (1988). Something you do for love: The question of money and foster care. Adoption and Fostering, 12, 34-38.
In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 13
PERSPECTIVES OF HOME ENTERAL NUTRITION THERAPY IN BRAZIL
1
Ana Lúcia Ribeiro Salomon Zaban1* and Maria Rita Carvalho Garbi Novaes2
Master of Science – Human Nutrition Post Graduation Program - Faculdade de Ciências da Saúde / Universidade de Brasília, Brazil. Specialist in Parenteral and Enteral Nutrition Therapy – Brazilian Society of Parenteral and Enteral Nutrition (SBPNE). Specialist in Management of Health Institutions – CPEx/ESCS/FEPECS/SES/GDF 2 PhD, Professor of Medicine College at Escola Superior em Ciências da Saúde/ESCS/FEPECS/SES/GDF. Coordinator of Research Ethics Committee Secretaria de Saúde do Distrito Federal/SES/GDF. Professor at Human Nutrition Post Graduation Program, Universidade de Brasília, Brazil
ABSTRACT Introduction The Health Sector has been facing a huge paradox concerning the availability of its resources: the conflict between the increasing requirements of health services against the limited financial resources to support them. When analyzing the worldwide view, a tendency towards an integrated hospital-home model of health assistance is found, emphasizing its importance concerning the patient‘s quality of life and the humanization of health care, and also concerning the economic benefits it provides to the health sector. Home enteral nutrition favors the warranty of continuous assistance to patients that need enteral nutrition therapy, through the supply of special formulas and the reduction in complications related to nutritional status unbalance and on hospital length of stay.
* Corresponding author: E-mail:
[email protected],
[email protected] Phone: 55-61-84248864 Universidade de Brasília (UnB) – Faculdade de Ciências da Saúde – BRAZIL
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Objective The present article aims at analyzing through bibliographic research the tendencies of the Enteral Nutrition Therapy and the cost-benefit of Home Enteral Nutrition establishment.
Methods Review of a range of articles published from 1996 to 2008 on databases such as: Medline, Lilacs, Proquest, Cochrane and Doyma, which adopted as key words: home enteral nutrition therapy and synonyms, in English, Portuguese and Spanish.
Results and Discussion. The analyzed works (n=28) reinforced the need of setting health policies which may emphasize Home Care as a way of generating economy of health resources, of improving quality of life and of increasing the availability of hospital beds in Brazil.
Key words: Enteral Nutrition, Home Care Services.
INTRODUCTION According to Fabrício et al., Home Assistance, a modality of assistance also known as home care, may be defined as a set of hospital procedures possible to be done in the patient‘s home.[1] In Brazil, the estimate points towards the occurrence of a 30% rise in the number of hospital beds over the last ten to fifteen years [2] with the objective of improving access of the population in general to health services. However, a growing demand for health services has been observed, which is directly related to access to health (principles of universality and equity in the Brazilian Health System - SUS) [3] in opposition to the scarcity of resources for financing the SUS, which ends up by generating health access restriction, the limitation in offering services and the growing dissatisfaction in population. Therefore, the need of an adequate management of health resources is noticed so as to promote the universal access to related services. When one analyses the world view especially in developed countries, one may observe the tendency to a dehospitalization, emphasizing its importance in preserving the patient‘s life quality and the humanization in assistance, in addition to providing the rise in the number of beds offered, and consequently, the economy per patient in various studies [4,5]. Between 1994 and 1999, the United States has witnessed a significant drop in hospital bed activity, from 1,2 million to 425 thousand beds [4]. But specialists still believe that there should be a greater reduction in hospital sizes [5], emphasizing the importance of home care as an alternative to improve the attention towards health. In Brazil, Home Assistance began in 1919. Since the 60s, the community family environments have gained value as a space for health assistance [1].
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The possibilities of Home Assistance may be split into three actions according to their degree of complexity as follows: Home Visit, Home Care and Home Hospitalization. The authors point out the importance of providing the patient/client a 24-hour support service for urgent/emergency assistance, since the majority of the services available for such are done through phone calls [1]. Home Assistance provides a series of advantages, among which one may point out the greater humanization of the treatment provided reintegrating the patient to the company of his/her family; the reduction of hospitalizations and demand for hospital emergency services; the reduction of hospital length of stay with a consequent lower risk of comorbidities acquisition and the reduction of hospital expenditures; as well as the patient‘s and family‘s satisfaction [1]. One of the components of Home Care is related to Enteral Nutrition Therapy (ENT), once the maintenance of a patient in a hospital bed with the objective of conducting this therapy for nutritional status recovery, generates a cost increase related to the hospitalization, as well as the exposure of this patient to hospital infections. Moreover, studies have demonstrated that viability of this home therapeutic modality and the economy it brings to the Health Sector[6,7,8]. The main objective of this study is to evaluate the actual tendencies of the Home Enteral Nutrition Therapy (HENT) by analyzing the stages that comprise it, from the nutritional evaluation to the decision of which access should be provided and the therapy implementation, as well as its legal fundaments, emphasizing the cost-benefit of this therapy.
METHODS This article consists of a critical literature review on the theme, based on articles published especially in indexed journals in databases such as Medline, Lilacs, Proquest, Cochrane and Doyma, searched from 1996 to 2009, in English, Portuguese and Spanish, with the use of descriptors: enteral nutrition, home enteral nutritional therapy and home assistance services. The criteria of inclusion in articles search was the approach of Home Enteral Nutrition (HEN) prevalence and incidence, epidemiological profile of patients undergoing HEN and articles that dealt with the potential of cost-savings of this therapy, either in an indirect manner (which is by reducing complications related to malnutrition and length of hospital stay) or directly involving costs. For the purposes of this work, Home Enteral Nutrition was defined as the administration of enteral feeding formula by nasal route (nasogastric – NGT - or nasoenteric tubes - NET) or ostomy (gastrostomy – GT - or jejunostomy - JT), including cases of administration of specialized formulas through oral route, as national legislations also consider as Enteral Nutrition Therapy the use of Oral Supplements in order to recover malnutrition.[9,10]
RESULTS AND DISCUSSION An amount of 32 articles were evaluated in order to analyze all aspects involved in HENT establishment, involving nutritional status assessment and also considering the
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procedures related to ENT (access routes, enteral devices). 10 articles were considered in order to analyze costs related to enteral nutrition therapy, comparing the one applied in hospital environment to the one applied at home. Brazilian legislation was also researched so that legal aspects related to HENT were defined. This section is divided into subsections, according to the procedures involved in HENT establishment.
Brazilian Legislation From a legal point of view, ―Health‖ may be pointed out as an individual‘s fundamental right. According to the Brazilian Federal Constitution, it is everyone‘s right and a State‘s duty [11]. According to the principles of SUS [3], one of the determining and conditioning factors for health is one‘s diet. It may be reinforced then, the individual‘s fundamental right to having access to food and nutrition. In the last few years, the Health Ministry has been trying to rescue the principle of Integrality existent in SUS, which comprises rescuing a view of the human being as a whole [12]. Within this approach, public policies have been emphasizing the need of a follow up treatment after patients are released from hospital care, in order to guarantee the maintenance and/ or total recovery of health and reduce the need of further hospitalization. Thus, Home Assistance is emphasized as a more human way of treatment (also including fewer risks of complications due to contact with the hospital environment), in which the individual is assisted in his/her home environment of comfort. The Universal Bioethics and Human Rights Declaration recognizes that ―(...) scientific and technological development has been and may be of great benefit to humanity inter alia in the extension of life expectancy and in the improvement of living standards‖ and it emphasizes that ―such development should always seek the promotion of welfare for individuals, families, groups or communities and of humanity as a whole, in the recognition of the human being‘s dignity, in the universal respect and observing fundamental rights and freedom‖ [13]. In Brazil, within the hospital scope, Nutritional Therapy (NT) is legally very well safeguarded, but there are gaps in relation to its continuity at home.
Steps for Home Enteral Nutritional Therapy Prescription Step 1 - Nutritional status assessment According to NT regulations in Brazil, the conduction of the patients‘ nutritional status assessment previous to the establishment of this kind of therapy is a must [9,14,15]. In Brazil, the criteria for an anthropometric assessment established by the Health Ministry through the Food and Nutritional Surveillance System – SISVAN includes the evaluation of Weight for Age for children (according to the classification of the National Center for Health Statistics – NCHS) and the Body Mass Index (BMI) for adolescents, adults and elderly people, besides the Relationship Waist–Tight for adults [16]. According to Schattner et al., the normalization of the BMI is an effective way of reducing mortality [17].
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However, various authors have proposed the use of subjective assessment tools for the prediction of patients‘ nutritional risk, previous to the setting of physical alterations imposed by the process of malnutrition [18,19,20,21,22,23]. This is corroborated by Arnaud-Battandier et al., who emphasize that the diagnosis of malnutrition already established, would provoke slower effects on a patient‘s recovery, exposing this patient to greater risks of morbid mortality, and they defend the importance of the precocious detection of the nutritional risk for the more precocious and consequently, more effective intervention [24]. For pediatric patients there are also studies concerning methods of nutritional risk screening, involving the assessment of subjective parameters other than direct measures only [25,26]. According to the American Society for Parenteral and Enteral Nutritional – ASPEN, Malnutrition corresponds to a state of nutritional disorder resulting from a nutritional low intake and metabolic disfunction [27]. According to Coats el al. [28] and Reilly et al. [29] the concept of nutritional risk has been included in the definition of malnutrition and may lead to the clinical commitment of organic functions. Various researchers have given great importance to the prevalence of malnutrition in the hospital and social environments, due to their great deleterious effect upon the general health status, above all, in individuals already bearing a disease. Malnutrition has been strongly correlated to an increase in morbid mortality, in costs and time of hospitalization [8,19,22,24,30,31]. In addition, it has been demonstrated that individuals in the community with a malnutrition risk have demanded a greater use of health resources (a greater search for family doctors, a greater need of medical prescriptions and a greater tendency to hospitalization) when compared to well nourished individuals [31]. In the clinical practice, further studies are required to identify the most adequate method for the nutritional assessment, as for more precocious identification of patients at risk for malnutrition, in order to lead to an immediate nutritional intervention [32]. In Brazil, a multicentric study conducted by Waitzberg et al., the Brazilian National Survey on Hospital Nutritional Assessment – IBRANUTRI – demonstrated that around 50% of hospitalized sick patients in general hospitals are malnourished, and that only 7.3% received nutritional therapy. When the length of stay in hospital was analyzed, the authors observed a median of 6 days permanence to nourished patients and 13 days to severely malnourished patients, who also presented greater complications (specially the elderly patients and those bearing infectious disease) and greater mortality, directly related to malnutrition. The highest numbers of obituaries were related to the malnourished elderly patients and to patients bearing cancer [33].
Step 2 – Decision for routes of access By definition of August et al., the specialized nutritional support corresponds to the administration of non oral products (enteral or parenteral) to supplement or substitute the ingestion of oral nutrients [34]. Brazilian legislation includes in the definition of enteral nutrition therapy the use of specialized and chemically defined formulas through oral route [9]. The routes of access for ENT are considered of short term when introduced through nasal or oral ways. McMahon et al. define short term access as those predicted to last less than four to six weeks [35].
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The long term accesses are the percutaneous or surgically implanted ones. In case the access recommendation is superior to a month, long term accesses are recommended [36]. One may point out the importance of a follow up assistance by a Multi professional Team in the sense of preventing complications, favoring the participation of the patient and his or her relatives in the treatment and providing his/her recovery [37].
Step 3 - Home enteral nutrition therapy indications HENT does not only aim at the humanization of assistance to the patient, but also the improvement and/or maintenance of his/her nutritional status, the reduction of post-surgery stress, the collaboration for the greater availability of hospital beds, also reducing hospitalization expenditure, the best response to a surgery treatment and the smallest risk of infection. One should point out, however, the imperative need of follow up assistance by specialized professionals [38]. Indications for HENT are related to those patients who may not achieve their nutritional needs exclusively through oral route. If the patient is not able to meet 2/3 ou ¾ of his/her nutritional requirements through oral route, a nutritional therapy should be implemented [10]. For cancer patients the minimum recommended achievement for nutritional requirements through oral route is 80%. Norton et al. report that a dysphagia secondary to a stroke has an indication of Percutaneous Endoscopic Gastrostomy (PEG) preferably to a NGT, and that an advanced stage dementia is not an appropriate reference to any form of artificial nutrition [39]. Some authors reinforce the fact that the implementation of PEG to patients with dementia had a correlation to mortality increase, although there was no data on comorbidities [40,41]. They also cite as morbidities and comorbidities indicative of HEN, especially through PEG, the following: pressure ulcers, neoplasms [42], stroke sequel. Moreover, one may also cite swallowing neuromuscular disorders and a variety of intestinal disorders, including disabortive syndromes and anorexia associated to the disease [43]. Studies emphasize that in the United Sates, neck and head cancer have an annual incidence of more than 41,000 cases, corresponding to the most common malignancy among HEN patients, and the most common problem associated to nutrition and resulting from this type of cancer and its therapy is dysphagia. They also report that an estimate of 10% of chronic head and neck cancer bearers require permanent Enteral Nutrition [17,44,45,46]. In Europe, between 1980 and 2000, patients submitted to HEN were mainly affected by malign neoplasm. However, in the last two decades, patients bearing other pathologies (neurological, traumas, among others) have increased in number, overcoming neoplastic diseases [47]. Other indications, specially regarding pediatric patients comply: swallowing problems, risk of aspiration with oral feeding, gastrointestinal disfunction [48,49], neurological and muscular disorders [49], incapacity of attaining the nutritional needs orally (respiratory and cardiac problems, muscle spasms) [50].
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Incidence and Prevalence of Home Nutritional Therapy In relation to the incidence of Home Nutritional Therapy, The North American Register of Patients on Home Enteral or Parenteral Therapy describes that in 1992 there were an estimated total number of 73,000 patients on HENT in the United States [43], which corresponds to a prevalence of 360 cases per million inhabitants [47]. The working group of the European Society of Clinical Nutrition and Metabolism reported that in 2003 there was an incidence of Home Enteral Nutrition that varied from 62 to 457 per million inhabitants per year (163 adults per million inhabitants per year), according to the region studied [31,8]. Planas et al state that the incidence of HEN in the United States is around 460 patients per million inhabitants and that in Spain that incidence is close to 40 patients per million inhabitants [51]. Paccagnella et al. reveal an incidence of 400 cases per million inhabitants of Home Enteral Nutrition in the Northeast of Italy, which according to the authors, are in consonance with the Centers of Excellence in HEN, as an indicative of a greater awareness developed by doctors and other health professionals [47]. In Brazil, mean incidence of HEN in 2005 was 147.98 cases per million inhabitants [52].
HENT Follow up Ireton-Jones emphasizes the need of a more effective patient clinical monitoring as for HENT, which for the most stable patients may only comprise the monthly review of the nutritional status (for monitoring the gain or loss of weight) and the evaluation of tolerance to the formula measured by the presence of diarrhea, nausea, vomit, abdominal distension or cramps, as well as the evaluation of water intake. For the more complex patients the complete review of the laboratorial data is also necessary [53]. This scenery is highlighted by Making, who clarifies that before making any decision in relation to HENT, an interdisciplinary evaluation should be conducted including the analysis of the nutritional status and of the nutritional needs, as well as the analysis of motor, neural, physical, and psychological abilities of patients. Sorting out family information is also necessary (social evaluation) [50]. It is worth pointing out that the interaction between hospitals and communities is fundamental, as well as the consistent monitoring of patients in HENT [54]. In the Federal District, Brazil, before HENT implementation patients are evaluated by a multidisciplinary team, who analyses the nutritional status and needs, the patients‘ clinical stability and sorts out family information. The stable patients in HENT are followed up every 3 months by nutritionists and every 6 months by physicians, in order to assess formula tolerance, nutritional status and clinical evolution, as well as clinical intercurrences [10].
Costs of Enteral Nutrition Therapy: Home x Hospital When analyzing cost-benefit of HENT, it is worth emphasizing that Brazilian legislation includes in this therapy‘s definition the use of specialized formulas through oral route [9]. This way, for the purpose of economic analysis in the present work, studies dealing with costeffectiveness of oral supplements prescription are also taken in account. This section is
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divided into 2 subsections, one that analyzes the cost savings generated by the use of oral supplements and the other, by HENT itself. Fuentes et al. investigated in a Spanish hospital that the average value of patient home assistance was 4,17 times smaller when compared to the expenses in the same conditions, in a hospital environment [7].
a) Cost savings with the use of oral supplements Arnaud-Battandier et al. proceeded a cost analysis with 311 patients split into two groups. In Group 1 there was a prescription of hiperproteic and hipercaloric supplements significantly smaller than in Group 2. As a conclusion, it was verified that the total cost per patient, per year including the costs with supplements was € 195 lower in Group 2 when compared to Group 1 [55]. Flynn and Leightty demonstrated the reduction of post-operation complications, the length and cost of hospitalization with the supplementation of HEN of 61 malnourished patients in their pre-operational stage of head and neck surgery [56]. Beattie et al. reported a positive correlation between the post operation status and Home Enteral supplementation of 101 malnourished patients, with the reduction of weight loss, an increment in muscular strength, the presentation of more favorable indicators of Quality of Life and the reduction of the need for antibiotic therapy [57]. In an analysis by Russell [31] in the United Kingdom, it was verified that in 2003, the annual expenditures with the management of patients with moderate to severe nutritional risk, related to the disease was at least £ 7,3 billion. More than half this amount (£ 3,8 billion) was spent in the hospital care of malnourished patients and £ 2.6 billion covered costs of treatment of patients needing prolonged care. Most part of this expenditure (£ 5 billion) was accomplished with elderly patients. The additional costs for the management of patients in moderate to severe nutritional risks, when compared to those involved in the treatment of patients with low nutritional risks were £ 5.3 billion [31]. For abdominal surgeries, the use of nutritional supplements generated average savings of £ 700 per patient. There was also saving for patients of orthopedic surgeries, for the care of the elderly and for pre-operational care of elective surgeries [31]. The studies analyzed in this meta-analysis have shown a net economy of costs in favor of the use of nutritional supplements, whether for length of stay or due to costs of complications. A combined analysis of all the studies reveals savings of £ 849 per patient with the use of oral supplements related to daily hospital cost and £ 298 per patient due to the reduction of any complication incidence [31]. Studies with the use of home nutritional supplements have demonstrated average savings of £ 688 per person in terms of length of hospital stay. In this case, the use of supplements was conducted before hospitalization [31]. In the United Kingdom, in 1992, an annual saving of £ 266 million was estimated if 10% of the hospitalized patients received nutritional support. There would also be a reduction of 5 days on length of stay [31]. Also, according to Russell [31] the costs of treating patients with malnutrition secondary to a disease, in the United Kingdom, were approximately 2 times higher than those estimated for obesity treatment and its consequences.
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b) Cost savings with the use of enteral nutrition therapy In an economic study involving the Home Enteral Nutritional Therapy, Baxter et al. followed 56 surgery patients in similar conditions split into two groups - a Study Group: an integrated Hospital-Home model and the Control Group: a conventional intra-hospital model. As a conclusion, the authors verified that the length of stay and costs referent to the Study Group were 2,7 times smaller compared to the Control Group with a total economic benefit of R$ 9.132,83 for each patient in the study group [6]. Elia and Stratton [58] also made a cost-utility analysis in patients receiving enteral tube feeding at home compared to the costs of the same therapy in nursing homes and in public hospitals. For the purpose of this analysis they used as a cost-utility indicator the establishment of a cost per quality adjusted life years (cost/QALY). They found that when there was full contribution from the state to nursing homes, the cost/QALY of tube feeding in nursing homes was 5.3 folds higher than the one of the therapy applied in patient‘s own home. They also found that if patients were treated in a public hospital, the cost/QALY would be 13.4 folds greater than at home. The authors still emphasize that keeping a large number of patients with chronical diseases in hospital would deny treatment to the other patients with pressing medical needs, reinforcing that cost-effectiveness can be improved by managing patients outside the expensive hospital environment [58]. Wolfe reports that in a study conducted in the Medical Center New England in Boston, MA, United States that NT in children with cancer, based on the integrated home-hospital model maximized the efficacy in patient assistance, diagnostic services and the therapy used itself [59]. Salomon-Zaban and Novaes observed that the costs associated with Hospital ENT were 2.65 fold higher than the same therapeutic modality at home. It is worth mentioning that this study included only the analysis of direct costs related to enteral formulas and infusion set [52].
CONCLUSION Data related to cost-effectiveness of nutritional support are still very scarce. However, when analyzing the clinical benefits of nutritional therapy, such as the reduction of hospitalization, through the best therapeutic response and reduction in complications incidence, one may observe a tendency of Home Enteral Nutritional Therapy in propitiating savings in managing expenditures in the health sector. In addition, the precocious establishment of this service may minimize the problem of lack of access to health services through the availability of hospital beds, contributing to the accomplishment of the principle of Universality in SUS. For the accomplishment of HENT implementation strategy, the adequate training of health professionals is necessary and their awareness in relation to the importance of precocious detection of nutritional status deviations, in order to promote intervention within appropriate time and prevention of health risks due to these deviations.
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[35] McMahon, MM; Hurley, DL; Kamath, PS; Mueller, PS. Medical and ethical aspects of long term enteral tube feeding. Mayo Clin Proc., 2005, 80(11), 1461-76. [36] DeLegge, MH. Enteral access in home care. J Parenter Enteral Nutr., 2006, 30(1), S1320. [37] Crosby, J; Duerksend, A retrospective survey of tube-related complications in patients receiving long-term home enteral nutrition. Dig Dis Sci., 2005, 50(9), 1712-17. [38] Baxter, YC; Cecconello, I. Nutrição enteral domiciliar. In: Pinotti, Henrique Walter. Nutrição enteral em cirurgia. São Paulo: Fundação BYK, 1997, cap. 29, 198-206. [39] Norton, B; Homer-Ward, M; Donnelly, MT; Long, RG; Holmes, GKT. A randomized prospective comparison of percutaneous endoscopic gastrostomy and nasal-gastric tube feeding after acute dysphagic stroke. British Medical Journal, 1996, 312, 13-16 [40] Sanders, DS; Carter, MJ; D‘Silva, J; James, G; Bolton, RP; Bardhan, KD. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol Head Neck Surg., 1998, 124, 871-75. [41] Monteleoni, C; Clark, E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. 2004. BMJ, 329(7464), 491-4. [42] Lee, JH; Machtay, M; Unger, LD; Weinstein, GS; Weber, RS; Chalian, AA; et al. Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and the neck. Arch otolaryngol Head Neck Surg., 1998, 124, 871-5. [43] North American Home Enterai and Parenteral Patient Registry: annual reports 19851990. Albany, NY: The Oley Foundation, 1987-1992, 122 08. [44] Jemal, A; Tiwari, RC; Murray, T; Ghafoor, A; Samuels, A; Ward, E; et al. Cancer statistics, 2004. CA Cancer, 2004, 54, 8-29. [45] Chua, KS; Reddy, SK; Lee, MC; Patt, RB. Pain and loss of function in head and neck cancer survivors. J Pain Symptom Manage, 1999, 18, 193-202. [46] Machtay, M; Rosenthal, DI; Hershock, D; Jones, H; Williamson, S; Greenberg, MJ; et al. Organ preservation therapy using induction plus concurrent chemoradiation for advanced respectable oropharingeal carcinoma: a University of Pennsylvania phase II trial. J Clin Oncol, 2002, 20, 3964-71. [47] Paccagnella, A; Baruffi, C; Pizzolato, D; Favaro, V; Marcon, ML; Morello, M; et al. Home enteral nutrition in adults: a five-year (2001-2005) epidemiological analysis. Clin Nutr., 2008, 27, 378-85. [48] Vanderhoof, A; Young, RJ. Overview of considerations for the pediatric patient receiving home parenteral and enteral nutrition. Nutr Clin Pract, 2003, 18(3), 221-6. [49] Daveluy, W; Guimber, D; Mention, K; Lescut, D; Michaud, L; Turck, D; et al. Home enteral nutrition in children: an 11-year experience with 416 patients. Clin Nutr., 2005, 24, 48-54. [50] Making the decision about home enteral nutrition. The Exceptional Parent, 2004, 34(7), 60-2. [51] Planas, M; Lecha, M; García Luna, PP; Parés, RM; Chamorro, J; Martí, E; et al. Registro nacional de la nutrición enteral domiciliaria del ano 2003. Nutr Hosp., 2006, 21(1), 71-4. [52] Salomon Zaban, ALR; Novaes, MRCG. Impact of the home enteral nutrition regulation issue in public hospitals in Distrito Federal, Brazil. e-SPEN e-journal. 2009, e-193-8.
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In: Advances in Sociology Research. Volume 8 Editor: Jared A. Jaworski
ISBN: 978-1-61728-997-2 ©2011 Nova Science Publishers, Inc.
Chapter 14
URBANIZATION: CAUSES, ECONOMIC EFFECTS AND ENVIRONMENTAL EFFECTS ON MENTAL HEALTH IN ASIA Norifumi Tsuno* Department of Psychiatry, Tokyo Jikei University, School of Medicine, Tokyo, Japan
ABSTRACT The ageing of populations is now a global phenomenon. The ageing of populations means that the proportion of people in the older age range increases, and the share of children and youth decreases, resulting in an ascending median age. Although it is driving the economies of most of the nations of the world, a serious concern regarding the impact of urbanization on mental health is warranted. Indeed, epidemiological studies over the last decade have supplied growing evidence of an association between urbanization and the prevalence of mental disorders. On the one hand, urbanization seems to affect the entire gamut of population especially the vulnerable sections of society elderly, children, and women. On the other hand, urban population is heavily influenced by changing cultural dynamics leading to particular mental problems like depression, alcoholism, and dementia. In view of the increased rate of psychiatric morbidity in urban areas there is likely to be a relation between urbanization and the extent to which patients use the care services. This relation might be particularly strong in the case of long-term service-dependent patients with mental health problems. The determinants, extent and outcome of the association between urbanization and mental health would require multidisciplinary research by social scientists, social psychiatrists and public health professionals. An appreciation of different conceptual models and associated methods would be required before effective research can begin. This article plans to review the demography and population ageing in Asia and the research literature on the relationship of urbanization and mental health, and finally to describe an example of health service and social welfare for the elderly in Japan. * Corresponding author: Email: E-mail: [email protected] 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461 Japan tel: 3-3433-1111 Fax: 3-3437-0228
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INTRODUCTION Urbanization in developing countries involves changes in social support and life events which have been shown to affect mental health. Although mental disorders, such as depressive or anxiety disorders, have a high prevalence and account for a large proportion of visits to primary health services there is little international health research in this field. The determinants, extent and outcome of the association between urbanization and mental health requires multi-disciplinary research by social scientists, social psychiatrists and public health professionals. An appreciation of different conceptual models and associated methods is required before effective research can begin. Other issues such as the avoidance of environmental determinism; the separation of macro-social and micro-social variables; the weakness of urban/rural comparisons of mental health; the role of rural to urban migration; the debates about cross-cultural psychiatry; and the policy-relevance of research, all need consideration in the development of research into this rapidly emerging, but relatively neglected problem. Asia is very large area and has a great variety of geographical, cultural, historical backgrounds. The diversities in Asia might have cultivated a various problems of mental health. However, the shortage of psychiatrists and other co-medical staffs, and the differences between rural and urban area is likely to be the common problem of Asian countries. In the past few decades, many efforts have been made for changing the situation in these countries. This paper aims to review the effects of urbanization in mental health and to introduce the elderly care systems in Japan.
Figure 1. Tsuno World population1950-2050
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DEMOGRAPHY AND POPULATION AGEING IN ASIA In demographic terms, the ageing of populations means that the proportion of people in the older age range increases, and the share of children and youth decreases, resulting in an ascending median age. The ageing of populations is now a global phenomenon. In 1950, there were about 130 million persons aged 65 and over in the world, constituting 5.2 per cent of the total global population. By the year 2050, there will be a tenfold increase; the world's elderly population is projected to be 1.4 billion people, about 15 per cent of the total 9.2 billion people (Figure 1). The median age of the world population will jump from 23.9 years in 1950 to 38.1 years in 2050. It is now widely recognized that the demographic trend of the past decades in Asia, are leading to unprecedented increases not only in the absolute numbers of older persons but also in the relative share of the population that belong to the elderly age groups. Most countries in Asia have a relatively young population at present. However, the majority of the elderly in the world will be living in Asia by 2035. Several Asian countries will experience a rapid change from young to old in their demographic structure. The regional distribution of the population aged 65 and over reflects the growing tendency of the world's elderly to be concentrated in developing regions. The proportion of the world's elderly population was evenly distributed between developing and developed regions from 1950 to 1975. However, by 2035, about 60 per cent of the elderly are projected to be living in Asian areas. Disaggregating these data further reveals the trend more clearly. If 1975 and 2035 are taken as two years of reference to consider the proportions of the total elderly population in different regions, it will be seen that Asia had 40 per cent of the total in 1985 but the proportion will increase to 57 per cent in 2035. Comparative figures for other regions are: Europe, 33 and 14 per cent; North America remains 10 and 7 per cent; Latin America and the Caribbean, 6 and 8 per cent; Africa, 6 and 7 per cent; Oceania, less than 1 per cent (Figure 2).
Figure 2. Tsuno Proportion of population over 65 years of age, by region, 1975 and 2035
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Norifumi Tsuno Table 1. Proportion of population aged 60 and over in Asian countries, 2005
China Japan Republic of Korea Bangladesh India Pakistan Sri Lanka Indonesia Malaysia Philippines Singapore Thailand
Total of population aged 60+ (thousands) 144 025 33 725
60+ (%)
65+ (%)
80+ (%)
11 26.4
7.7 19.7
1.2 4.8
6 571
13.7
9.4
1.4
8 777 84 661 9 323 1 863 18 869 1 711 5 054 531 7 122
5.7 7.5 5.9 9.7 8.3 6.7 6 12.3 11.3
3.5 5 3.9 6.5 5.5 4.4 3.8 8.5 7.8
0.4 0.7 0.5 1.1 0.6 0.6 0.5 1.5 1.3
In terms of proportions of the whole, therefore, developed regions will have less of the world's elderly, with an actual decline in Europe. Developing regions, by contrast, will have an increasing share of the world's elderly, with proportional increases in Asia, Latin America and the Caribbean, and Africa. Table 1 shows the proportion that older age groups represent of the total population in various Asian countries in 2005. The proportion aged 65 and over varies from a high of about 19.7 per cent in Japan to a low of 3.5 per cent in Bangladesh.
Changes of Economic Status and Family Structures in Asia In Asia, the past two decades have seen rapid demographic changes, including a shift in the population age structure, while increases in urbanization, educational attainment, and nonagricultural employment are affecting the social and economic landscape. The traditional family structures of Asia are considerably varied. Although to imagine that there is a single "Asian" family that traditionally supported the elderly in particular ways and that modernization has changed in a uniform manner would be highly misleading. In general, traditional Asian families are strongly male-dominated. Young women in Asian countries are likely to have less independence than young women in Western countries. However, with economic development and modernization, women in most Asian countries now enjoy a great deal more autonomy than they did in the past. Urbanization is seen to increase at a phenomenal rate and more women are employed. The status of women in societies of Asia has consequently been boosted which must inevitably lead to changes in family structure. In the Asian countries and areas that have experienced the greatest economic development, including Japan and Taiwan, the percentage of the elderly who reside with their children has indeed declined in the past three decades. Indeed, the percentage of the elderly who reside with their children has declined in the past three decades. In Japan, Martin
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reported a decline from 77 per cent in 1970 to 69 per cent a decade later (this occurred among individuals 65 or more years of age) (Martin 1988). Thus, although a majority of the elderly in Japan continues to co-reside with an adult child, the proportion doing so has dropped rapidly in recent decades. Other study reported a similar drop in Taiwan among the parentsin-law of native women aged 20-39 years. In 1973, 83 per cent of these women's parents-inlaw were living with a son, while in 1985, the percentage had dropped to 70.
URBANIZATION IN ASIA The rapid socioeconomic changes are underway that are assumed to have profound implications for the circumstances under which the elderly live. These changes include declines in the number of children couples have, greater longevity, increased involvement of women (the predominant providers of care) in economic activities outside the home. Physical separation of parents and adult children might be associated with urbanization and ageselective rural-to-urban migration, and ideational change, especially the spread of westernstyle individualism through the mass media and public education (Caldwell 1982; Martin 1989). While the timing and speed of urbanization have varied and are varying between countries, regions, and continents, the urbanization process has taken hold everywhere. It has proven to be an unstoppable and a mostly desirable phenomenon. Cities are the foundation of modern civilization; they are the engine room of economic growth and the centers of culture, entertainment, innovation, education, knowledge, and political power. Urbanization alters the dynamics of society at large and family in particular. Rapid increase in urban population as a proportion of total population is resulting in rapid urbanization of the world. In the near future, a majority of the world's population will be living in the cities. Rapid urbanization has created a huge population of older men and women left to fend for themselves in the rural areas while the young make their living in the cities. While the antecedents of urbanization are long, contemporary urbanization is now predominantly a developing-country phenomenon, centered largely in Asia. In addition, Asia has unique, diverse and enormous urban and urbanization problems. Asia not only has the largest number of people among the continents, it also contains the largest number of urban dwellers, accounting for about half of the world's urban population. Urbanization levels in Asia are regionally diverse with South Asia at the bottom with only 26% (1989) of the population living in urban areas; West Asia has a high of 60% and East Asia 47%. In future, therefore, the tempo of urbanization will be most rapid in South Asia, where rural-urban migration emanating from the rural push factor will be intense. Historic and cultural differences, which are reflected in urban form and function, occur not only in the macro-regions of Asia, but also within countries, where these diversities are often polarized from one region to another. Islamic cities of West Asia differ from the colonial and traditional cities of South Asia. The introverted urban form of Islamic cities which are centered around the mosque and bazaar, contrast with traditional cities of South Asia which generally do not have a religious focus. The relatively less commerce-dominated cities of socialist China stand in contrast to the market economy-dominated, modern central business district (CBD)-based cities of Japan.
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EFFECTS OF URBANIZATION ON PSYCHIATRIC DISORDERS Urbanization brings with it a unique set of advantages and disadvantages. Though it is driving the economies of most of the nations of the world, a serious concern regarding the impact of urbanization on health is warranted. Data that are available indicate a range of urban health hazards and associated health risks: substandard housing, crowding, air pollution, insufficient or contaminated drinking water, inadequate sanitation and solid waste disposal services, vector-borne diseases, industrial waste, increased motor vehicle traffic, stress associated with poverty and unemployment, among others. Local and national governments and multilateral organizations are all grappling with the challenges of urbanization. Urbanization has brought its own set of problems pertaining to mental health and wellbeing. Many studies suggest that prevalence of mental disorders is higher in urban areas than in rural areas (Eaton 1974; Cagle 1986; Keatinge 1987; Thornicroft 1993; Sytema 1991; Dekker 1997; Peen 1997). In addition, this urban/rural differences are reflected in various psychiatric disorder (Peen 2002; Van 2001). A plausible explanation for the urban-rural differences is that environmental factors associated with urban life make individuals more vulnerable to the development of mental disorders. This hypothesis is that people in highly urbanized communities suffer from psychiatric syndromes because of environmental stressors, such as a lack of social cohesion, restricted living space, over-stimulation, lowquality housing and higher levels of crime. Other explanatory hypothesis assumes that selective migration may take place, resulting in a concentration of the mentally ill in more urbanized environments. Although concentrations of, in particular, psychotic patients in deprived inner-city areas have often been documented (Giggs 1987), evidence about the "drift process" hypothesis within cities is sparse. The number of available studies about urban-rural drift is also sparse. This problem mainly stems from the difficulty in controlling, in addition to urbanization, other risk factors such as gender, socio-economic class and marital status. For instance, dementia, depression and anxiety disorders are more often found in women, and substance abuse disorders are more prevalent in men. Higher socio-economic class and being married/living with a partner are protective factors for psychiatric disorders (Thornicroft 1991). In the adult population, the influence of age as a risk factor is less clear in mental disorders, except for dementia (Reigier 1993). It is not currently known whether urbanization, gender, socioeconomic classes, marriage and age may be interrelated. The interaction of urbanization with these factors has rarely been investigated. The impact of urbanization on mental health in Asian countries needs to be examined. These countries, particularly in South Asia, by virtue of their developing economies and a significant proportion of population still living below poverty line are vulnerable and tend to have a higher burden of diseases with an already compromised primary health care delivery system. The range of disorders and deviancies associated with urbanization is enormous and includes psychoses, depression, dementia, substance abuse, alcoholism, and developmental disorders. Urbanization is affecting the entire gamut of population especially the vulnerable sections of society - elderly, children, and women. Rapid urbanization has also led to creation of "fringe population" mostly living from hand to mouth which further adds to poverty. Poverty
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and mental health have a complex and multidimensional relationship. Urban population is heavily influenced by changing cultural dynamics leading to particular psychiatric problems like depression, alcoholism, and delinquency. Judicious use of resources, balanced approach to development, and sound government policies are advocated for appropriate growth of advancing economies of Asian region.
SOCIAL POLICY ON URBANIZATION AND AGEING SOCIETY IN JAPAN All family systems in Asia traditionally faced the problems of generational succession, economic support of the non-active elderly and physical or mental care of the frail elderly. The structures that provided solutions to these problems were by no means uniform. There are no universal models for mental health care. Even in well-developed mental health programs, a wide variety of problems exist. Japan has different feature from developing Asian countries. There are a large number of psychiatrists, and the largest number of psychiatric beds in Asia. Almost 90% of the people in Japan choose medical facilities as their first caregiver when they are mentally ill. However the shortage of psychiatrists and other co-medical staffs, and the differences between rural and urban area is likely to be the common problem of Asian countries. To deal with problems related to the urbanization and ageing society, since 1989, the Japanese government was promoting the New Ten-Year Strategy to Promote Health Care and Welfare for the Elderly (The New Gold Plan) that is the compilation of health and welfare plans for the elderly formulated by all local governments in Japan. The New Gold Plan presented the basic framework for the measures to point out the directions for the development of various services by indicating that it was urgent to develop the infrastructure for long-term care service for the elderly. It determined the basic concept as user-orientation and self-sufficiency support, universalism, provision of comprehensive services, and localism. The much-lauded Japanese Gold Plan for providing health care for older citizens is increasingly being subjected to criticism on the basis of its expense. Major retrenchments are being proposed in light of economic recession and national conflict. The Japanese government has recognized the importance of family care as one aspect of panoply of formal provisions and the contradictory clashes imposed by need to work and need to care. Beginning in 2001, Japanese families started receiving payments for providing care to the most needy older relatives; no matter how little the payment, it was an ameliorative step in the provision of what are termed "silver services". For smooth implementation of the longterm care insurance system in April 2000 (this system is mentioned in chapter 6), it might be critically important to develop the long-term care service supply system in an orderly manner based on the New Gold Plan (MHLW 2007). For the long-term care insurance system individual municipalities are assigned to create the business plan for the long-term care insurance with understanding of the actual conditions of long-term care needs, etc. by projecting the required long-term care services in the future. During fiscal 1999 all municipalities in Japan were expected to create the first phase of the five-year plan of fiscal 2000 to fiscal 2004, and the preparation for service supply system for the five-year period began in accordance with the plan.
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1) Improving the foundation of long-term care services "Long-term care services available whenever and wherever" Secure human resources and enhance training. Develop long-term care related facilities. Improve the quality of services offered at such facilities. 2) Promoting support measures for the elderly "Building a society where the elderly can live with dignity" Develop group homes for elderly. Improve the quality of long-term care for elderly patients. Enhance the system for protecting the rights of the elderly. 3) Promoting measures to revitalize the elderly "Implementation of the 'Project Well Preserved Elderly'" Promote a comprehensive approach in disease management. Build a regional rehabilitation system. Promote a positive attitude in life, preventative approach in long-term care, and social participation by the elderly. 4) Developing a support system in communities "Creation of supportive and caring communities" Support to build a caring community. Enhance living support services. Improve the living environment, etc. 5) Developing long-term care services which protect and are trusted by users. "Creating services which one can choose with confidence" Promote the use of information technologies and protection of users. Encourage entries into the industry by a diverse range of businesses. Develop and spread welfare devices. 6) Establishing a social foundation supporting the health and welfare of the elderly "Laying the foundation supporting health and welfare" Promote longevity science. Promote social welfare education. Promote international exchanges.
Source: Ministry of Health, Labour and Welfare (MHLW). Direction of Health and Welfare Policies for the Elderly over the Next Five Years－Gold Plan 21－(2008) URL: http://www.mhlw. go.jp/english/topics/elderly/care/index.html
The Japanese government released a revised version of the New Gold Plan (The Gold Plan 21) in 2001. Basic direction of the plan were 1.vitalizing the image of the elderly, 2. ensuring and supporting the independent living with dignity for the elderly, 3. developing mutually supportive local communities, and 4. establishing long-term care services users can trust. Specific measures to be implemented in the plan are shown in Table 2. The Japanese government also encourages employers to hire more senior people. Until recently, most companies set the retirement age at 60, but the government started in 2006 to gradually delay the payment of public pension from 60 to 65, phasing the change in over some years. To fill the blank between 60 and 64, when many people would have few income sources, legislation was enacted in 2006 ensure companies to keep employees until the age of 65. They would receive a warning if they act against it. Although older workers are remaining in the labour force, employers are able to cut pay to older workers. The Government is also proceeding with comprehensive ageing-society measures to encourage the elderly to be more independent. In fiscal 2007, the Government set aside 13.63
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trillion yen, almost equivalent to the previous year, to support employment, nursing-care, education, social participation, living environment and research into cancer. "Innovation 25," Japan's first long-term policy roadmap on innovation released in May 2007, calls for greater working opportunities for women and the elderly and improving productivity over the next two decades with the advent of the ageing society. Public pension and insurance schemes are constantly being reformed.
SUPPORTS FOR THE ELDERLY - AN EXAMPLE OF HEALTH SERVICE AND SOCIAL WELFARE FOR THE ELDERLY IN JAPAN Japan has already experienced large declines in fertility and mortality and has tremendous momentum for further population aging. The aging speed of the Japanese population is faster than that of any other developed countries. The year when the proportion of those aged 65 and over reached 7 percent of the total population was 1865 in France, 1890 in Sweden, and 1970 in Japan. The time required to double this proportion was 115 years for France, 85 years for Sweden, and 25 years for Japan (Kim et al 2001). This increase will continue to reach 35.7% in 2050. The significance of the disproportionate increase in 'old-old' for long-term health care lies in the greater prevalence of functional impairment and chronic disease among older persons. Functional impairment and the need for help can have enormous impact on the elderly and their families. Thus, long-term health care for functionally impaired older persons is a serious concern for almost every older person, most multi-generation families, numerous service organizations, and public agencies at every level of government. The long-term care insurance, which was started in Japan from 2000 and is run by municipalities, provides nursing care for the aged person both at home and in institutions. It was introduced primarily as a mechanism to ease the burden of families looking after their frail elderly. Eighty five per cent of family members providing support are women. The need for such a mechanism has intensified as the population ageing advanced and the female labour market participation increased. Not only the number of elderly requiring assistance but also the age of the family members providing the support has increased. The introduction of this system was expected to bring with it an easing of the financial burden on the health insurance by shifting many inpatient elderly away from hospital beds towards nursing beds and by covering certain services that were subject to reimbursement by the health insurance. Half of the revenues of the nursing care insurance come from premiums that are paid by those 40 years of age or older, and the other half from the government. Premiums for persons aged 65 over are set by each municipality according to their income level but the gap among the municipalities is much smaller than that of health insurance because of a greater role of risk equalisation mechanism. A distinct feature of the long-term care insurance scheme is that it has a gatekeeper function. The needs of the elderly who ask for benefits must be assessed and the status of the elderly classed into one of six categories, each with a ceiling for maximum spending per month. The assessment, which is formally a decision of a specialised committee, is carried out by a newly created Care Manager in consultation with family members and, where necessary, doctors. Care managers then help
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the elderly to prepare a specific plan of service use that would best meet their needs within a ceiling of maximum allowable spending. A co-payment of 10 per cent applies. Overall, the new insurance system seems to contribute to the expansion of care services. While it is too early to draw firm conclusions, the wide acceptance for the introduction of the scheme suggests that it is possible to raise social charges if accompanied by a corresponding increase in the services for which latent demand is strong. Utilisation of care services has increased significantly, and so has their supply capacity with new service providers entering the market. There has also been a reduction in social hospitalisation with a significant decrease in the number of geriatric beds covered by health insurance. Surveys by municipalities suggest that 40 to 50 per cent of the families who received care services reported that their physical burden had been reduced compared with the situation prior to the introduction of the long-term care insurance. The introduction of the long-term care insurance so far has raised some issues. Firstly, co-payments have been criticised as discouraging the elderly poor unduly from using the services available, even though a cap applies for these people. As of the end of 2000, out of some 2.5 million elderly whose needs had been assessed, about 600 thousand were not using the services. Insurance premiums are also slightly regressive. The collection of premiums that started on October 2000 has encountered some compliance problems despite the fact that only half the premium applies until October 2001. Indeed, municipalities have adopted ad hoc measures to alleviate the financial burden for the elderly poor. Second, relative prices of various services need to be adjusted, particularly as between home care and institutional care. Actual utilisation of home-care services was about 80 per cent of the approved budget, while waiting lists have continued to expand for special care institutions. This suggests that the relative prices should be changed to shift demand from institutional care to home care. Among the various home care services too there seems to be a scope for changing relative prices. In particular, demand has expanded most for assistance for household work, which is the least expensive. But this service does not appear to be profitable for the service providers. Effective relative price changes for users of services can also be brought about through variable co-payment rates across services as well as net of transfer payments. Finally, there are issues concerning the linkages between the long-term care insurance and the medical scheme for the elderly. As noted above, the reduction in geriatric beds covered by the health insurance was less than anticipated, by about 40 per cent. This entailed a greater benefit payment by the health insurance than otherwise, and vice versa by the longterm care insurance. The less-than-hoped-for shift of beds from one insurance scheme to the other was primarily due to initial uncertainty about the benefit levels under the long-term care insurance. Certain municipalities also hesitated to encourage such a shift because it meant higher spending from their own budget. The lessons lLearnt from the first 5 years of experience through, the Review of the longterm care insurance in 2005 makescreated policy change in elderly care, with the main objective for to enhance the self-reliance of the elderly, by encouraging and training them to be active in self-care, including house cleaning and preparing meals-with the help of caregivers (MHLW 2005a, b, 2006).; Ffor example, the new form of assistance limits the use of wheelchairs and instead, offers "resistance training" to increase muscle strength. The new, immediate, initiatives are focused on the more fundamental shift from service to self-help for those who can manage their daily tasks and keep health in good shape: elderly are 'required'
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to attend preventive care services: oral care, training to prevent health deteriorations and accidents, diet advice and preventive nursing care visit.
INNOVATIVE PROGRAMS FOR AGEING SOCIETY IN JAPAN The impact of the ageing society is so huge that it is creating new problems even before the government can solve exiting ones. Policy and social prospectsdevelopments are looking increasingly worrying not only in Western countries but also in Asian countries. To relieve reduce risk negative factors from the ageing society, it is strengthening advanced medical research of diseases affecting the elderly and promoting preventive medicine. It is also boosting research into innovative technologies as substitute for or complementary to manpower. Over the past few years, many prospective technological studies in the field of ageing has been carried out with a focus on the role that information and communication technologies (ICT) can play to promote active ageing. For example, the European Union's Action Plan (2007-2015) for Ageing Well in the Information Society, accompanied by a new joint European research programme raising to over ?1bn the research investment on ICT, targets at improving the life of older people at home, in the workplace and in society at large (European Commission 2007). The issue from several perspectives includes the socio-economic and technological dimensions of both the ageing phenomenon and the active ageing policies that the EU is now adopting. ICT for active ageing attempts to reflect aspects of the contribution ICT can make to quality of life for older citizens in Europe. Benefits can be found in health, employment, housing and elsewhere. The Japanese government is also accelerating efforts to support medical research and technological development. As for ICT, the government's goal is to build up a so-called uJapan (ubiquitous Japan). This is very much in line with the policy initiative in most of the East Asian industrialized economies which have already been developing their portals for an e-government and e-commerce, and the development is always making mobile communication ubiquitous and omnipotent (Lai 2004, 2005, 2008; MPHPT 2004; MIC 2007; MHLW 2008). This mega-project initiative will be instrumental for enabling better quality of ageing life. ICT promise borderless, flexible and ubiquitous contacts: real time, round-theclock and anywhere...making geo-spatial conditions all but irrelevant. The ICT empowered digital gadgets, like mobile phone, PDA, iPod (described in detail in the paper by Lai 2008), have been constituting and facilitating various communicative encounters in both real and virtual worlds, as well as their differential forms of, mobile, mediated networking in new social life; obviously all these are well embraced by Japanese at large (Lai 2008). Besides ICT, robotic technology as substitute or complementary manpower is also one of the Japanese government's important initiatives on medical research and technological developments in an effort to sustain the rapidly ageing society. According to a report by the Machine Industry Memorial Foundation (Japan), next-generation robotics can replace some human labour such as nursing-care assistance, and lead to a shrinkage of 2 trillion yen in the government's expenditure on the long-term care insurance. So far, Japanese development of medical technologies has been largely initiated by private companies. However, in May 2008, the Council for Science and Technology Policy
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(CSTP), an S&T science and technology policy board of the Cabinet Office, announced a five-year roadmap to implement a 'project to accelerate the translation of research and development results into society.' The project consists of six categories that are stipulated in the'Innovation 25' report. It is also one of 'Innovative Technology Strategies,' which CSTP identified to make already globally competitive technologies even stronger. Programmes in each category have to proceed with some requirements, such as development of interdisciplinary technologies, collaboration between universities, the public and private sectors and deregulation/system reforms. In five years, researchers will be expected to enter an advanced research and development stage either in the form of verification research or clinical research. It is still a long way to go until research results start to benefit society. Many technological projects are at the stage of elementary development, and it will take several years at the earliest to start clinical testing of medical research. However, the potential market for innovative solutions in ICT and robotic technologies for active ageing would be crucial for the Japanese economy and for other ageing societies. Moreover, the promotion of societal values in Japan regarding ageing might serve as a model for other ageing societies.
REFERENCES Caldwell, John, C. (1982). The Theory of Fertility Decline, (New York, Academic Press). Cagle, LT; Banks, SM. The validity of assessing mental health needs with social indicators. Eval and Progr Planning, 1986, 9, 127-142. Dekker, J; Peen, J; Gardien, R; de Jonghe, F; Wijdenes, W. Urbanisation and psychiatric admission rates in the Netherlands. Int J of Soc Psychiatr, 1997, 43, 235-246. Eaton, WW. Residence. social class and schizophrenia. J of Health and Soc Behav, 1974, 102, 627-633. European Commission, Ageing well in the Information Society: An i2010 Initiative - Action Plan on Information and Communication Technologies and Ageing {SEC(2007)811}. Brussel: European Commission. Retrieved on: 2. URL: http://ec.europa.eu/information_society/newsroom, 2007. Giggs, JA; Cooper, JE. Ecological structure and the distribution of schizophrenia and affective psychoses in Nottingham. Br J of Psychiatry, 1987, 151, 627-633. Keatinge, C. Community factors influencing psychiatric hospital utilization in rural and urban Ireland. Comm Ment Health J, 1987, 23, 192-203. Kim, IK; Maeda, D. A comparative study on sociodemographic changes and long-term health care needs of the elderly in Japan and South Korea Journal of Cross-Cultural Gerontology, 2001, 16, 237-255. Lai, OK. Differential E-mobilization and cyberspace in East Asian economies: Contours of the emerging cyber-activism and (Anti-) democratic regimes in the informational society. In J. Abbott, (Ed.), The political economy of the internet in Asia and Pacific. Westport, CT: Praeger. 2004. Lai, OK. Cultural imperialism, state‘s power and civic activism in and beyond cyberspace: Asia‘s newly industrializing economies (NIEs) in comparative perspective. In R.
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Smandych, & B. Hamm(Eds.), Cultural imperialism: Essays in the political economy of cultural domination. Peterborough: Broadview. 2005. Lai, OK. The Enigma of Japanese Ageing-in-Place Practice in the Information Age: Does Digital Gadget Help the (Good) Practice for Inter-Generation Care? Ageing Int., 2008, 32, 236-255. Martin, Linda, G. "The aging of Asia", Journal of Gerontology: Social Sciences, 43 (July), S99-S113. 1988. Martin, Linda , "Living Arrangements of the Elderly in Fiji, Korea, Malaysia, and the Philippines", Demography, 1989, 26, 627-643. Ministry of Health, Labour and Welfare (MHLW). White paper on the elderly. Tokyo: MHLW. 2005a. Ministry of Health, Labour and Welfare (MHLW) (2005b). Review of long-term care insurance. Tokyo: MHLW. Ministry of Health, Labour and Welfare (MHLW). White paper on the elderly. Tokyo: MHLW. 2006. Ministry of Health, Labour and Welfare (MHLW) 2007. Annual Reports on Health and Welfare 1998-1999 Social Security and National Life. URL: http://www.mhlw.go.jp/english/wp/wp-hw/index.html Ministry of Public Management, Home Affairs, Posts and Telecommunications, Japan (MPHPT) (2004). Information and communications in Japan—white paper 2004. Tokyo: MPHPT. Ministry of Internal Affairs and Communication (MIC) (2007). 2007 White paper on Information and Communications in Japan. Tokyo: MIC. Ministry of Health, Labour and Welfare (MHLW) (2008). Direction of Health and Welfare Policies for the Elderly over the Next Five Years－Gold Plan 21－. URL: http://www.mhlw.go.jp/english/topics/elderly/care/index.html Peen, J; Dekker, J. Admission rates for schizophrenia in The Netherlands: an urban/rural comparison. Acta Psychiatr Scand, 1997, 96, 301-305. Peen, J; Bijl, RV; Spijker, J; Dekker, J. Does the prevalence of psychiatric disorders increase with urbanisation? Tijdschr Psychiatrie, 2002, 44, 225-235. Regier, DA; Farmer, ME; Rae, DS; Myers, JK; Kramer, M; Robins, LN; George, LK; Karno, M; Locke, BZ. One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study. Act Psychiatr Scand, 1993, 88(1), 35-47. Sytema, S. Social indicators and psychiatric admission rates: a case-register study in the Netherlands. Psychol Med, 1991, 21, 177-184. Thornicroft, G. Social deprivation and rates of treated mental disorder. Developing statistical models to predict service utilisation. Br J Psychiatry, 1991, 185, 475-484. Thornicroft, G; Bisoffi, G; De Salvia, D; Tansella, M. Urban-rural differences in the associations between social deprivation and psychiatric service utilization in schizophrenia and all diagnoses:a case-register study in Northern Italy. Psychol Med, 1993, 23, 487-496. Van Os, J; Hanssen, M; Bijl, RV; Vollebergh, W. Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Arch Gen Psychiatry, 2001, 58, 663-668.
INDEX A abortion, 173 absorption, 65 abuse, 2, 3, 5, 6, 7, 8, 133, 146, 174, 218, 220, 223 academic difficulties, 25 academic performance, 5 academic problems, 24 accessibility, ix, 89, 90, 103, 126 accommodation, 66, 152, 154, 157, 158, 159, 160, 162, 164, 165, 166 accountability, 55, 66, 82, 86 accounting, 103, 125, 247 accreditation, 119 accuracy, 96, 127, 136 activism, 254 activity level, 106 actuation, 97 adaptability, 7, 96 adaptation, 6, 13, 17, 26, 46, 110, 204, 206, 209, 213 adaptations, 204, 207 ADHD, 14, 19, 29 adjustment, 2, 3, 6, 127, 133, 134, 147, 148 admissibility, 61 adolescents, vii, ix, 12, 15, 17, 18, 19, 21, 22, 24, 27, 28, 29, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 142, 143, 144, 145, 146, 147, 149, 210, 232 adulthood, 3, 147, 149 advantages, 64, 125, 171, 231, 248 advocacy, 77, 83 aerodigestive tract, 241 aesthetics, 180
affective experience, 9 affirming, 45, 174 Africa, 204, 245, 246 African Americans, 135 ageing population, 90 agencies, 28, 85, 120, 153, 159, 218, 251 aggression, 3, 4, 8, 12, 15, 26, 27, 147, 205, 207, 214 aggressive behavior, 22, 26, 207 aging population, 91, 109 agoraphobia, 155 agricultural sector, 116 agriculture, 43, 44, 206 alcoholism, xii, 243, 248, 249 alertness, 12 alters, 247 altruism, 184 American Psychological Association, 23, 24 Americans with Disabilities Act, 157, 164 amphibians, 206 amygdala, 14 analytical framework, 127 anger, 4, 5, 24 anorexia, 234 ANOVA, 139 anterior cingulate cortex, 14 anthropocentrism, 32, 38, 43, 44, 181 antibiotic, 236 antisocial behavior, 3, 5, 26, 209, 211, 213 antitrust, 46 anxiety, 3, 5, 8, 11, 13, 14, 16, 18, 20, 22, 24, 26, 27, 28, 106, 207, 244, 248 anxiety disorder, 3, 18, 22, 24, 27, 244, 248 apathy, 193 appointments, 68 architects, 91
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architecture, 66, 68, 90, 91, 110 Aristotle, 34, 37, 38, 40, 170, 178 arousal, 4, 5, 11, 12, 16 arthritis, 101 articulation, 76 Asia, vi, vii, xii, 39, 204, 243, 244, 245, 246, 247, 249, 254, 255 Asian countries, 39, 63, 244, 245, 246, 248, 249, 253 asphyxia, 114 aspiration, 234 assessment, 55, 63, 106, 109, 160, 164, 231, 232, 233, 239, 251 assessment tools, 233 assets, 104 assimilation, 64 assistive technology, 157, 161, 166 asymmetry, 175 attachment, vii, ix, 3, 5, 6, 11, 20, 23, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 142, 143, 144, 145, 146, 147, 148, 149 attachment theory, 23, 132, 144, 147, 148 attentional bias, 5, 11, 18 attentional training, 28 attribution, 15, 16, 28, 61, 220 attribution bias, 15, 16 authorities, 36 autism, 12, 26 autonomic nervous system, 27 autonomy, x, 36, 46, 47, 65, 66, 93, 147, 169, 176, 177, 181, 189, 246 avoidance, 13, 22, 112, 207, 208, 244 avoidance behavior, 13
B back pain, 94 background noise, 102 balanced state, 12 Bangladesh, v, 51, 59, 66, 67, 68, 69, 246 banks, 196 bargaining, 74, 83 barriers, viii, ix, x, 71, 74, 89, 90, 119, 126, 151, 160, 162, 166 basic research, 22 baths, 101 behavior of children, 18 behavioral disorders, 4, 19 behavioral problems, 3, 6, 16, 132, 148 behavioral sciences, 214
behaviors, xi, 6, 7, 8, 9, 13, 15, 19, 122, 124, 133, 203, 204, 205, 207, 208, 209, 210, 211 Beijing, 27 Belgium, 63 benchmarking, 87 benchmarks, 76 benign, 13 beverages, 156 bias, 5, 15, 24, 34, 85 Bible, 33 biodiversity, 179, 180 bipolar disorder, 156 birth control, 121 birth rate, 116, 118 births, ix, 113, 114, 115, 118, 120, 121, 125, 126, 129 body weight, 238 bonds, 91, 144, 224, 228 bones, 104 borderline personality disorder, 23, 28 Bosnia, 58 brain, 4, 14, 27, 179, 214 Brazil, vi, xii, 229, 230, 232, 233, 235, 240 breakdown, 19 breastfeeding, 123, 128 breathing, 12 bridges, 97, 98, 148 Britain, 62, 63, 204 Buddhism, 39, 43 buildings, 91, 104 bulimia, 28 bulimia nervosa, 28 burn, 106, 161, 164 bystander effect, 208, 209
C Cabinet, 62, 254 cabinets, 62, 95, 102 Cambodia, 58 campaigns, 218 cancer, 14, 23, 233, 234, 237, 240, 241, 251 candidates, 63, 193, 197 CAP, 159 capitalism, 32, 37, 39, 41, 42, 44 carbon, 92 carbon monoxide, 92 carcinoma, 240 care model, 19
Index caregivers, vii, 1, 2, 6, 8, 9, 10, 16, 17, 133, 145, 148, 252 caregiving, 3, 109, 133, 144, 146 Caribbean, 245, 246 cartel, 188 case study, viii, 51, 196 catalyst, 122 catastrophes, 56 categorization, 53, 195 category a, 221 cattle, 173 CEC, 87 cell culture, 182 Census, 213 chaos, 2, 6, 196 charitable sector, 82 Chief Justice, 67, 68 child abuse, 2, 24, 27, 147, 227 Child Behavior Checklist, 3, 18 child maltreatment, 19, 25 child mortality, 115, 120, 125, 127 child protection, xi, 217, 218, 221, 222, 226, 227, 228 childhood, 2, 3, 5, 6, 7, 15, 19, 20, 21, 23, 122, 133 childhood sexual abuse, 23 China, 12, 27, 118, 127, 246, 247 Christianity, 48 chronic illness, 14 churches, 36 circulation, 94, 99 citizenship, 55, 75, 190 city, vi, 48, 184, 203, 208, 212 civil rights, 189 civil society, x, 52, 58, 68, 69, 74, 79, 80, 85, 86, 187, 188, 189, 190, 191, 194, 195, 196, 197, 198, 199 civil war, 56 civilization, 32, 43, 247 clarity, 33, 154, 160 class, 248 classroom, 3, 5, 28, 156 classroom environment, 156 cleaning, 252 cleavages, 59, 66 clients, 8, 154, 197 climate, 162 clinical trials, 239 close relationships, 134 coding, 192
259 coercion, 45 coffee, 100, 135 cognition, 5 cognitive abilities, 90 cognitive ability, 27 cognitive flexibility, 17 cognitive function, 97 cognitive impairment, 164 cognitive performance, 12 cognitive process, 9 cognitive processing, 9 cognitive representations, 133 cognitive therapy, 23, 26, 27, 28 coherence, 174 college students, 208, 213 colleges, 160 collisions, 107, 172, 173 Colombia, 212 colonization, 124 communication technologies, 253 community, viii, ix, x, 2, 5, 9, 15, 20, 28, 31, 35, 37, 41, 45, 46, 47, 51, 52, 54, 55, 56, 57, 63, 65, 81, 82, 83, 84, 91, 106, 109, 111, 112, 115, 121, 127, 131, 132, 134, 149, 151, 155, 158, 160, 163, 164, 165, 167, 171, 209, 210, 211, 215, 219, 228, 230, 233, 241, 250, 255 compatibility, 96, 181 competition, xi, 61, 203, 204, 215, 216 competitiveness, 84 compilation, vii, 249 complaints, 3, 15 complement, 162, 164, 205 complex interactions, 160 complexity, 6, 72, 73, 75, 86, 96, 97, 163, 231 compliance, 22, 66, 252 complications, xii, 104, 229, 231, 232, 233, 234, 236, 237, 240 composition, 114 compounds, 7 compulsory education, 118 conceptual model, xii, 243, 244 concordance, 146 conditioning, 232 conduct disorder, 12, 26 conduction, 232 conference, 76 confidentiality, 160, 162 configuration, 180 conflict, xi, 4, 14, 52, 55, 57, 59, 64, 66, 80, 99, 190, 205, 207, 229, 249
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Confucianism, 39 consciousness, 32, 40, 41, 45 consensus, 56, 63, 64, 66, 77, 84, 85, 178, 190 consent, 135, 136, 176, 177 Constitution, 67, 88, 232 constitutional amendment, 67 constitutional principles, 64, 68 consumer goods, 116 consumption, 206 contingency, 60, 226 control group, 3, 5, 11, 14, 15 convergence, 64, 66, 77, 82 conviction, 58, 67, 170, 172, 174, 176 cooking, 106 coordination, viii, 71, 76, 87, 127, 159 coping strategies, 13 correlation, 214, 234 correlational analysis, 137 correlations, 137, 139, 144, 216 corruption, 67 cortisol, 13, 19, 21 cost, xii, 105, 119, 123, 158, 159, 163, 166, 204, 230, 231, 235, 236, 237, 241 Council of the European Union, 87, 88 coup, 190 covering, 159, 251 creativity, 157 criminal behavior, 4 criminality, 4 criticism, 37, 43, 83, 205, 249 critics, viii, 31, 32, 39, 47 crop production, 124 crops, 42 cues, 5, 11, 97, 210 cultural differences, 65, 208, 247 culture, 10, 43, 65, 92, 170, 190, 247 curriculum, 12 cyberspace, 254
D daily living, 90, 152, 153, 154, 163 damages, iv, 222 danger, 43, 206 data set, 219 death rate, 116, 118 deaths, ix, 103, 106, 113, 114, 115, 121, 122, 124, 125, 126, 127 decay, 175 decentralization, 193
decision-making process, 75, 78, 85, 86 decomposition, ix, 113 deduction, 158 defence, 68 deficiencies, 179 deficiency, 115 deficit, 72, 78, 81, 86 degenerate, 34 delegation, 65 delinquency, 3, 19, 249 delinquent behavior, 210 dementia, xii, 171, 234, 240, 243, 248 democracy, viii, x, 44, 51, 58, 59, 60, 61, 63, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 187, 188, 190, 199 democratic elections, 60 democratisation, 72, 80 democratization, xi, 59, 119, 187, 188, 189, 190, 198 democrats, 73 demographic change, 246 demographic factors, 210 demographic structure, 245 demographic transition, 118 demography, xii, 243 deontology, 173 Department of Health and Human Services, 6, 27, 149 Department of Veterans Affairs, 158 dependent variable, 60 depression, xii, 5, 8, 11, 12, 13, 14, 16, 20, 23, 134, 148, 149, 243, 248, 249 depressive symptoms, ix, 24, 131, 134, 135, 136, 137, 138, 139, 140, 142, 144, 145 deprivation, 148, 215, 255 deregulation, 254 destiny, 183 destruction, x, 43, 169, 170, 173, 176, 180, 181, 184 detachment, 12 detection, 55, 122, 123, 233, 237 determinism, 244 deterrence, 57, 211 developed countries, 115, 126, 190, 230, 251 developing countries, ix, 66, 113, 125, 127, 129, 244 developmental disorder, 248 developmental milestones, 123 developmental psychopathology, 20 diabetes, 103
Index diagnosis, 17, 233 diarrhea, 124, 235 diet, 232, 253 digestion, 4 dignity, x, 55, 97, 169, 172, 176, 177, 181, 182, 232, 250 diplomacy, 46 direct cost, 237 direct costs, 237 direct measure, 233 directives, 111 disability, x, 37, 90, 151, 152, 153, 154, 157, 158, 160, 161, 162, 163, 164, 165 disadvantages, 248 disaster, 173 discontinuity, 149 discrimination, 64, 65, 173 disorder, 11, 24, 26, 28, 215, 233, 248, 255 dispersion, 73 disposition, 197 dissatisfaction, 230 dissociative disorders, 3 distortions, 5 distress, 13, 145 disturbances, 3 diversification, 64 diversity, 65, 73, 81, 85, 90, 91, 111, 163, 165, 192, 193, 216 doctors, 233, 235, 251 dogs, 174 domestic demand, 116 domestic violence, 8, 148 dominance, xi, 62, 187, 189, 190, 192 donors, x, 59, 169, 176, 177, 181 draft, 85 drawing, 62, 226 dream, 46 drinking water, 124, 248 drugs, 119 duality, 191 dysphagia, 234
E early warning, 55 East Asia, 247, 253, 254 East Timor, 58 eating disorders, 3 ecology, 204 e-commerce, 253
261 economic development, 57, 115, 246 economic disadvantage, 210 economic goods, 195 economic growth, 115, 116, 118, 127, 247 economic incentives, 43 economic policy, 64, 77 economic reform, 84 economic resources, 42, 46, 57 economic status, 226 economies of scale, 81 economy, ix, xii, 42, 44, 46, 47, 81, 113, 115, 117, 118, 119, 123, 127, 230, 231, 236, 254, 255 educational attainment, 124, 246 educational settings, 26 El Salvador, 200 elaboration, viii, 51, 76, 227 elderly population, 91, 110, 245 elders, 112 election, 60, 61, 67, 195, 196, 197 elementary school, 24 eligibility criteria, 158 emotion, 4, 5, 6, 7, 8, 14, 16, 20, 23, 24, 26 emotion regulation, 5, 6, 7, 14, 16, 20, 23, 24, 26 emotional intelligence, 15 emotional responses, 4, 6 emotional well-being, 28 emotionality, 7, 21 empathy, 147 employment, x, 42, 77, 84, 86, 117, 118, 151, 157, 158, 161, 163, 164, 165, 166, 167, 199, 246, 251, 253 empowerment, ix, 58, 113, 123, 127 endurance, 109 enforcement, 58, 66 engineering, 38, 90 enrollment, 119, 125 environmental contamination, 115 environmental factors, 104, 207, 248 epidemiology, 129 epistemology, 31, 40, 47, 192 equality, 61, 62, 74, 90, 123, 171 equilibrium, 53 equity, 117, 127, 129, 230 ERA, 148 ergonomics, 90 erosion, 80 ethics, 32, 40, 41, 42 ethnic groups, 65, 66 ethnicity, 135, 190 etiology, 122
262
Index
etiquette, 162 European Commission, 77, 253, 254 European Parliament, 72, 87 European policy, 77, 79 European Union (EU), v, vii, viii, 71, 72, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 103, 110, 198, 253 executive function, 3, 4, 5, 7, 16, 19, 25 executive functioning, 3, 5, 16 executive functions, 19, 25 executive power, 62 exercise, 11, 97, 111 exit poll, 60 expenditures, 231, 236, 237 experiences, ix, 2, 11, 13, 40, 78, 82, 83, 113, 114, 126, 144, 154, 161, 166, 219, 225 expertise, 74, 76, 81, 82, 197 exploitation, xi, 203, 206, 207 exploration, 17 export promotion, 117 exposure, 8, 17, 23, 194, 206, 231 expulsion, 56 externalities, 36 externalizing behavior, 3, 4, 7, 15, 18, 24, 132 externalizing disorders, 19
F fabrication, 190 factor analysis, 136 factories, 44 fair procedures, 73 fairness, 54, 55, 57, 61, 67, 68 faith, 40, 43, 44, 46, 47 family environment, 28, 220, 230 family income, 116 family members, 104, 158, 166, 220, 227, 251 family planning, 118, 119, 121, 125, 127, 128 family support, 2, 21 family system, 249 family violence, 2 farmers, 126, 195 fears, 79, 205 federalism, 65, 66 feedback, 96, 97, 211 feelings, 4, 165, 174 fertility, ix, 113, 116, 118, 121, 124, 127, 177, 251 fertility rate, 116, 118, 125 fetus, 121, 171, 172, 173, 174, 175, 184
fibromyalgia, 14, 21, 22, 24 fidelity, 13 Fiji, 255 financial crisis, 118 financial resources, xi, 229 Finland, 109, 111 fishing, 35, 37 fitness, xi, 203, 205, 211, 213 flexibility, 5, 63, 77, 101 flight, 4 flooding, 173 flooring, 95, 101 focus groups, 156, 162, 218, 219 food industry, 177 foreign assistance, 116 foreign policy, 39, 46 formula, 124, 231, 235 foundations, x, 72, 169, 214 Fourteenth Amendment, 68 fragments, 38 France, 63, 251 free will, 170, 171, 172 freedom, 45, 65, 74, 78, 90, 172, 210, 218, 232 freedom of choice, 90, 172 friendship, 210 funding, x, 2, 74, 121, 124, 151, 152, 154, 155, 157, 158, 159, 160, 163, 164, 178
G gait, 109 gamete, 177 gangs, 57 garbage, 209 gastroenteritis, 114 gender differences, 138 gender equity, ix, 113, 127 General Accounting Office, 2, 3, 28 generalized anxiety disorder, 18, 24 Generalized Anxiety Disorder, 5, 11 genes, 174, 205 Geneva Convention, 56 genocide, 54 genotype, 206 Germany, 62 gerontology, 90, 110 glasses, 100 global aging, 91 global economy, 37 GNP, 115, 116, 117
Index God, 32, 36, 39, 41, 43, 170, 172, 178, 184 good deed, 222 governance, viii, 71, 72, 73, 74, 76, 77, 81, 82, 83, 87, 118, 209, 211, 213 government policy, 79 grades, 3 grading, 239 Grand National Assembly, 192 greed, 44 gross national product, 115 group interests, 197 group processes, 205 group size, 208 grouping, 52 guardian, 7 guidance, 37, 38 guidelines, 9, 58, 76, 77, 92, 96, 97, 98, 158, 163 guilt, 209 Guinea, 212
H happiness, 34, 36 harbors, xi, 203, 209 harmful effects, 178 harmony, 12 hazards, 96, 105, 106, 107, 248 head and neck cancer, 234, 240 head injury, 155 health care reform, 128 health care system, 119, 128 health education, 121, 123 health insurance, 119, 126, 128, 251, 252 health problems, xii, 3, 20, 120, 121, 122, 243 health services, ix, xi, 109, 113, 120, 121, 122, 123, 125, 126, 129, 229, 230, 237, 244 health status, 20, 233 hearing impairment, 99, 157, 164 heart disease, 14 height, 100, 101 helping behavior, 209, 210 hemorrhage, 125 heterogeneity, 210, 211 high school, 116, 118, 212 high-risk populations, 17 Hispanics, 135 historical overview, 115, 123 home care services, 252 homelessness, 2 homework, 92
263 homicide, 172, 215 homogeneity, 190 honesty, 162 Hops, 8, 23 hospitalization, 231, 232, 233, 234, 236, 237 host, 2, 4, 6, 9, 12, 106 household income, 115 housing, 90, 91, 92, 106, 110, 112, 198, 199, 248, 253 human actions, 180 human behavior, 204 human dignity, 171 human nature, 34, 35, 37, 40, 41 human resources, 160, 250 human rights, 55, 57, 61, 64, 176, 193, 198 humanism, 38 husband, 37, 41, 220 hybrid, viii, 67, 71, 72, 73, 79, 80, 86 hygiene, 123, 129 hyperactivity, 4, 5 hypochondriasis, 11, 25 hypothesis, 203, 210, 211, 212, 213, 248
I ice, 99 ideal, viii, 31, 33, 35, 36, 37, 51, 52, 53, 54, 57, 64, 75, 80, 124, 136, 195, 197 ideals, viii, 31, 33, 34, 47, 53, 54, 71, 72, 73 ideology, 40, 42, 44, 45, 190 illumination, 98 image, xi, 172, 217, 218, 224, 250 imagery, 218, 219 imagination, 223 immigrants, 188 immigration, 65 immunization, 117, 120, 121, 123 impacts, 14, 91 impairments, 105, 164 imperialism, 254 impulses, 4, 6 impulsive, 147 impulsivity, 5, 8, 18, 21 in transition, viii, 51, 53, 201 in utero, 176 in vivo, 9 inattention, 5 incarceration, 9, 20 incidence, 104, 124, 231, 234, 235, 236, 237 income distribution, ix, 113, 115
264 income inequality, 127 independence, ix, 56, 63, 68, 89, 90, 91, 92, 94, 97, 104, 109, 111, 194, 246 Independence, 9, 21, 154, 164, 166 independent variable, 60 India, 246 individual character, 106 individual characteristics, 106 individual differences, 98, 210 individual personality, 40 individual rights, 65 individualism, 247 individuality, 170, 174, 175 individualization, vii, 1 Indonesia, 246 induction, 240 industrial revolution, 204 industrialization, 117, 125 industrialized countries, vii, 127 inequality, 73, 76, 81, 128 inertia, 45 infancy, 114, 122, 124, 133, 149 infant mortality, vii, ix, 113, 114, 115, 120, 121, 122, 123, 124, 125, 126, 128 infants, 114, 121, 122, 124, 126, 132, 133, 148 informal practices, 199 information processing, 11 informed consent, 184 ingestion, 233 inhibition, 19, 215 inner development, 175 insertion, 77 instinct, 36 Institute of Justice, 29 institution building, 52, 54, 58 institutional change, 57, 227 institutional configurations, 53 institutional reforms, 57, 66 institutionalisation, viii, 67, 71, 77 institutionalized care, 133 integration, 58, 82, 241 intellectual disabilities, 8, 27 intensive care unit, 120 interdependence, 148 interest groups, 74 interface, 25 interference, 14, 25, 54, 68 internal mechanisms, 195 internal working models, 133 internalizing, 3, 5, 7, 132
Index International Criminal Court, 58 international law, 55 international relations, 54, 56 international standards, 53, 58, 91 international terrorism, 52 interpersonal interactions, 211 interpersonal relations, 209, 211 intervention, vii, 1, 2, 3, 6, 8, 9, 10, 12, 13, 14, 18, 20, 24, 25, 27, 28, 52, 54, 56, 57, 58, 59, 83, 117, 120, 122, 184, 215, 233, 237, 239 intimacy, 177 intrinsic motivation, 26 intrinsic value, x, 169, 170, 174, 176, 177, 179, 180 intrusions, 20 inventions, 46 investors, 52 iPod, 253 Ireland, 62, 254 irradiation, 240 Islam, 200 Islamic state, 52 isolation, 163 Israel, 61, 201 Italy, 235, 255
J Japan, viii, xii, 31, 32, 39, 42, 44, 47, 49, 243, 244, 246, 247, 249, 251, 253, 254, 255 job skills, 154 judicial review, 63 judiciary, 190 junior high school, 118 juries, 85 jurisdiction, 135 justification, 52, 64, 73
K Kentucky, 110 kindergarten, 23, 122 knees, 94 Korea, 246, 255 Kosovo, 55, 58
L labeling, 14, 20
Index labor force, 118 labour force, 250 labour market, 83, 251 lack of control, 13 landscape, 205, 211, 246 language skills, 96 languages, 38, 46 larva, 206 Latin America, 245, 246 Latinos, 135 layoffs, 46 leadership, 67, 86 learning, 24, 76, 77, 78, 82, 83 legislation, 80, 163, 164, 193, 232, 233, 235, 250 leisure, 103 lending, 14 lesson plan, 156 liberalism, 31, 42, 43, 44, 63, 189 liberation, 36, 59 life expectancy, 91, 232 life quality, 230 life satisfaction, 132, 134, 135, 137, 138, 139, 140, 142, 145 Limitations, 145 Lisbon Strategy, 86 literacy, 96, 118 living conditions, vii, 31 living environment, 89, 92, 108, 109, 227, 250, 251 lobbying, 74, 192, 193, 197 local authorities, 198 local community, 58 local government, 115, 193, 249 longevity, 247, 250 longitudinal study, ix, 131, 132, 133, 135 long-term care insurance, 249, 251, 252, 253, 255 low birthweight, 114 loyalty, 162, 195 lying, 92
M machinery, 117 Mainland China, 121 major depression, 25 majority, 2, 14, 59, 61, 62, 63, 64, 65, 103, 144, 178, 204, 206, 218, 219, 222, 231, 245, 247 majority group, 65 malaria, 124
265 Malaysia, 246, 255 malignancy, 234 malnutrition, 124, 231, 233, 236, 239 maltreatment, vii, 1, 2, 3, 5, 20, 25, 133, 146, 147 management, 4, 9, 10, 22, 24, 120, 122, 123, 125, 156, 230, 236, 239, 250 manipulation, 67 manpower, 253 manufacture, 116 mapping, 26 marital status, 248 market economy, 247 marketing, 92 marriage, 118, 248 married women, 125 Martin Heidegger, 31, 37, 43, 47 mass media, 247 materialism, 32, 39 media, 42, 78, 85, 177, 218, 220, 228 median, xii, 66, 233, 243, 245 mediation, 53, 66, 75 Medicaid, 157, 158, 159, 160, 163, 165 medical care, 119, 153 Medicare, 159, 160 membership, x, 80, 169, 174, 178, 179, 185, 188 mental disorder, xii, 243, 244, 248, 255 mental health, ix, xii, 3, 10, 11, 14, 21, 23, 122, 131, 148, 243, 244, 248, 249, 254 mental illness, 2, 12, 26, 27 mental retardation, 12, 27, 155 mentoring, 156 meta-analysis, 13, 14, 22, 23, 24, 26, 28, 111, 147, 209, 216, 236 metabolic disorder, 122 methodology, 13, 18, 60, 240 Mexico, 212 Miami, 25 microscope, 178 Middle East, 201 migration, 244, 247, 248 military, 46, 47, 55, 56, 57, 121 minorities, 63, 64, 65, 178 minority groups, 58, 62, 64, 65, 66 misunderstanding, 40, 162 mobile communication, 253 mobile phone, 253 model system, 241 modern capitalism, 42 modern society, vii, 31, 33, 35, 45 modernism, 42
266
Index
modernity, vii, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 42, 43, 44, 45, 46, 47 modernization, 190, 246 modification, 11, 18, 68, 163 momentum, 115, 251 monitoring, 10, 13, 14, 76, 98, 121, 122, 235 monopoly, 46 moral code, 173 morale, 162 morality, vii, x, 31, 32, 35, 36, 39, 40, 41, 43, 44, 85, 121, 169, 170, 173, 177, 181, 183 morbidity, 23, 104, 115 mortality rate, 113, 114, 126 motivation, 215, 223, 224, 228 multidimensional, 249 multi-ethnic, 65 multiple regression, ix, 131, 137 multiple regression analyses, 137 multiple regression analysis, ix, 131 multiple sclerosis, 156 murder, 208, 211 muscle spasms, 234 muscle strength, 252
N national income, 117 national interests, 78 national policy, 82, 121, 128 National Survey, 233, 239 nationalism, 42 NATO, 55 natural growth rate, 121 natural pregnancy, 177 natural resources, 46 natural selection, 204 nausea, 235 needy, 249 negative consequences, 7, 38, 43 negative emotions, 13 negativity, 4 neglect, 2, 3, 5, 6, 7, 27, 32, 44, 133, 146, 147, 197, 220 neonates, 117, 122 neoplasm, 234 Netherlands, 97, 169, 254, 255 networking, 253 neural network, 4 neural networks, 4 neurobiology, vii, 1, 22, 25
New England, 129, 237 New Zealand, 21, 126 NGOs, 59, 74, 75, 76, 77, 79, 80, 81, 82, 84, 85, 86 Nietzsche, 34, 43 Nigeria, 125 noise, 102 North America, 204, 235, 240, 245 nurses, 121, 122 nursing, 91, 119, 237, 241, 251, 253 nursing care, 119, 251, 253 nursing home, 237, 241 nutrients, 206, 233 nutrition, xii, 115, 122, 123, 129, 229, 230, 231, 232, 233, 234, 237, 238, 239, 240, 241 nutritional assessment, 233
O obesity, 14, 236 obstacles, vii, 1, 2, 17 occupational groups, 192 Oceania, 245 offenders, 20 Oklahoma, 69 old age, 106, 108 open spaces, 209 operant conditioning, 9 opinion polls, 85 opportunities, xi, 79, 81, 85, 105, 118, 165, 187, 189, 193, 251 optimization, 238 organ, 176 organism, 177, 178, 179 organizing, 154, 156 outpatients, 19, 241 outreach, 121, 122, 127 overlap, 219 ownership, 83, 85
P Pacific, 254 pain, 14, 22, 179, 225 Pakistan, 246 panic disorder, 11 panic symptoms, 13 parallel, 126, 174, 179, 184 parasite, 124
Index parasitic diseases, 114 parental care, 147, 224 parental consent, 176, 177 parental support, 145 parenthood, 2 parenting, vii, 1, 9, 16, 21, 26, 224, 225, 227 parity, 125 Parliament, 59, 60, 61, 62, 63, 65, 66 parole, 9 pathology, vii, 1, 214, 227 pathways, 23, 98, 102, 115, 125, 129, 147 patriotism, 46 payroll, 119 peacekeeping, 57 pedagogy, 183 peer relationship, 134 peer review, 76, 82 peer support, 149 performance, 4, 14, 21, 26, 110, 154, 162 perinatal, ix, 113, 114, 122, 125, 126 periodicity, 216 permit, 68, 214 personal choice, 35 personal hygiene, 101, 121, 122 personal life, 170, 174 personal relations, 32, 47 personal relationship, 32, 47 personality disorder, 3, 4, 147 personhood, x, 169, 170, 171, 172, 173, 174, 175, 177, 178, 179, 180, 181, 182, 184, 185 persons with disabilities, 98 phenotype, 206, 214 Philippines, 246, 255 phobia, 11 physical abuse, 6, 28, 133 physical environment, 91, 204 physical health, 14, 26 physiological arousal, 14 pilot study, 21, 23, 28, 239 planning decisions, 205 plasticity, 20, 216 Plato, 34, 38 plausibility, 86 pleasure, 43, 179 pluralism, 63, 80 pneumonia, 114, 124 polarization, 170, 191 police, 57 policy initiative, 253 policy instruments, 117
267 policy making, 79, 86, 87, 116, 119, 194 policy responses, 77 polio, 117, 121 political ideologies, 190 political instability, 116 political legitimacy, 60, 61 political parties, x, 60, 64, 66, 74, 78, 187, 188, 189, 191, 192, 193, 194, 195, 196, 197, 198, 199 political party, 189, 192, 193, 194, 196, 197 political power, 61, 65, 247 politics, 33, 45, 46, 47, 52, 64, 81, 188, 189, 191, 194, 195, 196, 197, 199, 226, 228 pollution, 248 popular vote, 61 population density, vii, xi, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214 population growth, 121, 124 positive attitudes, 162 positive correlation, 236 positive reinforcement, 10 positive relationship, x, 152, 164 poverty, 2, 76, 77, 83, 84, 87, 116, 127, 248 poverty line, 248 power relations, 195 praxis, 40, 227 precedent, 218 prefrontal cortex, 14, 25 pregnancy, 28, 121, 122, 125, 126, 129, 171, 173, 175, 177, 184 prejudice, 36 premature death, 185 premature infant, 174 prematurity, 114, 125 preparedness, 3 preschool, 5, 25, 117, 122 preschool children, 117, 122 preschoolers, 7, 21 prevention, vii, 1, 17, 55, 56, 121, 122, 124, 129, 210, 237 price changes, 252 price mechanism, 46, 47 primary caregivers, 6, 132 primary school, 123 prioritizing, 15, 173 probability, 125, 184, 213 problem behavior, 5, 7, 9, 18, 21, 24, 133, 134, 144 problem behaviors, 5, 7, 18, 24, 133 problem-solving, 8
268
Index
producers, 42 product design, 109 productivity, 118, 155, 162, 166, 251 profit, 37, 41, 42 profitability, 159 project, 31, 32, 37, 40, 42, 44, 45, 46, 47, 83, 93, 124, 125, 190, 198, 219, 222, 223, 253, 254 property rights, 44 proportionality, 61, 62, 63 proposition, 198 prosecutors, 58 prosocial acts, 209 prosocial behavior, 9 prosthetic device, 104 protective factors, vii, 1, 6, 17, 26, 248 proteins, 124 psoriasis, 14 psychiatric disorders, 5, 248, 255 psychiatric morbidity, xii, 243 psychiatry, 244 psychological development, 3 psychological distress, 20 psychological health, 149 psychological well-being, ix, 19, 91, 112, 131, 132, 134, 137, 139, 142, 143, 146, 148 psychology, 25, 110, 174, 204, 208, 210 psychopathology, 19, 20, 28, 147 psychoses, 248, 254 psychosocial development, 133 psychosocial functioning, 23, 132, 133, 146 psychotherapy, 28 psychotic symptoms, 255 PTSD, 8, 17, 20 public administration, 155 public education, 247 public health, xii, 2, 119, 120, 121, 122, 127, 128, 129, 243, 244 public opinion, 74, 79 public pension, 250 public policy, 80 punishment, 211, 213, 214 purity, 42
Q qualitative research, 191 quality improvement, 92, 240 quality of life, vii, xii, 1, 14, 90, 92, 97, 102, 229, 230, 253 quality of service, 250
questioning, 40, 188
R race, 92, 164, 226 radio, 184 rape, 41 rationality, 73, 170, 171, 172 reactions, 6 reactivity, 3 reading, 33, 100, 154, 155, 164, 204, 213, 221 real time, 253 realism, 53 reality, x, 53, 104, 152, 172, 190, 224 reasoning, 172 recall, 64 reception, 4 recession, 249 reciprocity, 223 recognition, 65, 67, 76, 91, 161, 215, 226, 227, 232 recommendations, iv, 110 reconciliation, 53, 57, 58 reconstruction, 52, 53, 57, 59, 124 recreation, 180 recruiting, x, 52, 151, 160 reforms, viii, 51, 58, 83, 119, 190, 199, 254 Registry, 240 regression, 36, 137, 139, 140 rehabilitation, 6, 154, 160, 166, 250 Rehabilitation Act, 152, 153, 163, 164 rejection, 16, 35, 45 relationship quality, 145 relative prices, 252 relatives, 7, 21, 41, 42, 175, 207, 234, 249 relativism, 41 relaxation, 9, 11, 12, 14, 28 relevance, 21, 52, 56, 58, 66, 75, 81, 82, 174, 176, 178, 244 reliability, 162, 197 religion, vii, 31, 33, 40 religious beliefs, 121 remediation, 6 replacement, 118 repression, 207 reproduction, 33, 177, 196 reputation, 115, 211 research and development, 254 resilience, vii, 1, 2, 17, 19, 20 resistance, 46, 252
Index resolution, 160 resource availability, 205 resources, x, xi, xii, 16, 44, 47, 77, 119, 121, 125, 126, 132, 151, 158, 159, 162, 165, 188, 192, 194, 195, 196, 197, 203, 204, 205, 206, 209, 225, 229, 230, 233, 249 responsiveness, 77, 83 retirement, 67, 250 retirement age, 67, 250 rewards, ix, 42, 74, 113 rhetoric, 217, 218, 219 rights, iv, 32, 55, 61, 64, 65, 74, 77, 78, 86, 170, 171, 172, 173, 180, 181, 190, 220, 227, 232, 250 risk factors, 16, 17, 28, 106, 108, 248 robotics, 253 rodents, 205 romantic relationship, 146, 148 routines, 9 rule of law, viii, 44, 51, 52, 53, 57, 58 rural areas, 117, 120, 122, 124, 204, 209, 212, 247, 248 Rwanda, 55, 58
S salmon, 99 sanctions, 56, 74 savings, 117, 231, 236, 237 scaling, 119 scarce resources, 46 scarcity, 171, 206, 230 scatter, 176 scheduling, x, 151, 162 schizophrenia, 254, 255 school activities, 156 school adjustment, 6, 7 school failure, 29 school performance, 7 schooling, 125, 225 screening, 117, 122, 160, 233, 239 Second World, 119 secularism, 44, 190 seed, 184 segregation, 64 seizure, 208 self-assessment, 160 self-awareness, 8, 15, 16, 170 self-control, 27, 170, 207 self-destruction, 34
269 self-esteem, 132, 134, 135, 136, 137, 138, 139, 140, 142, 147, 148, 149, 177 self-image, 148 self-improvement, 57 self-interest, 33, 45, 53, 208 self-monitoring, 4 self-presentation, 33 self-reflection, 15 self-regulation, vii, 1, 3, 4, 5, 6, 7, 14, 16, 22, 25, 26, 27 self-understanding, 177 semi-structured interviews, 192 Senate, 28 sensations, 10 senses, 10, 53, 92 sensing, 206 sensitivity, 148, 206, 213 sensory impairments, 97 separation of powers, 66 sepsis, 125 sertraline, 20 service provider, x, 151, 154, 159, 160, 161, 164, 166, 252 settlements, xi, 203, 204 sewage, 124 sex, 122, 146 sexual abuse, 6, 8, 19, 22, 24 sexual orientation, 164 sexuality, 177 shade, 98 shame, 180 shape, x, 82, 174, 187, 188, 252 shareholders, 198 shelter, 6 shortage, 119, 161, 244, 249 shrinkage, 253 sibling, 206 siblings, 206 Sierra Leone, 58 signals, 97, 226 silver, 213, 249 Singapore, 246 skeleton, 192 smoking, 106 social anxiety, 11, 26 social attitudes, 212 social behavior, vii, xi, 12, 27, 147, 203, 204, 205, 208, 209, 210, 212, 214 social capital, 209, 215 social change, 191
270 social class, 254 social competence, 3, 20, 23 social context, 115, 221, 226 social control, xi, 203, 210, 211 social development, 26 social environment, 147, 204, 210, 211, 233 social evaluation, 235 social exchange, 211 social exclusion, 76 social indicator, 254 social justice, 221, 223, 227 social learning, 9, 10, 214 social learning theory, 9, 10 social life, 196, 253 social movements, 188 social norms, 208, 209, 211, 214 social participation, ix, 113, 127, 250, 251 social phobia, 11, 18, 28 social policy, viii, 71, 72, 75, 77, 79, 80, 81, 82, 83, 84, 85, 119 social problems, 45, 47 social psychology, 204, 207 social relations, 37, 41 social relationships, 37, 41 social resources, 226 social responsibility, 227 social sciences, 37, 109 Social Security, 129, 153, 158, 159, 164, 255 social services, 2 social situations, 212 social skills, 15, 23, 24, 174 social structure, 63, 190 social support, 227, 244 social theory, 214 social welfare, xii, 119, 122, 243, 250 social workers, 135, 221, 223, 227 socialization, 104, 191 Socrates, 31, 34, 37 software, 154, 161, 192 solid waste, 248 somatic cell, 177, 178 South Asia, 247, 248 South Korea, 212, 215, 254 sovereignty, 54, 55, 56, 57, 63, 228 Soviet Union, 34 Spain, 61, 235 special education, 3 specialists, 81, 120, 230 species, x, xi, 43, 169, 173, 174, 179, 180, 181, 183, 185, 203, 204, 205, 206, 207
Index speech, 74, 78, 157, 217, 228 sperm, 182 spin, 224 spirituality, 24 sponge, 101 Spring, 77, 83, 87 Sri Lanka, 246 stabilization, 57 stakeholders, viii, 58, 71, 72, 77, 81, 82, 85, 152 standard deviation, 137 standard of living, ix, 113, 123, 127 starvation, 56 State Department, 159 state intervention, 52, 55 statistics, 104, 116, 127, 128, 240 stimulus, 4, 5, 11 storage, 98, 103 stratification, 44 streams, 157, 160 stressful events, 6 stressors, 5, 6, 8, 16, 248 stretching, 195 stroke, 234, 240 subsistence, 53 substance abuse, 2, 4, 28, 132, 248 substitutes, 58 substitution, 116 successful aging, 91 succession, 249 suicidal ideation, 3, 8 suicide, 25 suicide attempters, 25 Sun, 127 supervision, 9, 46, 210 supervisor, 157, 160, 162 support services, 250 suppression, 13, 20, 28 Supreme Court, 67, 172 surplus, 175, 184 surveillance, 122 survey, 2, 26, 55, 91, 111, 120, 135, 154, 240 survival, 113, 115, 119, 123, 125, 127, 129 survivors, 8, 19, 178, 240 susceptibility, 105 suspensions, 3 Sweden, 120, 251 Switzerland, 63 symptoms, 5, 8, 11, 13, 14, 17, 20, 23, 25, 28, 136, 138, 139, 140 syndrome, 114
Index synthesis, x, 152, 204, 205, 208, 211
T tactics, 210 Taiwan, v, ix, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 246 tar, 27, 149 tariff, 117 technical assistance, 162, 165 technological developments, 46, 253 teleology, 36 tempo, 247 tension, 11, 207 territorial control, 67 territory, 46, 205, 209 terrorism, 8, 52 test scores, 3 testing, 122, 177, 209, 254 tetanus, 121 textiles, 117 texture, 62, 66 Thailand, 246 therapeutic agents, 9 therapeutic intervention, 126 therapeutic interventions, 126 therapeutic relationship, 8 therapy, xii, 8, 14, 18, 19, 20, 23, 24, 27, 229, 230, 231, 232, 233, 234, 235, 236, 237, 238, 240 third dimension, 53 thoughts, 4, 8, 10, 11, 12, 13, 14, 37, 39, 42, 207 threats, 173, 205 time frame, 122 Title I, 154, 158, 164 Title II, 158 toddlers, 171 torture, 174 total parenteral nutrition, 239 toys, 107 trade-off, viii, 71, 80, 86 traditions, 178, 199, 204 training, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, 32, 44, 45, 57, 58, 109, 120, 154, 157, 160, 161, 162, 192, 193, 224, 237, 250, 252 training programs, 13, 24, 120 traits, 62, 206 trajectory, 9, 72, 77
271 transcription, 219 transcripts, 192 transfer payments, 252 transformation, 73 transition period, 118 transition to adulthood, 132 translation, 39, 59, 68, 254 transmission, 68, 124 transparency, 67, 68, 76, 82, 84 transportation, x, 152, 156 trauma, 5, 8, 17, 19, 20, 21, 28 traumatic events, 8 traumatic experiences, 28 treatment methods, 12 trial, 18, 19, 20, 21, 23, 26, 27, 239, 240, 241 triggers, 209 tuberculosis, 121 Turkey, vi, xi, 89, 108, 109, 110, 187, 189, 190, 191, 193, 195, 196, 197, 198, 199, 200, 201 turnout, 77 turnover, 61, 210 typology, 57, 61
U UNESCO, 238 uniform, 246, 249 uninsured, 119 unions, 192, 195 United Kingdom (UK), 26, 61, 62, 73, 79, 80, 82, 83, 87, 88, 103, 126, 129, 236 United Nations (UN), 46, 54, 55, 56, 58, 69, 75, 120, 127, 128, 204, 215 universal access, 123, 127, 230 universalism, 249 universality, 230 universe, 173 universities, 254 urban area, xii, 124, 204, 212, 214, 243, 244, 247, 248, 249 urban areas, xii, 124, 204, 212, 214, 243, 247, 248 urban life, 208, 248 urban population, xii, 243, 247 urbanisation, 255 urbanization, vii, xii, 124, 196, 204, 205, 210, 243, 244, 246, 247, 248, 249 use of force, 56
272
Index
V vaccinations, 121 vacuum, 68 validation, 57, 239 variations, 93, 96, 204 Vatican, 184 vector, 248 vegetation, 43 vein, 66 ventilation, 105, 107 veto, 56, 66 victimization, 4 victims, 3 violence, 29, 207 violent crime, 215 vision, 31, 32, 33, 36, 39, 99 vocalizations, 207 vocational training, 159 voicing, 75 volatility, 191 voluntarism, 190 voters, 60, 62, 63, 66, 191, 194, 197 voting, 44, 45, 60, 61, 63, 68 vulnerability, 37, 65, 208
walking, 208, 210 waste, 248 weakness, 32, 244 wealth, 37, 55 wear, 222 websites, 163 weight loss, 236 welfare, 2, 3, 6, 32, 33, 44, 45, 55, 92, 221, 228, 232, 249, 250 West Virginia, 151, 157 Western countries, 44, 176, 246, 253 windows, 17, 95, 98 wires, 107 witnesses, 179, 208 wood, 99 work environment, 154 work ethic, 42 workers, 23, 37, 46, 122, 126, 153, 158, 159, 161, 162, 163, 164, 165, 166, 188, 222, 227, 250 working hours, 156 workplace, x, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 227, 253 worry, 38, 39
Y W wages, 160, 161 waiver, 157
young adults, 146 young women, 246 youth transition, 147 Yugoslavia, 58, 66
