prime focus on dementia

쐽 THE STRAITS TIMES SATURDAY, SEPTEMBER 27 2008 PAGE A16

Many
helping
hands
needed
Mental Capacity Act necessary but
community support vital too: Vivian
BY RADHA BASU
SENIOR CORRESPONDENT
PARLIAMENT enacted a landmark
law last week that will allow peo-
ple to appoint guardians to look af-
ter them should they lose their
mental capacity to illness or acci-
dents.
The law also criminalises wilful
neglect, abuse or abandonment of
mentally incapacitated people by
caregivers.
A new government body, the Of-
fice of the Public Guardian, will be
set up to supervise the process and
investigate claims of abuse.
The chief architect of the Men-
tal Capacity Act, Dr Vivian
Balakrishnan, who is Minister for
Community Development, Youth
and Sports, spoke to The Straits
Times on why the Act is needed
and about social-safety choices
facing Singapore as it copes with
the double whammy of a rapidly
ageing population and low fertility
rates.
쐽 Why should people be interested
in the Mental Capacity Act and
appoint proxy guardians, or
donees?
It’s important to get people to
start thinking about the issue of
mental incapacity. I am not expect-
ing huge numbers of people to cre-
ate a lasting power of attorney –
that’s only part of the Act.
There are other sections that
cover, for instance, informal care-
givers, to set out limits of what
they can do, should not do, giving
them protection, and clarifying ill
treatment and neglect. All these as-
pects are relevant even if people
don’t sign up. All of us will be in-
formal caregivers – this Act is rele-
vant for us all.
The appointment of donees is
just the tip of the iceberg. But this
Act will set the ground rules, re-
sponsibilities, obligations and ex-
pectations for how Singapore soci-
ety as a whole is going to deal with
this problem of mental incapacity.
This is a growing, difficult-
to-pin-down problem that does
not involve just the person who is
suffering, but also the family. It re-
quires many helping hands; you
need a whole system of communi-
ty support.
쐽 There is a growing group of
single or childless people. They say
Mrs Ong Siew Kean, 81, a dementia patient who can no longer fend for herself, with family helper Mary Ann Valmoja (left), 32. Mrs Ong’s daughter, Mrs Moira Kwan,
55, relocated back to Singapore from London five years ago to look after her. ST PHOTOS: STEPHANIE YEOW
it would be good if the state could
act as a proxy decision-maker for
them, as is the case in Britain.
You may be childless or single, but
that does not mean you do not
have good, close, trusted friends.
I’d rather that you work through
your own social networks, through
people you know and can rely on,
rather than give you false assur-
ance that there will be an elabo-
rate, expensive bureaucracy to
look after you.
The Government’s first duty is
to set up a legislative framework
and a good competent and power-
ful Office of Public Guardian. We
have given significant investiga-
tive powers to the office because
we want to protect the vulnerable.
But once you get into personal
areas – where you want to stay,
what you want to eat, the way you
want to spend your money – these
are private matters that you
should decide when you have ca-
pacity. And if you don’t, it is bet-
쏆
ter to have loved ones – family or The key thing is whether we as a
friends – participate in this deci- society are ready for the sheer
sion making. numbers that are going to have de-
mentia in the future.
쐽 But what if people don’t want We are going into uncharted
to “impose” on extended family territory. We have never had so
or friends to play this role? many old people and so many peo-
I recognise this fear about imposi- ple with dementia. This whole is-
tion, but family and friendships sue of shrinking families and sin-
are obligations you enter into for gles is a big complication.
mutual support. We should not My second concern is about
become a society where we say “I families: the size, the sense of du-
dare not impose on you because it ties, obligations and expectations
may inconvenience you in fu- and how that is changing.
ture”. My third concern is what is the
The whole concept of society most effective way of taking care,
surviving in adversity is that we where and how people should be
take on mutual responsibility for cared for to make sure that subsi-
each other. We have the archetyp- dies do not distort or lead to per-
al example of the samsui women verse outcomes. That one re-
who made pacts of mutual sup- quires a lot of deep and careful
port to look after one another in KEY CONCERN planning.
old age.
How have we forgotten these “The key thing is 쐽 What kind of perverse
age-old traditions? Why have we whether we...are ready outcomes do you mean?
lost that spirit of self-reliance? Money, human costs, the toll on
I recognise, however, that for the sheer numbers our society. For instance, if you
there will be some cases, in our that are going to have provide huge subsidies to C class
homes for example, who need dementia in the wards, people with dementia will
state help. We will make special be dumped in hospitals. That is
efforts to keep their affairs in or- future.” the wrong outcome, not just for
der, but those are exceptions to Dr Vivian Balakrishnan the family, but for the person and
the rule. for the system.

쐽 The Act criminalises wilful
neglect and abuse. Some say that
increasing support for caregivers
– rather than criminalisation –
helps stem abuse.
We will try to do both. Criminalis-
ing it is a message, a signal that
ill-treatment and neglect of peo-
ple who are particularly vulnera-
ble is something that this society
is strongly against. I hope it is
something that we will invoke
very rarely but, ultimately, we
need to focus on systems to sup-
port and train caregivers.
We recognise the reality that
caregivers need protection, assist-
ance, training and sometimes res-
pite, but the latter are not legisla-
tive; we need to organise them on
the ground.
On the legislative front, we
have to monitor the outcomes, to
check whether any refinements
are needed in future. I think this
piece of legislation is needed, use-
ful, maybe even overdue. But it is
not the panacea for everything
that needs to be done to support
people who have lost mental ca-
pacity.
쐽 Dementia is a big cause of
mental incapacity. What are your
key concerns about dementia care
here?
쐽 You prefer people to be looked
after at home, but government
subsidies for home care are very
limited.
We start carefully and small.
Once you give, you can’t take
back. I look at the total cost to so-
ciety – not just the monetary cost
– of these decisions on where and
how and who to provide care.
Now, we have got our toes wet in
providing means-tested subsidies
for home care. We have to be
very careful that we don’t distort
the delivery and consumption of
services because I have seen it go
wrong overseas.
We need to do more, but we
can argue about how much and
how fast we can move in that ar-
ea.

쐽 What’s your message to older

Madam Elsie Wee, 57, admits finding it extremely difficult coming to terms with
her 79-year-old mother Tan Kim Neo’s dementia when she was first diagnosed.
She now finds strength in her faith and dementia support groups.
쐽 MORE STORIES: SATURDAY SPECIAL, PAGES S1-S9
About the Mental Capacity Act
THE Mental Capacity Act
allows you to appoint
guardians to make decisions
on your behalf should you lose
your mind to illness or
accident.
This guardian – a trusted
relative or friend – is known
in legal language as the
“donee”, and you can appoint
one or more donees.
You can decide the areas in
which your proxy guardian
can make decisions on your
behalf.
The new law also
empowers parents of children
with intellectual disabilities to
apply to the High Court to
appoint a “deputy” to act for
their children after the
parents’ deaths.
Donees are not allowed to
make decisions in six highly
sensitive areas: consent to
marriage or divorce, sexual
relations, sterilisation,
adoption, renouncing a
religion and change of gender.
The law also makes it a
criminal offence for caregivers
to wilfully neglect or abuse
mentally incapacitated people.
folk who say they helped build
Singapore, don’t have much
savings left and need more help
with social and health-care costs,
and find it hard to depend on
their children?
We have amended the eligibility
criteria for public assistance (PA).
We now have more flexibility to
provide PA to those who have
adult children who are unable to
assist because they themselves
have difficulty coping.
At a philosophical level, the
question is: Should we tax the
children more to give the older
folk more help or should children
provide for their older parents
out of their own sense of love and
family duty? The logical answer
may not be the emotionally cor-
rect one.
The bigger issue is that we are
trying to create a society where
every generation earns, saves and
provides for its entire set of
needs.
The older generation built Sin-
gapore on pillars of self-reliance
and mutual support. The strate-
gic question before the next gener-
ation of Singaporeans is: Do we
want to dismantle those pillars
and substitute them with a
high-tax, high-entitlement social
security system?
Let us look around and ask our-
selves which system is better and
more sustainable, especially
when we are facing low fertility
rates and a rapidly ageing popula-
tion.
radhab@sph.com.sg