A protected life is not yet a full one

[SINGAPORE] Jeffery Tan’s commentary “In a super-aged Singapore society, we must learn to differentiate independence from dignity” on Sep 19 made an argument that Singapore’s ageing debate badly needs: Independence and dignity are not the same thing. Independence may diminish, but dignity should not follow.

He is right about the mechanism, too.

Care can turn into control gradually, through a sequence of individually sensible decisions – a child takes over the appointments, a helper decides the bath time – until “a life gets organised around a person without being lived with them”, as he put it. 

Nobody intends it. Everybody is being reasonable.

I want to carry his argument one step further, because I think it stops just short of where it is going.

Consider what the instruments mentioned in his commentary actually do. A Lasting Power of Attorney, an Advance Medical Directive, Advance Care Planning, the discipline of offering choices that are real rather than token: These are good things, and far too few families use them. 

But they protect just two things – the older person’s autonomy, and their security. They settle who decides, and they keep the person safe.

That is a floor. It is not a room.

Seven domains, but only two funded

American geriatrician G Allen Power, working with people living with dementia, builds his case on a seven-domain model of well-being developed by the non-profit organisation Eden Alternative: identity, connectedness, security, autonomy, meaning, growth and joy.

Set that list against our care system, and the asymmetry is immediate. Society has instruments for security and autonomy – legal, clinical, procedural, auditable. For the other five, there is almost nothing.

No care plan in Singapore asks whether a person still has an identity beyond “patient” or “resident”. None asks whether anyone in the building knows what they were good at, or who they were at 40. None asks what they are still learning. None asks when they last laughed at something.

Our licence conditions for nursing homes are precise about safety: fall risk reassessed every six months, skin inspected daily, every medication error documented and reviewed, nutritional status screened. Quite right. 

They also require psychosocial assessment and meaningful activities, but name no instrument, no interval and no threshold. A home can meet every requirement in that document, and still be a place where people have nothing to look forward to.

This is not for want of measurement instruments. In a 2021 study I conducted with other academics, we measured psychosocial qualities directly in 696 residents in seven Singapore nursing homes: quality of life, well-being observed minute by minute, and the level of person-centred care each home achieved.

Person-centred care in the homes scored 2.3 out of 4. Resident satisfaction was 3.43 out of 5, lowest of all on lifestyle and the quality of interaction.

And the homes scoring higher on person-centred care had residents who were measurably better off.

The assessment tools exist; they have been validated in our study of nursing homes in Singapore, yet they form no part of how anyone is held to account.

Growth is the domain society finds hardest to take seriously. It is assumed to belong to the first half of life, that after a certain point, a person is maintained rather than developed. 

Yet, the people I meet in their 80s who feel most alive are almost always learning something: a language, an instrument badly, their great-grandchildren’s names and politics. 

Nothing in Singapore’s system of care has a place to record this, and so nothing in it is organised to make it possible.

Why society does not ask

Part of the reason is that society has quietly made enjoyment conditional.

Pleasure in the later parts of life gets justified by what it does for health: Singing is good for the lungs, friendship is good for cognition, gardening counts as exercise. The activity has to earn its place by its health dividend.

This instinct has a name: healthism. It has a weaker evidential basis than most people assume.

In another study I co-authored, we followed a cohort of 6,073 older Singaporeans for nearly 12 years, and found that happiness predicted survival, until health and psychological functioning were accounted for, at which point the association disappeared. 

We gave the paper the title the data deserved: Happy people live longer because they are healthy people.

Enjoyment does not have to buy its keep by extending life. It has value in itself. And once that is clear, something else follows; the pleasures of later life need no justification, beyond being good.

A hot drink taken slowly. A room where someone uses your name. Being asked for a recipe that only you still remember.

For a person whose capacity is genuinely diminishing, these are not consolations for the life that has been lost. They are life itself.

What this asks of society are modest and specific. When a family is choosing a care arrangement, the question to ask on the visit is not only what is prevented, but also what a good day looks like here. 

When a board or investor looks at a care operator, the quality dashboard will be composed almost entirely of safety measures – ask what sits beside them. 

In July 2026, the Ministry of Health’s deputy director-general of health regulation, Dr Raymond Chua, said a public rating system for nursing homes was worth studying.

If one comes, the question it must settle is whether it counts only what is prevented, or also what a resident’s day contains. For instance, Australia publishes what residents themselves say.

And it is not a trade-off between psychosocial satisfaction and running a good operation. When one Singapore home for residents with dementia rebuilt its care around the resident rather than the routine, well-being improved measurably, withdrawal and passive engagement fell, and staff attrition dropped by 55 per cent.

When Singapore builds on the support for ageing people that Tan mentioned in his article – the Agency for Integrated Care, Dementia Singapore, the Caregivers Alliance – it should be remembered that the circle is also made of unofficial things: a choir, a fishing trip, a weekly breakfast, the neighbour who still drops by.

As he wrote: “Someone who can no longer manage money or walk unaided may still... ask for a familiar visitor.”

These are not the soft edges of care. For five of the seven domains, they are the whole of it.

Tan ends with a line worth keeping in mind: Good care is not taking someone safely to a destination others have chosen for them, it is helping them stay part of the journey. That is exactly right. 

But staying part of the journey is the minimum they are owed. The harder question, and the one society has not begun to fund, is what is on the journey that makes it worth staying for.

The writer is an associate professor at the S R Nathan School of Human Development, Singapore University of Social Sciences. He has researched ageing in Singapore for two decades, and is the editor of a forthcoming volume on ageing in Asia.