Continence, Care and Ethics

By Adriana Rehbein
Wednesday, 27 February, 2013



A central ethical value in relationships between health professionals and their patients is respect for human beings, more often called respect for autonomy or, simply, autonomy. The expression has become very familiar in medical ethics, prominently because it was instrumental as an ethical foundation for patient led responses that gradually overturned a prevailing professional paternalism (“doctor knows best”) of later decades of the last century.
Respect for autonomy has focussed on the process of seeking and gaining consent to treatment. An essential condition for the exercise of individual autonomy is adequate capacity to understand the implications of consent.
This requirement rests on one aspect of the meaning of autonomy. To be autonomous or self-governing, a person needs to have not only capacity to make a decision but also to implement that decision by deliberate action: to be in control of both mind and body. Sickness can rob a patient’s capacity for control of either mind or body or both.
Continence needs control of both mind and body: the capacity to recognise the symptoms of the need for release of bladder or bowel discomfort and to act in response. Where sickness robs a patient of both the capacity to control mind and body, the management of bladder and bowel movements is taken over by others. The fact that a patient in that condition is not described as incontinent indicates that we use that term to refer to patients whose condition has robbed them of capacity to control their body but not their mind. Thus, incontinence is defined as the involuntary loss of urine or faeces at an inappropriate time or place.
The ethical difficulties faced by these patients and those caring for them flow from our culture’s practices and attitudes to continence. In the first place, it is an intensely personal matter - we have difficulty discussing it with others. Secondly, people are expected to behave in a continent manner, to know when they need to seek appropriate facilities and to do so. Failing to meet these expectations is a serious social failing because the underlying assumption will be that the failure was a matter of choice, or knowing carelessness with resulting stigma.
Many people who can no longer reliably control their bladder and bowel functions face an agonising ethical dilemma. Not only can they not control these functions but they know that they cannot do so. If, because of the sensitivity, they are reluctant to explain their partial loss of control, when they do lose control, others will assume that it was through their carelessness for which they are likely to held morally responsible. They are therefore likely to feel shame, but that reaction is, ethically speaking, undeserved: they could not help it happening.
These are matters of ethics, rather than mere courtesy. Ethics is essentially about relationships between and among people. While relationships among neighbours and communities are not well defined, those between health professionals and patients have attracted definitions of ethical responsibility, in which respect for the autonomy of patients is prominent.
In caring for patients who lack continence, a task that can be demanding and time consuming, a sound understanding of what respect for autonomy demands is important.
Because of the energy and time involved, therecan be a focus on managing the patients and the results of their lack of control. There is a risk that these strategies can overlook and even appear to ignore the ethical dilemma that these patients face.
They may have lost a degree of their autonomy in that they can no longer control all their bodily functions, but many have not lost their capacity to understand their situation. Maintaining respect for their reduced autonomy remains essential to care that is ethically sound.
The problems of continence frequently increase with age and can be associated with a gradual decline in capacity to understand and maintain insight into their condition – often a progressive loss of control over both body and mind. Here, it is important to recognize that the full scope of respect for human beings is broader than autonomy. It is to respect a person for who they now are and for what they are now capable or not capable of doing or deciding. Taking account of a patient’s ebbing ethical insight into his or her condition remains important, but will demand time and patience.
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