Ethics and Aged Care

In this AHHB exclusive, Professor of Law at the University of Wollongong unpacks the issues facing an Australia with an increasingly ageing population. The number of people aged 65 or older has more than tripled over the last fifty years and was 3.4 million in 2014, while the number of people aged 85 and over increased nine fold to 456,600. The Australian Bureau of Statistics predicts that there will be 9.6 million people aged 65 and over and 1.9 million people aged 85 and over by 2064.
Although these statistics reveal that older people are living longer and healthier lives, there is likely to be an increase in demand for care; not necessarily intensive medical care but ongoing care for health and lifestyle needs.
Care for the aged resembles healthcare in some respects so that the familiar principles of medical ethics – respect for autonomy, beneficence (acting for the good of the patient), nonmaleficence (avoiding harm) and justice (treating like people alike) - would also apply to ethics in aged care.
There are however some significant differences. The principles of medical ethics have emerged primarily in the context of the healthcare treatment of individual patients, so that, for example, the focus of respect for autonomy is on the capacity and the freedom of individual patients to make decisions about their own health care. Certainly, there are occasions when partners or family members may be involved in those decisions, but the ethical focus has been on the individual patient.
To an important degree, this is recognised in formal statements of the ethics of aged care that, while recognising some features of an older person’s situation, whether in a residential facility or at home, retain that individual focus. One variation to the conventional focus on autonomy is the added recognition of respect for dignity. Similar patterns of individual emphasis can be seen in the development of proposed national codes of ethics for residential aged care.
Aged Care and Healthcare
This individualist ethical focus can mask the reality that aged care has a wider frame of reference than healthcare: it is concerned with promoting an older person’s welfare. Decisions around welfare include not only healthcare but also living arrangements, family and business affairs, financial and estate planning - all of which commonly intimately involve partners and family members. Accordingly, ethics in aged care operates in a far more complex decision-making environment in which multiple influences, both beneficial and supportive and also potentially manipulative and debilitating, will need to be taken into account.
The other two constant considerations are the older person’s reduced independence (in all respects) and the fact that he or she is living his or her last years.
Even if there remains a primary focus on the individual older person, their age brings to the fore not only their declining physical and intellectual capacities, but the legacy of their family life. Complex intersecting relationships can lie at the base of obligations or perceived obligations within and beyond the generation of the older person.
Advocacy - it’s not always family first
As a result, respect for autonomy will need to recognise when an older person’s capacity to reach decisions is enhanced by their family circumstances and when it is impaired. Acting for their benefit will need to take into account the influence of family history and family relationships so as to avoid inadvertently and indirectly causing harm by supporting decisions that run counter to established family understandings.
Lastly, the intergenerational complexity for the consideration of justice in relation to an older person’s care and support will merit careful and ongoing attention. For aged care workers, whether in residential facilities or in supported housing, these complexities are likely to present difficulties in role definition.
For example, nurses have often adopted the role of advocacy for patients in their care. The value for patients is that such advocates have a clear audience for their advocacy, namely the healthcare system, which nurses usually know intimately.
In aged care, although the role of an advocate is equally available to nurses and other health care professionals, the audience for the advocacy is much more disparate in ways that are likely to complicate the expression of that advocacy and mitigate its value and effect.
Adding to the complexity of aged care are competing obligations that can arise from the discovery of abuse or neglect, not only in the provision of aged care, but in the conduct and decision-making of family members and even guardians.
As a result, it may be more difficult for healthcare workers in aged care to establish and exercise a clear advocacy role that can confidently contribute to the welfare of an older person. Some healthcare workers in aged care describe themselves as being ‘the meat in the sandwich’ between the resident and his/her family, the resident and other residents, the resident and multiple health and aged care providers or a combination of all of these.
This complexity merits careful attention to the development of a compassionate, holistic and realistic account of the competing ethical obligations of healthcare workers in aged care.

---

Colin Thomson - BA, LLB, LLM (Sydney) www.ehealthinfo.gov.au
Colin Thomson, BA, LLM (Sydney) is Professor of Law at the University of Wollongong and Academic Leader for Health Law and Ethics in the Graduate School of Medicine. He also works as a consultant.
He was a member of the Medical Research Ethics Committee (1988-91) of the National Health and Medical Research Council and, from 1998-2002 a member, and from 2006-2009, chair of the Australian Health Ethics Committee. As a consultant, he has advised NHMRC, FaHCSIA, Health Departments of NSW, Qld and Vic and several universities. He is a Senior Consultant with Australasian Human Research Ethics Consultancy Services (www.ahrecs.com).
Colin has provided training to human research ethics committees, chairs the CSIRO Social Science HREC and is a member of HRECs at Department of Health and Ageing and University of Wollongong/ Illawarra Shoalhaven LHD.
He is a joint author of Good Medical Practice: professionalism, ethics and law, 2010, Cambridge University Press.