Theory/approach
Proponent(s)
Premise
Focus
Utilitarianism
Jeremy Bentham, John Stuart Mill
Ethical actions provide the greatest balance of good than evil
Utility and consequences
Rights approach
Immanuel Kant
Ethical actions protect individual dignity and freedom of choice
Self-determination; individual rights
Deontology
Kant, Descartes, Calvinists
Ethical actions comply with divine command
Duty and right by God’s law
Fairness and justice approach
Aristotle
Ethical actions are fair and equal for all
Consistency; equal distribution of benefits and burdens
Common good approach
Plato, Aristotle, Cicero, John Rawls
Ethical actions serve the common good
Interconnectedness of individual and communal good
Virtue ethics
Aristotle, Thomas Aquinas
Ethical actions are virtuous
Virtuousness (e.g., prudence, compassion, integrity, honesty, courage)
These principles have been applied to the field of aging, although some have voiced reservations about issues of interpretation and application (Moody 1992; Polivka and Moody 2001). Holstein and Mitzen (2001) and Holstein et al. (2011) argue that principlism fails to consider the heterogeneity of older adults, while others have argued that strict or rigid applications of these principles may result in undesirable results. For example, an overemphasis on nonmaleficence may lead to paternalism, thereby limiting freedom of action for competent older adults, and upholding autonomy may detract from recognizing the importance and responsibilities of membership in social and collective networks (Polivka and Moody 2001; Holstein and Mitzen 2001; Holstein et al. 2011). Thus, these perceived limitations of using principlism, including the emphasis on individuals to the detriment of community, neglect or nonconsideration of factors such as context, circumstance, and agents to which it is applied, and its tendency to view relationships as adversarial because of its origins in law and philosophy, have led to the exploration and development of alternative frameworks more suited to addressing aging (Hofland 2001). These frameworks are presented below; what they share in common is the focus placed on the perspectives of agents, subjects, and context in the consideration of ethics (see Table 34.2).
Table 34.2
Ethical frameworks
Framework | Premise | Focus |
|---|---|---|
Phenomenology | Ethics should consider shared experience, understanding, and meaning | Perspectives of participants themselves |
Hermeneutics | Ethics should respect diversity of experiences and relativity of ethical situations | Meaning and validation |
Narrative ethics | Ethics should consider more facts of the case | Experience, dimensions of meaning as well as facts |
Virtue ethics | Virtuous character leads to ethical acts | Moral character, not actions performed |
Ethics of care | Caring for others as human activity, based on action and practice, not rules | Care that is attentive, responsible, competent, and responsiveness |
In addition to the creation of alternative frameworks, other avenues have been explored for a more meaningful interpretation and application of ethics in aging. For instance, other principles, such as honesty, integrity, compassion, caring, and privacy, are of particular resonance when dealing with older adults and can be used as tools to guide ethical action and decision-making. Finally, principlism still has relevance, in as much as the principles of beneficence , nonmaleficence, justice , and autonomy are evaluated, interpreted, and applied with due consideration for how well they can be manipulated or adapted to address aging issues meaningfully. For instance, a consideration of what constitutes ethical standards and practices relating to LGBT elders must consider their personal and group history and experience as it relates to sexual orientation and/or gender identity, and the implications for the provision of care and other services.
Why Ethics Is Important for Working with LGBT Elders
Understanding ethics as applied to elders, particularly the LGBT elder population, is important for a number of reasons (i.e., decision-making, habilitation, resource allocation, dementia, end of life), which are discussed below. Older LGBT adults represent a special population highly deserving of ethical considerations and treatment. The aging population, of which LGBT elders are a part, presents unique and confounding ethical challenges for healthcare and human services professionals. The complexities of an aging society include ethical considerations heretofore historically unheard of as recently as the 1900s when the average US life expectancy was age 47, to today, when it is 76 (World Health Organization 2014). Several domains pertinent to aging LGBT individuals warrant ethical attention.
Decision-Making. Competent elders are often capable of making decisions for themselves, even until the end of their lives. However, their ability to make decisions for themselves can become compromised due to such reasons as medication interactions, chronic illness, dementia, general weakness, or all of the previous reasons in combination. Also, because of vulnerabilities that some elders experience at the end of their lives, they may be the focus of unhealthy dependencies by their care providers (formal or informal) and so may become the unwitting victims of undue influence (Nerenberg 2000) when making decisions.
For elders who are competent and who wish to authorize another individual to make decisions for their health care, finances, or both, a power of attorney (POA) document must be executed, while the older adult still has the capacity to make decisions (see Chap. 22). Such a document executed under undue influence or when an older adult no longer possesses the capacity to make decisions is not a legally executed or binding document. In addition, should an older adult fail to appoint a surrogate or become incompetent without executing a POA, many states have a statutorily established order of surrogacy, which usually begins with the spouse of the elder, followed by a son or daughter and continuing to next of kin. This designation can be particularly problematic for older LGBT persons, since the law in many states does not recognize the marital status of a same-sex partner. Due to divided acceptance of an elder coming out, some family members are estranged and so may be very poor surrogates for the incapacitated elder. Also, the isolation that some older LGBT persons experience may make surrogate decision-making even more challenging, because his or her wishes for health care and service acceptance may not be discernable or followed. This situation would be particularly difficult should an LGBT elder require that a guardianship be initiated due to his or her incapacity (Teaster et al. 2010).
The emphasis on autonomy to the exclusion of other ethical principles (Holstein and Mitzen 2001; Holstein et al. 2011) is one not as deeply held in other countries (and actually, not by all older adults) as it is in the USA. Some countries have far different approaches toward treating persons who are dying or persons who are suffering from a terminal illness. For example, Moody (2001) describes the conundrum faced when a US-based and indoctrinated medical team faces the wishes of an Asian family concerning the issue of veracity . The US team wants to tell the old Asian mother that she has terminal cancer, but the family members, acting within the value system of their culture, want to withhold this information.
Habilitation. Unlike the majority of their younger counterparts, older adults live in both community and facility settings, and many will live in both at some point in their lives (Congressional Budget Office 2013). The meaning of place and where an elder identifies his or her home reflects important ethical concepts of belonging, respect for persons, autonomy, and justice (Beauchamp and Childress 2012; Holstein and Mitzen 2001). For many adults, the home in which they intended to live for the remainder of their days may become inappropriate for them: Upkeep or house payments may become too expensive, the neighborhood is no longer safe, the elder is no longer able to traverse stairs, and little accommodation is possible, or the elder experiences dementia and cannot attend to activities of daily living or instrumental activities of daily living. Making decisions concerning one’s habilitation is life-altering and may be irreversible, a situation different from when they were a younger adult.
One of the most wrenching decisions that many families face is whether or not to have an elder leave his or her home and move to either an assisted-living facility (if resources allow it) or a nursing home (synonymous with death for some elders) (Kane and Caplan 1990; Powers 2003). Bed availability and quality of care are ongoing concerns for care provision in nursing homes (see, generally, Web sites for the Centers for Medicare and Medicaid Services and National Consumer Voice for Quality Long-Term Care). For LGBT elders, there is an added concern, which is that of being outed in a care environment that may be inhospitable to him or her. Some facilities have staff members who are vicious and abusive, and some such facilities, which may provide excellent and loving care, may be the only one available within a huge radius, as is often the case in rural areas. Here, ethical dilemmas revolve around limiting freedoms to protect and preserve safety. This aspiration may not be realized if the care environment does not welcome LGBT elders (see Chaps. 16, 17, 25, and 28).
Resource Allocation. Resource allocation is yet another arena in which ethics informs how healthcare providers and service professionals treat the needs of LGBT elders. Even though approximately 20 % of the population will be composed of older adults, policy tends to lag both scholarship and demographic realities. In addition, uncomfortable questions arise as to deservingness. Whose interests have primacy? Young children? Adolescents? Young or old LGBT persons? Gay or straight? The allocation of resources is usually not so blatantly black or white. More often than not, simmering below the surface are issues of who gets what, when, and where. When resources are scarce, these issues become even more heated. Guns or butter, or in another interpretation, guns or canes, is a frequently debated issue, particularly at the national level. Ethical issues of justice (Callahan 1995; Moody 1992; Rawls 2009) come to bear when resources are allocated. As an example, a goal of the 2010 Affordable Care Act has been to widen healthcare coverage for persons who have heretofore been unable to access it. Questions concerning the fairness of compelling persons to purchase health care, despite hardship, strike at the bedrock principle of autonomy , one fiercely guarded in the USA.
In addition to this, the allocation of healthcare resources is the developing conundrum concerning access to technology (Lesnoff-Caravaglia 1999). Perhaps nowhere in the USA is the digital divide more keenly felt than that which divides generations coupled with those who are well off and those who are not. As an illustration, LGBT elders with the ability to teleconnect via some form of computer (e.g., laptop, mobile phone, iPad) with others are thus able to reduce isolation and its effect on health and well-being. Elders who are able to live in homes that are becoming increasingly “smart” may be able to reduce injuries at rates far higher than their poorer and older counterparts. Also, elders with means are able to afford better assistive devices such as canes, walkers, mobile scooters, and the like far more easily than elders who have limited means to acquire them.
Dementia. Also, unlike their younger counterparts, older adults, who are disproportionately affected by the problem, may develop a type of dementia (Binstock et al. 1992; Post 2000; Purlita and ten Have 2004). About 4–5 million people in the USA have some degree of dementia at any given time, a number expected to increase over the next few decades due to the aging of the population. Dementia affects about 1 % of people aged 60–64 years and 30–50 % of people older than 85 years. Dementia is the leading reason for placing elderly people in institutions such as nursing homes. Dementia is a serious condition that results in significant financial and human costs (Alzheimer’s Association 2014). Dementias are not all alike. In the USA, 50,000–60,000 new cases of Parkinson’s disease (PD) are diagnosed each year, adding to the one million people who currently have PD (National Parkinson Foundation, n.d.), while an estimated 5.2 million Americans of all ages had Alzheimer’s disease in 2014, including an estimated 5 million people aged 65 and older and approximately 200,000 individuals under the age of 65 (Alzheimer’s Association 2014).
Regardless of type, cures do not yet exist, and the march of such chronic diseases is relentless. When persons become deeply forgetful (Post 2000), it is all the more important to provide respectful care to such afflicted individuals who may be unable to remember that they are lesbian or for that matter, their very name. It is in these particular positions of vulnerability that afflicted LGBT elders must be treated with dignity and respect for personhood, though many former vestiges may become unrecognizable.
End of Life. Finally, considerations of what is ethical come to bear at the terminus of a long life. This is not to say that end-of-life issues do not affect younger populations, but living to an old age involves the certainty that older adults are nearing the end of their lives, a time when the complexities that append to living a long life intersect (Ellingston and Fuller 2001; Gaventa and Coulter 2005). End of life can involve addressing real pain encountered through chronic illness and that encountered as a consequence of living. Personal pain can be acute when families and friends fail to accept the needs and wishes of an LGBT elder. Ideally, end-of-life circumstances allow for the resolution of a life that is coming to an end, one that requires special attention and care if the dying elder is LGBT. It may be very important to the elder that, despite years of friction, family conflict is confronted and resolved. Issues of religiosity and spirituality are also highly important at this time in life (see Chap. 29).
The ethical issues presented above that are germane to an aging LGBT population are not exhaustive of those that may arise. They are, however, illustrative of why an understanding of ethics is critical when healthcare and service professionals confront conundrums of aging LGBT persons. The following section explores the application of ethical principles and approaches to specific issues that such professionals encounter as well as offers suggestions for ways to approach ethical dilemmas.
Application of Ethics
Ethics can be applied in a variety of ways. Ethics can be used as rules of conduct “moral code” for individual behavior, as well as for groups such as those adopted as professional codes of ethics , as a means to determine rights, duties, and responsibilities to others as well as to inform decision-making (Pozgar 2012). Applying ethics to LGBT elders requires considering not only what rights accrue to LGBT older adults, but also what duties and responsibilities are incumbent on health and social services providers in order to effectively care and serve this population. It is also important to consider what ethical considerations need to inform optimal decision-making and how current ethical principles can be interpreted to reflect LGBT elders’ reality.
Interpreting ethical principles through the LGBT perspective can help develop an ethical framework or “moral map” for caring for LGBT elders and the unique ethical dilemmas that may arise. Such applications must at the very least affirm LGBT elders, address prejudice, recognize inequalities and vulnerability, and be flexible.
One alternate framework, whose precepts provide a good starting point for application of ethics to LGBT elders, is Joan Tronto’s Ethic of Care (1993). Care is defined as “activity that includes everything that we do to maintain, continue, and repair our ‘world’ so that we can live in it as well as possible. That world includes our bodies, our selves, and our environment, all of which seek to interweave in a complex, life-sustaining web” (Fisher and Tronto 1990, p. 40, as cited in Tronto 1993, p. 61). According to Tronto, how we “care” for others is a human activity, and because it is an action and practice, rather than a set of rules, which is based upon a flexible standard, what constitutes good and thus ethical care reflects “the way of life, the set of values and conditions, of the people engaged in the caring practice” (Tronto 1993, p. 61). Also, four phases of care and the correlating ethical principle have been recognized:
Applying the ethics of care to LGBT elders requires health and social services providers to become knowledgeable about the unique needs and challenges these elders face, as a necessary foundation in order to properly discern the needs to be addressed, as well as to determine the scope of responsibility. It requires competence not only with regard to the nature of work performed, but also cultural competence in issues affecting sexual orientation, gender identity, and how these may interact with aging to determine unique needs and inform appropriate interventions. Additionally, by considering the response of LGBT elders, the application of the ethics of care places the LGBT elder in the epicenter of decision-making and action, ensuring a voice in the issues that affect them, such as the efficacy of services received.
Phase 1:
Caring about—Attentiveness as the ethical quality (dimension) of being able to perceive the needs of others and one self.
Phase 2:
Caring for—assuming the Responsibility for responding to the identified need for care.
Phase 3:
Caregiving—ethical requirement of Competence in performing the functions of care.
Phase 4:
Care receiving—relates to the Responsiveness of recipients of care, to care received, and the ability of care to meet/address identified needs.
Another way to promote the application of ethical standards and practices with LGBT elders is to embed appropriate ethical principles and values in the professional codes of conduct for the different disciplines that work with LGBT elders. These codes are important because they prescribe agreed-upon standards and expectations of conduct, as well as consequences for breach, if that occurs (Pozgar 2012; Resnik 2011). Professional codes of ethics protect both providers and LGBT elders by promoting responsibility, accountability, and professionalism in service delivery. They can provide a method, lens, or perspective to guide decision-making, problem identification, and solution, as well as promote the social and moral values that they consider important (Resnik 2011). It is critical, therefore, that these codes clearly include ethical principles germane to working with LGBT elders.
Codes of Ethics
In order to provide guidance for elevating members’ behavior and to instill confidence (both within and outside the organization), various disciplines as well as government and professional organizations have developed and subsequently adopted codes of ethics that guide the conduct of professional behavior (Plant 2001). Most codes of ethics, also called codes of conduct, explicate an organization’s values, mission, and vision. Additionally and typically grounded in the ethical principles and frameworks delineated earlier in this chapter, an organization’s code of ethics provides direction to its members on appropriate standards of conduct, including how to adhere to them (Adams et al. 2001). Most mature professions have developed codes of ethics or conduct (e.g., social work, law, medicine, gerontology). Such guidance is critical for the complex situations that can arise when working with older members of a sexual minority. Below, we return to our case study earlier and discuss codes of ethics for social work, law, medicine, and gerontology, highlighting how they might guide members’ treatment of LGBT elders.
The man who sat in the chair of the beauty salon did, in fact, make a report to Adult Protective Services. The report was logged in the state system, and an APS worker was assigned to investigate the case. The APS worker had a Master’s of Social Work and belonged to the National Association for Social Work.
Code of Ethics for Social Work. According to the preamble of the Code of Ethics for Social Work, promulgated by the National Association of Social Work (NASW) (2008),
The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession’s focus on individual well-being in a social context and the well-being of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living.
The preamble of the code stresses that the profession should promote social justice and social change with and on behalf of clients whom they serve. The code stipulates that the term “clients” is used inclusively and refers to “individuals, families, groups, organizations, and communities” and that “social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice.” Core values of the NASW include service, social justice, dignity and worth of persons, importance of human relationships, integrity, and competence.
Most pertinent to clients who are LGBT is Section 1 of the code, “Social Workers’ Ethical Responsibilities to Clients.” Subsections within Section 1 include social workers’ commitment to clients, respect for clients’ self-determination, informed consent, professional competence, cultural competence and social diversity, conflict of interests, privacy and confidentiality, access to records, sexual relationships, physical contact, sexual harassment, derogatory language, payment for services, clients who lack decision-making capacity, and interruption and termination of services. Particularly salient for social workers who are addressing the needs of older LGBT clients is the guidance that the code provides on self-determination and cultural competency, which defer to the ethical principles of autonomy, nonmaleficence, and justice. According to the Section 1.02 on self-determination,
Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.Related posts:
African-American and Black LGBT Elders
LGBT Elders in Nursing Homes, Long-Term Care Facilities, and Residential Communities
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