Peeking Under the Covers: Ethics in Long-Term Care
BY CANDACE L. KEMP
In our article, “The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living,” my colleagues and I pull back the metaphorical covers on value conflicts and uncertainties in assisted living, a popular place for older people who no longer can live independently. We argue that because assisted living communities are simultaneously places where people live, work, and visit, and where daily life, relationships, and care are negotiated in private and public spaces, ethical challenges commonly arise. Ethics, broadly defined, is a field of study that examines what should be done in situations of value conflict and weighs the range of possible decisions and outcomes considering what is morally right or just. Applying an ethics lens, we demonstrate that on an ongoing basis residents, staff, and visitors face a range of scenarios that involve uncertainty and have implications for residents and care partners’ quality of life. Frequently, however, stakeholders do not recognize, understand, or have the resources to navigate value conflicts. Awareness is an important step.
Our “Ethics in Long-Term Care Model” draws attention to ethics in complex dynamic care settings like assisted living. Having a better understanding of where tensions might arise is an important step towards promoting ethical decision-making. The model shows that conflicts can take place at multiple levels: personal, professional, organizational/institutional, and societal. It situates residents within convoys, which are networks made up of people who support them (i.e., family and friends, staff, and others within and external to the care community). Daily life and care relationships, processes, and experiences, therefore, take place between individuals and within convoys, shaped by their individual and collective notions of what is right and just. Yet, these interpersonal encounters and subsequent decision-making do not take place in a vacuum. Rather, they are nested in the care setting itself, which has its own set of values and influences, rules and regulations. Stepping back further, we see that care settings are located within local communities and care industries, including regulatory context, and at the broadest level, macro-level comprised of the social, political, economic, and public health contexts, as well as common morality and laws.
We illustrate and apply the model through a series of case examples drawn from our research. Rather than resolving each case, we provide the particulars, identify the key or sensitizing issues (e.g., quality of life, autonomy, decision-making capacity, home versus workplace, safety, risk, resident and worker and individual and collective rights), and suggest questions that could be asked to support ethical decision-making and resolution through policy, practice, and education.
What should be considered when emotionally close relationships between residents and direct care workers develop, and personal and professional boundaries are blurred? What about when physical intimacy occurs in public and private spaces between two residents, both living with dementia? Is it just for a husband to relocate his wife to an apartment in an unfamiliar wing because another resident, a man with dementia, continually appears in her room believing it is his own? What should be considered when a care worker believes she is protecting a resident who identifies as lesbian from potential ridicule by other residents and possibly staff by not dressing her in her favorite t-shirts with gay-pride sayings?
In order to support ethical decision-making in these and other cases, it is essential to recognize all potential stakeholders (e.g., residents, staff, family), conflicts, and factors that influence the outcome of situations, including personal values and preferences, sense of what is right and wrong, care philosophy, rights, regulations, and even social norms and laws. Sometimes what is right may be obvious, uncontested, or pre-determined. Other times, however, the correct path forward may be less clear. Resolving ethical issues depends on whose perspective is taken, which value or values are prioritized, and who has the final say. We hope our model will guide future research and raise awareness of ethical considerations in assisted living and other long-term care settings.
Article details
The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living
Candace L. Kemp, Jason Lesandrini, Jennifer Craft Morgan and Elisabeth O. Burgess
First Published: October 14, 2021
DOI: 10.1177/07334648211049806
Journal of Applied Gerontology
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