New Directions in Nursing Home Ethics
Nursing homes can be frightening and depressing places. They remind us of our own mortality and of the inevitable time when most of us will face the frailty, ailments, and incapacities of old age. At the same time, nursing homes are places of refuge and respite; essential places to which exhausted families turn when they can't manage at home and when adequate community support is unavailable or unavailing. For some residents, too, moving to a nursing home represents escape from the loneliness, isolation, and danger of a solitary house or apartment. It means return to a social setting and a community of care and concern. Nursing homes are places to go home from--and many do. They can also be--and are--places people go home to.
How can we best make sense of the deep ambivalence, even the antipathy, that so many in our society feel toward nursing homes? How can we articulate a positive and constructive vision of the nursing home as a community of caring and a habitat that facilitates and nurtures the good living of the end of a life? To answer these questions we believe it is necessary to rethink some of the most common assumptions and orientations now applied to nursing homes in the regulations we impose upon them and in the ethical standards we ask them to meet.
First, we need to rethink the concept of autonomy, so central to bioethics in recent years. In the nursing home setting, because of the kinds of physical and mental limitations most residents face and because of the social functioning of a nursing home as an institution, autonomy and dependency cannot be seen as opposites. Instead, they must be seen as intertwined facets of one's life and one's state of being. Similarly, autonomy and community must be made mutually compatible in a nursing home setting if we are to get a full and realistic moral purchase on how life is actually lived there.
Second, we need to consider the difficult problem of justifiable limitations on individual freedom of choice and the institutional management of behavior. Problems of this type simply come up differently and have a different feel about them in a nursing home setting than they do in the acute care context, or in most other spheres of social life. And they come up every single day.
Finally, we need to reconsider the basic directions and purposes of our public and regulatory policies concerning nursing home care. There is a growing awareness that an exclusive focus on protection and adversarialism in nursing home regulation is sometimes self-defeating. The policies and the means of their enforcement can create such defensiveness and rigidity in nursing homes that what should be the common goal of everyone involved, namely, the well-being and care of individual residents, gets lost in the process.
The history of the modern nursing home has harsh beginnings, dating back to the nineteenth century almshouses and poorhouses that sheltered the destitute elderly. These institutions were places of both asylum and detention, housing a diverse population of the poor, the chronically disabled, and the mentally ill. Mid-nineteenth-century morality tended to see poverty and disability, even in old age, as signs of an undisciplined, improvident, even profligate life. The harshness of the poorhouse and the social stigma attached to it were intended, therefore, to be socially therapeutic, prompting citizens to be provident for their old age and to avoid, at all costs, the bleak harbor of public dependency.
Despite their punitive morality and grim physical conditions, poorhouses remained the primary institutions for the dependent elderly well into the twentieth century. Even though, near the turn of the century, churches and benevolent associations began to sponsor private old age homes, the number of elderly seeking refuge in county or municipal poorhouses continued to rise. …