Academic journal article Generations

Care of Elders in the Community: Moral Lives, Moral Quandaries

Academic journal article Generations

Care of Elders in the Community: Moral Lives, Moral Quandaries

Article excerpt

The questions of bioethics and medical ethics are not purely intellectual questions. They are questions of the heart as well as the mind, and questions of social organization, not just the marshalling of arguments. It is harder to reform one's heart or one's society than to improve one's arguments. The sort of disciplined reflection we need on these questions is not merely intellectual. -Baier, 1992

This issue of Generations, with its focus on the ethics of noninstitutional long-term care for the elderly, comes at an auspicious moment for two very different reasons. Applied ethics, the study of how we ought to behave in situations involving human care, is in flux. No longer does it appear sufficient to call upon set principles and rules to guide action. Contributions from feminism, narrative, moral psychology, and the social sciences have recently invigorated conversations about "ought" questions and raised doubts about the possibilities for moral certainties. It is an exciting, albeit difficult, time as we seek to integrate the new with the old. Simultaneously, caring for older people outside of institutions is gaining momentum; given the available alternatives, it seems to be what older people want above all. This wish and its fulfillment, however, can be quite problematic for individuals, for families, and for communities. In this introduction, we would like to explore both aspects of this changing situation.

Setting a consistent theme, Larry Polivka challenges policy makers and policy analysts (including himself) to make homecare a more viable option for older people needing care. He insists that one more "perfect" study will not "prove" anything more than we already know about homecare. While another study may add information about cost effectiveness, for example, the moral values at stake are already quite clear. Yet, even if older people regularly opt for and receive homecare rather than institutional care, that can neither eliminate value conflicts nor solve larger moral concerns. While the entire issue of Genn,:ren/ will examine these problematic areas, this introduction will touch upon them briefly to set the stage for what follows. (We also note that several examples in these artides are acute-care cases. Sometimes acute-care situations differ so much from those in homecare that they can offer little guidance, but in these cases [see especially Harry R. Moody, and Hilde Nelson and James Nelson] the authors' points apply quite well to the homecare setting.)


The lack of adequate public resources to serve clients in a time of perceived scarcity is often the source of much of the ethical anguish that care providers and families face. Homecare and community care are tied to state and federal policy developments that determine the reimbursable service package. Recent federal developments do not bode well for local programs. Changes in reimbursement for home healthcare and Medicare + Choice and other forms of managed long-term care seem likely to seriously affect the care available to elders at home and in the community. (This problem is of course mitigated for individuals and families who do not rely on public funding to cover the costs of care.)

Short of remarkably generous donors, agencies and their employees must make choices about allocating resources. In choosing, there may be no "right" strategies but only marginally acceptable options that serve in the absence of the broader policy changes that we as advocates seek. It is also a time when moral imagination can open new possibilities. For example, can we find voluntary assistance beyond the family? Could a person do with less?

States with Medicaid homecare waivers and other state-funded programs have historically justified providing home- and community-based care on two grounds: It is the preference of elders, and it costs less than nursing home care. But in fact, states are often reluctant to develop community care programs because they fear the costs. …

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