Ageing- The New Ethical Frontier

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Ageing: The New Ethical FrontierPatrick McArdle

a

aAustralian Catholic University , Canberra , Australia

Published online: 10 Jan 2012.

To cite this article:Patrick McArdle (2012) Ageing: The New Ethical Frontier, Journal of Religion,

Spirituality & Aging, 24:1-2, 20-29, DOI: 10.1080/15528030.2012.633042

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Journal of Religion, Spirituality & Aging, 24:2029, 2012Copyright Taylor & Francis Group, LLCISSN: 1552-8030 print/1552-8049 onlineDOI: 10.1080/15528030.2012.633042

Ageing: The New Ethical Frontier

PATRICK MCARDLEAustralian Catholic University, Canberra, Australia

The ethics of health care has been dominated by a crisis

approachwhen new issues, such as the refusal of life-sustain-

ing treatments or assisted reproduction, etc., arise we apply tested

precepts to new situations. If traditional ethics fail, new ethicalthinking is developed. Ageing demands an altered paradigma

fundamental change of thinking. Ethics related to ageing now

represents an intersection of health and welfare. Ethically, the for-

mer is considered primarily the provenance of professional ethics

and personal choice; the latter of social structures and obligation.

Ageing then represents a new ethical frontier in terms of definition,

framing health and social policy and the ethics that underpins

these considerations.

KEYWORDS Ethics, relationality, ageing ethics, personhood,medicalization

INTRODUCTION

There are several preliminary comments that need to be made before mov-ing to the article proper: first, my background is in the ethics of healthcaremy training and perspectives come from within the framework ofChristian philosophy and theology. My research focus develops the post-

modern concerns raised by John Macmurray (18911976) and EmmanuelLevinas (19061995) relating to understandings of the human person andapplies them to the context of health care. Both philosophers were centrallyconcerned with the concept of relationality. Relationality can be defined asa primordial dimension of every real being, inseparable from its substan-tiality (Clarke, 1993, p. 136). That is, the quality of human relationships andhow these are expressed in ethical behaviour and decision making. They

Address correspondence to Patrick McArdle, Campus Dean, Canberra Campus andDirector, Institute for Catholic Identity and Mission, Australian Catholic University, 223 AntillStreet, Watson, ACT 2602, Australia. E-mail: [email protected]

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Ageing: The New Ethical Frontier 21

argued and I agree with them that our behaviours and actions precede ourthinking and reasoning about our actions (Levinas, 1989, 1998; Macmurray,1991). Ethics, then is first a practical activity and only then a source and fieldof reasoning. My own work in this field centres on the question of what is

a person? In this context, we implicitly assume that all humans are persons;yet our actions and behaviours, at times, call this into question (McArdle,2008). My other preliminary comments concern the nature of ethics, espe-cially in relation to health care; and the general new situation created by thecontemporary experience of ageing.

Ethics is one of the oldest formal disciplines in philosophical discourse:along with metaphysics and epistemology it dates back to the pre-Socracticphilosophers in Ancient Greece. Clearly, as a practice ethics is much olderthan any philosophical reasoninghuman beings have been determininggood and evil, right and wrong, for as long as human beings have been

confronting issues since they first entered into relationships with anyonewho thought and acted differently. Yet, this origin is symptomatic of whatcan often be a problem when we are dealing with ethics in health care andrelated areas.

Health care too has a long practical history, though the ethics of healthcare is relatively recentdating from the 1950s and more fully since the1970s (Jonsen, 2000). For centuries physicians were regarded as people

with expertise who were able to be trustedthe Hippocratic Oath andsimilar injunctions are the formal grounds of why such persons could betrusted. However, in my view these statements of ethical intent hold signif-

icant power because of the actions of the physicians. In other words, theirstatements were credible because of their actions.

Following World War II, when the atrocities of physicians on behalf ofthe combatants became increasingly well known, there were a variety offormal moves to try to ensure that physicians behaved in an ethical manner.For the next 30 years various ethical paradigms and positions were devel-oped on a range of issues; as new issues arose, the relatively new disciplineof health care ethics applied previously tested responses to new scenarios,or, if really new, then developed new responses.

Two features of the discipline of health care ethics are significant here:first, that it has primarily been concerned with health care practitionerbehaviour; second, that it has been reactivewhether in terms of responsesto Dr. Mengele or the Tuskagee Syphilis Experiment or organ transplanta-tion or the therapeutic use of embryonic stem cells. This approach is theestablished frontier of ethics related to health care.

Our new experience of ageing represents the emergence of a new eth-ical frontierwe are all called to go where no one has gone before! Ageingis part and parcel of the human experience but it is being encountered in

Western societies in new ways: much longer times of independent living;

much longer life expectancy combined with an increasing degree of formsof chronic ill health and debility; limited social infrastructure to cope with


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22 P. McArdle

this new scenario of ageing. Two other features of the modern phenomenaof ageing are new and relevant to our discussions of ethics and ageing:the sheer numbers of older people is increasing and increasing rapidly; sec-ond, this particular group of new older people is part of the baby boomer

generation who, since their appearance in Western societies, has heraldedsignificant social and ethical change.

NEW SCENARIOS

Health care, especially in the twentieth century, has caused questions ofpersonhood to take on new significance. In the Western context, particu-larly, health resources are scarce, various aspects of medical research andthe application of expertise and technology are controversial, and the moral

axioms of previous ages, such as the doctrine of the sanctity of life are nowquestioned. Similarly, ethical questions related to intergenerational ques-tions, the obligations of the state and the nature of welfare raise particularlyimportant issues for this article. In order to demonstrate that personhoodis of central importance in health care and to indicate why a relationalapproach to personhood is more appropriate, I refer to and analyse particu-lar cases related to health, human community, and ageing. This applicationof the theoretical components of relational personhood to flashpoints inhealth care is the distinctive contribution of this article.

I think that what our experience of this new situation calls for is a newparadigm in ethical thinking. What are these new experiences? As signalled amoment ago, the phenomenon of more peoplemany more peoplelivinglonger will bring its own challenges. Only a few years ago the thought ofan 80-year-old in otherwise good health receiving a transplant would havebeen unlikely; in the future this may be much more common. The so-calledcutting-edge issues in health care will only be one feature of the ethicallandscape requiring new thinking.

Much more difficult are the systemic issues of the availability of veryhigh quality high dependency care with high levels of amenity where it

is required. Similarly difficult is the question of patient/client autonomynot in the right to request or refuse certain treatments, but the desire torequest substantial commitment of health care resources simply because ofdisposable financial resources without regard for clinical determinations. Stillmore challenging are the interpersonal questions that are currently emerg-ing and that will become increasingly part of decision making in terms ofdeterminations about health and mental states in relation to older personsfor example, the rise in later life de facto relationships in order to avoidentanglements of estates (not that this actually achieves the desired out-come); personal decision making that may be routinely called into question

by those closest to them; quite drastically altered life choices, especially inrelation to sexuality, sexual expression, and health care treatment.


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Within my own training in ethics and highly applicable in inductiveapproaches to the ethical reasoning, the examination of case studies permitsthe possibility of a detailed examination of new ethical situations. For thatreason the bulk of this article is taken up with the examination of two cases

that illustrate important new dimensions in the field of ageing. In particular,the cases demonstrate how clinical, medically focused models of health careand the ethical reasoning which, all too often, accompanies it will no longer

work for this new frontier.

Case 1

A 72-year-old patient with prostate carcinoma and metastases in bones(MRI reveals cancerous masses in ribs, spine, and skull) attends hospitalfor radiotherapy to reduce prevalence of the cancer in bones, principally

the spine. It has been determined to hospitalise the patient to minimisethe risk of fractures and to provide some respite for his principal carer,his partner.

During his admission he develops pneumonia and staff begin to wonderif it is a good idea to treat the pneumonia. It is reasoned that he isfar from being in a terminal phase and still has generally good health,

within the parameters of his condition. The resident prescribes antibioticsfor the pneumonia.

Several weeks later the patient is readmitted with a broken arm. A wide-

ranging discussion takes place between the patient, the consultingoncologist, the palliative care team, and the patients partner and hisadult children from a previous relationship. A number of treatmentoptions for the broken arm, subsequent chemotherapy/radiotherapy,antibiotics for pneumonia, palliative pain relief, respite and hospiceadmission, etc., are discussed.

The patient wants to recover and states this several times during the con-sultation. He also rejects the options of respite and hospice admissions.The patients children indicate that they are happy with options to keep

him comfortable and ease his passing. The patients partner is largelysilent but appears exhausted and distraught.

This case appears to be a standard end-of-life care case relatively eas-ily resolved through the use of an advanced care directive. Its solution isrelatively simple: determine the patients autonomous decisions and, if thisis not possible, arrive at some conclusion about who will hold a medicalpower of attorney and the responsibility of the health care professional isresolved, perhaps even absolved.

Based on my own relational interpretation and analysis, I argue that

this kind of case is not as straightforward as the typical examination yields.


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A relational analysis reveals further dimensions which indicate why ageing ispart of a new ethical frontier. It is not that the medical issues are discounted,simply that other matters are recognised as equally relevant.

Let me explore some of the additional items in this case that highlight

my argument.

1. The issue of the partners health condition is becoming one of the majorcategories in the new paradigm. No longer is the concern simply thatof the health condition of the patient/client/resident. Albeit, in this case,

which centres on a person with a terminal illness, in others it may bethat the demands of caring for a person with chronic ill-health conditionsmean that increasing numbers of partners and carers will require regularrespite in order to continue high-quality care in the community or home

setting. Without the provision of such careindeed, without the aware-ness that such care is requiredsignificant numbers of the chronicallyand terminally ill will require additional longer-term care in acute andpalliative settings. Quality health care support for the partner means thatoptimal care in settings more conducive to patient well-being are possiblefor substantial periods of time.

2. Cases of terminal illness and, increasingly, of chronic ill-health lead medi-cal staff to focus on the quality of life and decision making that is outsidethe central health and clinical condition of the patient. It is also worthnoting that the staff are having this conversation in the absence of thepatient or family members. Implied in this description is the notion thata pre-determined response will be presented to the patient and familymembers leaving only a yes or no response from those who are heldto be the decision makers as possibilities.

3. Multi-level dialogues involving health care teams and a range of relevantfamily members will become standard in a way that is only beginningto be the norm. The feature of this item is that there may well be arange of perspectives presented; families are increasingly complex andthe decisions within them are, likewise, complex. Before this kind of

model will be accepted the associated issues of hierarchy in health careteams will need careful attention.4. The patient wants to recover. The health goals of this patient are largely

unrealistic. In the current paradigm predicated on patient autonomy, thereis nowhere for health care professionals to go with this situation except toseek, ultimately, a declaration of incompetence. The patient is expressinga view consistent with any psychological analysis of the baby boomergeneration: they want to live forever, to live well and to have what they

want, even, perhaps especially, when they cannot have it. How this situ-ation is dealt with will determine not just treatment and lifestyle options

but also the well-being of the man, his partner, and the family. Rejecting


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alternatives such as respite and hospice admission demonstrates the limi-tation of the autonomy paradigm. Such admissions would not be for thepatient but for his principal carer. If this were part of the explanation, itmay be that the response might be different.

5. In our traditional health care ethics model, it is not conceived that therewould be significant disagreement among the interested parties. In thiscase, since the patient is competent, other views are irrelevant. However,it may be that persistence in his assertion of a desire to recover in theface of increasing frailty due to terminal illness is taken by the healthcare professionals to be an indication of a lack of competence. Hencethe views of family members whose stance reflects that of the health careprofessionals may be accepted as the more legitimate perspective, whilethose supporting the less professionally validated view, that is, the oneheld by the patient, is delegitimised and even used as evidence of a lack

of competence.6. The partner, the next person to be actively considered as the likely advo-

cate for the person, is rendered silent by their circumstance. What dowe know? This is a subsequent relationship, perhaps one resented by thepatients adult children. Perhaps issues linked to the estate or propertyare sensitive ones for the partner or children or simply the existenceof a sexual relationship with a new partner is the point of aggrava-tion. A not uncommon provision in such circumstances is that the newpartner has life-time tenure in property which subsequently reverts toother beneficiaries. Other alterations in bequests can also arouse hostility.

While these matters are irrelevant to professional clinical decisions aboutpatient care, they are relevant to the decision-making processes that car-ers may face. In addition, how is the health care team to respond whenan advocate, especially one who is formally a decision maker, is renderedmute?

A second case will flesh out some additional issues for consideration.

Case 2Mary-Jane is a long-term resident (7 years) in a religiously based andoperated residential aged care facility, Happy Home. She is 88 and ingenerally good health, for someone of her age. She is hard of hearingand has some very brief periods of confusion, though these may well berelated to her hearing condition than any indication of dementia.

Mary-Jane had a loving 55-year marriage to Colin prior to his death some11 years ago. Over the last three years Mary-Jane and Brian, anotherlong-term resident, have become very good friends. It is clear that their

relationship is moving to a new and more physical level.


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Mary-Janes adult children, Susan, Samantha, and Nicholas, are deeplyconcerned about her behaviour. They have spoken to her and havesuggested that their father would never approve. Mary-Jane is a woman

who knows her own mind and is absolutely convinced that her belovedhusband would have no objections to her finding happiness and comfortin the arms of Brian.

Brian and Mary-Jane seek to move from their single facilities into sharedaccommodation. On hearing this, Mary-Janes children approach themanager of Happy Home suggesting that their mother must now beconsidered completely incompetent on the basis of this decision and herunwillingness to yield to their demands for the relationship to cease.Further, they propose that her choices and freedoms be completely cur-tailed; Samantha and Nicholas wonder if some pharmacological remedyis warranted.

This situation will be increasingly common and will reveal the depth ofour attachment to autonomyat least in the case of other people. We areall generally pleased with people having complete freedom to choose, aslong as those choices are in accord with our own; make sense to me; align

with common values. We are far less enthusiastic about choices that do notcoincide with those we would make.

In the case of Mary-Jane a number of features illustrate the newparadigm:

1. She is a long-term resident of a residential facility; this will become thenorm to a greater extent than is the case now, meaning more suchfacilities will be required.

2. Though moderately aged, Mary-Jane is in good health. Her associatedhealth condition, being hard of hearing, is linked to perceptions that hermental acuity might be diminishing. Any record of such perceptions byphysicians or staff of the facility may well return to deprive Mary-Jane ofher choices.

3. She had a long and happy marriage but now, 11 years after the deathof her husband, she has a new relationship, which is developing in afairly natural way for a relationship of three years standing. How will theresidential facility respond to the question raised by these two competentresidents?

4. The response to her choices is that her children, rather than accept thather life choices, even if they appear contrary to her previous stance or lifechoices, are valid, are prepared to question their mothers competenceand her freedoms. Those we should expect to be our advocates and

defenders may well be the architects of the limitations of our freedom.


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A NEW FRONTIER

To formulate a new way of responding to the various new scenarios posedby an ageing population, those indicated above and those not yet antici-

pated, a new frontier for ethics is required. It should be one that is richer,more multi-faceted and relational in character. Let me offer an examplefrom the area of medical practice. Michelle Clifton-Soderstrom has pointedout that as medicine becomes increasingly scientific in orientation, method-ology, and discourse, the distance between practitioners and patients isalso increasing. Associated with this increasingly scientific orientation ofmedicine is the view that the uniquely female aspects of health care needto be controlled. Child-bearing, which in most pre-medicalised cultures is

viewed as a natural process, is viewed in contemporary Western medicine inquasi-pathological terms.1 The physician is the agent on whom all activity

is focused; the woman is passive and needs to have her condition man-aged and controlled (Clifton-Soderstrom, 2003, pp. 447450). This tendencyto view health care professionals as the agents, and patients as merely pas-sive in the process of health care, implies a distinct philosophical stance,however unavowed. This is certainly the case in the quite different settingof the ethics of ageing. Dominant models of health care, especially whenthey are basically utilitarian, and their associated ethics, filter all health deci-sions through a lens focused on autonomy, beneficence, non-maleficenceand justice. They are subject to the calculus of the greatest well-being forthe greatest number, so that the emphasis is overwhelmingly on the activi-

ties and responsibilities of professionals according to particular professionalcodes of conduct. As a result, little credence is given to the response of theperson who is the subject of care or recognition of his or her significancein the processthey are the subject of the activity, not a participant in theactivity.

Undoubtedly, the frontier presented by our new engagement with thephenomena of ageing will be a more complex frontier: the boundariesbetween health and welfare; service delivery and policy will be increas-ingly blurred. In the past, governments in Australia, but almost certainly

in other countries, have courted the senior citizen vote, more recently theself-funded retiree vote. Next it will be the aged care services vote!Some examples of changesfirst in health care: Governments will need

to put in place processes that enable this demographic group to have whatthey want: very high quality community services to enable independentliving for the maximum period, including access to health care proceduresand drugs that permit this lifestyle choice. This will be followed by increasedaccess to high-quality residential facilities that enable high dependency carein a comfortable state.

Second, social structures and conventions will need to adapt. Increasing

numbers of older people will be anxious to both develop meaningful


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intimate relationships that do not jeopardise their estates but also adequatelyhonour their partner. One example of this kind of situation that is emergingin Australia is the trend to writing a formal will that entails the bulk of anestate to, for example, the children of a former relationship and, as well, a

binding superannuation beneficiary declaration that bequeaths the superan-nuation portion of the estate to a new relationship. This avoids substantialconflict during life, but may cause significant litigation later. Currently, undersuch binding declarations in Australia, superannuation fund trustees have nochoice but to honour the declaration regardless of the provisions of a will.Linked to this, a number of older people are indicating that while they havebeen life-long and devout members of churches, their new relationships arenot marital ones because of the limitations that marriage places on theirfinancial circumstancesat least in their minds.

Third, thinking about sex and sexual activity among older persons

will need to be revised. The baby boomers have consistently altered pub-lic perceptions about sex during their reign as the dominant demographicgroup; this will not change as they become older. Perceptions that sex israre or not possible into the 90s and beyond will change; it will be forcedto do so. Along with this our perceptions of beauty and virility will also shiftto account for this powerful new block.

At least initially, we may well find that governments have begun tobudget for a declining pension base, to be taken up through superannuation.In the first large group of people to live actively into their 90s, who will alsobe those with lower superannuation balances, and, most likely, higher health

care costs, there may be a sharp rise in pension costs as they outlive theirsuperannuation balances.

These are all fairly positive or neutral features of the new frontier. Thereis one obvious negative that will almost certainly increase, since it has alwaysbeen our community response to situations we do not like. This is, of course,the scenario indicated in the story of Mary-Jane. When people engage inbehaviours that are considered inappropriate by a group with some imme-diate but usually limited power, the response of those seeking to cling topower is to establish a diagnosis of mental illness. Throughout history those

who feel their grip on power slipping have resorted to claim that those whomake different choices are somehow mad. History demonstrates that we areoften too willing to accept this claim. Hopefully, this time will be different.

CONCLUSION

Though unable to resolve all the ethical dilemmas associated with ageing,thinking about personhood in relational terms opens the possibility of aseries of dialogues between, for example, various parties in the two case

studies outlined and considered above, together with those who provided


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care for them. In this case, thinking in relational terms may not alter clini-cal outcomes, but would bring the key people, the person requiring care,into the conversation. Adopting relational personhood might have enableda wider conversation that included the voices of the elderly.

Relational personhood represents a pathway to a fundamental shiftin the discourse of ethics and ageing. Since it focuses on relationships, itinspires a priority for the vulnerable and gives rise to an ethic of responsi-bility. This is not a dramatic claim but it does have the capacity to transformthinking about ethics and ageing.

The perspectives offered in this article are suggestions about ways thatwe may engage in thinking ethically in the context of the new situationsdeveloping through our new experiences of ageing. They are leading us toinevitable new ways of thinking and responding, new ways of learning tolive together and decide together; this will be a new frontier. It remains to

be determined if we will be dragged to the frontier or whether we will goboldly where no one has gone before.

NOTE

1. I recognise that this is a provocative claim, even with supporting research; however, the kinds oflanguage which are associated with pregnancy and birth do lead to such conclusions. For example, onecause of the inability to carry an embryo to term is described as an incompetent cervix. More overtly isthat the procedures for birth described in standard nursing and medical texts simply assume that this isfirst and foremost a medical procedure.

REFERENCES

Clarke, W. N. (1993). Person and being. Milwaukee, WI: Marquette University Press.Clifton-Soderstrom, M. (2003). Levinas and the patient as other: The ethical

foundation of medicine.Journal of Medicine and Philosophy, 28(4), 447460.Jonsen, A. R. (2000). A short history of medical ethics. New York, NY: Oxford

University Press.Levinas, E. (1989). Ethics as first philosophy (S. Hand & M. Temple, Trans.). In

S. Hand (Ed.), The Levinas Reader (pp. 7587). Oxford, England: BlackwellPublishers.

Levinas, E. (1998). Of God who comes to mind (B. Bergo, Trans.). Stanford, CA:Stanford University Press.

Macmurray, J. (1991). Persons in relation. Atlantic Highlands, NJ: Humanities Press.McArdle, P. (2008). Relational health care: A practical theology of personhood.

Saarbrucken, Germany: VDM Verlag Dr. Muller.

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Ageing- The New Ethical Frontier