Adult Protective Services Library

A Community Dialogue Series on Ethics and Elder Abuse: Guidelines for Decision-Making

Georgia J. Anetzberger, PhD
Carol Dayton, MSW
Paulette McMonagle, MA

ABSTRACT. Ethical dilemmas characterize the prevention and treatment of elder abuse. Yet, few guidelines exist for professionals or communities to examine and resolve them. A Community Dialogue Series on Ethics and Elder Abuse was held in Cleveland, Ohio. Focused discussion across professional disciplines, service systems, and cultural groups resulted in written guidelines for ethical decision-making related to six dilemmas common to practitioners and policy makers concerned about elder abuse. The guidelines are presented along with a description of the Series and suggestions for replicating it in other locales. [Article copies available for a fee from The Haworth, Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworth.com]

INTRODUCTION

Ethics is a branch of philosophy that explores the mores or character of cultures or subcultures. It provides a guide for right conduct (Johnson, 1995). Ethical dilemmas arise when values compete with one another for an individual or a group of individuals. For example, key ethical values for human service professionals in the United States include autonomy, privacy, beneficence, justice, no maleficence, fidgety, and accountability (Johnson, In Press). Interaction with clients may confront professionals with such ethical dilemmas as “Should vulnerable clients be allowed to remain at home because this is their preference, or should they be placed in the protection of nursing facilities, where the risk of malnutrition and other potential harm is reduced?”

Ethics is different from but related to law. Law results from the translation of moral judgments into moral standards. It takes a view upon which broad consensus has been achieved and then attempts to direct conduct into approved channels by sanctioning certain behavior and punishing other behavior (Capron, 1996). For instance, most elder abuse or adult protective service law includes mandatory reporting provisions (Tatara, 1995). This reflects the generally prevailing view that those human service professionals in frequent contact with vulnerable older persons should be required to report any known or suspected elder abuse situations or else be subject to specific penalty, like a fine or imprisonment (Schimer & Kahana, 1992). Ethical dilemmas about elder abuse reporting arise under various circumstances, including when legal definitions of elder abuse are vague (Callahan, 1988; Daniels et al., 1989) or when reports must go to agencies ill-equipped to adequately intervene (Ambrogia & London, 1981).
Elder abuse is fraught with ethical dilemmas. The earliest research on adult protective services, the primary intervention for treating elder abuse, raised concern about its abridgment of individual rights (Blenkner et al., 1974). Later enactment of mandatory elder abuse reporting laws brought accusations of ageism and excessive paternalism (Faulkner, 1982; Regan, 1981, 1990). More recently ethical issues have become attached to program priorities, as communities struggle to address elder abuse and a host of other problems in the face of shrinking resources (Mixson, 1996).
During the mid-1990s, ethics emerged as an area of focus within the field of elder abuse (Johnson, 1995). This occurred because preventing and treating elder abuse means encountering ethical dilemmas at nearly every juncture. There typically are no answers or absolutes with respect to elder abuse, only different perspectives and different implications based upon actions taken Anetzberger & Miller, 1995). This fact is as true for the person who reports the problem as for those who investigate or deliver services to alleviate it.
Unfortunately, there are few guidelines for resolving the ethical dilemmas associated with elder abuse. Those that do exist tend to rest on articulating beliefs or values (Hayes & Spring, 1988; McLaughlin, 1988), employing professional codes of ethics (Burstein, 1988; Mixson, 1995), or assessing the use of influence in protective practice (Abramson, 1991). Anetzberger (1988) offers a hierarchy of principles in adult protective services (Appendix A), but its usefulness is limited to those investigating elder abuse situations and delivering protective services. Holstein (1995) suggests an approach for multidisciplinary teams to use in working through ethical problems in elder abuse, but it was developed to examine individual cases rather than establish directions that have relevance to multiple situations. Spencer (1996) offers imperatives for developing a framework for ethical decision-making in elder abuse but no actual framework for decision-making. There are no guidelines for agencies or communities representing multiple systems, professional disciplines, services, or cultures to examine and apply to the ethical dilemmas of elder abuse that they regularly confront.

SERIES DESCRIPTION

Purposes and Assumptions

The Community Dialogue Series on Ethics and Elder Abuse, held in Cleveland, Ohio over a six-month period in 1995, had three purposes: (1) identify important ethical dilemmas In the prevention and treatment of elder abuse, (2) consider various perspectives regarding these dilemmas, and (3) suggest ways for resolving the dilemmas in order to address situations of elder abuse. The goal of this Series was development of written guidelines for ethical decision-making related to elder abuse.
Series discussions were based on several assumptions about which there is general consensus in the field of elder abuse: (1) The definition of elder abuse is broad and incorporates various recognized forms. Series participants defined elder abuse as the infliction of harm or suffering upon an older person, including self-abuse and self-neglect. (2) Elder abuse is a complex problem which the entire community has the responsibility to resolve. Series participants believed that no one system, agency, or discipline alone could succeed in preventing and treating elder abuse. Rather, this requires collective action by multiple concerned and cooperating organizations and individuals. (3) Ethical dilemmas can be resolved best through open exchange. In this regard, Series participants embraced ‘Habermas’ (1990) model of “communicative ethics,” which suggests that “finding the ‘correct answer’ to an ethical dilemma may be less a matter of agreeing on an abstract set of principles than it is a matter of sharing a commitment to free and open communication” (Moody, 1992: 38).
This article describes the Community Dialogue Series on Ethics and Elder Abuse and presents the guidelines for decision-making that were produced (Appendix B). It also illustrates Series deliberations through a case study used to explore one of six ethical dilemmas discussed by Series participants: “Should the civil liberties of the abused elder be removed in the interest of providing protection?” Finally, it identifies benefits derived from the Series and how the Series might be replicated effectively elsewhere.
The intent of this article is to describe the Series and present its guidelines for decision-making. The article will not include suggested ways to resolve identified ethical dilemmas outside of the Series discussions or to analyze approaches for identifying and intervening in elder abuse situations that were offered by the Series participants. Although these activities are worthy of exploration, they are beyond the scope of this article.

Structure and Organization

The Community Dialogue Series on Ethics and Elder Abuse had five sponsors. Four represented service providing agencies: The Benjamin Rose Institute, Cuyahoga County Department of Senior and Adult Services, Lakewood Division on Aging, and Volunteer Guardianship Program. The fifth sponsor was the local elder abuse network: Western Reserve Consortium for the Prevention and Treatment of Elder Abuse. The four agencies belong to the Consortium, along with nearly eighty other member organizations and individuals in Greater Cleveland. The authors of this article represented their agencies in planning and implementing the Series. Sponsors assumed the cost of the Series, including mailing session announcements, duplicating handouts, and providing refreshments and meeting space. The idea for the Series resulted when sponsor representatives realized that many of the ethical dilemmas they confront as service providers concern elder abuse and protective intervention. Dealing with these dilemmas was less effective when done in isolation than collectively.
A diverse group of professionals was invited to participate in the Series to facilitate a broad range of perspectives and suggestions for resolving ethical dilemmas in elder abuse. Series participants numbered 34 and represented eight professional disciplines, including medicine and law; ten service systems, such as social services and mental health; and various ethnic groups, including African-American, Puerto Rican, and Asian Indian.
The initial session of the Series generated ideas about the ethical dilemmas to be addressed. Participants offered eighteen suggestions. They were collapsed into six broad dilemmas for discussion, one during each monthly two-hour session of the Series. The six ethical dilemmas discussed were: (I) Should health and social service professionals be mandated to report a known or suspected elder abuse situation? (2) Is elder abuse in the “eyes of the beholder?” (3) Should the elder abuse perpetrator be regarded as a criminal or person with problems? (4) Should the civil liberties of the abused elder be removed in the interest of providing protection? (5) Should the focus of elder abuse intervention be on preventing or treating the problem? (6) Do we have a responsibility to intercede in elder abuse situations at all?
Sessions began with a facilitator from one of the sponsoring organizations identifying the ethical dilemma for discussion and providing background information on it, often in part through the distribution of related journal articles or other handouts. Group discussion followed, sometimes stimulated by case analysis, video presentation, or storytelling. Sessions ended with the facilitator summarizing the discussion and identifying key suggested strategies for resolving the ethical dilemma. Refreshments and continuing education credits were offered with each session, Proceedings of the group discussion were recorded, summarized, and mailed in advance of the next meeting. Time was set aside early in the meeting for comment or revision of the mailed proceedings.

ILLUSTRATIVE DILEMMA

Describing one of the Series sessions will help illustrate the range of methods for the presentation of the ethical dilemmas. Perhaps the most challenging dilemma presented for deliberation in the Series was discussed in the fourth session: Should the civil liberties of the abused elder be removed in the interest of providing protection? This question places two principles in contrasting positions: Autonomy, the right to be left alone to make one’s own choices and beneficence, the position of acting in the best interest of another. Parens patriae is the term used to indicate that society, through the establishment of law, has taken the role of “parent of the people” and, due to endangerment of a dependent or vulnerable segment of society, has a right and obligation to infringe on autonomy. This can be justified broadly in terms of protecting the general health and welfare of the society and narrowly in terms of relieving the suffering of an individual.

Research and Theoretical Information

In considering the issues that result from autonomy versus beneficence, the participants in the Series spent about one-half hour of the two hour session considering theoretical information, including early research by Blenkner and her associates (1974) at The Benjamin Rose Institute on the outcomes of protective services and a recent article on hoarding (Dunn, 1995). Blenkner prefaced her pioneering research as a “search for truth” and stunned colleagues when she presented the results. Those subjects receiving extensive adult protective services not only had a higher rate of institutionalization but also a higher rate of death. The only strong positive correlation with service provision was relief of the stress level of collaterals. This sobering outcome has influenced and cautioned the delivery of adult protective services since its publication. Dunn’s article examined case examples and theories concerning hoarding behaviors. The material indicated that in most instances hoarders are mentally competent although frequently experiencing mental illnesses, such as obsessive-compulsive disorder.
During the discussion of this information, a range of perspectives was presented by Series participants that challenged and clarified viewpoints. Intrusion on the individual due to a mandated adult protective services investigation was the most controversial aspect. Intrusion by government due to lifestyle was considered unacceptable in a society that supports civil liberty; however, the issue of defining lifestyle versus risk to community safety can present a dilemma. When the issue surrounds community values, not community safety, can an intrusion be justified, e.g., when the hoarder is perceived as reducing property values? The point of common agreement that was reached in this discussion was that the presence of mental impairment can justify intrusion. Another difficult issue was the concern about displacement of individuals to cleaner and safer environments while putting at risk their ability to adjust and even survive the disruption. “Will we have served well?” was the prevalent question. The point of common agreement was that involuntary placement of mentally impaired persons is justified only if it is likely to result in less harm to these individuals than is continued residence in their present settings.

Practice Discussion

The case example of Vera then was discussed for the remainder of the two hour session. The intent was to develop both clinical and community guidelines for reference when faced with the dilemma of removing civil liberties in the interest of providing protection. The interventions in the case were presented in four segments, each given separately and discussed at a point of decision and action. The participants’ reactions and practice recommendations, including contrasting and contradictory viewpoints, were examined. The multidisciplinary backgrounds of the Series participants added to the divergent points of view. Presenting the case sequentially and stopping to examine options captured both the real-life component of not knowing what will happen next but needing to make decisions anyway and the theoretical opportunity to examine choices and compare these to the unveiling of real outcomes.
This case began with a crisis call by the police to the Cuyahoga County (Cleveland) Elder Abuse Hotline on a very hot day during the summer of 1994, the summer that brought the deaths of many isolated elderly persons in Chicago.
A mini-version of the case is presented here:

Elder Abuse Hotline Call # 1

Report from a police officer on the scene: Neighbors call the police out of concern for an 86-year-old woman and her dog who are dependent on them for water due to a lack of working plumbing in her sinks. The woman has not been seen for several days and due to the hot weather the neighbors fear that the woman and her dog are dead. Police enter the unlocked house, finding a nearly impassable floor-to-ceiling accumulation of trash. A clear angry voice of an elderly woman calls to them from the second floor, “Who is in my house? Get out!” The police proceed up stairs that are filled with slippery debris. The woman appears to be dehydrated. It is obvious that there is no working toilet and the woman and dog instead have used the floor and newspapers, perhaps for years.
The police call the Elder Abuse Hotline both to report the condition of the woman and her environment and to ask if the protesting woman can be hospitalized against her will. She is refusing to leave valuables that she claims are kept in a padlocked closet.

Elder Abuse Hotline Call #2

Eight days later a police officer calls the Hotline irate that a woman hospitalized more than a week ago has been returned home, along with her dog returned from the kennel. He believes that this woman may die due to lack of water; suffocate under fallen debris (if any of the numerous trash piles fall), and is now at greater risk than a week ago because the temperature is higher and there is little, if any, air circulation possible in the house. Fire also is a huge risk. The woman had accurately described locked valuables of rare coins, a record collection, and unopened aged champagne. The coins had been taken to the police station for safekeeping; the woman is demanding their return. A call placed to the hospital medical records room confirms that the woman was discharged as a competent person, free of psychiatric diagnosis.

Follow Up Calls

In addition to the assessment of the adult protective services worker who had interviewed the woman at the hospital and on her porch, an assessment by the Adult Mobile Crisis Mental Health Team was carried out at the request of the protective services worker and the police. Both the crisis team members and the protective services worker assessed the woman to be rational, eccentric, and difficult. However, at the insistence of the police officer, the protective services worker and crisis team member returned with the police when the woman was again out-of-contact with her neighbors, and therefore without water, after two more days of extreme heat.It appeared that all of the woman’s doors were barricaded. The police, accompanied by the fire department, broke a window to enter. The officer had to enter head first, legs held by the protective services worker and others present, while he cleared sufficient trash to reach a door knob. Upon an earlier entry to the scene known only to the police, the protective services worker and crisis team member agreed that the woman’s judgment was severely impaired and she was a danger to herself. She was hospitalized in the psychiatric unit of a different hospital.

Outcome

The woman was evaluated to be mentally incompetent during her second hospitalization. While verbally skillful, her ability to execute behaviors was severely diminished. The occupational therapy evaluation most clearly documented the areas of dementia. Guardianship application resulted along with placement in an adult home care setting, with the first placement lasting one day. The Probate Court held several hearings on this case. The first hearing included the woman’s demand for her own attorney and the appointment of a pro bono lawyer to protect her rights. The woman’s legal advocate strongly believed that her client was competent and able to return home if it received a major clean up. A third evaluation of competency was ordered by the Court. Based on verbal interaction and a mini-mental test, the woman was found competent. In reviewing all the evidence, including photos of the interior of the home, the magistrate ordered appointment of an interim guardian.

Review of the guardian’s report three months later led to a final judgment of incompetence and a full guardianship. In fact, the woman’s high verbal skills masked an inability to act on decisions.
In presenting case material and stopping at points of decision-making, it is critical not to direct discussion to support the actual end-result. Lively debate and discussion then can result.
Series dialogue resulted in guidelines for this dilemma which underscored the following: Comprehensive assessment of mental capacity; primary focus on the client, not the community; avoidance of ageism in problem resolution; gradualism in protective intervention; and community education on self-determination and individual rights.

DISCUSSION AND RECOMMENDATIONS

The Community Dialogue Series on Ethics and Elder Abuse achieved its three purposes: Identifying ethical dilemmas common to elder abuse, considering various related perspectives, and suggesting strategies for resolution. Participants identified six broad ethical dilemmas in the prevention and treatment of elder abuse. They agreed that the selected dilemmas define the quandaries in elder abuse that present greatest concern to professionals and demand examination and strategies for problem-solving.
The second purpose was achieved through the inclusion as Series participants—persons from various professional disciplines, service systems, and cultural groups. Sharing professional and cultural values, norms and personal experiences revealed that solving ethical dilemmas common to elder abuse is extremely complicated and challenging, often requiring a balancing act.
The third purpose of the Series was achieved by developing the Guidelines for Decision-Making. The outcome of the six sessions was the formation of written clinical and community guidelines for ethical decision-making related to elder abuse. The Guidelines were developed from the recommendations of Series participants for resolving the ethical dilemmas presented in the Series. Recommendations were organized into those with relevance for clinical practice and those requiring community actions (especially in the areas of education and training, program planning, and policy development). Finally, the Guidelines were formatted for consistency and general understanding outside of the context of the Series itself.
The Guidelines are broad enough to be used by multiple systems and professional disciplines. Although produced for use in Greater Cleveland, they can be applied to elder abuse situations across the country. The Guidelines related to clinical practice support a multidisciplinary approach wherein representatives of involved agencies and disciplines come together to negotiate activity and debate measures to effectively resolve situations of abuse and neglect (Harshbarger 1988). The Guidelines related to community action suggest education as a primary prevention strategy, with each agency and system assuming ownership for some aspect. Participants were asked to evaluate the Series after each session for the quality of its organization and content. Both dimensions were rated on a Liker-type scale ranging from little or none to exceptional. The mode rating for session organization and quality of content was exceptional.
Once the Series was completed and the Guidelines were developed, the latter were disseminated to all the participating agencies and individuals as well as member organizations of the Western Reserve Consortium for the Treatment and Prevention of Elder Abuse. Based on a telephone survey of randomly-selected Series participants several months after the Series ended, the Guidelines were widely employed, most commonly for in-service staff trainings. In addition, some agencies used the Guidelines as a point of reference in supervisory meetings and ethics committee case conferences, and several participants reported sharing the Guidelines and various Series handouts with staff and colleagues, especially those on the front line who constantly grapple with ethical dilemmas and decisions. In the future the Consortium intends to use the Guidelines for training and education purposes with new members and the Series format for addressing other issues, such as the interfacing problems of elder abuse and domestic violence.
While the Series was considered a success as far as fulfilling its established purposes, much was learned in the process and in the final analysis a few recommendations are suggested to strengthen the Series as a practice concept. First, the Series can be enhanced by including as participant’s older adults, caregivers, elder abuse victims, and in some instances elder abuse perpetrators. The Series in Greater Cleveland consisted of professionals except for one caregiver, and among the participants only 24 percent were age 60 years or older. The viewpoint of non-professionals, especially older adults, adds a new dimension to the identified ethical dilemmas related to elder abuse, particularly mandatory reporting and societal intervention. While the sessions may require intense discussion to eventually come up with practical resolutions, and therefore be intimidating to nonprofessionals, they can benefit from the practical and realistic perspectives of people directly associated with elder abuse and its etiology. Second, an ethicist should be included in the group planning and implementing the Series. This helps ensure that Series discussions and guidelines integrate established ethical principles and frameworks. Although ethicists were among the Series participants in Greater Cleveland, they were not in the planning group. As a result, their contributions to the Series were irregular because of attendance and often muted because of the intensity of those more often in direct contact with elder abuse victims.
Replication of the Series elsewhere is encouraged. This can be accomplished in a single setting—agency or system—using staff and consultants across various disciplines and levels of authority to insure broad perspective. However, there are benefits in making the Series a community-wide initiative. For example, the Series furthers understanding and networking across multiple organizations, and therefore can serve as a catalyst for future project collaboration and problem-solving. Also, because the diversity of perspectives is likely to be greater community-wide than in a single agency or system, information shared in the Series will be richer and recommendations for resolving ethical dilemmas more complete. Finally, the Series’ format fosters nonjudgmental high level thinking that engages participants and encourages camaraderie, which can improve professional relations in other contexts.
Based on the experience of having sponsored a dialogue series on ethics and elder abuse, several steps are suggested to promote success when replicating it community-wide in other locales:

  • Include several community agencies which assume responsibility for sponsoring and planning the series. Involving various agencies sends a message about the breadth of interest in the issue and helps to decrease the cost and burden experienced by a single agency.
  • Offer continuing education units. In addition to the general community and agency benefits gained, continuing education units contribute to concrete personal benefits for individual participants.
  • Keep the sessions time-limited and adhere to the agenda topic. This is critical when the participants are active people who value their time. The very nature of the series makes it quite easy for the discussion to take on other issues and to be drawn out.
  • Distribute the recordings of the previous session prior to the next session. The recordings not only recapture the last session, they also serve to cultivate interest in all aspects of the Series.
  • Make the final session a celebration with refreshments and time out for socializing. Celebrating the mutual exchange and work accomplished will bring closure to the Series.

The Series Guidelines presented in this article can stand alone. They do not require community-specific replication to use. Moreover, planning and implementing the Series is time-consuming and requires considerable commitment by the sponsoring agencies and their representatives. Yet, the benefits derived from a community undertaking its own Series to reflect its own areas of ethical concern in preventing and treating elder abuse cannot be under or over-stated.

REFERENCES

Abramson, M. (1991). Ethical assessment of the use of influence in adult protective services. Journal of Gerontological Social Work, 16(1/2), 125-135.
Ambrogi, D., & London, C. (1985). Elder abuse laws: Their implications for caregivers. Generations, 9, 37-39.
Anetzberger, Gd. (1988). Ethical issues. Paper presented at the National Conference on Elder Abuse: Linking Systems and Community Services, Milwaukee, WI.
Anetzberger, G.J., & Miller, CA. (1995). Impaired psychosocial functioning: Elder abuse and neglect. In CA. Miller (Ed.), Nursing care of older adults: Theory and practice (2nd ed.) (pp. 518-552). Philadelphia: Lippincott.
Blenkner, M., Bloom. M., Nielson, M., & Weber, R. (1974). Final report: Protective services for older people. Findings from The Benjamin Rose Institute study. Cleveland, OH: The Benjamin Rose Institute.
Burstein, 8. (1988). Involuntary aged clients: Ethical treatment issues. Social casework: The Journal of Contemporary Social Work, 69, 518-524.
Callahan, J. J., Jr.(l988). Elder abuse: Some questions for policy makers. The Gerontologist, 28(4), 453-458.
Capron, AM. (1996). Morality and the state, law and legalism. Hastings Center Report, 25(6), 35-37.
Daniels, R.S., Baumhover, L.A., & Clark-Daniels, CL. (1989). Physicians’ mandatory reporting of elder abuse. The Gerontologist, 29(3), 321-327.
Dunn, R. (1995). Extreme hoarders. Caring, 14(7), 36-42.
Faulkner, Lit. (1982). Mandating the reporting of suspected cases of elder abuse: An inappropriate, ineffective, and ageist response to the abuse of older adults. Family Law Quarterly, 16(1), 64-91.
Habermas, 1. (1990). Moral consciousness and communicative action. Cambridge: MIT Press.
Harshbarger, S. (1989). A prosecutor’s perspective on protecting older Americans: Keynote address. Journal of Elder Abuse & Neglect, 1(3), 5-IS.
Hayes, C., & Spring. J,C. (1988). Professional judgment and clients’ rights. Public Welfare, 46(2), 22-28,
Holstein, M. (1995). Multidisciplinary ethical decision-making: Uniting differing professional perspectives. In T.F. Johnson (Ed.), Elder mistreatment: Ethical issues, dilemmas, and decisions (pp. 169-182). New York: The Haworth Press, Inc.
Johnson, T.R (Rd.). (1995). Elder mistreatment: Ethical issues, dilemmas, and decisions. Binghamton, NY: The Haworth Press, Inc.
Johnson, T.F. (In press). Handbook on ethical issues in aging. Westport, CT: Greenwood Press.
McLaughlin, C. (1988). “Doing good”: A worker’s perspective. Public Welfare, 46(2), 29-32.
Mixson, P.M. (1995). An adult protective services perspective. Journal of Elder Abuse & Neglect, 7(213), 69-87.
Mixson, P.M. (1996). How adult protective services evolved, and obstacles to ethical casework. Aging, 367, 14-18.
Moody, HR. (1992). Ethics in an aging society. Baltimore: Johns Hopkins University Press.
Regan, J.J. (1981). Protecting the elderly: The new paternalism. Hastings Law Journal, 32(5), 1111-1132.
Regan, J.J. (1990). The aged client and the law New York: Columbia University Press.
Schimer, M. R., & Kahara, J. S. (1992). Legal issues in the care of older adults: The magic of legal labels. Cleveland, OH: Western Reserve Geriatric Education Center.
Spencer, C. (1996). Abuse and neglect of older adults: An examination of ethical dilemmas and a model for ethical decision-making. Paper presented at the Annual Scientific Meeting of the Gerontological Society of America, Washington, DC.
Tatara, T. (1995). Elder abuse: Questions and answers. Washington, DC: National Center on Elder Abuse.

APPENDIX A

There are ten principles of Adult Protective Services. Arranged in hierarchical fashion, from the most to the least important, they provide the Adult Protective Services Social Worker with a framework for case planning and intervention.

  • FREEDOM OVER SAFETY: The client has a right to choose to live at risk of harm, providing he/she is capable of making that choice, harms no one and commits no crime.
  • SELF-DETERMINATION: The client has a right to personal choices and decisions until such time that he/she delegates or the court grants the responsibility to someone else.
  • PARTICIPATE IN DECISION-MAKING: The client has a right to receive information to make informed decisions and to participate in all decision-making affecting his/her circumstances to the extent that he/she is able.
  • LEAST RESTRICTIVE ALTERNATIVE: The client has a right to service alternatives that maximize choice and minimize lifestyle disruption.
  • PRIMACY OF THE ADULT: The worker has a responsibility to serve the client, not the community concerned about safety or landlord concerned about crime or family concerned about finances.
  • CONFIDENTIALITY: The client has a right to privacy and secrecy.
  • BENEFIT OF DOUBT: If there is evidence that the client is making a reasoned choice, the worker has a responsibility to see that the benefit of doubt is in his/her favor.
  • DO NOT HARM: The worker has a responsibility to take no action that places the client at greater risk of harm.
  • AVOIDANCE OF BLAME: The worker has a responsibility to understand the origins of any maltreatment and commit no action which will antagonize the perpetrator and so reduce the chances of terminating the maltreatment.
  • MAINTENANCE OF FAMILY: The worker has a responsibility to deal with the maltreatment a family problem, if the perpetrator is a family member, and give the family the necessary services to resolve the problem.

Source: Georgia J. Anetzberger (1988, May). Ethical Issues. Paper presented at the National Conference on Elder Abuse. Milwaukee, WI.

Published in: C.A. Miller (1990). Nursing care of Older Adults: Theory and Practice. Glenview, IL: Scott, Foresman. Printed with Permission.

APPENDIX B

Ethical Dilemma: Should Health and Social Service Professionals Be Mandated to Report a Known or Suspected Elder Abuse Situation?

Clinical

  • Report when suspicion of elder abuse exists along with a belief that reporting will produce more good than not reporting for the older adult and family.
  • Report when suspicion of elder abuse exists and the potential harm caused by reporting is less than the harm caused by the situation in question (see “Principles of Adult Protective Services”).

Community

  • Encourage Adult Protective Services to establish quality improvement and inspection systems, including the regular opportunity for professionals to assess the agency service delivery system.
  • Maintain good relations with Adult Protective Services, working with the agency to address problems in report receipt and investigation.

Ethical Dilemma: Is Elder Abuse in the “Eyes of the Beholder?”

Clinical

  • Do not assume knowledge or expect to understand cultural norms and values that are outside of one’s own experience. Openness to listening to the perceptions and expectations of those in the situation is critical.
  • Educate and interpret for families the Ohio Protective Services Law for Adults as representing the norms and values officially presented as acceptable by the dominant society.
  • Be creative in seeking resources and answers to issues of harm and scarcity.
  • Evaluate the potential harm produced by enforced change when the legally defined abusive behavior is acceptable to the older adult.
  • Self-neglect is a condition that has a range from minimal harm (e.g., insufficient exercise) to life-threatening behaviors (e.g.) lack of utilities during cold weather). Remember that tolerance for self-neglecting behaviors is very individual and must be assessed.
  • Place central importance on the presence of mental impairment in determining the need to intervene in opposition to the accepted norms of an individual.
  • Insure that comprehensive assessments reflect values and cultural issues relevant to elder abuse.
  • In conducting the assessment, identify a point of reference for behavior an indicator of “normal” in relation to the present conditions.

Community

  • Educate the community on acceptable standards for the care of impaired older adults in a way that reflects public policy and reinforces broad cultural norms.
  • Offer training programs in human service agencies which provide an understanding of cultural issues in assessment and communication.

Ethical Dilemma: Should an Elder Abuse Perpetrator Be Regarded as a Criminal or a Person with Problems?

Clinical

  • Promote a multidisciplinary approach for effectively resolving acts of elder abuse. Input from various disciplines provides a more balanced approach to the problem, in addition to supporting and minimizing the trauma to the victim.
  • Through investigation and comprehensive assessment distinguish family involvement from the criminal act. Evaluate the benefits to the older adult to criminalize the actions.
  • Resolve the problem within the family context. In some situations this means helping the victim to understand that prosecuting the family member perpetrator can become a point of leverage for the perpetrator to get assistance through treatment and services. In other situations services to multiple family members may be the solution.

Community

  • Sponsor cross-trainings for professionals, including prosecutors, police, protective service workers, and health care personnel. Through cross training professionals have an opportunity to understand each professional’s role in effective resolution and to promote complimentary working relationships among the professions.
  • Increase professional and public awareness of the criminality of elder abuse. Exploitation and other acts of abuse and neglect are in and of themselves violations of the law.
  • Examine state law for possible changes, reinforcing that elder mistreatment can be a crime, Laws can be changed and a change in law can possibly better serve the older population.

Ethical Dilemma: Should the Civil Liberties of the Abused Elder Be Removed in the Interest of Providing Protection?

Clinical

  • Provide comprehensive assessment of mental capacity:
  • Understanding the individual in the context of lifestyle and capacity to make life-supporting decisions is essential.
  • Community and Adult Protective Services Social Work input are needed as well as in-patient observations.
  • Ensure that primary responsibility is to the client, and not the community (see “Principles of Adult Protective Services”).
  • Give the benefit of doubt to the client (see “Principles of Adult Protective Services”).
  • Guard against ageism in responding to this dilemma.
  • Make change in the older adult’s lifestyle as slowly as possible, measuring the “cost” in intrusion.

Community

  • Offer community education focused on self-determination and individual rights.

Ethical Dilemma; Should the Focus of Elder Abuse Intervention Be on Preventing or Treating the Problem?

Clinical

  • Prevent the recurrence of elder abuse in the context of the case plan that treats the immediate abuse situation and its effects.

Community

  • Begin prevention strategies with children, socializing them against violent behaviors.
  • Define elder abuse as a public health problem, like cigarette smoking. Then educate society as to its harmful effects and costs.
  • Present elder abuse prevention as both a private and a public responsibility. As a private responsibility, each of us must become educated and empowered to avoid victimization. As a public responsibility, we must bring elder abuse to the attention of legislators and the media. Legislators must be encouraged to find both prevention and treatment strategies. The media must be encouraged to increase public awareness about the problem as well as existing resource gaps.
  • Educate the community on elder abuse by reaching those not previously targeted through outreach activities. This especially applies to persons in regular contact with older adults or their families, such as funeral directors, bankers, and pharmacists.

Ethical Dilemma: Do We Have a Responsibility to Intercede in Elder Abuse Situations at All?

Clinical

  • Empower older adults to advocate for themselves and their more vulnerable peers when policies are contrary to their best interests.
  • Develop creative and timely approaches for interventions, giving clients a chance to build trusts and not feel intruded upon. People are more likely to respond positively to services when the approach is non-intrusive
  • Determine the competency of the older adult in order to resolve the situation within the framework of respecting individuals’ rights.

Community

  • Promote collaboration between legal, medical, and psychiatric professions to safeguard against improper, authoritative acts. Such actions put clients and agencies at risk, when the responsibility is to protect.
  • Provide education and training for all disciplines affected by mandatory reporting. Education and training can provide tools and skills for when to suspect elder abuse.