Ethical Considerations of Elder Abuse: Identifying the Breach

   Experts suggest that as many as 10% of older Americans are victims of abuse. Elder abuse can occur at a licensed or accredited healthcare facility or even in the elder's own home. In fact, most abuse is thought to occur at home by family members and may not entail physical abuse.1

This article examines the current legal descriptions of elder abuse. Ethical considerations and professional obligations are presented in particular in the presence of physical manifestations such as pressure ulcer development and other forms of skin injury. A case study is presented.

Defining Elder Abuse
   Reports reveal that physical abuse accounts for only one in four cases, although the victim may be subjected to one or more of the five categories of elder abuse. These include neglect, emotional abuse, sexual abuse, financial abuse, or physical abuse. Neglect accounts for 49% of substantiated elder abuse cases and can be intentional or unintentional. Emotional abuse, described as the intentional infliction of emotional stress through verbal threats, intimidation, humiliation and social or physical isolation, is involved in 35% of cases. Sexual abuse is described as nonconsensual sexual contact of any kind, including unwanted touching, all types of sexual assault or battery, and photography of a sexually explicit nature. The misuse of an elder's property or financial resources is referred to as financial abuse. Financial or material exploitation is documented in 30% of cases. Physical abuse accounts for 25% of reported cases and is described as the use of physical force that results in pain, impairment, or bodily injury. Physical abuse can be further described as hitting, slapping, restraining, molesting, biting, pushing, or pulling.2

Case Study
   Anna was an 82-year-old woman who died shortly after she was brought into the emergency department after a fall outside her small suburban home. Eight weeks before the hospitalization, Anna cared for her 58-year-old son, Peter, who had never worked and was unable to contribute to his own care because of a brain injury that occurred more than 50 years before. Anna used public transportation, paid bills, shopped, and coordinated household activities - all despite very limited income and other resources.

   Two months before the fall that brought her to the hospital, Anna developed a stomach flu that lasted several days and led to dehydration and confusion. Anna forgot to take her routine medications, was unable to prepare meals, and failed to accomplish the required activities of daily living for herself and Peter. The stomach flu escalated to frequent and persistent vomiting and diarrhea, accompanied by weight loss, incontinence, and superficial skin breakdown over most of her trunk and legs.

   Like many abused or neglected elders, Anna and her son seemed to have lived in isolation from neighbors, friends, or community members. Adult protective services were immediately notified by paramedics. On admission to the emergency department, further investigation was initiated. The nurses photographed the dried vomit in Anna's hair, skin folds, under her arms, and over her entire trunk. Further photodocumentation was used to illustrate dried fecal matter on her buttocks, perineal area, and legs. Eschar-covered pressure ulcers over Anna's mid-back and sacrum were just beginning to open, with subsequent drainage of a foul-smelling, thick liquid. Although photography failed to capture the essence of this skin injury, every patient and clinician in the emergency department was affected by the odor emanating from Anna's room.

   Imagine the disdain that the involved clinicians felt for Peter before he even arrived to visit his mother. Without an understanding of the entire set of circumstances, it was difficult not to form a judgment regarding the emotionally overwhelming situation.

   Peter was allowed to visit his mother once she was transferred to the intensive care unit. Although the pressure ulcers were cleansed and dressed, the material that had dried on Anna's skin was very difficult and painful to loosen. Debris remained in place on more than 40% of her trunk and legs. The son looked confused and frightened; when he touched Anna, he seemed to be very aggressive with her. However, what initially appeared to be rough treatment was later thought to be his awkward, uncoordinated mannerisms. Further, Peter expressed his fear at seeing his mother in the intensive care unit and his desire to have her home. Again, fear and the drive for control have sometimes been associated with elder abuse.

   Anna's son was initially held legally accountable for her physical condition. He was at the police station at the time of her death. Informing Peter of his mother's death was an emotionally disturbing ordeal for Peter, the clinicians, and law enforcement.

Ethical Debate
    This case raises a number of legal and ethical questions. Shortly after Peter's police interview, charges were dropped and Peter was placed in protective custody as a dependent adult. Unfortunately, despite the goals of the legal system that strive to value the worth and dignity of elders, this system sometimes fails. This failure is largely because of the complex nature of people's lives; therefore, occasionally misunderstanding and lapses can exist between legal mandates and the patient's real life experience.

   From an ethical perspective, a multitude of dilemmas in this case stem from the ethical principles of respect for personal autonomy to beneficence and issues of justice, especially in relation to access to scarce resources. This case raises two important questions: What is the obligation of protective agencies to provide unsolicited monitoring of otherwise healthy elders at home? The opposing relevant question: To what extent do healthy elders have a right to autonomous decision making in the home care setting, without interference from government agencies?

   The first question appeals to the ethical principles of beneficence and to justice to a lesser extent. The role of protective agencies is to do good, not simply prevent harm, which, by definition, is the goal of the ethical principle of beneficence. Justice refers to the just distribution of healthcare goods and services. The elderly, children, and other dependent or vulnerable groups are considered protected; therefore, special services are available to these groups. Anna and her son would have qualified to participate in these services because of age and other circumstances. Yet, like Anna and Peter, many Americans do not access special goods and services even though these services are available to help the disenfranchised person meet basic human needs. This is because a right to refuse special services exists in many cases, raising the second ethical question: To what extent do healthy elders have a right to autonomous decision making in the home care setting, without interference from government agencies?

   The ethical right to respect for personal autonomy makes the argument in this debate. In the United States, the right to personal autonomy is an important ethical ideal. The U.S. Constitution is replete with relevant vocabulary that has become the norm in American culture. Therefore, unless special circumstances exist, personal autonomy is seldom challenged. This gives rise to special dilemmas for healthcare clinicians who, because of their experience and education, have a more comprehensive understanding of consequences that can stem from failure to accept special services. This creates conflict within members of the clinical community who are trying to balance respect for personal autonomy with the ethical obligation to do good (beneficence).

Recognizing Paternalism
    Paternalism is defined as a patient being cared for by a clinician, as a child is cared for by his or her father. Respect for personal autonomy and beneficence are always in conflict in the presence of paternalism; this tension is evident in Anna's case. A retrospective assessment of this case illustrates the need to do good for certain high risk groups such as elder (Anna) or dependent (Peter) adults. Anna's independence was seemingly important to her and failure to respect her autonomous right to personal decision making would threaten an important ethical ideal, along with her personhood, making what appeared as abuse a secondary issue.

Summary
   Ethics by nature is the philosophic study of right and wrong actions. It is useful in providing a structure for analysis in the presence of two or more equally unacceptable options.3 Imposing mandatory monitoring of Anna's lifestyle when she was healthy and independent was unacceptable. Retrospectively, respecting her autonomous decision ultimately may have led to her painful death.

   Policy change and legal intervention are often a result of ethical debate. Access of healthy elders to healthcare goods and services may prevent cases such as described herein. A better clinical understanding of breaches in protecting vulnerable groups is another. The clinician is in a key position to offer input to change - the front line professional who can interpret these challenges to the disciplines of public policy and law.