Chapter Eighteen: Can Ethics help with Dignity for Older People (& does faith add to ethical perception)?
‘I’m thinkin’ about home, I’m thinkin’ about faith: I’m thinkin’ about work; I’m thinkin’ about how good it would be to be here some day on a ship called dignity.’ Deacon Blue (Raintown)
1. Introduction
2. Definitions
3. Methods, Context and Risks
Introduction
A BBC News Headline on 13 February 2007 read ‘Pledge to end NHS Elderly abuse.’ The pledge comes as the government unveils a 10 year plan to improve England’s elderly care. Inspectors will be encouraged to view breaches of older people’s dignity as serious failures in care. But, the article continues, ‘there is no new money to back the plan.’ In this brief quote we see the dilemma facing those championing dignity for older people. The dilemma of good intentions versus scarce resources.
Daniel Callahan in ‘Setting Limits’ states that there is an urgent need for a public discussion of the values and distinctive characteristics of old age. He argues that modern patient centred medicine has tended to undermine the meaningfulness of old age by its emphasis on individualism and life extending treatments….’ Callahan 1987 pg 30,31 Setting Limits: Medical Goals in an Ageing Society New York: Simon and Schuster. The Cambridge Medical ethics workbook adds that ‘modern medicine make it possible to delay death and give a degree of control over dying.’ Pg4 Sometimes there will be partial recovery resulting in loss of independence. Such medical advances raises ethical issues regarding dignity of older people and specifically about respect for autonomy, truth telling, withdrawing treatment, non resuscitation and resource allocation. Each of these areas could warrant an essay in itself, non the less I propose to briefly consider such issues in a section on medical ethics which would ensure dignity for older people in healthcare. Prior to this focus I will look at some philosophical models of ethics and conclude by asking if religious faith adds an extra dimension to the very current subject of ‘dignity in health and social care services for older people in the United Kingdom?’ (To avoid endless clarification of terminology this paper will look at dignity for older people in the UK. However, there is a consensus that the issues highlighted are similar throughout Europe (Marti Parker: Dept. of Social Work University of Stockholm 1997) therefore, journals and text books considered will be global.
I will reveal my bias by referring to Florence Nightingale who, working in Yorkshire in the 1850’s introduced a ‘well being framework’ which focussed on the person, the body and the environment. I propose to show that we have lost our way in the third prong of her focus, the environment and also in the broader picture of who or what is ‘the person’. Nightingale, was petitioning to bring cleanliness to the environment, a focus which we are still trying to master in healthcare in 2007. However, our current drive for cleanliness on the hospital wards and in the nursing homes and societies focus on the ‘individual’ has perhaps neglected other aspects of ‘environment’ which were prevalent in the 1850’s such as respect for the elderly, the importance of life stories and ‘narrative’ of individuals which shapes the person and makes ‘community.’
In 2006 the Department of Health launched its ‘Dignity in Care Campaign.’ They laid down 10 challenges of dignity in care for older people which we shall note in this paper. We shall examine one NHS Trust’s response to that challenge. We will further explore whether this governmental challenge has also overlooked a more holistic view of the person i.e. the person within community and with a narrative of ‘being.’ This section of the paper will develop into a general discussion of medical ethical issues surrounding the health care of older people. The essay will conclude with a comment on a possible distinctive contribution that a Faith Ethic offers to the issue of dignity in health care for older people.
Definitions
For the purpose of this study I shall adopt the definitions of dignity used in a 2006 Nursing Ethics Journal 13 Article by LL Franklin et al which explored views on dignity expressed by elderly people living in a nursing home. “Mairis suggests ‘dignity exists when individuals are capable of having control over their behaviour, their environment and the way in which they are treated by others. Haddock defines dignity as having the possibility of feeling important and valuable in relation to other people…. MacIntyre, highlights the relevance and importance of dignity for all those involved in caring situations and Fenton and Mitchell argue that dignity for elderly people….is a state of physical, emotional and spiritual comfort.’ The plethora of definitions of dignity shows it to be a subjective, emotive and current topic which is affected by our personal histories and our sociocultural environment. ‘Dignity comprises an internal aspect, which is ones personal, subjective valuing of oneself, and an external aspect, which is the valuing of oneself by others.’ (Pg 134 LL Franklin et al)
In the following two definitions of human dignity we gain an understanding of the Theistic and non-theistic approach. The Dictionary of Christian Ethics pg 278 defines ‘human dignity’ as ‘the inherent worth or value of a human person from which no one or nothing may detract…. In systems of thought which are essentially non theistic, human reason alone provides the basis for the understanding of human dignity.’ In Judeo-Christian tradition, human dignity derives from the understanding that human beings are made in the image of God… ‘thus men and women possess no small dignity.’ Further more, human beings are ‘created by God and in relationship with God. Human beings are not to be considered simply as selves, but as selves in relation to God.’ Pg 279
Franklin et al’s study showed that understanding dignity has important implications for the quality of care provided….. ‘from the elderly people’s stories it is clear that in order to keep a sense of dignity people need to be seen and respected for who they are.’ (pg 144)
Making Moral Decisions
From a theoretical perspective, what is the ethical debate that best ensures that older people are treated with dignity in their latter years? I propose to look briefly at three ethical theories with a view to introducing a fourth at the end of the essay which will contribute to the discussion ‘can religious faith add to ethical perception. The three theories are Utilitarian, Kantian and Virtue ethics and a fourth is referred to as story telling or narrative ethics.
Firstly, the Utilitarian viewpoint would seem to favour an ethic which would minimise pain or misery for the maximum number of people. Conversely, an ethic which would maximise the happiness or pleasure of the maximum number of people. Where a number of groups or peoples are affected by an ethical issue Jeremy Bentham (English Philosopher) devised a calculation known as ‘hedonic calculus’ which is an abstract formula which would give group guidance regarding a particular matter. Virtue Ethics and Leadership CPT C A Pfaff – Journal.
Bentham influenced John Stuart Mill who argued that a physician faced with the dilemma of deciding between one versus many, he should favour quantity over quality. This approach may suit individual dilemmas but it fails to assist decisions about scarcity of resources that health care trusts face whereby different people groups are brought into competition because of scarcity. For example use of ICU’s for infants versus OAPs.
Utilitarian John Rawls tried to consider such issues and argued for a model of just distribution of scarce resources such as health care resources. He said, provided the decision makers ‘wear’ a ‘veil of ignorance’ (allow no influence of thee decision makers own position) the just thing to do would be to equally distribute resources unless unequal distribution would improve the position of the worst member of that society (the difference principle) Parker and Dickenson 2001 pg 262
In having to making such theoretical contortions I believe the Utilitarian viewpoint does not really assist our ethical debate regarding dignity.
Looking now at the effect a Kantian standpoint would have on dignity. For Kant, ‘the distinctive moral characteristic of the rational creature was the capacity to live by no means other than that of its own making…. We [thus] do our duty for no other reason than it is our duty.’
The attraction of this approach is in its simplicity. It is ones duty to never treat people as commodities or manipulatively. Kant would have said a society which condoned lying (for example to a patient) would ultimately be unsustainable. Duty insists we must have a presumption of truth telling. Kant argued that respect for autonomy flows from the recognition that all persons have unconditional worth…. Kant view entails a moral imperative of respectful treatment of persons as ends in themselves.’ Principles of Biomedical Ethics pg 64 Beauchamp and Childress (2001)
Kantin philosophy takes a high view of morality but there is a danger that it fails to cope with the ‘grey areas’ of ethics such as the universal duty toward people groups and vulnerable adults whose rationality is diminishing and whose independence and freedom is under threat through ill health. Ruud ter Meulen points out that ‘while Kant sees the freedom of the person as embodied in acting from duty, in healthcare ethics freedom is merely seen as a freedom to decide on one’s own body and mind, without any reference to a universal duty. Thus the difference is between autonomy as self legislation (Kant) and autonomy as self-determination (Healthcare)’ Pg 137
Further, in healthcare ethics, there must be a constraint to freedom, namely if the freedom of one person put others in danger or unreasonably affects the free choice of others. ‘This view of autonomy is more close to the ethics of John Stuart Mill …than Kant . …. In cases of conflict, one should.. negotiate to reach a mutual agreement.’ Pg 137
In my view, neither Kantian or Utilitarian theories have given us an adequate base for medical ethical guidance on the importance of dignity for older people in health care. Our third theory, Virtue Ethics deals primarily with issues of character, ‘focussing not on the act but on the agent’ Virtue Ethics and Leadership CPT C A Pfaff – Journal.
‘Virtue ethics is the moral theory that we should live a virtuous life….. In the absence of a belief in God, the foundation for ethics is in the notion of virtue, referred to be Aristotle in the 4th Centaury as ‘human flourishing.’ Virtue ethics focuses on moral agents rather than actions, rules and scenarios, the rather linear approach of both Kant and Utilitarians which can overlook character. Pg 1,2,3 Virtue Ethics Ed R Crisp and M Slote Oxford Uni Press 2003.
Alasdair McIntyre admits that there is great disagreement over what are the virtues but goes on to name four ‘cardinal virtues as [1] Courage [2] Temperance [3] Justice and [4] Wisdom Pg 164 The Nature of the Virtues MacIntyre.
It is still rather abstract to hold a list of virtues up as commendable in the midst of a discussion of dignity for older people. There is a helpful table of application in ‘Principles of Biomedical Ethics’ which roots the virtues in the practical world of dignity
Principles
Respect for Autonomy
Respectfulness
Nonmaleficence
Nonmalevolence
Beneficience
Benevilence
Justice
Fairness/Justice
Rules
Veracity
Turthfulness
Confidentiality
Confidentiality
Privacy
Respect for privacy
Fidelity
faithfulness
In addition there are four ideals of virtue, namely, forgiveness, generosity, compassion and kindness.
It would appear that the Virtues, of the three approaches discussed, offers more practical assistance in guiding the ethicist in matters of dignity for older people. However, as a footnote I would support Macintyre who pleads for a recognition of the spiritual dimension within virtue ethics - ‘unless there is a telos which transcends the limited goods of practices … it will both be the case that certain subversive arbitrariness will invade the moral life and that we shall be unable to specify the context of certain virtues adequately. Pg 140 The Nature of the Virtues MacIntyre.
The Dignity challenge
In November 2006 the Department of Health launched the Dignity in Care campaign which identified ten factors which high quality services should have in place in order to respect the dignity of service users. They also used the Social Care Institute of Excellence www.scie.org.uk web site to clarify their expectations which NHS Trusts and Local Authorities were encouraged to advance. On their web site they confess that dignity id difficult to define and say it consists of many overlapping aspects, involving respect, privacy, autonomy and self-worth. They adopt a standard dictionary definition of dignity as their guideline ie ‘a state, quality or manner worthy of esteem or respect; and (by extension) self-respect.’
Dignity in care, according to the DOH, therefore, means the kind of care, in any setting, which supports and promotes, and does not undermine, a person’s self-respect regardless of any difference.
While ‘dignity’ may be difficult to define, what is clear is that people know when they have not been treated with dignity
and respect. Helping to put that right is the purpose of this guide.
Ten subject areas relating to dignity were highlighted by older people and their carers in the Department of Health online survey carried out in 2006. The guide takes each of these and covers:
The web site provides direct access to practical ideas, resources and information to service providers on such matters as: training and educational support tools and initiatives: Audit Tools: Sample Policies
The Dignity Challenge
High quality care services that respect people's dignity should:
1. Have a zero tolerance of all forms of abuse
2. Support people with the same respect you would want for yourself or a member of your family
3. Treat each person as an individual by offering a personalised service
4. Enable people to maintain the maximum possible level of independence, choice and control
5. Listen and support people to express their needs and wants
6. Respect people’s right to privacy
7. Ensure people feel able to complain without fear of retribution
8. Engage with family members and carers as care partners
9. Assist people to maintain confidence and a positive self-esteem
10.Act to alleviate people’s loneliness and isolation
The response of Leeds Teaching Hospitals NHS Trust to the Dept of Health challenge was to invite interested parties to form a Dignity Workstream whose inaugural meeting took place on 24th January 2007. [Appendix 1]
Members who were present included senior Matrons, Managers from Leeds Hospital Mental Health Team, Manager of Older Peoples Modernisation team, Senior Occupational Therapists, Hotel Services Managers, Superintendent Physiotherapist, Consultant Physician, Clinical Nurse Educator, Clinical Team manager, Patient relations Manager and Chaplain. Interfaces will be with Leeds City Council Social Services: Independent Sector residential Care Homes and Nursing Homes: Commission for Social Care Inspection (CSCI): Leeds PCT: Voluntary Sector Older People’s Organisations: Leeds Teaching Hospitals Trust: Leeds Mental Health Trust: Strategic Health Authority: DOH: Older People’s Champions: Adult Safeguarding: Workforce Development: Design for Health.
It is not deemed to be within the scope of this essay to comment at length on the workstream’s meeting save to say that there was a declared commitment to contribute to the development, implementation and monitoring of a Leeds TH NHS Trust Dignity Work Programme which would work with users and carers to gain further insight into Dignity issues and to work with national and local groups to develop and share best practice.
The aim of the Leeds project is ‘to ensure that older people are treated with the highest standards of dignity when using health and social care services in Leeds.
It is intended to achieve this through [1] Raising the profile of Dignity in Care issues with older people, the public ad care staff. [2] Collating, sharing and publicising best practice [3] Adopting the ten factors of the DOH’s ‘Dignity Challenge.’
Initial deliverables were agreed as [1] To develop a Dignity Audit Tool for use in all Trust Areas (Appendix 2) [2] To support areas to carry out annual dignity audits for the trust. [3] To Develop and support a Dignity Champions Network across the Trust including a Dignity Champions Newsletter. [4] To Review in a manner consistent with existing trust processes to learn lessons from Dignity Issues
Ethics of Dignity for Older people
It is commendable that our DOH have raised the issue of Dignity and it is encouraging that my local NHS Trust has responded quickly and is networking and communicating the need to take the issue seriously. But what are some of the specific ethical issues that need to be faced if we are truly to make a difference in ensuring g our older people are treated with dignity in health care?
The media may sensationalise individual cases or issues but the daily grind of health care is not like that The ethical dilemmas whicb are faced daily arise from long term care. Parker and Dickenson 2001 Pg 125. Issues such as end of life matters, truth telling, confidentiality, autonomy, dignity at mealtimes, dignity at morning and night times, dignity in continence and incontinence, ethics of dealing with deteriorating mobility and the ethics of dealing with dementia, to name a few! We shall now look at some of these medical ethical dilemmas.
End of Life Matters
Parker and Dickenson 2001 Pg 22ask the question ‘what is the telos of medicine when healing is no longer possible?’ Some may respond by suggesting that the telos may be ‘alleviation of suffering.’ [It is my contention that health care practitioners could respect this period of life by encouraging time and space to be given for their story and for their preparation for the end of this life and for the beginning of eternity (whatever one conceives eternity to be). Thus the telos of medicine at the end of life should be broader than ‘alleviation of suffering.’
If we are faced with the issue of alleviating suffering, it brings to the fore other ethical dilemmas at the end of life such as withdrawal of treatment or non resuscitation
At the close of life Wilkinson (1988) pg 3 says there are 3 options [1] realise ends is near & try to keep highest quality of life & comfort to enjoy the time that remains. [2] Try to prolong life by resuscitating or by transplant of damaged and aged organs. On this question I will simply add that it is important to avoid inappropriate treatment. If the older person is not expected to regain health or recover partially it is not good treatment to burden the patient and the family with stomach tubes, drip feeds, anti biotics and cardiac resuscitation
[3] Euthanasia. (It is not within the scope of this paper to comment further on Euthaniasia).
Returning to option 1 - through modern medicine and pallitative care much can be done to make a dying patient more comfortable & able to face death with dignity. This is called ‘terminal care’- ie ‘support of patient ensuring freedom from distress, preserving dignity and preparing to meet death ‘serenely and without anxiety.’ (Wilkinson (1988) pg 285) Although focussed on the patient care also aims to provide support for family. From a faith ethic perspective it is helpful to see the dying person as a neighbour in need, a person special and unique in God’s eyes and deserving of our love and compassion. The dying patient is still a whole person physical,mental, spiritual. And all should be addressed .
Wilkinson 1988 Pg277 ‘When Elderly come to die, they are often already withdrawn from society by retirement and disability. They are commonly confined to their homes or isolated from community’ by being cared for in various kinds of Nursing homes & sheltered housing. 100 yrs ago 80% of people died at home today 80% die in hospital.
Other ethical questions arise such as [1] Should they be told they are dying? – who should we tell, when should we tell? How to tell? This is covered below in ‘truth telling’ but patients should be told the truth if possible. [2] Where should they die? Ideally a person should die where they wish to die if possible. Most would wish to die in the comforts of their own home particularly if there is family unity and if the Family Doctor and Primary Care team can provide the support. One’s home is important because contact is maintained with family, Church, community. It is also informal unregimented and the familiarity is therapeutic. On the other hand Hospital is most common place for a personal final days and if an ICU needed then hospitalisation is essential. Conversely, the layout of hospital wards may be inappropriate and a Hospice becomes another option for terminal care.
[3] What care should be given? The quick answer is whatever is necessary to give fullest quality of life as it draws to a close. Modern medicine should enable relief or control of pain and prevention of distress. It is also helpful if the health care team is able to encourage that the dying person is surrounded by support of family and community so that the older person does not feel abandoned at end of life, that they are still valued, of worth and loved.
When we introduce ethical considerations regarding quality of life we must note the faith perspective of the ‘sanctity of human life.’ Life is not the only basic good, there are factors such as friendship and community, knowledge and the enjoyment of beauty, these are ‘equally important aspects of a fulfilled life.’ (Parker and Dickenson 2001)pg29
Truth Telling. I said above rather simplistically that patients should be told the truth if possible. Indeed Truth is basic virtue in life. But it is never as simple as that. The Cambridge Medical Ethics workbook lists 4 types of professional truth telling:
1. the paternalistic model, the doctor decides, acting in the best interest of the patient.
2. The informative or consumer model is based on the autonomous choice of the patient, after being informed by the doctor.
3. The interpretive model aims at interpreting the patients values and implementing the patients selected intervention. IN this model the Doctor is a counsellor or adviser.
4. The deliberate model, where the patients values are in need of interpretation, discussion and deliberation. The doctor is this regarded as friend and teacher. (pg 151)
Often we choose to withhold information that we know either for the good of the recipient or because it would be too difficult to communicate the truth. These ‘omissions’ may not be falsehoods but it is withholding information. ‘Principilism in biomedical ethics applies various principles such as respect for autonomy and the principle of beneficence.’ (pg 127) In hiding the truth we do not take her seriously but along side this we may withhold information for the sake of the patients well being (beneficence). There is also the ‘Therepeutic approach’ which claims that truth telling is crucial because it helps the patient orientate themselves in the world (ROT Reality Orientation Therapy). Pg 128. This will stimulate and help elderly people keep contact with reality. One means would be to ask the patient about her life, using photos and family knowledge about children and grandchildren. Another third approach, ‘the validation approach,’ would not confront the patient with truth telling but begin by attuning to their way of understanding and making meaning. This approach focuses on the patients feelings. Accepting the patient as she is, showing interest, trying to gain the meaning from the patients view point however strange the point may be. Truth telling is not seen as a basic virtue in the validation approach, feelings are prioritised over objectivity. Indeed, truth may frustrate or add stress or even confuse. The validation approach is to be tactile, making contact eg hugging, hand holding… encouraging feelings. [KB asked to sit with stroke patient..language confused, pictures better etc….]
Resource allocation
There are tangible and intangible resources. Tangible being: people, buildings, equipment and finance. Intangible resources are such as is people’s enthusiasm, attitude, skills and time. For Dignity of older people in Healthcare to flourish we need champions of the intangible. Service providers need people who have concern for others and their welfare.
The fact is tangible medical resources, be it costs of staffing (human resources), medicine, medical equipment or buildings are limited and decisions have to be made in how they are used and about prioritising heath care spending. In addition the population is ageing, technological and medical knowledge is changing rapidly and financial resources are limited. These variables in themselves raise ethical issues. What can be a just distribution of such scarce recourses, how can we decide between the prioritising of treatment of different patients when each has a valid case for treatment and each should be shown the dignity of equality in personhood without looking at longevity or likelihood of the treatments success. The moral dilemma is obvious, the elderly may find themselves at the bottom of the pile when it comes to the consideration of scarcity of resources and their allocation. In addition there is conflict over resources between services such as the National Health Service Trusts and Social Services, between families and Primary Care Trust care in the community service providers and between private nursing and residential cares and public residential care.
Wilkinson (1988) speaks of a healthcare paradox ‘the more health care provided, the more is required.’ (Pg 383)
Reason are many, advances in medicine, extreme sports result in more injuries, more holidays abroad result in more tropical infections, more welalth result in more stress, more drink/alcohol/food/drugs and less exercise (physical/mental/spiritual) all leads to an increasing need for Healthccare. Furthermore, more surviving infants leads to more disabled people and more effective medicine results in more people surviving to old age and inevitably needing healthcare.
As more people survive to old age there becomes an increasing demand on elderly healthcare services. These demographic changes. Have also led to unexpected issues such as the outbreak of infectious diseases (MRSA or Cdiff) resulting in greater elderly demands. Added to this, some demands are taken up by pressure groups which in turn creates scarcity for other healthcare needs of other people groups.
[] Increase in Cost. ^scarcity due to rising costs. Also ^ in quantity & ^ in quality, std of H C (KB culture of standards). New & more sophisticated methods of diagnosis & treatment (usually more expensive than the ones they replace). ^ in quality result in ^ in specialisation which characterises modern Healthcare. [] Wastage. If resources used improperly or wastefully.
[] Unfulfilled expectations in 1942 Beveridge wrote ‘ comprehensive Nat health service will ensure that for every citizen there is available whatever medical treatment he requires in whatever form he requires it ..’ = KB Unrealistic expectations even reinforced in political speeches etc... Demand is also determined by expectations (Mary next door 4 times a day ‘they don’t do much.’) If expectations are unrealistic (eg family not local, not willing, not able), demands become irresponsible & can lead to scarce resources taken from other areas of need.
Autonomy:
Autonomy is defined as ‘participation and the right to self-determination.’ (Parker and Dickenson 2001 pg 137) In other words ‘making your own choices. On the other hand, it is normally only considered possible to respect someone’s autonomy if they are able to make competent decisions (eg an older person may begin wandering around the streets through dementia, worse still driving!) We thus need to consider risk to self and to others. Respecting autonomy in such cases is respecting the view he/she would have held prior to dementia. Thus, Tony Hope (in Parker and Dickenson 2001) pg 135) says autonomy is not about being able to do as you please but also acting in a responsible, competent manner. ‘Policies such as allowing elderly dependant people live in their own homes as long as possible.’ Autonomy is an important consideration in care management after loss of independance.
In health care ethics, the concept of autonomy is based on the philosophical concept of the person. According to Kant the person is a rational and free being who can determine his own actions, independent of both his natural circumstances or the desires and inclinations of his own body. Freedom, Kant says, is the following of duty….. When there is no respect for the freedom of the person, one looses the possibility of acting morally.’ (Pg137) Ruud ter Meulen in (in Parker and Dickenson 2001) points out that there is a difference between autonomy as self legislation (Kant) and autonomy as self-determination (Healthcare)’ Pg 137
There is a further objection to this concept of autonomy, namely that it is ultra individualistic. ‘The sense of community and of solidarity has been replaced by individualism and egoism….. The narcissistic concentration on one’s own individuality has resulted in a decrease of unity with the group. According to Cushman (1990), in the 21st Centaury individuals have been confronted with ‘an absence of community ties and shared systems of meaning. This has resulted in feelings of emptiness….. The concept of autonomy in ..healthcare ethics does not acknowledge these social determinations. It presupposes rationality, individuality and self-determination, ignoring the social structures in which these characteristics play a role……. The emphasis on autonomous individuality should be adjusted towards a social and relational concept of the person……Identification, identity and sense of meaning, each of these aspects of autonomy requires a social context for its development…… Respect for autonomy should not be limited to dramatic medical treatments… but should be a continuous process in daily care… and daily activities.’ (in Parker and Dickenson 2001) Pg 139.
To safe guard autonomy, one needs not only the commitment of the care giver but also a sense of meaning of what it is to be old…. The articulation of this individual sense of meaning of life and old age is hindered by the fact that , as a society, we have great difficulty giving meaning to old age and dependency. While In former times ageing was considered a normal process of existence, in modern times it seems a practical problem…. young seems to be the absolute norm.’ ... ‘A shared interpretation of ageing and dependency may prevent the relationships between carers and elderly….from becoming impoverished as a result of the individualisation process.’ (Pg 140)
Parker and Dickenson’s quote on autonomy leads us onto our final area of reflection, does religious faith add to ethical perception. As we noted in our discourse on three ethical theories, there are others and we will now consider a fourth, …………
Does religious faith add to ethical perception
In reply to the DOH’s 10 Dignity Challenges. Is it best ethical practice to set out with a set of moral convictions and then decide certain kinds of behaviour are right or wrong? I believe the effect is to abstract from the narrative. Most would agree the principle of the 10 challenges are plausible and to violate any of these 10 is an injustice BUT Hauerwas would argue (and I concur) that this process is flawed . This process of ‘10 challenges’ does not 1stly consider the narrative from which the challenges come and that ‘the virtues and the rules constituting a morality are community dependent.’… pg 119 The Peaceable Kingdom ‘Certain prohibitions of a community are such that to violate them means that one is no longer leading ones life in terms of the narrative that forms that community’s understanding of its basic purpose.’ In community of Character pg 9 ‘Every social ethic involves a narrative… the loss of narrative …. has resulted in a failure to see that the way the issues of social ethics are identified i.e. the relation of personal and social ethics, the meaning and status of the individual in relation to the community.’
By and large the emphasis in health care services is to ‘treat’ the individual. In limiting the ‘person’ to individuality health care services are overlooking that an important aspect of the person is in community. Zubair, a Muslim Chaplin colleague of mine was called to a Muslim patient who was withdrawn, depressed and refusing to communicate. After spending a difficult hour with the patient Zubair wrote in the medical notes of the patient ‘the medical staff should invite and encourage this patients extended family to visit in numbers.’ Zubair was recognising that the person was shrinking as an individual outside his community.
I do acknowledge that Hauerwas would not apply this approach to a Faith perspective, his view is distinctly Christian. ‘Whenever Jesus becomes a pattern for a universally valid moral way of life, his meaning is distorted…. there is no meaning that is separable from the story itself… Jesus’ person cannot be separated from his work, the incarnation from the atonement.’ Community of Character Pg42
However, I believe, since the Monotheistic faiths all speak of being a pilgrim people who have relied throughout history on narrative and how that narrative has shaped their community. I would thus conclude that religious faith does add ethical perception of dignity for older people, highlighting the importance of narrative and the place of faith community as a further important aspect of dignity. It could be contested that this approach does not help us to make moral decisions how to prioritise spending of scarce resources, to withdraw treatment, to administer higher doses of palliative medicine but it does shed new light on the meaning of personhood, i.e. a person is rarely an individual in the absence of community. Hauerwas replies ‘There is nothing about an emphasis on narrative and the virtues that in itself denies that we must still make decisions’ Pg 123… BUT we often do not have to decide…in the way assumed.’ Such comments are fuelled by Hauerwas’s pacifists point of view but the question remains does it work in Dignity of Elderly? I believe narrative does have more to do with decisions than at first sight, provided the ethicist is prepared to be alternative in understanding morality ‘if we have the … skills … to see the situation in a new light…. a light that enables us to [act] in a manner consistent with our moral commitments.’ Pg 125.
I wish to conclude this paper by focussing on the way in which story gives dignity and aids healing. Hauerwas says ‘we must challenge ourselves t be the kind of community where such a story can be told and manifested by a people formed in accordance with it…’ Pg 35. In the brief illustration which follows, I propose to show a way in which a chaplain can encourage story telling from an elderly patient and in the end become a member of the community through the reality of the narrative, told and heard.
Patient ‘I just want to go home, I want to see my time out at home.’
Chaplain: Where is home and what is it like?
Patient describes their home, their garden, the sounds of birds and the memory of them feeding on the bird table and nesting in the bird box. The panoramic view and the kinetic memories of being there can all be coaxed by the chaplain eager to hear the narrative of the elderly patients life.
“Do you have good neighbours?” Asks the chaplain, and he hears about the elderly patients community, the friends and sometimes the not so friendly.
“What about family?” The chaplain continues and the narrative develops around the family who visit, the family who are far away, those who send cards and flowers and those who may be estranged. As the story is told and heard the Chaplain becomes part of the story and therefore part of the community for the elderly patient. As time is given, so dignity is enhanced, the message to the story teller is you are valued, your story matters, your community is real and valid even though you may be separated from them through ill health. They are made a part of the present by the present telling of the narrative and by the links with the present hearer (the Chaplain) becoming part of the community.
Later the Chaplin may visit while family members are present. “Are you one of the family, pleased to meet you, I heard about you from Ethel. You must be Jake, believe you have flown in from Australia.”
As the Chaplain continues to exchange with the family, his membership in the community is cemented further especially as he is seen as one who has time and space for their loved one. Thus that aspect of the gospel of Christ incarnate who values each person as unique, is made real for Ethel and her family. The invisible God, made visible by the Christian presence and the Christian witness of the Chaplain. ‘Christian’ literally meaning, ‘Christ’s one’ and the truth of Col 1v15 ‘He is the image of the invisible God’ is demonstrated by the Holy Spirit present in the life and works of ‘Christ’s ones.’
In conclusion, Ethics clearly does help with Dignity for Older People in healthcare. It may be difficult to see how it all fits neatly into an ethic of consequences or duty or virtues but we are, through the ethic of narrative challenged to think ‘outside the box’ and after all, the ‘dignity challenge’ is what those in health care are called to respond to.
Beatitudes for the elderly by Barbara Beuler Wegner (from David Stoter’s Spiritual Aspects of Health Care).
Blessed are they who understand my faltering steps and shaking hand
Blessed are they who know my ears today must strain to catch the words they say
Blessed are they with a cheery smile who stop to chat for a little while.
Blessed are they who never say ‘You’ve told us that twice today!’
Blessed are they who make it known that I am loved, respected and not alone.
Bibliography
Hauerwas Stanley A Community of character Notre Damm Press 2005
Singer Peter 1995 oxford uni press : Rethinking life and death
Lise Lotte Franklin, Britt-Marie Ternesteldt, Lennart Nordenfelt Nursing ethics 2006 issue 13 ‘Views on Dignity of Elderly Nursing Home Residents
Callahan Daniel 1987 New York: Simon and Schuster. Setting Limits: Medical Goals in an Ageing Society
1 J Macquarrie; Three Issues in Ethics, pg 27
3 R A McCorrnick; Does Religious Faith Add to Ethical Perception, in Hamel and Hines eds pg 144.
4 J M Gustafson;, Can Ethics be Christian', pg 47 (neuter gender inserter).
5 R Hart; Unfinished Man and the Imagination, pg 147
6 Gustafson's Does Faith Add to Ethical Perception, in Hamel and Hines eds pg ase
8 S Hauerwas; Against the Nations, pg 23
11 J Millbank’ Can Morality be Christian, Studies in Christian Ethics 8/1 pg47 -57
13 O O’Donovan; Resurrection and Moral Order, pg 11
