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2/2015
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The problem of care of the elderly in terms of moral theory

Grażyna Kowalik

Studia Medyczne 2015; 31 (2): 155–160
Online publish date: 2015/07/13
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Introduction

In Poland one out of six inhabitants is older than 60 years of age. It is predicted that by 2020 the number of elderly people will constitute nearly 20% of the population [1, 2].
In view of this situation, ageing and old age are gaining particular importance. In recent years, attention has been paid to the demographic changes leading to permanent lengthening of life expectancy, and thus the extension of old age and a growing number of elderly people.
Moreover, the changes in civilisation have evidently postponed the age limit at which people become physically and mentally disabled. Aging causes significant changes in society, in the economy, in culture, and especially in health care.
It is widely known that the various kinds of health problems appear in the elderly due to ongoing degenerative changes in organs, which significantly increase the morbidity rate. Many diseases contribute significantly to the reduction of physical activity of older people, which makes the problem of care for this group of people one of the most important contemporary social challenges.

Innovativeness of Polish families and the problem of care measures towards their senior members

It is known that the Polish population are marrying later and having children later. Surveys show that fewer children are being born. To keep the birth rate stable, each statistical woman should give birth to 2.1 children, while currently this indicator accounts for 1.5 children. Demographers believe that in the next 25 years the number of Poles in Poland will decrease by several of hundreds of thousands [3].
As a result of lowering birth rate for many years the potential for family care has decreased. The average size of the Polish family has fallen systematically, and many families have become dispersed as a result of migration; young people often go abroad to study or work. This has transformed the nature of family relationships, and the intensity and frequency of family contacts have decreased.
Nowadays the younger generation has little time for their elderly parents. There has been a change in the function and structure of the family. Many social, economic, and cultural factors have contributed to a situation in which extended families in Poland are rare. Only a few such families remain in the country [4].
In Poland it is generally agreed that care of a dependent older person belongs to the family. This was confirmed by research carried out in 2011 [5].
There have been changes in the structure of families and conditions of family life, and there is doubt whether family members are able to properly care for the elderly. It seems that in the near future family care for the elderly who are unable to live independently will be more often replaced by the care of non-family members or by institutionalised care. It can be assumed that, in connection with this situation, the loneliness of seniors will increase. Nursing homes may be soon inhabited by more and more “sad old people”.
Since the nineteenth century, elderly people have been increasingly moved to nursing homes, a practice that first began in Germany [6]. Care of this group of people varies in different European countries, but always and everywhere old people were afraid of getting old. In the past, the fear that accompanied old age was associated with loneliness, and now this seems to be the same. Young people, overwhelmed by the responsibilities, are not aware of or do not understand the problem.
It is claimed that the fear of being alone is similar to the fear of death. Loneliness means, indirectly, death [6]. Often in this stage of life, people particularly appreciate the company of others and try to gain their acceptance. It appears that numerous contacts from young age are often re-established later in life. People try to build friendship based on their memories.
An older person decides to stay in a nursing home when their health or the family situation requires this. A positive image of nursing homes is sometimes shown in the media, but this image is often idealised. The opposite is also true, and the conditions in such institutions are sometimes criticised also.
In Poland, nursing homes are not highly regarded. According to a CBOS survey, very few old-aged Poles declare a willingness to live in such an institution [3, 5]. However, the real picture of these institutions in Poland changes from year to year. There has been an increase in the number of nursing homes that meet the expectations of patients and keep up with world standards. More and more Poles spend their later years in such places. Some older people make such a choice themselves, while others are placed in nursing homes by family members [3].
Despite this, the talk of the nursing homes in Poland is still a taboo subject; Poles feel embarrassed and ashamed when they discuss these issues. However, putting a family member in a nursing home is not an easy decision. There is often a sense of guilt, even for those who have nothing to feel guilty about [3].
We should consider the sources of such behaviour. One can hypothesise that the assessment of the activities of family members by society as well as the beliefs, traditions, and family ties are important in this regard.
It is bad that we avoid the topic or approach it with reluctance. Life experience shows that such behaviour results in consequences that over time have made this subject even more difficult.

Obligation or duty to care for an elderly person

The moral issues involved in such issues are included in the branch of philosophy, which is the ethics [...] defining the essence of man’s moral duty and ultimately the fact of moral action [7, 8].
However, there were some difficulties in defining standards of morality and the essence of moral obligation because of divergence of beliefs concerning what is morally right or wrong in special cases [9, 10].
Morally consistent action may be the only effective means to achieve one’s own happiness because of its achievement, and at the same time be the subject of an order of authority, or “duty” because of the warrant.
This is shown by two methods of revealing the moral obligation to act and separate it from the external moral duty.
One way is a direct reference to the experience of moral obligation, which appears in the judgement of conscience (“should”). The judgement reveals the moral duty of action, independent of the condition, which is the desire to achieve his/her own happiness by acting. The actual value that represents the dignity of the recipient’s personal action is considered.
Another way of disclosing the obligation of moral action and distinguishing it from the one that is beyond morality is that one is morally right about the decision taken [10].
The essential distinction between the terms “obligation” and “duty” is made on the basis of ethical studies.
While the “duty obligation” means a man needs to do something (act in a certain way with the internal order or external order, for example, legal, administrative), the “duty” is first and foremost a moral obligation, and hence the order of procedure. The obligation is a compulsion; the external stimulus to act is an imperative duty to itself [11, 12].
Reflection: “duty” vs. “obligation” is a consideration of above all the sources of decisions ordering the action and the reasons for such actions. In common parlance, as well as a large part of the publications devoted to ethics, a distinction is not being made between “ethics” and “morality”, while this difference determines the understanding of the conditions that we call a “moral duty” or an “ethical duty”. The same action, including the same standard of conduct, can be understood by a family member working in the care of an elderly person, as the will or coercion and taken by virtue of the duties or obligations [3, 11, 12].
One probably does not need to justify deeper social understanding of the difference between the activities undertaken under compulsion (the threat of sanction, promise, pity), and selfless action (self-satisfaction) and wonder which of them are ranked higher in social evaluation.
The extreme selflessness is a denial of the basic idea, which concerns the care of all members of the family, not just the elderly. Opposition may be raised by ceding of care measures to women only (in the case of a son and a daughter of elderly parents).
“The duty of moral action turns out to be the duty of affirmation of a person or a thing for their separate values, while ethics turns out to be a theory of duties of action due to the separate value of a person (dignity), or a thing as a norm of morality of that action” [11].
Duty meets the person’s reply, in the form of moral responsibility – the attitude of taking actions consciously and voluntarily that are consistent with the principles and moral standards, and the failure of performing these acts involves moral sanctions in the form of remorse, guilt, shame, and a feeling of deep resentment and bitterness [11, 12].

The main assumptions of selected ethical theories in relation to the care of an elderly person

While providing care for an older person in Poland, the family is still assigned particular importance. Older adults usually require complex and sometimes long-term care.
Tasks faced by family members require availability, knowledge of the care measures, financial resources, and the sensitivity to perceive moral problems. They also require the development of complex skills necessary for a thorough and rational reasoning in solving them.
Family members are often obliged to make very difficult decisions. Long-term care of an elderly person may be related to different ethical theories.
The ethical concepts, which usually take the form of a theory, consist of a bundle of ideas and claims resulting from them, on the basis of which only sets of moral precepts can be formulated.
Classical theories formed in the eighteenth century, characterised by the search for answers to both or at least one of the following questions: “what is a good life for people?” and “how people should behave?”.
Ethical theories can be an attempt to prove the validity of the moral functioning and can stand in sharp contrast with common morality, questioning the validity of a part of or even all current orders in force in a given society [10].
Ethical theories seem to be useful in the conduct of moral reasoning, especially in situations of conflict of values, principles, and moral obligations.
We can look from different angles at putting elderly people in nursing homes.
Nowadays, the utilitarian, deontological, and virtue theories are considered to be useful. It is true that these theories do not allow for settlements in any situation, but allow one to move away from routine decision making or relying on personal opinions [13].

Utilitarianism and the care of an elderly person in the family

Utilitarianism includes theories that bear the name of consequentialism as they relate to the moral consequences of human activity.
According to these theories, human actions are good when their consequences are judged as good, and bad if their consequences are judged as bad. The greatest good is happiness or pleasure, and it is right to take action to multiply the greatest good, or at least diminish the greatest evil, for the greatest possible number of people [14].
These theories (John Bentham and JS Mill) are used in care, but they seem to be controversial, for example, in relation to the unit of care including the care of an older person [13].
In the theories of utilitarianism, the good of a human being is not taken into account. It is also recognised that in making moral judgments the utility is not the only criterion. Utilitarian ethics are often used in making decisions related to the distribution of resources to the maximum number of people in connection with the principle of justice.
This ethic allows one to make a so-called utility bill, to assess what action will benefit the most people.
There are people who take into account the family as a whole and consider whether long-term care will not bring more damage (the need to quit their jobs, family conflicts, etc.) than benefits. Building a hierarchy of values relying on this system, the act performed by these people is not recognised as an immoral one under certain conditions [9].
It must be remembered that utilitarianism stands in contradiction to the ethics of an individual, according to which it is a minder’s moral duty to do everything that can be done for a person in need. It also remains at odds with the ethics of caring, which requires the minder to focus attention primarily on what is good for the one who needs help in relation to the purpose pursued by the person who takes on the care [14].

Deontological theories, the position of Christian ethics, and the ethical theory of Immanuel Kant as applied to business care

Deontology (Greek: Deon-ontos, what is needed, the obligation of DEI, need, duty). A branch of ethics that focuses on the moral obligations, and on what determines the moral value of acts; it is also a set of moral norms that apply to a given profession, for example, medical deontology which is a collection of rules laid down originally by Hippocrates and expressed in the medical oath, the rules of which are now determined by the Code of Medical Ethics [15].
Deontological theories, which are in opposition to utilitarianism, assume that the moral rightness of an action depends primarily on the nature (form) but not on the final effects, namely the consequences, to which the action is brought.
In this sense, both telling the truth and keeping one’s word, by nature, are ethical. The moral character is also entitled to interpersonal relations including welfare activities [16].
Rule-based ethics covers the general principles and theories that go beyond the opinions of their own, individuals, and groups, and penetrate to the basis of what constitutes human nature and activity.
Christian ethics recognises God as the highest good, and doing everything for his glory as the happiness of man. The happiness in God is achieved through self-denial, but not existential self-realisation [16].
There are immutable truths and standards of conduct that define our duties towards God and man. However, when in the Bible we look for an answer to the question of what we should do in a given situation, we must also know the situation. One must refer to the times in which we live, so that our study of scripture is adequate to the situation. It is not the desire and motivation that are to govern our conduct. Rather, we have to adapt them to the requirements of the Bible [10].
For this position you can suggest three points of the ethical decision-making procedure: 1. What is the problem? (Situational perspective). 2. What does the Bible say about this? (Normative perspective). 3. What needs to be changed so that a person acts properly? (Existential perspective).
We have to remember that none of these questions can be answered independently of each other [10].
The Fourth Commandment is: Honour your father and your mother, that you may live long on the land which the Lord – your God will give you. This commandment is clearly aimed at children, defining their relationship to their father and mother, which is the most common. It also relates to relationships with other family members. It demands reverence, love, and gratitude to grandparents and ancestors (KKK219) [17].
The family in the plan of God should live in such a way that its members care about young and old, sick or disabled, and the poor. Many families are not able to provide such assistance in some situations.
Then a person other than family and, secondarily, society should take care of their needs (KKK2208) [17].
Considering the ethical theories, one needs to mention Immanuel Kant (1724-1804) the German philosopher. In his view, ethics is derived from the duties of man, as a moral duty of man is telling the truth, keeping his/her word, and showing gratitude.
The need for gratitude may be referred to as paying off the debt by the young to old parents for the care that they provided their children.
Immanuel Kant formulated the following “categorical moral imperative” – “always proceed according to the rule, with which, at the same time, you want all people to act, and so it was the right for all”. He added: “As a man, treat other people like yourself, this means, always as a goal (end) and never as a means” [14].
Each person should treat other people as moral beings, respect their wishes and their desire to make their own decisions. In Immanuel Kant’s deontology, the imperative is the only indicator for moral decisions.
Representatives of other deontological theories, however, take the position that making moral judgments and decisions are still necessary standards, consisting of specific rules, such as telling the truth and keeping one’s word [13].
Deontological theories can be applied to the care of an elderly person because of taking into consideration both individual human dignity and equality among people, and introduce very clear criteria to distinguish good from evil.
If we consider deontological ethics, the rule-based ethics, a person who has put their father or mother in a nursing home actually has to be ashamed of this act.
According to Christian ethics and Kantian ethics, care for the elderly is our duty. In Christian ethics, tradition, family, and respect for the elderly are important, so help to an ailing and sick parent is an unquestionable duty.
Objection is raised in the criticism of these theories that they do not introduce clear decisions in situations where there is a conflict of the duties of man. Then, we do not know with certainty which of the duties is superior to the others [10].

The usefulness of the theory of virtue (virtue ethics) in future educational activities undertaken by the carers of elderly people

The discussion of virtue theory was made by the ancient Greek philosophers, including Plato and Aristotle. The set of classic virtues of the ancient world included courage, friendship, justice, moderation, and wisdom. In early Christianity, theological virtues such as faith, hope, love, or mercy also became a part of the set of classic virtues [10].
The character traits (virtues) recognised in the contemporary world include: compassion, thoughtfulness, responsibility, sensitivity, internal integration, wisdom, and authenticity [13].
One should pay special attention to the importance of character traits in the process of interaction and communication between an elderly family member and a carer of an elderly person.
An analysis of the basic assumptions of the theory of Aristotle points to his explanation, referring to the essence of good and its achievement, the acquisition of moral virtues by a human, and development of virtue ethics [13].
To explain the essence of good, you first need to determine as precisely as possible the specificity of what it relates to. Explanation of good human needs, therefore, to identify and define who is man, what needs does he have, and what is human life. Explaining good must also be associated with the role that a person plays. What is good for one role does not have to be good for others. Good must be possible to achieve [10].
According to Aristotle, the achievement of good by a moral person is more possible when it comes to him/her in the process of developing internal characteristics, rather than by a great effort of will, undertaken in order to change himself/herself. According to him, the development of character traits starts in the earliest years of life and is closely related to everything that affects a child in the process of socialisation.
Aristotle devoted much attention to the meaning of the feelings that accompany the activities one participates in, and he emphasised that the development of man’s moral character is required to progress in various situations [10].
Consideration of the principles of Aristotle’s ethics turns out to be useful for educational activities for children and young people. As is known, in the future these people will take care of elderly parents from the bottom of their heart or from duty, or they will turn away from care activities, putting parents in a care institution. This does not mean that the wisdom of Aristotle does not speak to adults. One should continually work on the character and not stop doing good in life [18].
Presenting an overview of the assumptions and limitations of some deontological theory, it is worth paying attention to their usefulness in solving problems, which are moral dilemmas in relation to the care for elderly family.
One should take a strong position on ethical issues. Either utilitarian rules or ethical principles are represented. Otherwise, the revealed falsehood consists of matching the arguments to the originally accepted assumptions.

Summing-up

Morality prevents harm to others. It seems that the moral life is the best way of life for two reasons. First, the moral life is in one’s own interest. The moral life brings a human the most satisfaction by satisfying desires, thereby ensuring the correct treatment of other people. According to this position, there is no conflict between morality and well-defined self-interest.
The second reason is the belief that the moral life is an internally valid or a good way of life, regardless of whether they can or cannot meet the needs of man [10].
The moral life is sometimes in conflict with one’s own interests and yet it seems that despite of this, we should act morally, but should not do whatever we want.
It can be assumed that the Poles are ashamed to talk about the fact that their family member is in a nursing home for the elderly, because in our society people believe in a very strong stereotype, which concerns the perception of the situation. Visions of an average person are more or less like this – poor children put elderly parents in nursing homes to get rid of problems arising from care.
This type of thinking was in force at the time when the model of the extended family predominated.
But the world has changed, and the family is becoming more and more closed. We are spending more and more time at work and rarely there is one who can afford to stay at home and nurse an elderly person for a long time. In addition, long-term care of the elderly is often a situation that is very difficult emotionally, mentally exhausting, and sometimes places a strain on the family life and marital relations of caregivers.
It is worth asking the question whether an older person can expect from their children that they will take care of her/him when she/he becomes dependent on others? Should a loving parent expect the form of “payment” for the upbringing of the child? Should the relationship between a parent and a child be treated as a contract?
Maybe we should start to learn from seniors living in Western Europe. In Sweden, for example, people approaching 50 years old prepare for the period of old age, looking for a harbour in the autumn of life. Of course, in Poland an appropriate legal basis is needed. Elderly people must have the means to pay for a nursing home or a fair pension. He/she must also have the confidence to selects a place that is safe and sound.
A nursing home meets the expectations of an older person provided that there is a place for comprehensive, subjective human treatment, taking into account not only the biological needs, but also the well-being and the ability to make choices [19].
The idea of caring for elderly people has a long history [20]. Most Poles are raised in rule-based ethics, and from this one can think that Poles are ashamed when family members decide to entrust carers from specialist centres with the care of an elderly person.
It must be clearly stated that none of us has the right to judge or condemn those who take such decisions; we do not know what their motivation was.
Willingness to support the families of the old and the sick family member, and a sense of responsibility and obligation to provide care in the family home must be supported at all costs. This form of assistance is the best and most valuable in terms of humanitarian aid form, but unfortunately in terms of quantity and quality it will continue to decline in the coming years [21].

Conflict of interest

The author declare no conflict of interest.

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Address for correspondence:

Grażyna Kowalik

os. Na stoku 72/19, 25-327 Kielce, Poland
Phone: +48 507 186 958
E-mail: grazynakowalik2@wp.pl
Copyright: © 2015 Jan Kochanowski University in Kielce This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
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