In 1980, one in ten younger households in the
USA was involved in giving care or support to enfeebled older relatives. Twice as many old people were cared for at home as were found in nursing homes. Greater numbers received assistance from
family members in their homes and apartments. Thus, the family remained the chief support of the elderly infirm. Long-term care facilities were populated disproportionately by unmarried persons, people without children, and the extreme elderly whose needs had grown too extensive for their adult children, who were themselves old. The situation in the
UK is similar, though the greater availability of health and welfare services extends the possibility of independent living for
Britons as compared to
Americans. The greater availability of services also reduces the care-giving burden of late-middle-aged children.
Theological background
Scripture: Though the Hebrew scriptures record a diversity of conditions among the elderly, old age is frequently pictured as a time of insecurity. The elderly fear the vulnerability and resourcelessness that comes with advanced age (Psalms 71:9-10). The biblical authors also show an aversion to dependence. At the same time, they enjoin respect and care for parents. (Exodus 20:12; Deuteronomy 5:16).
'Honour your father and mother.' The command of the Decalogue 'Honour your father and mother' requires a reverence akin to religious awe. The analogy between the parent-child relationship and the bond between Yahweh and Israel is a commonplace, especially in the prophets. This kind of filial piety is reflected in Thomas Aquinas's classification of filial piety alongside religion as a primordial virtue, and by Karl Barth's designation of parents as 'the ambassadors of God'. The other warrants for respecting parents are many and diverse: eschatological blessing (Deuteronomy 5:16) divine decree, atonement for sins, intergenerational reciprocity, and divine condemnation.
Reverence for parents preeminently entails caring for them in their old age (Genesis 45:9-11) and their abandonment is considered blasphemy. Particular consideration is required of those whose parents are feebleminded. 'Even if he is lacking in understanding, show forbearance; in all your strength do not despise him'.
Widowhood in the early church The NT assumes Israelite norms of filial piety, particularly the requirement that children support their parents in need (1 Timothy 5:3-4). Widowhood as an established order in the early church, however, represented a significant development in the care of the elderly. Widows had benefited from almsgiving in ancient Israel, but on the death of their husbands they usually fell outside the normal structures of family support. The institution of widowhood in the early church provided secure material support for family-less older women. In addition, widowhood conferred status on older women.
Theological warrants of care-giving One central theological motif consistent with the insecurity of old age is the biblical affirmation of the dependability of God as the Creator. This Christian belief affirms God's goodness and the goodness of creation. As God's creatures we are brought into existence and sustained by the one ultimately reliable power, who wills our good as the good of all he creates. Aged dependency itself takes on a kindly face because it reflects our ultimate dependence on the Source of all life. The dependability of family care-givers sustains the basic trust of old people at a time when they have much to fear. Thus, care-giving becomes a sign of God's unfailing goodness.
Related to the Creation motif is gratitude. Gratitude is a central affection of the Christian life. Care of aged parents might also be warranted, therefore, on grounds that it shows gratitude for God's special providence for us. Grateful service of parents replicates the joyful giving by which God creates, sustains, and redeems the world (Matthew 5:45).
A normative ethics of care-giving to the elderly Normative foundations for the familial dependence of the elderly are difficult to formulate in modern society because of the high valence assigned to individual liberty. For it appears incompatible with the dependent condition of the elderly infirm. Yet care-giving within families and between generations is extensive. What normative pattern could reconcile the priority of liberty with the familial dependence of the elderly?
One proposal is that liberty is only one component in a set of essential values whose relative weight changes with the advance of infirmity in old age. The core value is human dignity. In terms of biblical theology, one might talk of this core value as God's love for each man and woman. Another classic theological foundation of this affirmation is to found human dignity on 'the image of God in the human person'. If human dignity is the central value, then respect for liberty would be subordinate to the affirmation of personal worth.
The basic norms of care-giving to the elderly derive, then, from a tripartite division of human dignity into liberty, welfare, and family membership. Due to the infirmity and dependence of the elderly and the demands placed on the care-giver, there is a conditional priority to welfare. Welfare is a convoy concept embracing many different goods: e.g., financial support, bathing and grooming, provision of food, supervision of medication, assistance with movement. Of particular importance are continuity and regularity of care. Welfare would also entail prohibitions of neglect and abuse.
The liberty of the elderly is still to be respected. Dependence will reduce the reach of autonomy, but continues to retain its primacy in key decisions affecting the dependent elder's life: the decision to enter into a clearly dependent relationship like conjoint living, or to terminate one; changes in that status, such as home nursing care or institutionalization; major medical decisions and choices about the end of life (e.g., living wills). While accommodation required by familial dependence may reduce the range of a parent's effective preferences, children need to be alert to how the fulfillment of those preferences enhances an old person's sense of well-being and therefore shows respect for his or her own worth as a person.
The contexts of care Contextual questions are a part of ethical analysis because abstract norms seldom capture the complexities of moral responsibility. Knowing the particularities of a case helps in assessing the appropriateness of applying a norm to a given situation, in making a justified exception and in resolving conflicts of obligations.
The primacy of the family context Care-giving, as opposed to medical treatment, is a properly familial duty. Obligations to care for the elderly fall chiefly on two groups. The first is family members; the second is health professionals. In long-term care of the elderly, health professionals may be regarded either as extension of the family network or as family surrogates.
The family care-giving context For families involved in care-giving, there is seldom a need to make once-for-all decisions. Family involvement is usually an incremental affair with choices and adjustments to be made at each stage: e.g., cross-household support, shared living arrangements, long-term or hospice care. Since the changes in situation affect the elder's basic life plan, as a rule he or she should retain freedom with respect to entering on a new arrangement or not. Dependency does not entail paternalism.
On the side of the care-giver, possible limits on family care might include other family problems, the excessive needs of the elder or lack of capacity on the part of the child, and personality disorders or long-standing family alienation. The decision to institutionalise an elderly relative, ending immediate involvement in care-giving, is often warranted by the prolonged stress of chronic care and the difficulty in coping with the increasing debilitation of the patient.
Institutional care-givers The first responsibility of institutional care-givers is to ensure the quality of nursing care. But, since the majority of nursing home patients are family-less, it is also important that the institutional staff function as a surrogate family, showing the kind of personal interest in patients that might be found in the family. In addition, because the losses of old age can be so threatening, personal involvement is required in order to assist the infirm elder with the life tasks of the senior: accepting one's own worth, interpreting the significance of one's life, and coming to terms with frailty and mortality.
The role of the state Government bears three responsibilities in the care of the elderly. Under its police powers, it has the duty to protect the elderly from abuse and neglect. In virtue of its role in upholding general welfare, it has the duty to provide support for old people who have no near relatives to care for them. Finally, as the arbiter of social welfare, it may provide an array of programmes to assist the elderly and their care-givers alike. While the basic protections provided by the British welfare state are more extensive than those provided in the USA, the latter has made significant progress in reducing poverty among the aged and in making provision for their medical care. Because of the great increase in the number of elderly, both governments face major pressures to reduce and to control the costs of care for the elderly.
Sources: Aging Parents- P. Regan
Old People in Three Industrial Societies- E. Shanas