1. Kirsch, Nancy R. PT, DPT, PhD

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Rushworth Kidder (2003), the founder of the Institute of Global Ethics, said, "Ethics is what you do in the dark when no one's watching." The qualities of ethical behavior are private actions expected by the public. While all patients deserve to be treated with the highest ethical regard, nobody is more vulnerable than the geriatric population. Although older adults may access the same services in the same venues as the general population, they are more defenseless and an extra duty of care is owed to the geriatric patient. Understanding the body of knowledge surrounding healthcare ethics and the process of ethical decision making is critical to evaluating situations that might have an effect on the appropriate professional care of the patient.


Healthcare providers in all settings and disciplines report an increase in the number of situations they have found themselves in that resulted in the need to make an ethical decision. It is generally recognized that when the economy is in a downturn, ethical dilemmas increase. This inverse relationship, decreased revenue and increased ethical breeches, can result in significant stress. The stresses related to economic challenges are often concurrent with living arrangements of economic necessity, families moving in together, and difficulty accessing care.


Regardless of the economic times, issues concerning older adults often result in complex ethical challenges. In the following articles, the ethical considerations and concerns challenging the older population will be explored; in addition, services that are offered to the general population will be evaluated in the context of the special considerations that need to be made for the geriatric population.


The first article addresses the nature of healthcare ethics. The ethical standard for healthcare providers is not the same as that of practitioners in nonhealthcare fields. There is that expectation that goes beyond a general sense of duty to the special duty of care owed to a patient and in particular to an elderly patient. This article establishes the ethical framework used throughout this issue so terminology is consistent.


The second article specifically addresses the challenge of ethical decision making. The nature of recognizing and managing an ethical issue, distress, or dilemma is discussed. An ethical decision-making model is presented and the steps for ethical decision making are discussed.


Effective care of the elderly is best provided from a multidisciplinary team. The third article addresses the use of the multidisciplinary team in ethical decision making. The multifaceted medical conditions that confront older adults particularly at the end of life are managed effectively by using the expertise of multiple team members. This applies to the complex ethical issues that occur regarding care, end-of-life issues, and access to multiple levels of service provision. Each member of the multidisciplinary team brings a different perspective on the ethical issues that confront the patient, family, and caregivers. The interactions of the family member/caregiver with members of the team are explored. The necessity to explore the quality of life and communicate appropriately with the patient and the family are also addressed in this article. The complex questions surrounding futility are investigated from the viewpoint of the caregivers and the healthcare providers, particularly with their complicated role as stewards of the resources of society and as advocates for patient's rights to access care.


There are several case examples offered either imbedded in articles or as a stand-alone case. The case of chemical restraint by Barbara Gladson, PT, OT, PhD, demonstrates the complex balance that occurs between the patients' right to autonomy and the necessity of the healthcare provider to be nonmaleficent, ensuring that the individuals are not injured or permitted to harm themselves. Her detailed description of the patient and the course of events that resulted in her chemical restraint is a compelling argument for the importance of communication and the need to consider the ethical questions that arise in patient care that are important to correlate with the treatment recommendations.


Awilda Haskins, PT, EdD, and Cathy Hinton, PT, PhD, present a fascinating case involving not just the ethical concerns regarding treating the elderly but the cultural issues as well. They point out in their article that healthcare providers are dealing not only with an older population but one that is also an increasingly culturally diverse population as well. They present an article that compares and contrasts ethical norms and values and the beliefs surrounding the care of the elderly that are pervasive in the United States and in other cultures. They provide a reasoned look at the strategies that can be employed to reduce both the biomedical and the cultural ethnocentricity that may exist in ethical decision making.


Ellen Zambo Anderson, PT, MA, GCS, provides a thorough examination of how the popular complementary therapies impact older adults. In the past few decades, there has been a surge of interest in complementary and alternative medicine (CAM) approaches to health and illness. The purpose of this article is to (1) define CAM and identify its use among older adults and (2) provide a synopsis of the scientific evidence related to CAM for chronic conditions prevalent in older adults. The article is followed by a short case study that highlights some of the ethical concerns regarding the use of CAM as part of a comprehensive program for older adults.


One of the most difficult issues in gerontology is ensuring that treatment protocols are appropriate to the older population. Much of the research done does not include the elderly population as part of the study population. In the article cowritten with Christopher Haverlock, the challenges confronting the researcher in geriatrics were discussed. In addition, it is not always easy to recruit older subjects because of cognitive issues and questionable consent status. Study protocols often are associated with ethical situations, because in addition to issues of consent, some clinical trials may result in treatment regimes that may not be the best intervention for a particular patient and the healthcare providers working with the patients may be concerned about the limitations that exist for that patient as a result of the clinical trial. A case is presented that provides insight into the issues that evolve from clinical research.


The final article in this issue deals with a difficult topic, the abuse of the elderly. Elderly abuse, as the 2 cases indicate, can take very different forms in almost the same social setting. With the many confounding indicators of abuse and the legal demand to report abusive situations that are known or suspected, healthcare providers are becoming increasingly vigilant. Elder abuse can take many different forms. In addition to overt physical and mental abuse, there are other covert types of abuse, such as financial misappropriation of funds and self-abuse. There are often conundrums that confront healthcare providers when they encounter abuse, because the victim may not want to be rescued from the situation. They would prefer to manage within the abusive situation they are in rather than trade it for an institutional setting and/or perhaps a more abusive situation. Healthcare providers are caught between the autonomous right of the individual to choose their living situation versus the fiduciary responsibility of the healthcare provider to ensure that the patient's best interests are met and they are not in a harmful situation.


We are very grateful to the editor of Topics in Geriatric Rehabilitation for the opportunity to present a varied approach to the many ethical issues that confront healthcare providers in this complex and rapidly changing healthcare environment. Ethics has come to the forefront lately in many different organizations. Healthcare providers are well aware of the very special duty of care they owe their patients and their families. We hope this issue serves to make it very clear that the geriatric population presents special ethical considerations that we need to keep in mind when approaching their care. Throughout this issue discussing whether cultural differences, use of new interventions such as CAM, research challenges, or the topic of protecting the elderly from abuse, the overarching directive is good judgment. Choosing a path that reflects good judgment is not always easy, but there are many tools that exist to help us make good choices that reflect well on our decision making and assure our patients that their best interest is our primary concern.


-Nancy R. Kirsch, PT, DPT, PhD


University of Medicine and Dentistry of New Jersey, Newark, NJ