Ethics and Elder Care: Directions of Travel?

A story I recall from my youth is that of a tourist who stopped her car in a rural part of Donegal to ask directions of a local man.

The tourist asked: ‘How do I get from here to Buncrana?’

The local man replied: ‘Well, I wouldn’t start from here’.

Sometimes in our practice, it is not clear if we are starting from the right place. It may be unclear if our direction of travel is the right one. It may also be unclear if our travel plan is doable, given local conditions and culture.

So where to begin our journey towards a better understanding of ethics and elder care? Do we begin with practice examples? Which examples? Or with theory and research?

Starting with Practice?

As I was shown around the two care facilities I visited this week, I was struck by the cleanliness of the environments and the kindness of the care-giving staff.

The majority of older people in the 300 bedded elder care facility received fundamental care and many had feeding and other tubes. The small number of older people with dementia in the mental health facility I visited, were integrated with people with mental health problems such as schizophrenia and bi-polar disorder. The treatments in the second facility were medication and activities such as art and crafts, music, dancing and exercise.

[1st photo: Entrance to elder care facility with unit manager and professors of nursing. The sign refers to ‘Respect for elders and care from the heart’. 2nd photo: messages of gratitude to care staff from family members]

My reading this week took me back to the USA. John Leland’s book ‘Happiness is a Choice You Make: Lessons from a year among the oldest old’ brings together insights gained from the year he spent getting to know 6 New Yorkers who were over 85 years old. He detailed many learning points including:

‘Old age at some point forces us to accept help from other people. It can be hard on the ego, perhaps, because it means acknowledging that we are not in control of the world. But it also gives something valuable to the people who help us.’

Research and scholarship?

Witnessing the dependency of people in the elder care facility, I wondered if the practice of advance care planning (ACP) was common on China? Would people have welcomed the opportunity to make decisions in advance about the kinds of treatment and care they wanted in their later years? Might they, for example, have declined resuscitation, antibiotics or tube-feeding? Would you welcome this opportunity?

A paper recently accepted by the journal Nursing Ethics suggests that ACP is at an early stage of development in mainland China but the conversation has begun. Baimin, one of the graduate students here, told me about Chinese leader Chen Xiaolu who died recently. Based on his experience of his father’s futile resuscitation, Chen founded the ‘Beijing Living Will Promotion Association.’ There is then  a movement in China, as in many other countries, to take some control over treatment and care in later life. Given the population of China (1.4 billion) and of its elder population (over 200 million), it may take time for ACP and living wills to catch on and there are other challenges to respond to.

Bioethicist Jing-Bao Nie writes of an ‘erosion of eldercare in China’ contributed to by the damaging impact of the one-child policy and inequalities between rural and urban areas. Nie also writes of the high suicide rates amongst over 65s (44% of all suicides). Professor Ma and I have discussed the implications of some of these issues in a blog for the Nuffield Council on Bioethics in response to a recent briefing note on ‘The Search for a Treatment for Ageing’ (

So what sense can we make of all of this in relation to planning a direction of travel for ethics and elder care?

Direction of travel

The same local man was approached another day and was asked for directions to Sligo.

He replied: ‘Well, there’s a long road and a short road.’

The tourist asked: ‘Which road should I take?’

The reply came: ‘The short road of course.’

What we know about elder care across cultures is that many committed care-givers help people to be the very best they can be. Sadly, we know too that many elders are not receiving the care they need or desire.

The good news is that many practitioners, researchers and educators are on the case and progress is being made. But there is much more to do. What we know is that there are no short roads to solutions but rather a need for sustained inter-disciplinary, cross-cultural and cross-generational collaborative effort.

Next week, I’ll tell you about the exciting research in progress to improve the experience of elders in Xiamen by Professor Fang and her talented students. I aim also to say something about gratitude…

For now, I’ll leave you with another ‘lesson’ from elders gleaned by John Leland. He is commenting on our inclination to look to the future and elsewhere for our happiness:

‘The good things in life – happiness, purpose, contentment, companionship, beauty and love – have been there all along. We don’t need to earn them. Good food, friends, art, warmth, worth – these are the things we have already. We just need to choose them as our lives.’

Until next week.