As a society, we have ignored the material and social conditions that are required for autonomy to flourish. We have allowed autonomythwarting institutions to dominate the care of the infirm and sick old. Rather than building autonomy-sustaining institutions, long-term care of elders has accepted a medical paradigm of the delivery of services rather than a paradigm of providing an environment suitable for sustaining a compromised autonomy.
The nursing home in America has become the icon of the loss of independence. The nursing home often is a setting in which the individual is subject to impersonal institutional rules rather than self-control. Even when elders do not require skilled care, the medical model that dominates nursing homes creates a hierarchical and professionally dominated setting that forces residents to live under significant restrictions. In this context, it is understandable that reformers have used the concept of autonomy as a watchword for reform, but reforms that feature increased choices or rights cannot address the personal loss of dignity that elders experience.
Autonomy has traditionally supported liberation. In the nursing home, a patient rights' movement has developed that insists that residents of nursing homes be accorded basic rights, including degrees of self-governance and, most importantly, preservation of the rights that they possessed outside the nursing home. Liberating elders from an oppressive system, however, is not feasible if the elders truly need the supportive services that the nursing home provides.
While autonomy is an important value, respect for autonomy is a remarkably abstract formula for expressing the complex range of ethical obligations associated with respecting elderly persons. Persons deserve respect not only because they are capable of self-determination, but also because they are persons. In actuality, persons exhibit varying degrees and kinds of autonomy. Unfortunately, emphasizing the ideals of independence and unfettered decision-making that dominates most treatments of autonomy cannot be developmentally sustained throughout the life span. In contrast, respect for actual autonomy means that society must address the concrete actuality of the persons in question.
To respect autonomy thus requires that we develop policies and procedures that move beyond a focus on individual choice or decision-making to take into account developed personality and the limitations that actually define people as they age. The challenge of autonomy in aging is the challenge of respecting elders' actual expressions of autonomy in the face of compromised capacities without losing the protections afforded by the rights associated with traditional readings of the principle of autonomy.
GEORGE J. AGICH
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