Introduction
THECRITICALTURNANDITSMEANING
Thisbookreflectsthecommitmentoftwophilosophersandacritical gerontologisttobringtogetherinoneplacecriticalreflectionsonethics, aging,andsociety.Inthespiritofinterdisciplinaryscholarshipandin appreciationoftheworkofourfriendsandcolleaguesinbothphilosophy andgerontology,wehaveconceptualizedthisbookinwaysthatwe hopewillbebothintellectuallychallengingandpracticallyuseful.Wesee thisbookasenteringintoadynamicstreamofthoughtinbothgerontologyandphilosophy,whereoldcertaintiesarebeingrethoughtandnewpossibilitiesareopeningup.Hence,wethinkofthisbookasanadventurethat notonlymarriesdisciplinesbutopensmanyrichpossibilitiesforimproved careinhealthandsocialservicesettingsandforgrowingoldwithprideno matterone’sphysicalormentalhealthorone’seconomicorsocialstatus. Wefinditparticularlyexcitingthatintellectualfermentcancontributeto makinglivesbetter.
Achievingtheseendscallsforacriticalperspectivethatwehavesought toincorporateineachsectionofthisbook.Thisperspective,inharmony withagrowingtrendinbioethics,valuesandusestheinsightsofempirical researchandmultiplesourcesofmoralknowledge.Considerhowamorally complexplay,novel,orpoemprovidesinsightsandideasthatamorerulelikeapproachwouldnotreveal(see Nussbaum,1990).Thesecontextual andnarrativesourcesdonotrelyonmoralexpertisenorhonortherules ofimpartialityanduniversality.Infact,theyoftenleaveuswithfeelingsof moraluncertainty;yet,wearguethatfromsuchsourceswegainarichunderstandingofthemoraldomainanditspossibilities.
Aswethinkthisbookwillmakeapparent,wehavealsofoundthatmore empiricaldisciplinessuchaspsychology,sociology,andanthropologyadd immeasurablytoourunderstandingofethics.Empiricalresearchhelpsus tounderstandhowreveredvaluesactuallyworkinpractice.Weseethis clearlywhenanthropologists(Drought&Koenig,2002; Kaufman,2000)
raiseimportantchallengestothecherishedbeliefsincontrolattheendoflife orwhensociologists(Aronson,2006)exposehowolderwomenexperience thepublichomecaresystem’slimitedabilitytoprovideandreflectwhatthey mostcareabout.Wecansee,inpractice,howthecommitmentto“clientcentered”careinthesehomecaresystemsdissolvestherelationalcoreof careandappliesthethinnestconceptionofautonomyasmorallysufficient. Ifwearetoholdpeopleaccountableformeetingtheirmoralcommitments,itisimportanttoknowwhatkindofselvesweareandwhatitis possibleforustodo.Here,too,empiricalresearchisaguide.Philosophy, whenjoinedwithpsychology,sociology,andthecognitivesciences,tells usmuchaboutthenatureoftheself.Inrecentyears,theyhavepointedto thesocialorrelationalselfandhowthatunderstandingreshapesour moralcommitments.Theytellus,forexample,thatself-respectisnotsomethingthatweattainonourown;itisacommunalproductand,assuch,an achievementgainedthroughrelationshipswithothers.Thesedisciplines helpustounderstandthatobligationsarenotalwaysvoluntaryandthat wehavecriticalrelationalobligationstoothers,especiallytothosewho arevulnerable.Anunderstandingoftherelationalselfdoeswhatconventionalideasabouttheselfcannotdo—helpsustoconceptualizewhat countsinourmoralrelationshipswithpeoplewhoneedhelptomanage day-to-daylife.Thisviewoftheselfhelpsustoappreciatethattherealization ofautonomyisverynearlyimpossibleintheabsenceofasocialoreconomic foundationtosupportitsexercise.Thisunderstanding,oftheself,gains strengthfromitsinterdisciplinaryconfirmation.
Giventhesocialnatureoftheself,itisnotsurprisingthatthecritical perspectivewereflectisalsoattunedtocontext.Socialrelationshipshelp makeuswhowearebuttheyalsosustainusandouridentities.Thus, supportivesocialandculturalcontextsareessentialfordevelopingrichly formedidentitiesthatareworthyofrespectandallowustospeakinour ownvoice.Butsocialcontextsareoftennotsupportiveinthisway,especially forpeoplewhoarenotprivileged.Itisoftenastruggletoclaimtheirvoice. Thismeansthatwomen,oldpeople,thosewhoarepoor,andracialand ethnicminoritiesdonotgainthesupportthattheyneedfromthebroad contextsinwhichtheylive.Withotherfeministscholars,weholdthatif ourvalues,perceptions,concepts,andidentitiesareinlargemeasure socialproductsthenthesocialworldmustbeasimportanttoethicistsand gerontologistsasitistotheindividual.
Contextalsocallsattentiontoourparticularity.Asveryparticular people,manyofusdonotfindaneasyfitthenormativevaluesthatsuit themoreprivileged.Whilewewouldhopethattheculturalpractices, beliefs,andvaluescanbemodifiedtobemorehospitabletopeopleatthe xContents
margins,welooktosmallercommunitiesofmeaningassiteswherepeople findsupportfortheiridentities,meanings,andself-worth.Thesecommunitiescanalsobesourcesofpracticalandmoralknowledgethathelpto informpracticesofcare.
Othercontextualfeaturesofourlivesaremoredirectlyimportant.The receivedviewofethicsdoesnottakeintoaccounttheconditionsthat olderpeopleneedtomakeself-affirmingdecisions.Inhospitablestructural conditions,economicinsecurity,socialdisregardalongwithillness,disability,suffering,anddeathallimpedeourabilitytospeakinourown voice.Weseethisgraphicallydisplayedinhospitalsandnursinghomes butalsoinconditionsofelderabuseandneglect.
Thepolicyenvironmentisanothercriticalcontextualfeatureofour lives.Itdeeplyinfluencesthekindoflifewecanleadandthechoicesthat areavailabletous.Hence,wehaveadualinterestinpolicy.First,wewant torevealhowthevaluesthatsupportitarenotneutral:forexample, peoplenotwellservedbythemarketarevictimsoftheprevailingneo-liberal ideology.And,second,wewanttosuggestpolicyalternativesthatrelyon othernormativevaluesthatcangroundpolicychoicesthattakeinto accountsuchconcernsasgender,justice,andcare.Tointroducenewand differentnormativeidealsforpolicydevelopmentcallsforanactivistengagementwiththeworld.Itisnotenoughtonoticeproblems;itisalsoessential totrytodosomethingaboutthem.
Ourcriticalperspectivealsomeansthatwerejectstandardapproachesto ethicalthinking.Thisrejection,however,doesnotmeanthatwesupport relativism.WithMargaret Walker(1998),webelievethatcertainactions andpracticesareinfinitelybetterthanothers,butthatthewaytodetermine bestactionisnotthroughtheapplicationofprinciplesandtheoreticalideas. Rather,weachieveourbestendsthoughnarrativeandcommunicative approaches,inwhichtheintegrityofeachindividual,andofthegroup, bothcount.Wearenotsuggestingthatweabandonprincipledknowledge; wesimplyrecognizethatsuchprincipledknowledgeismerelythebeginning andnottheendpointofmoralengagement(Walker,1993).
Wewritethisbookforseveralratherdifferentaudiences:philosophers, ethicists,gerontologists,socialworkers,physicians,nurses,attorneys andotherswho,asscholars,teachers,orpractitioners,arecommittedto understandinghowtheconditionsofoldageareworthdetailedmoral inquiry.Wehopethatbybringingtogetherdifferentwaysofthinking,we willprovideanenrichingandprovocativereadingexperience.Wewrite fromthe“edge”ofbothphilosophyandgerontology.Whilerespectingand learningfromourmoremainstreamcolleagues,wewritespecificallyfrom thecriticalperspectivewehavejustbrieflydescribed.Ingerontology,for
example,thisperspectivehasbeenrepresentedbycriticalgerontology,an interdisciplinaryapproachutilizingthehumanitiesandpoliticalandmoral economytoraisequestionsabout“whateveryoneknows.”Thisapproach allowsustoseektheoftenhiddenvaluesthatsupportresearchagendas anddominantdiscourses;tospecificallycallattentiontothewaysin whichclass,gender,andraceaffectusasweage;andtoprobeforthe voicesatthemarginsthatrarelycommandnoticeandthatlacksocialand epistemologicalpower(Baars,Dannefer,Phillipson,&Walker,2006; Minkler&Estes,1999).
Whencriticalgerontologistsconsiderethicalissuesandaging(Holstein, 2010)thecanvasextendsbeyondclient-professionalissues,withitsfocus onclientautonomythathaslongdominatedscholarship.Whileconcerned withthoseissues—especiallywithaneyetoenlarginghowwethink aboutthem—criticalgerontologyhasalsobeeninterestedinsuchareasas normativeimplicationsofculturalimages,tropesandmetaphorsandthe waysinwhichsocialandpublicpolicycanasconstrainchoicesforolder people.Criticalgerontologyalsotakesembodimentasamorallyimportant featureofoldage.Awomanwithsevereosteoporosisexperiences theworldverydifferentlyfromayoungandwell-conditionedmarathon runner.
Inphilosophicalethics,provoked,inpart,bythepublicationofCarol Gilligan’s InaDifferentVoice (1982),tobeatthe“edge”hasmeantexploring themoralrelationsbetweenintimatesorbetweenpeopleinlegitimate relationshipsofdependency.Thishasmeantmovingbeyondindividual autonomy,assumedtobeacharacteristicpossessedbymostmoralagents, toaconsiderationofamorecomplexunderstandingofautonomythat understandstheselfasnecessarilyensconcedinrelationshipsofcare.It suggeststhatthepreoccupationswithindividualrightsasthegrounding ofobligationtoolderpeoplewhoneedcareareinadequate.Moralclaims, EvaKittay(1999) suggests,arise“outoftherelationshipbetweenonein needandonewhoissituatedtomeetthatneed”(p.55).Wethusreiterate thatthisviewoftheselfmeansthatourlivesarefilledwithnecessary obligationsthatweignoreatperiltoourself-respect.Butitalsomeans thatourresponsetotheseobligationscallsforsupportsothatwomen, whoaretheprimarycaregiversinoursociety,donotfaceexploitationasa resultofthisresponsiveness.
Tohonorautonomy,inourview,callsforafocusontheexternalconditionsthatsupportorimpedeitsexercise.Context,includingpractical matterssuchaseconomicinsecurity,physicallimitations,threatsofabuse, orlifeinanursinghomesetting,allcomebetween“realandapparent desires”(Meyers,1989).Thus,partoftheresponsibilityofprofessionals
workingwitheldersistostartwithawarenessabouttheautonomyconstrainingfeaturesofthesecontextsandtothenworkwithpersonsto revealtheirvaluesanddesires.Thispathtoreachinganauthenticvoiceis bestdonethroughnarrative,whichhasthecapacitytorevealwhatmatters mosttoelders.Italsohastheabilitytoallowustore-storyourlivesby lettingusbreakfreeofmasternarratives(LindemannNelson,2001; Ray, 2007)sothatitopensmorepathstolivinginwaysthatsupportidentity. Narrative,basedonacommunicativeordialogicapproach,istheway mostofusmakeimportantdecisionsandreflectuponourlives.Weurge itsfurtherpracticeinworkwitholderpeople.Onceagain,weaffirmthat muchoftheimportantcommunicativeworkinvolvedindevelopingemancipatorynarrativesanddefiningourcorevalues,beliefs,needs,andidentities,occursinsmallercommunitiesofmeaningwhereolderpeopleare freetodefinethemselvesinasafeenvironment.
AGLANCEATTHECHAPTERS
InChapter1,wepresentthereceivedviewofethicsthathasinformedagreat dealofworkonaging,aviewthatwebelievedoesviolencetotherealities ofagingandoldage.Thisapproach,whichtakesrespectforautonomyto betheultimateconcern,facesmanychallengesbecauseitignoresfactors suchasinstitutionalpower,compromisedautonomy,andthedegreeto whichourselvesaresociallysituatedandsociallyconstituted.
Asweargue,theprincipleofautonomyisproblematicwhenweareconsideringpeopleofadvancedage,whocannotmaintainafacadeofbeing independentandself-sufficient.Inaddition,theprincipleisnothelpful withinthecontextthatalargenumberofolderadultsfindthemselves: nursinghomesorassisted-livingcarecenters.Theconditionsofoldage andthelivingconditionsonefindsinlong-termcarefacilitiesarenotconducivetotheprincipleofautonomyasithastraditionallybeenunderstood. Inthischapterwecallfortherethinkingofautonomy,howweunderstandit, andthewaysinwhichitappliestoolderadults,inordertoensurethatpeople arenotundulyharmedbyit.
Chapter2exploreshownewwaysofthinkingaboutautonomycansignificantlyexpandourunderstandingofethicsandaging.Aswenotein Chapter1,initscommonunderstandingautonomycontinuestomeanselfdirectingaction,whichissymbolizedandenactedbytheprocessofinformed consent.Thisview,however,isfar“thinner”thanwhatarobustapproach toagingrequires.Autonomyisoftenreducedtomakingchoices,withno considerationoftheimpedimentsthatmakesuchchoicedifficultifnot,in
somecases,impossible.Withoutanavailabilityofoptions,theabilitytopay forthoseoptions,orthepresenceofmeaningfullifechoices,wefailto provideforourelderlyinwaysthataresignificantandmeaningfulfor them.Respectforautonomythusmeansmorethanremovingbarriersto andhonoringchoice:personalautonomyrequiresmuchmorethan uncoercedchoice.
AsweargueinChapter2,ourgoalisnottoeliminateautonomyfrom ethicsandaging,buttoaltertheunderstandingofautonomythatistypically invokedinconnectiontotheelderly.Respectforthechoicesandvaluesof olderpersonsareimportant,especiallyinthefaceofaculturethathas largelydenigratedtheelderlyandreducedthemtothestatusofchildren. Thewayinwhichautonomyisdefinedandunderstood,however,affects ourtreatmentoftheseindividuals.Ifaconceptofautonomyistoserve suchpersons,thenitmustbecouchedinamorallanguagethatfinds some“fit”withtheiractualexperiencesandcapacities.Forthisreason,we advocatearelationalconceptionofautonomythatisrootedinfeminist ethics.Whenunderstoodas“relational,”autonomyisdivestedofboththe socialcontractmodel(humanexchangeconductedamongequals),and theconceptofselfasdetachedandself-interested.Instead,wesuggestthat humanbeingsshouldbeviewedasbeings-in-relationship—asbeing necessarily andnotonlycontingentlyensconcedinrelationshipsofcare.Chapter2 setsoutthefeminist,narrativeandcommunicativeethicframeworksby whichwearguethatwecanachievesignificantchangeinhowwethink aboutourselvesinrelationtoothers.
InChapter3,weexploreoldwomen’sembodimentthroughcultural, moral,andbiologicallenses.Ourintentistoshowwhyembodimentand bodyimagematterinoursocialpracticesandinthemorallifemoregenerally.Inthischapter,weintegratebiologicalunderstandingsoftheaging bodywithsocialconstructionistviewsthattakebodilyexperiencestobea sociallydeterminedphenomenon.Insodoing,wesuggestthatbothbiological and socialunderstandingsconstitutewhatitmeanstohaveanagingor agedbody.
Howweexperienceouragingbodiesisthuscomplex,influencedby structural,institutional,andculturalforcesandthemyriadinteractions thatoccurintheoverlappinganddiscretecontextsinwhichwelive.Our embodiedselvesshapeandareshapedbytheseforcesandinteractions. Wedonotarguethatagingandagedwomenoughttobeentirelyfree fromculturaljudgementsconcerningtheirbodies:for,aswerecognize,as socialbeing,thebodyispartlyphysicalphenomenonandpartlysocialconstruct.Rather,werejecttheubiquitousnegativeunderstandingoftheaging body,whichdeniestheverypossibilityofanauthenticexperienceofit.
InChapter3wearguefortheneedtoopenupmeaningsofagingthat contributetoolderwomen’ssenseofself-worthandpersonalidentity, findingtheopportunitytodosowithinthemicro-communitieswithin whichagingandagedwomensocializeandlive.
Chapter4offersasustainedcritiqueofemergingnormativeideasabout whatoneoughttobeanddointhe“thirdage,”thatperiodafterretirement andpriortotheexperienceofseriousphysicalandcognitivelimitations. Thesenormativeideals,capturedinsuchexpressionsassuccessfulaging, productiveaging,andcivicengagement,envisionanelderpopulationthat isrelativelyaffluentandingoodhealthwho ought tousethatstatustocontributeactivelytothecommunity.Whilewehavenoobjectionstocreating opportunitiesforcontinuedparticipation,indeedfinditagoodthing,our objectionsarebasedonthenormativequalitiesthatinfusetheseends. Theseculturalidealsreflectaprivilegedviewthatupholdsforallolder peopleawayoflifethatmaybepossibleforonlyarelativelyfew.Given theimportanceofimages,tropesandotherculturalidealsasingredients inshapingandevaluatingone’sidentity,weseetheseidealsaspotentially damagingtothosewhocannotliveuptothemorwhodonotwishtodo so.Ifwedonotseeourselvesinthesemasternarratives,ourabilitytointeract withthelargercommunitymaybeconstrainedalongwithourfreedomto actaswemightwishto.Wearguethatitiscriticaltoseehowthepathsto oldagearedeeplyshapedbysociallocationwithsomelocationsproviding thefoundationfora“successful”oldagewhileothersmakeitverydifficult especiallyforlowerincomewomenandpeopleofcolor.
Insteadofthesebroadnarrativesofwhatisgoodanddesirableinold age—bothforindividualsandforsociety—weturnonceagaintosmall communitiesasplaceswhereolderpeoplewillfindtheresourcesto developtheirideasofwhatitmeanstoliveinwaysthatconfirmtheirselfworthandsupportidentityevenwhentheyarenolongerabletodowhat onceconfirmedwhotheywere.Inthesecommunitiestheyhaveachance tore-storytheirlivessotheyarenotboundbytheconventionalstory lines,whetherthosestoriesaretheoldonesofdeclineandlossorthe neweronesofanextendedmiddleagethathaveinfusedsociety.
InChapter5,Anti-agingMedicine,wegrapplewiththeideaofantiagingmedicine.Acommonlydiscussedconcerniswhetherortowhat extentthereisanyvaliditytotheclaimsputforwardbyenthusiastsof anti-agingmedicine.Despitetheenthusiasmoftheanti-agingproponents, weexpresssomeskepticismaboutthelikelihoodoftechnologicalsuccess inthisendeavor.Additionally,onecanspeculateaboutthelikelyeffects uponsocietyandsocialstructuresifanti-agingmedicineweretobecome areality:Wouldwetrulyenjoysuchvastlyextendedlifespans?What
wouldhappentosuchsocialinstitutionsasmarriageandfamily?Andwhat kindofpressuresmightthisputuponsuchsocialarrangementsasretirement,SocialSecurity,andsoforth.Butthereareverypresentsocialjustice issuesthathavereceivedconsiderablylessattention.Inparticular,we wouldliketoraisethequestionofhowtheenterpriseofanti-agingmedicine initscurrentform—whetheriteverprovestechnologicallysuccessfulor not—hasadverseeffectsupontheelderly.Specifically,wearguethatthe wholeenterpriseof“anti-aging”medicineperpetuatesandevenexacerbates negativestereotypesofaging.Thesenegativestereotypesdevaluethosewho areelderlyinoursociety,andcauseharmthroughthisdevaluationand theaccompanyinglossofself-esteem.Inshort,farfrombeingpositively beneficial,orevenjustneutral,theenterpriseofanti-agingmedicineis actuallyharmful.
Inthischapter,wewillarguethatethicscanimportantlycontribute topolicymakingwhilebeingmindfuloftheseriousimpedimentstoconstructingeffectivebridges.Wearguefortheimportanceofexposingthe valuesthatarethefoundationforpolicychoicessothattheycanbeinterrogatedandassessed.Wealsoarguethatwhilejusticeisadistributive issueitisalsoaboutwhositsatthetableasneedsareidentifiedandinterventionproposed.Becauseourcommitmentthroughoutthisbookisto counteraprivilegedviewperspective,wewillargueforbroadparticipation inpolicymaking.
Tolaythefoundationsforthealternativenormativevaluesthatwewill propose,wedescribeandcritiquetheideologyknownasneoliberalism, whichendangersthewell-beingofpeopleofallageswhoarenotwell servedbythemarket.Weargueforavaluefoundationforpolicythat supportsbothfamiliesandelderssothatindividualityandinterconnectednesscanthrivewithoutthegenderandclassexploitationsthatarenowso prominent.Itwillargueforsocial,economic,andinstitutionalsupports thatpermitfreedomcommensuratewithphysicalandcognitiveabilities. Thisalternativevaluefoundationrestsonarelationalontologyandcommitmentstopersonalandsocialinterdependenceandsolidarity,dignity,and genderjustice.Thischapterisonestepinanactofresistancetothosepolitics,ideologies,andindividualisticmoralvaluesthatdisregardcontextand theconditionsofpossibilityforpeopleofdifferentkinds.
InChapter7,weopenbyaffirmingthevitallyimportantrolethat “home”playsinallourlives.Asourbodiesbecomemoreuncertain, themoreweneedwhatisfamiliarandidentityconfirming.Tostayat home,forsomanyelders,meanshavingthesupportofothers—usuallya familymember,mostoftenawoman.Sincecaregivingisnotemployment atwill,wecritiquethecommonassumptionthatfamilymembers,primarily
women,areableandwilling,withminimalsupport,togivecareto theirelders.
Thischapterremindsusthatgivingandreceivingcareareessentialto thecontinuityofhumanlife.Thisfactisvisible“proof”thattheselfin relationshipisamoreaptdescriptorofwhowearethantheindependent selfthatisupheldasmorallycommendable.Thisviewoftheselfthatwe haveintegratedintoallofourworkopensthewayforamorepenetrating analysisofthemoralproblemsencounteredinhomecare.Thesituations thatoccurthere,sooftenproblemsoflivinginthefaceoflossandsocial devaluation,arenotsusceptibletostandardapproachestodecision-making. Becausetheyalsoinvolvedeeplyintimatepartsofourlives,theyare fraughtwithsensitivitiesandtheinevitableneedtonegotiatewhattodo andhowtodoit.Hence,inhomecare,weargueforjustice-basedcommitmentstothecareprovider,whoshouldnotsufferimmediateandlong-term harmsbecauseofherresponsetoneed.Butwealsoargueforacommunicativeapproachtoaddressingtheproblemsthatarisesincethisistheclearestwaytorespectnotonlytheindividualsbuttherelationshipsthatare sosustaining.
InChapter8,TheNursingHome:BeyondMedicalization,weconfront thesocialdescendantofAmerica’s“poorhouse.”We,asasociety,harbora loathingoftheseunderfundedandunderstaffedinstitutions.Placementin anursinghomestandsasanexplicitjudgmentthattheindividualhas failedatacentralAmericanvalue:independence.AndwhileAmericans aredeeplyaversetotheideathatweourselveswillbecomeresidentsin oneofthesefacilities,manyofusdowinduplivingoutourlastyearsin justsuchanursinghome.Wearguethatde-medicalizingourunderstanding ofthenursinghome—andnursinghomecare—andemphasizinginsteada senseofcaringforpersonsinwhathaseffectivelybecometheirhomewill beafarbetterwayofsupportingandbenefitingnursinghomeresidents thanhappensinthetypicalcontemporarynursingfacility.Wealsoargue thattruenursinghomereformwillultimatelyrequirearevaluationof American’sobsessivefixationonindependenceandaversiontodependence inanyform.Accordingly,fromourcriticalperspective,wecallforareconceptualizationofthephysicalandorganizationalenvironmentofthe nursinghome,de-emphasizingthemedical-acute-careflavorofsomany institutionstoday,andarguinginsteadforthenursinghomeasahumane, environmentallyenrichedplacetolivewherepersonsarecaredfor,not bodiesinbeds.
Chapter9addressesasamplingofrelationalissuesthatarisewithinthe long-termcaresetting.Theissuesweconsiderincludeconfidentiality,power, boundaries,bias,andconflictsofinterest.Weexaminetheseissuesasthey
emergeindifferentsettings,bothinthecommunityandwithininstitutions. Inparticular,weincorporatethenewapproachestodoingethicsthat wediscussinpreviouschapters.Weconsideracasestudythathighlightsa commonlyoccurringrelationaldilemmainthenursinghomesetting—the developmentofromanticrelationshipsbetweennursinghomeresidents andtheconflictsthoserelationshipsmaycause.
AsChapter9argues,anappealtotraditionalautonomyisnotresponsive totherichandcomplexrelationalissuesthatarisebetweencaretakersand theelderlyinlongtermcare.Bytakingseriouslytherelationalautonomy approachdetailedinChapter2,wecanmoreeffectivelyaddressthe complexsocialrelationshipissuesthatariseinthelongtermcaresetting. Wearguethatafeministconceptionofrelationalautonomybestcharacterizestherelationshipsbetweencaretakersandcarerecipientsandrecognizes theuniquefeaturesofeachrelationship.Ifhumanbeingsare,asthisview claims,interdependentbeings,andifourveryidentitiescomeoutofthe relationshipsinwhichweareinvolved,thenweoughttojudgetheethical natureoflong-termcarebythequalityoftherelationshipsinquestion, notbythedegreetowhichindividualautonomyisrespected.
Chapter10addressesthepainfulquestionsassociatedwithelderabuse, neglect,andself-neglect.Whilerecognizingthattheetiologiesandtheprobableinterventionsinthesesituationsareverydifferent,ourinterestisin exploringhowthe“criticalturn”inethicscanopennewpossibilitiesfor addressingtheethicalproblemsthesesituationscreate.Forhealthand socialserviceprofessionals,muchhingesonquestionsofdecisional capacitysincethatdeterminationhelpstogoverntheactionsthatare deemedmorallyacceptable.Thechosenactionsthensupporteitherautonomyorbeneficence/paternalism.Theseareseenasoppositional.One cannotrespectautonomyatthesametimethatoneactspaternalistically. Thisapproachtakesthesecorevaluesasdeterminative—thebeginning andtheendofethicaldeliberations—evenwhenprofessionalscontinueto feeldissonancebetweentheirwishnottotrampletherighttochoosewith theirsenseofobligationtoprotecteldersfromharm,whenprotectionis possible.Torespondtothisdilemma,weargueforasustainedeffortto detect,throughnarrative,re-storying,andvariedcommunicativestrategies, whattheabused,neglected,orself-neglectingeldercaresmostabout.Itaims tohelphertorecoverordiscoverherauthenticvoice(Meyers,2002)that issooftenhiddenevenfromherselfbyreasonsthataresocial,cultural,familial,andeconomicinorigin.Wefurtheradopt Kittay’s(2006) conceptofthe “transparentself”asthemostcongenialmeanstoreachthatend.Wesuggest thatthisdissolvestheoppositionbetweenautonomyandpaternalismsince
both(orall)peopleinvolvedhaveacommonaim—helpingthiselderhave whatshemostcaresaboutmet.Thisapproach,weknow,isadifficultone inthetimeandresourceconstrainedenvironmentinwhichmanyprofessionalswork.Itisalsocomplicatedbythelonghistoriesoffamiliesand howtheyrelatetooneanotherandisfurthercomplicatedbythedisturbing factthatviolenceisprobablynoteliminable.We,nonetheless,argueforthis approachasthemostlikelywaytomeetprofessionalresponsibilitiesatthe sametimethatwetrytomeettheelder’sgenuineautonomouswishes.
InChapter11,Alzheimer’sDiseaseandanEthicsofSolidarity,weargue thatprevailingculturalandphilosophicalnormsofpersonhoodand dignitycometogethertoradicallydevaluethatindividualwithAlzheimer’s disease.TheobsessioninWesternculturewithhighlyindividual,fully rationalautonomy,byfocusingononlyonefacetofpersonhood,obscures anddevaluesallotheraspectsofbeingaperson.Yet,Alzheimer’s(and suchdementiasingeneral),mightbethoughtofasanextremechallenge tothenotionofpersonhood.Ascognitionisinterruptedandmemory fades,inwhatsensecanpersonalidentity—selfhood—remain?And,in our“hypercognitive”culture,whenwegazeuponthoseindividualswith dementia,weseeinherentlycompromisedanddiminishedpersons:They becomelessandtheycountforless.Wearguethatunderstandingpersons asrelationalratherthanasisolatedbothhelpsexplainhowselfcanbe sustainedthroughdementiaandwhatkindofcareisofgreatestvaluefor thosewithdementia.
InChapter12,wetakeonthetaskoflookingatend-of-lifecarefrom avantagepointsimilartothatweadoptedinotherchapters,thatis,by raisingquestionsaboutthe“takenforgranted,”byusingempiricalresearch toraisequestionsabout“ideal”formulationsofwhatisgoodattheendof life,andthenconsideringanenlargedscopeofapproachestosuchcare. Wedescribeefforts,suchasadvancecareplanningandhospicethatare designedto“tame”deathandthencritiquethecommitmenttocontrolas acentralgoalforend-of-lifecare.Wearguethatcontrolreliesonproblematic assumptionsaboutwhatitisthatpeoplemostwant,theirwillingnessand abilitytorationallyplanfortheirowndying,andtheinattentiontothe medicalculturethatstronglyinfluencethepossibilitiesopentomany people.Weworrythatoverrelianceonrationalplanningerasesthevulnerable,hurting,emotionalselfinfavoroftherational,cognitiveselfandthat theindividualisticfocusofsomuchadvancecareplanningdenigratesthe continuedconcernforothersthatpeoplewhoaredyingcontinueto express.Fearofburdensignals,onceagain,thecentralplaceofrelationships inourlives.
Whilesupportiveofhospiceandpalliativecareandeffortstoimprove advancecareplanning,weargueforabroaderrangeofinterventions thatlessentheimportanceofindividualtreatmentchoicesthateasethe burdenofdecisionmaking,andaddressthecaringneedsofpatients andfamilies.Welookto“bottomup”ideasdirectedatthestillstubbornly resistantproblem—howtoeasethetransitionfromlifetodeathinways thatrespectindividualsandthesignificantrelationshipsofwhichthey areapart.
Chapter13,AgingandDisasters:FacingNaturalandOtherDisasters,is anefforttotellaconsistentandcompellingstoryabouttheelderlyamidst catastrophicdisaster,andtothendevelopanethicalanalysisandpractical strategyforaddressingtheiruniquesituation.Inthefirstportionofour chapterwemakethecasethattheelderlyareroutinelyoverlookedamidst catastrophicdisasters,andtherebyoftensufferdisproportionatelyrelative tothegeneralpopulation.Morethanbeingjustavulnerablepopulationof people,eldersaresusceptibletoadditionalandcompoundharms.A failuretorecognizetheirspecialneedswillconsistentlyleadtotheirmarginalizationindisasterresponseefforts.Therefore,inthesecondsectionofthe chapter,weemphasizeourethicalobligationsto(1)responsibleplanning priortotheoccurrenceofadisasterandalsoto(2)promoteandmaintain effectivecommunicationandcollaborationbothinplanningforand respondingtoamajordisaster.Thesetwoelementsseektoaddresstheparticularsituationofolderpeoplerelativetomajordisasters.
Tofurtherspecifyandmakemeaningfulthesebroadcommitments,we introduceanethicsofplaceholding,arisingoutofworkby Lindemann (2009) and Young(1997),asanimportantframeworkforanalysisand assessment.Inthefinalportionofthechapter,weoffersomeconcreterecommendationsforarenewedapproachtodisasterplanningandresponse thatisconsciousoftheelderlyamidstcatastrophicdisasters.
CONCLUSION
Asyouengagethistext,weinviteyoutojoinusinthespiritofcommunicativeethics—withanopenmindandawillingnesstosettleinforaconversationaboutmattersofpracticalandintellectualimportance.Wehope thatbringingtogetherthesevariouselementsofacriticalethics,wehave enteredintoandadvancedonongoingconversationaboutethics,aging, andsociety.Sincebothethicsandgerontologyarehistoricallysituated practices,weanticipatethatwhatwehavedoneinthisbookwillunlikely
betheendofthisprocessofedgingconversationinnewerdirections.As readers,youstarttheprocessofrevisioning,adoptingwhatmakessense toyouandrejectingwhatdoesnot.Wefeelfortunatethatwehavehadthe chancetospeaktoyouinwhatweconsiderourauthenticvoices.
REFERENCES
Aronson,J.(2006).Silencedcomplaints,suppressedexpectations:Thecumulative effectsofhomecarerationing. InternationalJournalofHealthServices, 36(3), 335–356.
Baars,J.,Dannefer,D.,Phillipson,C.,&Walker,A.(Eds.)(2006). Aging,globalizationandinequality:Thenewcriticalgerontology.Amityville,NY:Baywood Publishing.
Drought,T.,&Koenig,B.(2002).Choiceinend-of-lifedecisionmaking:Researchingfactorfiction? TheGerontologist, 42(SpecialIssueIII),114–128. Gilligan,C.(1982). Inadifferentvoice:Psychologicaltheoryandwomen’sdevelopment Cambridge,MA:HarvardUniversityPress.
Holstein,M.(2010).Ethicsandaging:Retrospectivelyandprospectively.InT.Cole, R.Ray,&R.Kastenbaum(Eds.), Aguidetohumanisticstudiesinaging. Baltimore:JohnsHopkinsUniversityPress. Kaufman,S.(2000).Senescence,decline,andthequestforagooddeath:Contemporarydilemmasandhistoricalantecedents. JournalofAgingStudies, 14(1), 1–23.
Kittay,E.F.(1999). Love’slabor:Essaysonwomen,equality,anddependency.New York,NY:Routledge.
Kittay,E.F.(2006).Beyondautonomyandpaternalism:Thecaringtransparent self.InT.Nys,Y.Denier,&T.Vandervelde(Eds.), Autonomyand paternalism:Beyondindividualismandgoodintentions (pp.1–29).Leuven: Peeters.
Lindemann,H.(2009).Holdingoneanother(well,wrongly,clumsily)inatimeof dementia. Metaphilosophy, 40(3&4),462–474. LindemannNelson,H.(2001). Damagedidentities,narrativerepair. Ithaca,NY: CornellUniversityPress. Meyers,D.(1989). Self,societyandpersonalchoice.NewYork,NY:Columbia UniversityPress. Meyers,D.(2002). Genderinthemirror:Culturalimageryandwomen’sagency. NewYork,NY:OxfordUniversityPress. Minkler,M.,&Estes,C.(1999). Criticalgerontology:Perspectivesfrompoliticaland moraleconomy. Amityville,NY:BaywoodPub.Co. Nussbaum,M.(1990). Love’sknowledge:Essaysonphilosophyandliterature. NewYork,NY:OxfordUniversityPress.
Ray,R.(2007).Narrativesasagentsofsocialchange:Anewdirectionfornarrative gerontologists.InM.Bernard,&T.Scharf(Eds.), Criticalperspectiveson ageingsocieties (pp.59–72).Bristol,UK:PolicyPress. Walker,M.(1993).Keepingmoralspacesopen. HastingsCenterReport, 23(2), 33–41.
Walker,M.U.(1998). Moralunderstandings:Afeministstudyinethics. NewYork,NY: Routledge.
Young,I.M.,&Princeton,N.J.(1997). Intersectingvoices (Houseandhome:Feminist variationsonatheme).Princeton,NJ:PrincetonUniversityPress.
