Wilda and Thomass Story

Wilda was blind and nearly deaf. Although arthritis and hypertension posed additional difficulties, she enjoyed reasonably good health. At age 85, she had outlived two husbands and currently resided with her only child, 57-year-old Thomas, in a second-floor inner-city apartment. The bottom floor housed a grocery of sorts on one side and a small bar on the other. Both offered staples for the household. Wilda could manage the stairs and get food at the grocery; Thomas spent most of his day drinking at the bar.

Alcoholism was a long-term problem for Thomas. His excessive drinking began in the armed forces. It became addictive following a divorce and period of unemployment that never ended. Years ago Thomas gave up looking for work, accepted public assistance, and grudgingly came to live with his mother. It was not the arrangement he preferred. However, it was cheaper than living alone, and someone had to be on hand to help when blindness and other disabilities prevented Wilda from effectively navigating her way in the world.

The household generally had an uneasy tension about it. When he was home, Thomas tended to station himself in the living room by the front window, trying to remain distant from Wilda and her constant demands. For her part, Wilda did what she could around the house and called out for Thomas when she needed help. Thomas regarded Wilda's requests as incessant nagging. Sometimes he ignored them, even to the extent of leaving the house. Other times he became enraged and lashed out at Wilda both verbally and physically. Although tirades had been going on for years, twice recently they had resulted in injury—once bruises and a bloody nose, the other time a broken arm.

Ethical Dilemmas: Comparing Elder Abuse and Other Forms of Family Violence

In some ways, the ethical dilemmas surrounding elder mistreatment by others (henceforth referred to as elder abuse) are the same as those surrounding other forms of family violence. In other ways, they are different. Some similar dilemmas include the following:

• Should health and social service professionals be required to report family violence when reporting is seen as an abridgment of patient confidentiality or may erode hard-won rapport established with the patient?

• Is family violence a private matter, or by its very nature is it subject to public scrutiny?

• Should family violence be reframed when an ethnic or religious group defines particular behavior otherwise?

• Should perpetrators be treated as criminals or persons with problems?

• Do individuals have the right to elect to remain in violent relationships? Does this right of self-determination change when society is asked to bear related health care and other costs?

• Do victims have a right to expect quick and consistent response to calls for help, even when they refuse to follow through with recommended protective measures?

Elder-abuse dilemmas differ from those for other forms of family violence. They differ from those surrounding violence against younger adults, including spouses, because age is more likely to bring with it chronic illness and disabilities. The results are dependency, need for care, and diminished opportunities for self-sufficiency or escape from the current situation based more upon physical than psychological incapacity. However, it is important not to overgeneralize the diseases and disabilities associated with old age. Most older people are not functionally incapacitated, and few suffer from Alzheimer's disease or other forms of cognitive impairment (R. A. Kane & R. L. Kane, 1987; Office of Technology Assessment, 1990). The tendency of American society to infantilize older people can result in the acceptance of this negative image by elders themselves and their consequent adoption of childlike behavior as a kind of self-fulfilling prophecy (Utech & Garrett, 1992).

Moreover, the distinctions between victim and perpetrator as well as independent and dependent are often blurred in elder abuse. There are many documented instances of violence going in both directions in these situations (e.g., Steinmetz, 1981, 1988; Coyne, 1991; Paveza et al., 1992). Typically, dual-directional abuse happens when the ''victim'' has dementia or other cognitive impairment with violent behavioral manifestations and the ''perpetrator'' is the primary or only caregiver with few coping skills or sources of social support. Similarly, several studies have found that at least with regard to physical abuse, perpetrators are more likely to be financially and otherwise dependent upon the elder than vice versa (e.g., Pillemer, 1986; Anetzberger, 1987). The introductory story illustrates the blurred dependency often characteristic of elder abuse. Thomas is financially and socially dependent on Wilda, but she is physically dependent on him.

Elder-abuse dilemmas also differ from those surrounding violence against children, because older persons who have not been adjudicated legally incompetent are categorically adults, with all the rights and responsibilities accorded adults in American society. This includes the right to pursue unpopular and even unhealthy or risky lifestyles. In addition, the caregiver role for parents with young children is clearer than that for adult children with elderly parents needing assistance. For example, it is understood that all infants need physical help and guidance from their parents. In contrast, the care requirements of disabled elderly parents by their adult children are neither culturally prescribed nor certain. Therefore, child care and its antithesis, child abuse, are less subject to ambiguity and uncertainty both legally and morally than elder care and elder abuse. Finally, the disturbing or troublesome behaviors of children that can contribute to child abuse are seen as transitory, with the expectation that children will outgrow them in normal development (Straus, Gelles, & Steinmetz, 1980; Frodi, 1981). The same perception does not apply to older people in elder-care situations, where disturbing behaviors, such as those exhibited by Wilda, represent deterioration and increasing difficulty over time (Korbin, Anetzberger, & Eckert, 1989).

Ethical Dilemmas in Elder-Abuse Roles

Ethical dilemmas in elder abuse can be analyzed by intervention role. Ten roles are particularly important to understanding and addressing this problem:

• Victim: experiences elder abuse

• Perpetrator: inflicts elder abuse

• Family, friend, or neighbor: witnesses elder abuse or its effects

• Reporter: detects elder abuse and describes it to authorities

• Investigator: assesses reported elder abuse and determines the need for services

• Service provider: offers assistance in correcting or discontinuing elder abuse

• Program administrator: manages services aimed at preventing or treating elder abuse

• Community planner: develops program and community education initiatives to address elder abuse

• Legislator: enacts public policy related to elder abuse

• Researcher: conducts studies to better understand elder abuse and effective strategies to impact it

The first three intervention roles are held by persons closely associated to particular abuse situations, the remainder by persons with professional responsibility for addressing or studying elder abuse. Each role has inherent ethical dilemmas that reflect its unique perspective on elder abuse. Illustrations of these ethical dilemmas by intervention role follow:

• Victim: If authorities find out about my situation, what will happen to me? Will they blame me for causing the problem? Find me mentally ill or incompetent? Remove me from my home? What will the authorities do to the perpetrator, who also represents family to me? What are my responsibilities to that person?

• Perpetrator: Doesn't the elder have an obligation to help me out with housing and spending money, since I'm unemployed and likely to inherit her estate anyway? Isn't it better to tie the elder in a chair than to have her wander out of the house and maybe get hurt?

• Family, friend, or neighbor: Does the abusing family's right to privacy take precedence over my responsibility as a neighbor to help? When should I act to protect others from the possibility of the perpetrator exploiting elders whom he befriends?

• Reporter: Should I report an elder-abuse situation when I don't believe that reporting will make any positive difference in it? Should I report if this places the elder at greater risk or labels someone as an elder-abuse perpetrator?

• Investigator: How honest am I with the victim as to the purpose of my visit? How much contact do I initiate with family and neighbors of the victim in an attempt to gain information?

• Service provider: What separates establishing rapport with the victim in an effort to offer service from cajoling her into compliance with my service plan? Is it appropriate for me to abandon a victim who refuses protective intervention?

• Program administrator: What are the implications of offering elder-abuse programming when scarce funding limits it to short-term crisis intervention without provision for follow-up services? How much emphasis should be placed on use of the criminal code in elder-abuse situations?

• Community planner: Should community education on elder abuse be initiated when insufficient resources exist locally for addressing the problem? What is the relative importance of case finding and crisis intervention to case prevention?

• Legislator: Should elder-abuse laws be enacted without adequate accompanying appropriations? Should protective-services laws cover all adults or only elderly ones? Does this decision in any way reinforce ageism in American society?

• Researcher: What should I do if a respondent acknowledges elder abuse? Will reporting the situation to authorities compromise my role and integrity as a researcher?

Mandatory Elder-Abuse Reporting as an Ethical Issue

Probably no ethical issue in elder abuse has engendered more controversy and discussion than mandatory reporting (e.g., Faulkner, 1982; J. J. Regan, 1990; Kapp, 1995a; Capezuti et al., 1997). The controversy surrounding mandatory reporting begins with the vague definitions of elder abuse usually associated with these laws, which do not provide a clear basis for abuse identification (J. C. Callahan, 1988; R. S. Daniels, Baumhover, & Clark-Daniels, 1989). Without this, there is concern that reporting may result in the inappropriate labeling of persons or situations as abusive, with consequent stigma or even criminal sanction wrongly applied (J.J. Callahan, 1982; Blanton, 1989). Beyond this, reporters worry about the following issues in mandatory reporting:

• Abridging patient confidentiality (Thobaben, 1989)

• Jeopardizing the relationship established with the patient (Coyne, Petenza & Berbig, 1996)

• Referring patients to agencies in which they have little confidence or that are ill equipped to provide adequate follow-up (Ambrogia & London, 1985)

• Liabilities accompanying the reporting of patients who deny that the injuries were caused by another person's actions or failure to act (Clark-Daniels, Daniels, & Baumhover, 1990)

• Reporting when there is a difference of opinion among professional colleagues on whether or not the situation should be reported or what kind of response is appropriate with ambiguous symptoms (Wetle & Fulmer, 1995)

Mandatory reporting became commonplace following the introduction of H.R. 7551 in the 96th Congress, which encouraged states to modify their adult-protective-services and elder-abuse laws and procedures to include required reporting by health officials and others in order to be compliant with the anticipated new federal law's provisions (Cravedi, 1986), which stated that the federal government would ''provide assistance to States which provided for the reporting of known and suspected instances of elder abuse, neglect, and exploitation'' (U.S. House Select Committee on Aging, 1981, p. 126). Today nearly all states have enacted laws that require health and social service professionals to report known or suspected situations of elder abuse (Tatara, 1995). The vast majority of states also have enacted these laws without accompanying appropriations, thereby often effectively limiting interventions to reporting and investigation (Quinn & Tomita, 1997). As a result, the variety of services required to address elder abuse situations typically is not available through public agencies charged with handling abuse reports (Capezuti et al., 1997; Jones, 1994; Meagher, 1993).

Legislators argue that the importance of mandatory reporting lies in case finding (J.J. Regan, 1990). Even if resources are not presently available to adequately address every reported abuse situation, case discovery provides a foundation from which to advocate for increased funding for protective services (Salend, Kane, Satz, & Pynoos, 1984).

An alternative perspective is offered by Crystal (1986), who argues that instead of increasing resources for older people, elder-abuse legislation has had the effect of drawing revenues away from other deserving service programs. Actually, revenues for adult protective services have decreased as elder-abuse reports have increased. In 1986, the National Aging Resource Center on Elder Abuse documented 117,000 elder-abuse reports nationwide. By 1991, reporting had reached 227,000, a 94% increase (Tatara, 1993). In contrast, the percentage of state budgets for adult protective services declined from 6.6% in 1980 to 4.7% in 1985 to 3.9% in 1989, a 41% decrease (U.S. House Select Committee on Aging, 1990).

It is interesting to note that in an effort to evaluate the effectiveness of mandatory elder-abuse reporting, the U.S. General Accounting Office (1991) surveyed 40 officials in state units on aging and adult-protective-services agencies. The results suggested that a high level of public and professional awareness was more effective for identifying abuse victims than mandatory reporting. In addition, in-home services were seen as more effective than mandatory reporting for both preventing and treating elder abuse.

D. A. Gilbert (1986) analyzed mandatory elder-abuse reporting laws from ethical and health professional perspectives. She concluded that mandatory reporting contradicts the current trend in health care that emphasizes patient autonomy. Therefore, voluntary reporting laws that promote respect for individual wishes are preferred over mandatory reporting laws. In addition, Gilbert argues:

• It is more important to obtain patient consent based upon an assumption of competence than it is to stop harm through abuse reporting.

• It is more important to protect patient confidentiality than it is to report abuse, since elder abuse is not a threat to the general public.

• It is inappropriate to report elder abuse without an adequate intervention system in place to address it; otherwise, reporting simply creates false expectations and offers no necessary benefit to abuse victims.

Several others offer guidance on when, or if, to report elder abuse, notwithstanding the mandate of reporting laws. For example, Matlaw and Mayer (1986) recommend reporting only when it will produce the most benefit for the parties involved, especially the victim. This requires assessment of the positive and negative effects that reporting will have on the elder-abuse victim. Fulmer and

O'Malley (1987) find that if the potential harm caused by reporting is great and the benefits marginal, then the situation probably should not be reported.

Assessing the effect of reporting may include evaluating the performance of agencies charged with handling elder-abuse reports (Fulmer & Anetzberger, 1995; Stein, 1991). There is some evidence to suggest that the reporter's satisfaction with authorities charged with report investigation varies inversely with the number of situations reported (Clark-Daniels et al., 1990). The result may be a reluctance on the part of victims and professionals to report further elder-abuse situations (R. S. Daniels et al., 1989). One way to overcome this barrier to reporting is for professionals to maintain a good working relationship with protective-services workers and address reporting problems directly (Anetzber-ger et al., 1993). Another way is to promote the establishment of public agency quality-assurance and inspection systems (Manthorpe, 1993). Too often now there is little emphasis on either quality-assurance or inspection systems in public agencies. Quality assurance means the formation of performance standards, peer-review panels, and staff training on quality improvement. Inspection systems means regular oversight by state authorities and community advisory councils. Both require an openness to scrutiny and willingness to undertake needed change.

Anetzberger has developed a hierarchy of principles for adult protective services that reflects an emphasis on individual autonomy (Anetzberger & Miller, 1995). From the most to the least important considerations for intervening on behalf of abused elders, they are the following:

1. Freedom over safety

2. Self-determination

3. Participation in decision making

4. Least restrictive alternative

5. Primacy of the adult

6. Confidentiality

7. Benefit of doubt

9. Avoidance of blame

10. Maintenance of the family

These principles can be useful to the adult-protective-services worker investigating Wilda's abuse, described earlier in the chapter. Respecting Wilda's wish for privacy (principle 5), the worker will restrict contact with family and neighbors to that absolutely essential for determining the extent of endangerment and Wilda's need for protective services. The focus of intervention will be on preventing further harm (principle 8), so long as actions taken reflect Wilda's choices and decisions (principle 2), even if that means that she continues to live in an abusive relationship with Thomas (principle 1).

In discussing the abuse with Wilda, the adult-protective-services worker learns that Wilda would ask Thomas to leave if he were not financially dependent on her. This means that the worker must try to help Thomas become self-sufficient. Possible interventions include alcoholism treatment, housing assistance, and job training and placement. As these are being explored, Thomas can benefit from counseling aimed at redirecting his aggression and frustration more appropriately and productively.

The adult-protective-services worker must establish rapport and work with both Wilda and Thomas, recognizing and emphasizing their strengths as a family (principle 10) and avoiding blame of either one as contributing to abuse occurrence (principle 9). Also, since Wilda would be less demanding of Thomas with assistance available from other sources (principle 4), the worker can help make service arrangements, including telephone reassurance and housekeeping, so long as Wilda has participated in all decisions about their selection and delivery (principle 3).

Lehmann (1992) offers an approach to evaluating clinical decisions about abuse against women using Kitchener's model of ethical justification. Like Anetzberger's, Kitchener's model is hierarchically tiered. When individuals cannot resolve ethical dilemmas at a lower level, they can engage in ethical reasoning at higher, more abstract levels. The lowest level, intuitive, focuses on ordinary moral sense and the facts of the situation. The second level, critical-evaluative, considers ethical principles, notably autonomy, nonmaleficence, beneficence, justice, and fidelity. The highest level, ethical theory, is concerned with universality and balancing achieved in ethical decision making.

Kitchener's hierarchy suggests that autonomy does not denote unlimited freedom. Applied to Wilda and Thomas, this means that Thomas does not have the right to cause Wilda physical harm and thereby jeopardize her safety and well-being. Reporting the abuse situation is desirable because of the possible benefits intervention would bring to either or both Wilda and Thomas. If Wilda refuses assistance, her right of refusal will need to be respected, because she is competent. As Quinn (1985, p. 24) reminds us, the greatest ethical challenge to practitioners in the field of elder abuse is presented by ''the competent elder adult who is being abused or neglected and refuses intervention.'' However, reporting the abuse situation allows for the option of accepting or refusing services in a way that failure to report cannot.

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