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Caring About Long-Term Care

An Ethical Framework for Caregiving

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Thanks in part to a century of progress in public health and medicine, many people are enjoying healthier lives. Yet the success of modern medicine also presents us with challenges: As Americans live longer, the need for long-term care and long-term caregivers will continue to grow. Indeed, a defining issue for current and coming generations is how the United States and other nations will address the needs of their aging populations and  provide adequate care for the dependent elderly.

The number of Americans over the age of 75 will more than double and the number of those over 85 will roughly quadruple in the first half of this century, overwhelming the nation’s long-term care services with 80 million elderly by 2050—up from the 34 million today who are already mostly underserved or worse. The current health care system is poorly suited to serve the needs of the elderly and their families, and we lack a framework to address and improve it.

Assisted living facilities, residential care facilities, and adult day care centers are plagued by insufficient funding; shortages of staff, particularly experienced staff; and unsafe conditions. And paid caregivers account for only 20 percent of long-term care.

The majority of long-term care—a staggering 80 percent—is provided by unpaid caregivers, usually family and friends. At least six out of 10 of these caregivers are also employed in the paid workforce, and 42 percent are over the age of 50 themselves. Yet few employers have written policies regarding elder care, and even fewer subsidize any elder care benefits.

The United States is ill-equipped to handle the current demand for long-term care, and the growing elderly population will only exacerbate these strains. It is therefore vital to explore the range of concerns raised by the current system of caregiving now and create an ethical framework for addressing the issues.

A strong ethical framework for discussing and understanding long-term care—as well as evaluating programs and practices—will provide a foundation for meeting the needs of the dependent elderly and their caregivers, and serve as a guide for policymaking.

This report outlines seven ethical principles of caregiving that can help guide policy makers and other stakeholders in their efforts to ensure that the country meets its obligations to the dependent elderly and their caregivers. From this principled foundation, we can better envision and design specific policy strategies. The seven principles are:

  • An Ecological Ethic: Recognizing the interconnectedness of people, systems, and policies.
  • Respect for Human Dignity: Respecting the unique worth of all people and their pursuit of a good life at all stages.
  • Beneficence: Maximizing benefits, including health and security.
  • Compassion: Demonstrating concern for the well-being of others, especially the vulnerable.
  • Reciprocity: Appreciating and compensating those who give back to society.
  • Temperance: Taking a long view rather than looking for short-term fixes.
  • Social Justice: Treating all people fairly and equally and building just social institutions.

This report reviews the circumstances facing the dependent elderly and their paid and unpaid caregivers. It highlights how the needs of dependent elders and those who care for them are intertwined. And it shows that policy sectors are interconnected, affecting decisions made across the policy spectrum and, in turn, affecting the lives of these givers and recipients of care. The report follows this ecological analysis and elaborates on the ethical framework that can guide policymakers and other stakeholders in their efforts to envision and implement specific, integrated policy strategies and ensure that the country  meets its moral obligations to the elderly and their caregivers while also growing stronger  socially and economically.


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