Center Acting Director and Professor Dr. Leonard Fleck recently presented at the 2019 International Bioethics Retreat, held in Paris, France on June 26-28. Dr. Fleck chaired a session titled “In the Clinic” which featured topics on clinical ethics and medical decision-making.
In a session titled “Elder Ethics,” Dr. Fleck presented a talk on “Whither Frailty: Ethical, Economic, Medical and Policy Challenges.” Dr. Fleck addressed four key questions: (1) How should frailty be defined as a medical phenomenon? (2) What should be the scope and limits of respect for autonomy in the case of the frail elderly? (3) What should be the scope and limits of acceptable risk of harm to the frail elderly in the case of aggressive medical or surgical interventions? This question pertains to the responsibilities of physicians and surgeons in proposing such interventions. (4) What issues of health care justice deserve the attention of policymakers when it comes to meeting the health care needs of the frail elderly?
The first problem refers to the complexity of frailty as a medical phenomenon. Frailty is not disability; frailty is primarily associated with the elderly. Some researchers describe frailty as “accelerated aging.” Roughly 38% of individuals over age 90 would be described as being frail. Individuals may be frail and not have any life-threatening medical problems. Most of the frail elderly are able to make medical decisions for themselves, which is why there is the ethical issue of respect for patient autonomy versus justified medical paternalism. Among the behavioral traits of the frail elderly would be reduced activity (prolonged bed rest), very slow mobility, weight loss, extreme old age, diminished handgrip strength, polypharmacy, and social isolation. Clearly, frailty exists along a complex spectrum requiring considerable acuity of judgment to avoid ethical missteps.
To illustrate the potential for ethical missteps, labeling an elderly individual as “frail” can result in inappropriate paternalistic decisions, negative stereotypes, and discrimination. Alternatively, failure to identify an elderly individual as frail can result in overly aggressive medical treatment (and a range of avoidable medical harms) as well as a lack of attention (and resources) that might better address the social needs of the frail elderly that would represent a greater net benefit than aggressive medical treatment.
We might wish to go to the research literature for some guidance. However, there is little actual research regarding the frail elderly and aggressive medical or surgical care. Further, it is difficult to imagine how such research could be accomplished in a way that was not ethically problematic. This makes the responsibilities of physicians in clinical practice who care for the frail elderly all the more challenging.
Dr. Fleck concluded with two points: (1) From the perspective of health care justice, from the perspective of what a just and caring society ought to do, resources should be redirected from aggressive medical care for the frail elderly to their social service needs. However, the fragmented system for financing health care in the U.S. gets in the way of easily making this re-allocation of resources. (2) Soft paternalism will often be ethically justified in caring for the frail elderly considering aggressive medical care. A non-committal stance on the part of physicians in these circumstances, under the ethical guise of respect for patient autonomy, will most often be neither just, nor caring, nor respectful of patient needs and their considered values.