Legal, Ethical and Policy Issues

Older adults and drinking can raise a variety of legal and ethical dilemmas among people who work with, or provide services to seniors. Often people ask themselves 

• To what extent can we legitimately intrude into their lives?

• To what extent can we become involved with seniors "living at risk"? and

• "What is considered an acceptable risk for a senior to take?".
   

We justify becoming involved and limiting personal choice in the lives of people. For youth, we may place limits on their access to alcohol out of concern to their physical vulnerability to alcohol and their lack of experience with the drug (responsible drinking). For pregnant mothers, we  may try to persuade women to not drink or limit their drinking during pregnancy out of our concern of harm to the foetus. For workers, we may offer help to them through employee assistance programs if the alcohol consumption is affecting their work and productivity (e.g. absenteeism).

But what about older adults?
 

Looking at Alcohol Use as an Ethical Issue 

There are at least two distinct views of alcohol use, misuse, or abuse. 

One view sees it as a lifestyle choice. As a personal choice, the decision whether or not to drink (and whether or not to cease drinking) is left to the individual. If the individual is encountering a problem, the individual is responsible for extricating him or herself from the situation. 

This view gives precedence to the ethical principle of autonomy over other competing ethical principles such as beneficence ("do good" and "promote well-being") or non-maleficence ("do no harm"). This approach focuses on autonomy in the sense of non-interference.

An alternate perspective also starts from a respect of autonomy, but in the sense of ensuring that the senior has relevant information on which to make choices, that the senior is capable of making choices and that the choice is voluntary. This approach asks: "In some circumstances, does alcohol use remove choice and if so, what is our responsibility at that point?" It is also important to consider, how heavy-handed do we become in "helping" a person or protecting the person from himself or herself? How do we avoid "health promotion" from becoming "health tyranny"?

 

One Example of the Antagonism Between Respecting, Caring and Protecting

In care facilities (nursing homes), the ethical issues around alcohol consumption and "deciding for the person" often arise because of the dual nature of the facilities. These are places where a senior receives care. They are also the person's home. They are also other residents' homes and staff's workplace.

Directors of Care often struggle with policy issues such as:

• Should there ever be any restrictions on residents' alcohol consumption?

• Should the facility sponsor "pub nights"? 

• Should residents be able to drink on the premises or in their own rooms? 

• Should there be any repercussions if a resident returns to the facility inebriated?

• Staff issues flow from the policies: 

• Is it appropriate for nursing staff to administer alcohol in the same way they administer medications? 

• Should Janet be giving Mrs. B. her nightly tot? 

• Are the staff enabling an alcohol problem? 

Or, alternatively, is the facility being unduly paternalistic by requiring abstinence of all residents?

Practically and legally speaking, how will restrictions be enforced? For example, under what circumstances, if any, should staff be able to search a resident's personal belongings? What about searching the person? What about searching family or friends who visit? Each of these questions has an ethical and legal component.

Ethics takes in social considerations too. Many people drink within a social frame of being with others and enjoying their company, or drinking in the context of a meal and people they enjoy. So, ethically, what happens when we remove drinking from that social context, such as in a care facility, and insist that the senior consume his beer or shot at the nurses' station. 

The ethical issues at the other end of the continuum where there are no restrictions on consumption are equally challenging. If a resident becomes drunk and abusive towards other residents or staff, the welfare of others may be at risk. 

It is important to neither exaggerate this risk, nor to downplay it. The most appropriate responses will differ whether there is real or just a possible risk to others, whether there is a real harm or possible harm to self. The risks also need to be considered in the context "Are we doing more bad than good here?"

 

The Law

Alcohol is a legal substance. There is a presumption that once a person reaches 19 or the age of majority, decisions about alcohol consumption rest with the individual. At the same time, our society restricts access to alcohol by placing controls on when it can be purchased or consumed; where; and by whom.

Liquor licensing in most jurisdictions treats care facilities in the same way as a private residence. A national accreditation organization for care facilities notes the importance of resident choice around alcohol.

At the same time, a significant percentage of residents in care facilities are experiencing some degree of cognitive impairment. It may range from mild to severe.  Depending on the type of facility, the prevalence of cognitive impairment among residents ranges from 10 to 40%. The ability to choose whether or not to drink may be substantially impaired. The challenge to Directors of Care and staff, alike, is how to protect those who cannot care for themselves while respecting the choices of those who can, as well as determining the most effective and respectful ways of accomplishing that.