Who's safe? Who's sorry? The duty to protect the safety of clients in home- and community-based care.

First, do no harm. This is a major tenet in medical ethics. It is also the first statement of the ethical principle of beneficencedoing good, which holds that ethical professionals act so as to benefit their clientele and, at the very least, to do no harm. This most basic goal of doing no harm has been extended in the view of some people to mean that the care and service plans developed for home- and community-based services (HCBS) for older people should be designed to maximize physical safety and protection and to minimize the likelihood of preventable negative events, such as falls, injuries, or relapses. The social workers, nurses, and others who hold up safety as a goal may be doing so as part of their commitment to do no harm. But such professionals may have lost perspective on the nature of their appropriate role in helping individuals plan their lives; they may be assuming too much responsibility. They may have also lost perspective on the facts-that is, what actually constitutes safety and what actually constitutes risk. With "do no harm" as the overriding goal, protecting clients ultimately may mean declining to serve them in their own homes because the plan may be unsafe. Protecting clients ultimately may mean reshaping assisted living settings through regulations until they mirror more restrictive settings like nursing homes. Paradoxically, the desire to do no harm and to achieve safety above all other goals may actually result in harm for the consumer. The most exquisitely difficult ethical dilemmas that arise in home- and community-based services concern the proper boundaries between promoting freedom for older people and avoiding interference with their life goals, on the one hand, and acting responsibly to promote their health and safety, on the other. These are anguishing situations for professionals. The case files of ethics committees that have sprung up in HCBS are littered with examples wherein professionals wrestle consciously and conscientiously with the problems of striking the right balance between safety and freedom. Often, the professional has the painful sense that he or she is joining the forces pushing unwilling clients toward nursing homes, yet the push seems to be for their own good. The problems are exacerbated by the profound ambivalence that so many people feel about tradeoffs between their freedom and safety. Older people-like people of all ages-want to be both free and safe. Older HCBS consumers, who often are aware of their increased risks and diminished capabilities, can have great difficulty making a necessary choice between the two values. In one study of more than 800 elderly clients in these settings, about a third chose freedom, a third chose safety, and a third vacillated between the two (Degenholtz, Kane, and Kivnick, I997). Professionals express similar ambivalence. One study (Kane, 1995) showed respondents overwhelmingly agreeing with the proposition that older HCBS clients should be free to act against advice of a professional from an agency or program regarding risk-taking without the agency or program withdrawing from the scene. When asked to elaborate the circumstances under which such client risk-taking would be permissible, almost all responded with a variant on the phrase "when it does not jeopardize their own safety and that of others. " Professionals endorsed informed risk-taking, but apparently only when it was risk-free! In this article, we examine the concept of consumer risk-taking and professional responsibility in home- and community-based services. We then turn to possible ways for professionals to negotiate these ethical minefields, including an exploration of the relatively new concept of managed risk contracting, or negotiated risk. We argue that active steps need to be taken to preserve and promote the right of competent older people to make decisions about their care in general, not just narrow decisions about specific procedures. …