Medical empowerment of the elderly.

Medical Empowerment of the Elderly "Empowerment" of the elderly has become a popular gerontological buzz-phrase of the 1980s.[1] It refers to the movement among advocates for older individuals to encourage activism among the capable elderly regarding their own rights and interests whenever possible, within a society in which rights are respected and acted upon only if one claims those rights personally or through a proxy.[2] There is widespread philosophical agreement among professionals concerned with the well-being of the elderly that political, legal, social, economic, and health-related services that support the capacity of older persons to speak for themselves--that is, that empower older persons--greatly enhance the autonomy, independence, and dignity of the older self-advocate. Additionally, recent research underscores the relationship between a sense of control over one's decisions and life goals and positive outcomes in aging.[3] Many interpret such data to show that the extent to which individuals are encouraged to take more control over their lives and health may be a major determinant of satisfaction and well-being (that is, quality of life) in their later years. The chief legal mechanism of empowerment in the health area is the doctrine of informed consent, the requirement that medical interventions be administered to a patient only if preceded by the voluntary, adequately informed agreement of a capable patient or that patient's legally authorized substitute decision-maker. The depth of commitment to the notion of empowerment of the elderly in health care is manifested in the growing use of legal planning devices, such as the living will and the durable power of attorney, on a prospective basis to effectuate informed consent later in life.[4] Through these legal mechanisms as well as other means, professional advocates, family members, friends, physicians, and other health care providers all play an important role in helping the elderly to make and exercise their own life choices. Limits of Empowerment The enthusiasm for empowerment must be tempered with caution, however. There are important limits and nuances to this concept that must be thoroughly considered. First, power over one's life entails more than mere control over particular choices. In a real sense, it is knowledge that creates power. Hence, the older individual's purported right to make choices about matters affecting him or her acquires meaning only if those choices are accompanied by adequate information, both about the personal rights involved and the factual ramifications of one's decision, as well as the range of reasonable alternatives among which to choose. As our early experience with "Medigap" insurance policies teaches, the older person's right to choose should not be confused with the "right to be ripped off." Thus, insistence on adequate information is essential to meaningful (as opposed to apparent) empowerment. Second, decision-making power must be accepted voluntarily (if at all) by the older person. We rightly start with a legal and ethical presumption that most elderly people wish to make their own decisions regarding health care. However, this presumption is rebuttable, not conclusive. There are a significant number of adults, including but by no means limited to a substantial percentage of the elderly, who would not voluntarily accept responsibility for making some or all of their own difficult decisions.[5] This paradox--older individuals who would rather not make their own decisions--compels us to confront a fundamental policy issue of whether we should permit capable, informed older adults voluntarily to waive empowerment if they so wish, or instead force empowerment on them. Put more starkly, should we recognize a right of the elderly to be dependent on others? This dilemma invokes basic philosophical premises about the nature of personal choice and responsibility, and their interaction and tension. …