Flash: Not all difficult situations solvable

Self neglect in at-risk groups, particularly the elderly, presents some unique problems for those working in the community care sector.

A recent Australian study (PDF) by Dr Shannon McDermott of the University of New South Wales explores the distinction between self neglect, squalor and hoarding.

Self Neglect: inability or refusal to perform essential self care tasks, such as adequate feeding, shelter or medical care for themselves.

Squalor: neglect of one’s immediate personal environment.

Hoarding: inability to throw objects away.

Such behavioural problems can present challenging practical and ethical dilemmas not only for community health professionals, but also the person’s loved ones, neighbours, etc. The study cites an extreme case in which

an older woman kept 500 pigeons inside her home. The birds were noisy and their faeces had an extremely strong odour, which prompted complaints from the neighbours.

The woman refused assistance and was determined by local authorities to be legally capable of making decisions; this meant that professionals were bound to respect her decision to refuse assistance. Eventually the local council became involved because they believed that the situation threatened public health.

The council spent thousands of dollars to remove the birds but, because the woman refused to stop leaving food out, the birds quickly moved back in.

One can only agree that this kind of thing does indeed present dilemmas in spades. It may be tempting for local councils to pass ordinances outlawing actions which, whether deliberately or inadvertently, give rise to a threat to public health. But then, assailing a little old lady with the full force of the local bylaws would be too much like breaking a butterfly on a wheel.

Dr McDermott suggests what might be thought of as a ‘middle way’:

Resolving these situations required that professionals strike a balance between the duties of autonomy, beneficence and justice with a wider organisational context which required that they also manage risk and provide services in an increasingly efficient and effective manner.

The research found that a pluralistic approach to decision-making, along with formal and informal support from their colleagues, was important to ensure consistency between ethical approaches and to accept that not all difficult situations could be resolved.

Leaving aside the challenge of unpacking all that jargon, it must be said that “accepting not all difficult situations can be resolved” is hardly a cutting-edge ‘finding’. Most people out in the field know only too well.

Clues to some solutions may be afforded in Dr McDermott’s research paper of some 340 pages. I’ve added it to my (interminably yawning) reading list, and suggest interested readers might like to do the same.