Creation and Nursing Home
In 1991 the Hastings Center, a prestigious New England think tank on problems of bioethics, published an important and widely distributed study on nursing home care, "New Directions in Nursing Home Ethics."' The article is about as good and informative as it can be from the secular humanist perspective. However, God and biblical Christianity are completely omitted, and hence the authors cannot give any real answers to the ethical problems they raise.
The paper opens commendably: "It has been said that the moral heart of a society can be judged by how well it provides for those at the dawn of life, those in the shadows of life, and those in the twilight of life." We agree from the biblical Christian perspective, but we immediately note that the many millions of babies murdered by legal abortion in our society during the last twenty years show that our society's "moral heart" is desperately sick. We do not [yet] murder our elderly wholesale by "euthanasia," but the authors point out that our social support system for them is "a tattered, patchwork arrangement of overlapping and conflicting programs." With regard to nursing home care in particular, the authors believe that existing regulations and social policy may make good care harder to provide "because we have not, as a society, truly worked out a moral vision and a set of aspirations for what we want nursing homes to be."
The article gives a brief history of the modern nursing home. In the nineteenth century the destitute elderly were put into the harsh surroundings of public almshouses and poorhouses, which also housed the indigent poor, chronically disabled and mentally ill. Churches and other charitable groups began to sponsor private old age homes by the turn of the century, but the number of indigent elderly in public poorhouses rose nevertheless. In the early 1900s mentally incapacitated elderly were usually sent to state mental hospitals. The "deinstitutionalization movement" of the last twenty years sought to replace this solution by other ways of care, with attendant new, serious problems.2
The Great Depression of the 1930s was marked by the rise in the number of dependent elderly and also by the introduction of the Social Security system. Early on this system did not pay for the housing of the elderly in public institutions. This exclusion, the authors write, "contributed crucially and purposefully to the demise of the county poorhouse." This development led to the start of private nursing homes. Government funding for nursing home care steadily increased after 1950, "culminating finally in the 1965 Medicaid program, which now covers more than 40 percent of all nursing home costs."
By the 1960s nursing homes had become the standard long-term care institutions for the elderly. Despite many scandals involving poorly run nursing homes and their resultant poor public image, there are now over 19,000 in the United States. Annual cost per patient ranges from an average of $20,000 in the south to $28,000 in the north and east. 2.3 million elderly now reside in nursing homes during a yean and with the continuing aging of our population this number will rise by 75 percent over the next thirty years. This means that by 2020 A.D. about one in four people over 65 will spend time in a nursing home. The average age of the nursing home resident is now about 84; 75 percent are women; about half suffer from serious dementia or organic brain damage.
While numerous studies have shown that "heavy care [at home] of the elderly [is] the norm in family relationships," there is a widespread notion that "the relatively full rosters of most nursing homes is proof of yet another breakdown of the family in the United States." However, as the authors point out, most families "find themselves backed against the wall of last or only resort when they approach a nursing home. the primary moral issue is ... determining the limits of family obligation [and ability] to care for the elderly." A further enormous burden is the scarcity of hospital and nursing home beds and highly rationed Medicare coverage of nursing home care, which becomes available only when the patient's own funds have been completely exhausted.
Finally, the authors predict that there will be less and less available help with home care for frail but not acutely ill elderly in the near future, an additional burden on families. The Christian community should be made aware of this trend and enter the field of home care support services either through churches or private Christian caregivers. A pioneer effort in this field was the founding of the Hospice organization assisting with home care for the dying.3
After this survey of the historical development and present status of care for the dependent elderly, and a brief outline of the problem of the nursing home patient's loss of independence in the institutional setting, the authors turn to the central point of their discussion, their section "Toward Autonomy within Community." This section, too, is about as appealing as it can be if God's purpose for people is completely disregarded. The farthest horizon visible to people without God is precisely "autonomy in community," how to reconcile the needs and claims of an individual with those of the "community." According to the authors,
The central figure of the standard bioethical model is the competent adult... The values and principles that bioethical analysis relies upon are notions such as rights, liberties, self-determination or autonomy, privacy, doing good beneficence), not doing harm (nonmaleficence), and justice......these various bioethical concepts ... are largely designed to ensure the moral person sufficient resources to allow him to be a rationally self-directing being. Bioethics seeks to carve out ... the moral space needed for a human being to live her life in her own way (p. 8).All these are humanistic rather than biblical concepts. The authors are right in saying that these "individualistic assumptions are deeply embedded in American culture." This merely shows that there is something very wrong, biblically speaking, with contemporary American culture; we have largely replaced trust in God with trust in self. Besides, as Christians we must never base our morality on the culture in which we live!
Next the authors offer their remedy, the concept of "autonomy within community" Their remedy is not fundamentally different from the moral paradigm they seek to modify or replace. The old model, too, spoke of ~beneficence, nonmaleficence and justice," all designed to protect the "community" We rather deal here with a shift in priority and emphasis as between the individual and the community, the one and the many, autonomy and dependency Nothing fundamentally new has been introduced, nor can be if the almighty and transcendent God of Scripture, the Creator and Sustainer Who alone can "make all things new," is deliberately excluded from consideration. True to their humanistic principles, the authors speak of "attempts to live a private life in a public institution." That is still the old desire for autonomy.
Later on the authors discuss the use of dependency, an "inevitable reality for most nursing home residents," to "grow as human beings." They write:
[T]he reality of the moral situation is that the person must embrace dependency rather than resisting it ... In certain situations of incapacity, autonomy and respect for persons simply come to mean the creative, enabling use of dependency to give richer meaning to the lives of individuals who can no longer be self-reliant (p.9).But practically speaking, what "growth" and "creativity" are still possible to the dependent elderly nursing home dweller? The authors provide no specific details, nor do they define "creativity" even within the humanistic parameters of "autonomy within community" Where can patients find the inner resources for growth and creativity in the regimented nursing home setting? What can the nursing staff do to help them, hampered as it is with chronic lack of personnel and obligation to run the entire home safely and economically? The authors do not say, nor can they, for they have limited themselves strictly to the humanistic perspective with its monistic, impersonal, godless world.
The answer must come from within the context of the purpose of one's whole life. Now human life is only a cosmic accident according to evolutionists of the secular humanist variety Alternately it is but one temporary expression of the cosmic life force or forces in the emergent evolutionist, pantheistic world view of the religious, neo-pagan humanist. Neither world view can give absolute, transcendent meaning and purpose to individual men, to society as a whole, or for that matter to anything whatsoever. The purpose of life cannot be defined from within this world; it requires a personal Creator of the world above and outside the world which He created out of nothing. More, it requires the Creator's revelation of His will and His purpose for His creatures, and this revelation is given to us in the Bible. According to the Bible, life's purpose is not growth of the personality for its own sake, but a goal - the goal of the Creator, which is to redeem us and to recreate us in newness, holiness and righteousness in Christ. If we do not see that the nursing home, too, works for our good under Romans 8:28 "according to His purpose," we cannot help but fear it. It is no wonder that secular and religious humanists are so concerned with ensuring their own "death with dignity," that is, assisted suicide on a large scale (as already practiced in post-Christian Holland), with murder of aged and other "useless eaters" by "euthanasia" in the wings.
The authors themselves sense this crucial point in the very last words of their paper: "The trouble is that we cannot really talk about nursing homes without also examining the values and aspirations we hope to discover in ourselves, in the twilight of our lives. Can we summon the courage to look into that twilight and find something to affirm there?" (p.13) It is appalling but, alas, to be expected from the humanist mindset that again the authors point us only to "ourselves" as the source of our values and aspirations, of "something to affirm." Here, surely, the Christian must recognize the bankruptcy of their thought. Their humanism breaks down, as it must, in the face of utter helplessness ending in death. They end with a question because they have no real answer. In a way the entire article is whistling in the dark.
Sugary talk about "autonomy in community" is mere semantic juggling and cannot comfort the non-Christian nursing home resident in confusion, pain, often unable even to toilet himself, and surrounded mostly by others in like miserable dependency. It cannot provide answers for nursing staff or social workers who must deal with individual patients day by day. It cannot help families to comfort their lonely, helpless relatives, usually mothers or grandmothers. Unless we know we are infinitely precious to God our Creator and Redeemer Who does not look on our outward appearance and quite apart from our dependency upon or "usefulness" to our fellow men, what purpose or comfort is there for the dependent, "useless" person? But the authors never mention God our Creator and Redeemer. Nursing home staff members and social workers may even be forbidden to speak of Him to the residents, as this might cause anger and possible law suits on the part of the families.
What, then, are practical biblical Christian answers? First, "autonomy" is not the measure of our value in the eyes of our Creator. None of us is autonomous, for God is the Ruler of us all. Hence, to lose a measure or even all of our supposed "autonomy" is no loss in His sight, nor in our own sight when we are renewed and taught in Christ. Mary Tenbrink, a dear young friend of this writer's, suffers from severe multiple sclerosis, has been in a wheelchair for years and is utterly dependent upon others, especially her godly husband Pat. She has had her dark times, yet in the midst of her literal "valley of the shadow of death" she has written beautiful poetry praising our Lord.4 The whole lives of this godly couple are full of inspiration and glorious purpose the purpose of God "Whose strength is made perfect in weakness" (2 Corinthians 14:9). This writer's daughter Becky has Down's Syndrome and an IQ of about 40. She cannot exercise any "autonomy," but our Lord's love in her overflows to family and friends. She would not understand the words "autonomy in community," but she daily practices what is far better, love of neighbor, that is, love for those closest to her each moment, as Jesus Christ taught us.
Our suffering, including confinement in a nursing home when old, is "an essential part of what He calls Redemption"5 not only for patients but also for caregivers. This fact remains invisible to the unbeliever who measures human value by "utility." What use is the helpless person to others except as the cause for salaries paid to nursing staff? In contrast, Pat Tenbrink with Mary and this writer with Becky praise our Lord for our own sufferings which immeasurably helped us to grow in Christ. A friend of this writer's eldest daughter helped care for her senile, almost completely helpless grandmother at home and praises our Lord for how this difficult experience helped her grow to greater love of God and neighbor As the psalmist wrote, "It is good for me that I have been afflicted, that I may learn your statutes" (Ps. 119:71).
Finally, the humanistic world view measures a person's worth in terms of his or her prominence in the eyes of others. The nursing home resident is shut away from the rest of society, with no prominence whatever. The helpless old man or woman can no longer shine before others but vegetates as it were forsaken in a desert. Yet Christians know that in Christ we live to God (Romans 6:11) Who sees us and loves us no matter how shut away or how "invisible" to other people we may be. He is glorified by all His works, including His flowers blooming in the desert, including His people blooming unto Him in nursing home bed or wheelchair. Our nursing home caregivers must be allowed, even encouraged, to share these God-given answers with nursing home residents. They should also be free to point patients to God and Christ and witness to them of their own experience and blessings in Him.
To sum up, the article contains much factual information. However, its attempt to improve the bioethical foundation of nursing home care, and by extension our society's attitude towards the elderly and helpless at large, is strictly humanistic and hence doomed to failure. Its proposed new bioethical model of "autonomy in community" is in principle no different from the paradigm it seeks to alter, but merely a shift in emphasis from self-reliance to dependence upon others. Thus where theory meets life, that is, where the individual caregiver must confront the individual nursing home resident or other helpless person, there is no help here, only semantic reformulation. If God the Creator and His Word are left out of our thought, we are all ultimately helpless to solve our problems, especially the very problem of dealing with helplessness itself. Both as individuals and as communities, as patients and as caregivers, we must be God-directed, not self-directed. The purpose of our lives lies in Him, not in us.
1 Bart Collopy, Philip Boyle, and Bruce Jennings, `New Directions in
Ethics,' a Hastings Center Report Special Supplement, March-April 1991. rhe
Hastings Center, 255 Elm Road, Briarclliff Manor, NY 10510. 15 pages, $4/copy ppd.
2 For a discussion of the treatment of the mentally incapacitated, see Ellen Myers,
'Madness: Myth and Reality,' in Creation Social Science and Humanities Quarterly,
vol. XIIi, No.4 (Summer 1991), pp. 12-19.
3 The Hospice movement in England, its point of origin, and the United States began with
explicit Christian motivation. However, this writer has recently been informed that
Hospice volunteers may not initiate conversations pointing dying patients to Christ.
4 Some of Mary Teobrink's wonderful poems have been published in past issues of the
Creotion Social Science and Humanities Quarterly. For available collections of her
poems write to Pat & Mary Teabrink 2021 N old Manor # lot Wichita KS 67208.
5 C S Lewis The Screwtape Letters (New York The Macmillan Company Macmillan
Paperback Ediflon Thirteenth Printing 1970) p 27