The American nursing home is a total institution, with rigorous top-down control over the environment and personal property of residents. Medicare and Medicaid initiated the modern nursing home industry and the medicalization of geriatric care management. These structural and historical factors produced dehumanizing systems of bureaucratic long-term care that obstruct the autonomy and dignity of elderly residents. Therefore, nursing homes are oppressive institutions, constructed to facilitate ageism, discrimination against older adults based on a sociocultural perception that values physical beauty, sexuality, and economic productivity. The effect of ageism on elder rights grows progressively more difficult to address, as death and dying become increasingly taboo subjects of discourse. The case for abolition contends that nursing homes actualize these ageist norms, committing physical and psychosocial injustices against 1.4 million aged Americans, a class of marginalized people often disregarded in civil rights advocacy. Abolition will initiate a cultural revaluation of old age towards elderhood, a stage of life where individuals can have independent, meaningful lives with space for growth and development.

Most Americans dread the thought of nursing homes. We imagine sick and dying elderly people in hospital beds or wheelchairs, emotionally disengaged and bored with life (Hogan and Mickus, 2002). The sociologist Erving Goffman likens nursing homes to prisons, as “total institutions” where individuals lead isolated, supervised and carefully administered lives, in which there is no control over environment or personal property (Goffman, 1961). The nursing home contributes to the stereotype that old age is equal to frailty and requires the standardized medicalization of personal needs. However, alternatives to this highly regimented life exist that optimize dignity for the elderly by adjusting resources to provide only enough for basic activities in daily living and establishing community-based residential homes necessary for strong long-term care.

This essay will argue that the 15,700 nursing homes in the United States harm over 1.4 million marginalized residents based on their age and health (Harris-Kojetin et al., 2013). First, the case will be framed within the history of nursing homes and the current debate over the ethics of care of the elderly. Then it will be argued that principally, nursing home abolition would preserve the dignity of the elderly and help overcome societal ageism through culture shifts, which is preferable to increasing enforcement of standards and system reform. These contentions collectively support the value of elderhood, a proposed stage of life past adulthood. Finally, the practicality of alternatives, such as assisted living and the experimental Green House Project, will be assessed.

What are nursing homes and what is their purpose?

Many types of residential community facilities for the old exist. They are either managed commercially, through voluntary nonprofits, or by the government. Nursing homes specifically focus on providing constant nursing care, assistance with daily living and mobility, psychosocial and personal care and paramedical care (Morley et al., 2013). Within the total institution, every sequence of daily activities is tightly scheduled and enforced by officials. There is no segregation between settings for work, play and sleep and almost every phase of life is carried out in the immediate company of others (Johnson and Grant, 1985).

This contrasts with other types of facilities, such as assisted living housing (also called residential homes), which require no more nursing care than can be provided by a visiting nurse. However, nursing aides and personnel with little or no training provide the most care. Generally, residents have private, apartment-style rooms that are independently managed. Assistance is given for everyday activities, including help with dressing.

Nursing home reform has and continues to be the subject of focused debate in bioethics because increased standards (e.g. fire and safety standards) often hurts smaller nursing homes, allowing larger for-profit homes to homogenize the industry. However, the U.S. Nursing Home Reform Act of 1987 finally set national minimum standards for care and rights of people living in long-term care facilities.

Through modern eyes, nursing homes seemingly act to house the elderly when they become too old to be cared for at home. However, the evolution of long-term care in America reveals an unexpected purpose of the nursing home. Its history begins with the emergence of almshouses and poorhouses as solutions to indigence after the American Revolution. Poor relief administrators designed these institutions to reform and punish the poor through close supervision, but also through minimal standards of comfort and cleanliness. Grungy living conditions encouraged residents to find work and families to care for their members. Older Americans who were infirm, poor and without family support had few options other than the almshouse (Haber, 1993). Since the old were less likely to find work, attitudes towards them harshened and they were excluded from a standard of being “worthy” that was reserved for younger, able-bodied inmates. Hospitals and private charities refused to assist the old, who were viewed as chronically impaired, permanently dependent and therefore a waste of resources (Rosenberg, 1987). Over time, reformers moved different groups into separate institutions (the young to orphanages, the insane to mental institutions and the able-bodied to workhouses), relegating the almshouse to a residence for older, often foreign-born poor people (Katz, 1984).

The stigma against almshouse incarceration motivated the struggle for old-age pensions to provide older people with a dependable source of income. The modern nursing home industry began in the 1930s to compensate for the failures of the Social Security Act in providing sufficient health insurance benefits, as well vacating hospital beds for “better” use. Old Age Assistance funds authorized federal grants for needy older people, ensuring that they avoid indigence in almshouses and either remain at home or seek care in commercial nursing homes. Proprietary nursing homes continued to receive expanded loan programs, proliferating their construction. The Hill Burton Act of 1965 required long-term care facilities to affiliate with a hospital, which initiated a trend towards the greater medicalization of nursing homes (Binstock et al., 1997).

The adoption of Medicare and Medicaid in 1965 accelerated the spread of nursing homes by limiting the time between hospitalization and nursing home placement. This unintentionally supported for-profit facilities, which had shorter waiting lists than voluntary homes (Dunlop, 1979). Furthermore, because Medicaid provided medical coverage to all people who met the criteria for medical indigence, more patients were reclassified as needing skilled nursing care (Vladeck, 1980). States began to transfer patients from state-supported institutions, such as hospitals, to nursing homes to capitalize on this federal funding stream. The number of nursing homes had increased by 58% in the 1950s, but increased by 107% in the following decade (Binstock et al., 1997). Nursing home reform has and continues to be the subject of focused debate in bioethics because increased standards (e.g. fire and safety standards) often hurts smaller nursing homes, allowing larger for-profit homes to homogenize the industry. However, the U.S. Nursing Home Reform Act of 1987 finally set national minimum standards for care and rights of people living in long-term care facilities.

As can be seen from this history, the modern nursing home developed by accident. America did not turn to them immediately to help the elderly manage daily living, but relied on hospitals, where the frailties and sicknesses of old age could be “cured.” While pensions could give the elderly funds to manage independently, it could not restore them from suffering physical decay and senility. Almshouses emptied and hospitals overflowed. The modern nursing home was constructed as a custodial extension to the hospital to clear out hospital beds, not to altruistically care for beloved elderly Americans.

Nursing homes are dehumanizing

The goal of long-term care is a good quality of life for the elderly. However, quality of life is dependent on the viewpoint of nursing home residents, not on how satisfied society is with standards. Entrenched stereotypes and total institutional constructs make nursing homes dehumanizing by nature even if regulatory compliance, resident rights and high-quality care are achieved (Berdes, 1987). Dehumanization, characterized by a loss of human attributes (e.g. self-awareness, intellect, will, the capacity to love), is the cumulative impact of top-down norms, rules and systems, and is not necessarily the fault of the often well-intentioned staff of these nursing homes (Vail, 1966). It is instructive to recognize that all health care is dehumanizing to the extent that it objectifies patients (Howard and Strauss, 1975); however, nursing homes are unacceptably dehumanizing because of the level of resident control and access to privacy.

A sense of control over one’s self and one’s environment is related to high morale, high life satisfaction and a higher likelihood of survival (Noelker and Harel, 1978). Unfortunately, the defining structure of nursing homes restricts numerous important openings for autonomy throughout the process of institutionalization. Firstly, residents often do not choose whether to be admitted to a nursing home or which nursing home they would like to live in. This arrangement happens either through family members or through health care institutions when no family support exists. Often, the decision to institutionalize can be traumatic, causing new residents to feel unwanted or abandoned by their family members, causing despondency and dependency. In situations where individuals do choose to institutionalize themselves, it is usually caused either by societal pressures to avoid becoming a “burden” or because community and familial support systems break down (e.g. death of a spouse) (Cox, 2001).

Within the nursing home, standardized treatment of residents depersonalizes and dissociates. For example, residents are often fed and bathed with insufficient regard for individual differences. Complaints and other activities that assert dignity but interfere with staff priorities are met with resistance and abuse (Gawande, 2014). A study conducted in Michigan found that the estimated incidence of abuse in nursing homes was 24.3%. These incidences ranged from physical mistreatment, like hitting, to caretaking mistreatment, such as forced feeding, to sexual abuse (Schiamberg et al., 2012). Furthermore, activities of daily living (e.g. showers, routine wheelchair rides, meals) are restrictive and regimented. As residents become accustomed to their nursing home’s itinerary, they can become defeatist and do not express their own desires. Moreover, residents have little control over doctor-patient relationships. Physicians generally visit at the discretion of nursing staff and are barriers rather than facilitators of conversations about the resident’s fears and concerns. For example, a study in Chicago found pervasive attitudinal conflicts between hospice care physicians and nursing home staff, where providers withhold prescribed pain medication, assuming that they have a claim to the best interest of patients (Denys, 2010).

One of the largest issues with the medical model of nursing homes is the hospital-like environment. Unfortunately, the homelike setting, which is more conducive to visitors and privacy, is physically impossible to arrange considering that nursing homes must be built to maximize efficiency and to blur the boundaries between private and public spaces (Trierweiler, 1978). Since residents often share spaces with roommates, family visits cannot be truly private and intimate. Furthermore, the elderly often lose control over personal possessions either during admission to a nursing home or through theft. These personal items symbolize continued context and identity to the elderly (Hofzapfel, 1982). Without sufficient privacy, individuals cannot live life as they choose and stop existing as individuals with agency. For this reason, the physical structure of nursing homes can obstruct social relationships, personal identity and human dignity by depriving the elderly of privacy, a privilege enjoyed by the “young.”

Nursing homes obstruct the struggle against ageism

America has a cultural problem: we hold stereotypic and usually negative biases against older adults, using age as a primary social category. This form of discrimination, called ageism, is distinct (e.g. from sexism, racism) because age classifications change over the life cycle and thus everyone experiences ageism (Butler, 1969). Ageism is damaging not only because this prejudice affects the way we treat older adults, but also because the elderly often internalize these societal perceptions and come to believe them. The nursing home, analogous to slavery as an institution that purveys racism, is a symbol of and a mechanism for ageism, which in the long term has major psychosocial impacts on the elderly.

The issue is related to America’s hyperbolic youth-oriented society and its modern values of physical beauty, sexuality and productivity (Butler, 1975). In the past, surviving into old age was uncommon and the elderly were treasured as guardians of tradition and knowledge, commanders of respect and political power and as heads of the household (Fischer, 1978). People used to lie and pretend to be older, a demographic phenomenon called “age heaping.” However, over the eighteenth century this trend reversed and old age was devalued. The elderly no longer held a monopoly over knowledge and wisdom; new technologies led to new occupations and new expertise, undermining the value of experience (Gawande, 2014). Furthermore, global economic development had transformed opportunities for the young, encouraging individual fulfillment, irrespective of family expectations. As mainstream culture became increasingly divided from the elderly, the reverence of old age became alien and replaced by generalized assumptions. The most common emotion felt towards the elderly is pity (Fiske et al., 2002). Dying and death are socially taboo subjects and discourse about death is considered morbid or boring. When these conversations do occur, they are filled with euphemisms (e.g. “out to greener pastures”) that reveal our perception that old age is defined by the inevitability of death. However, old age is neither inherently depressing nor incredible. It is contingent on physical health, personality, earlier life experiences and social support systems (e.g. finances, medical care, religious support). However, because of this emphasis on youth and productive capacity, we allow cultural myths to pervert our conception of old age, causing us to blame the old for being burdens and neglecting their physical and emotional needs (Butler, 1975) when they fail to satisfy society’s mold of the “perfect grandparent” or “golden ager” (Fuscher, 1978).

It has been argued that the most crucial determinant of well-being is how individuals are defined and categorized by others in their social environment. People often behave and identify with the stereotypical images carved out by their social world (Cox, 2001). One common stereotype is that all elderly people are alike, regardless of actual differences in health, lifestyle, race and socioeconomic circumstances. This outlook spawns the mechanisms for the loss of individualization discussed previously (e.g. residents all served the same food), which dehumanizes the elderly. A further misconception is that elderly people are all in poor health; that is, old age is equivalent to disease and frailty. In fact, among Americans over the age of 85, over 55% are able to live independently without assistance (Harris-Kojetin et al., 2013). However, this stereotype often encourages family members to preemptively admit the elderly into nursing homes, worried that a single fall could be fatal. This concern is not unreasonable; although, it is often the action of transferring to the nursing home lifestyle, which instigates identity loss and fosters depression and senility. The fear of age-related incidents creates a self-fulfilling prophecy where older adults are sent to nursing homes, which result in greater psychosocial and physical damage.

The elderly are stereotyped as incapable of sexual intimacy despite the statistic that 53% of older Americans, aged 65 to 74, report being sexually active (Lindau, 2008). Nursing homes actualize our discomfort with this sexuality, implementing explicit policies that restrict sexual expression and enforce propriety, shaming sexually active residents as abnormal (Jonathan, 2013). Retirement is heralded as the start of the dying process despite longitudinal studies that find that most retirees show slight improvements in health following retirement (Heidi et al., 2013). These misconceptions are ingrained into the structure of nursing homes and not only allow the continuous, tangible infliction of prejudice on the elderly, but also pressure them into becoming complicit, leading to a loss of identity.

Dr. Bill Thomas argues that “prejudice and bigotry of all kinds take root where people fail to understand the experience of others as individuals” (Thomas, 2015). Therefore, the struggle against ageism benefits from a conception of old age as not the process of dying, but as a new stage in the life cycle beyond adulthood with wide possibilities for growth and development. Dr. Thomas calls this stage “elderhood.” This cultural shift requires, in the abstract, that society accept that aging is inevitable and ultimately good for us. It involves a revaluation of the elderly, who are capable of binding families, providing affection and acculturation and leading independent, meaningful lives.

Nursing homes are an obstacle to this culture change. They allow Americans to neglect valuable individuals while pursuing their fast-paced work lives. Ageism cannot simply be reformed away. Like issues of racism and sexism, ageism is a cultural and structural battle, requiring abolition, rather than a reformation of the standards and conditions of indelibly unethical institutions. Nursing homes did not cause ageism, but they are the most harmful way to forget the issue exists.

Practical assessment of alternatives

The cost of nursing homes is unsustainable. They are the most expensive long-term care option, with private rooms costing an average of up to $83,000 per year. Presently, 10,000 baby boomers turn 65 everyday and by 2050 the total population is projected to reach 89 million. However, only 2.8% of the present population actually lives in nursing homes (Centers for Medicare & Medicaid Services, 2013).

20.4% of the 1.4 million American residents in nursing homes have no Activities of Daily Living (ADL) impairment and 36.6% have no more than mild cognitive impairment (Ellis, 2013). This population is likely to profit the most from nursing home abolition as they do not require 24-hour skilled nursing, and would benefit from reduced dependency and increased autonomy in alternatives such as assisted living facilities and Green House Project homes.

The bureaucratic structure of nursing homes opposes the values of human dignity, personal identity and autonomy. These issues cannot be solved through reform, as the concept and nature of nursing homes are unethical. As cultural symbols of ageism, nursing homes misguide our perception of the elderly and alienate them.

The Green House Project is a non-profit organization founded by Dr. Bill Thomas in 2003 that helps companies and individuals build residential homes that provide “person-centered” assisted living and foster “person-directed” lifestyles. This mission aligns with the fight for elderhood by creating non-institutional, affordable options for the elderly that also use core values of intimacy, autonomy and warmth to drive structural decisions. The Green House Project homes provide the necessary amenities and emergency medical security for daily living, while empowering older adults to control their identity and environment (Larsen, 2015).

However, on the extreme side of the elderly are the people that fit the stereotypes of the demographic: the terminally ill or clearly dying. Generally, these residents are held in nursing homes under a hospice care program, which focuses on improving quality of life through compassionate end-of-life care rather than medication (Hanks et al., 2011). Ostensibly, this could be an obstacle for nursing home alternatives: how can proper hospice care be delivered outside a hospital-like setting? A major assertion in hospice care is that the presence of the home environment is essential to maintaining the natural dying process, an ideal associated with dignity. Nursing home alternatives provide space for homeliness and well being, invaluable to the dying process, and unobtainable in total institutions.

Conclusion

The bureaucratic structure of nursing homes opposes the values of human dignity, personal identity and autonomy. These issues cannot be solved through reform, as the concept and nature of nursing homes are unethical. As cultural symbols of ageism, nursing homes misguide our perception of the elderly and alienate them. Abolition is the first, at the very least principled, step in recognizing that individuals have an intrinsic and societal value beyond their youth and productivity in elderhood. This new stage of life can be achieved by the birth of a cultural, anti-ageist movement and by the downfall of the nursing home.

 

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