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Ethical training essential

Elderly care facilities must be flexible in dealing with situations such as those described in the story above, according to Dr. Abraham Schwab, a medical ethicist at IPFW.

In the Iowa nursing home that the story describes, caregivers struggled with the question of whether to tell the families and notify authorities when they observed sexual activity between a man and woman who both suffered from dementia.

“They kept going back to the question of consent,” Schwab said.

Consent is just one factor of the questions caregivers have to consider, Schwab said.

“If there’s a clear case of sexual assault, you have a responsibility to report it” to authorities, Schwab said. However, if sexual interaction between two people with dementia is going to be treated as criminal activity, “you have a double question.”

One participant may have to be judged on intent at the same time the other is evaluated on consent, he explained.

Indeed, it is a difficult subject even to converse about. “We want them to act like adults – to understand the situation and make judgments that we think are reasonable,” Schwab said. But it is not that easy to evaluate the motives of a person with dementia.

“That’s why it’s taken on a case-by-case basis,” Schwab said. “What is the relationship between the patients? … What do they need to feel comfortable and good?”

Even the question of when to tell family members about a patient’s sexual encounters is a difficult one. Medical confidentiality is a concept that arose to encourage patients to be honest and open with their doctors. It’s a matter of encouraging trust, Schwab explained. But trust and confidentiality may have no relevance to how one deals with inappropriate behavior by a patient with dementia in a nursing home, Schwab said. The caregiver might be guided more by “the need not to tell the family – but for the family’s sake,” not for the sake of confidentiality. In other cases, there might be a clear need to tell relatives about a dangerous or harmful situation.

Schwab emphasizes the need for ethical training for those caring for the growing population of the elderly. “There’s a need to protect those who are vulnerable,” he said. The overriding consideration has to be “a simple commitment to limiting harm.”