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In a previous article I mentioned the need to understand important philosophical concepts for managerial ethics. This article will examine one important area of ethics as it relates to Alzheimer's disease. Immanuel Kant wrote about the importance of ethics over 200 years ago, and his theoretical perspective, which falls into a category of ethical perspectives referred to as deontological or nonconsequentialist, still continues to hold a considerable impact in the study of ethics.¹

Kant's ethical perspective was based on what he called the "categorical imperative." For Kant, the categorical imperative was a prior concept that existed independent of human experience.²  In fact, it was viewed as a universal moral concept that did not yield to the relativity of the situation. Kant stated that people should be treated as an end in themselves and never as a means to an end:

"All imperatives command either hypothetically or categorically. . . .If an action is good only as a means to something else, then the imperative which commands it is hypothetical only; if it is conceived to be good in itself, that is, without reference to any further end, the imperative which commands it is categorical."²

Kant himself was undeniably brilliant and he continues to be revered as one of the greatest minds of all time. During his time, little was known about Alzheimer's disease. Although some who lived to elder ages no doubt suffered from it during the eighteenth century, Kant himself never addressed ethical issues of Alzheimer's disease. However, his ethical concepts are nevertheless applicable and extend into our current century. The cosmology that he developed toward understanding the ethical treatment of individuals transcends the eighteenth century in which he wrote and forms a solid perspective for understanding the ethical care for those in long-term care, and in particular, the care and treatment of those with Alzheimer's disease.     

Kant and his philosophies are relevant today. Many people who are initially labeled with dementia are frequently stripped of their rights. Once given a diagnostic label of Alzheimer's or some other form of dementia, many family members and caregivers feel that the person is no longer able to make any informed decisions on his own behalf. Oftentimes, the person is treated in an infantile manner, leading to his dehumanization. In fact, this all too common scenario often begins as soon as the person is given the Alzheimer's diagnosis. 

When the person is in the early stages of the disease, he is still able to adequately advocate for himself on many, if not most, issues. Yet, those who work with people with Alzheimer's and associated dementias in long-term care regularly feel compelled to treat them in a dehumanizing and infantile manner, often without the slightest reservations.  For sure, long-term care is not the only place that this type of treatment happens. It is quite prevalent throughout society.             

So at a period of time when a disease is ravaging individuals on a neurobiological level, eventually stripping them of their selfhood, those who are caring for these patients are further stripping them of their selfhood on a social and psychological level. In addition, quite frequently family members will use legal tools, such as a durable power of attorney to justify their ability to take away their rights. Even though the durable power of attorney is not legally set up to work in such a manner, staff will often acquiesce to the protestations of the family, even when the resident has the ability to offer their views, as well as advocate their wants, which may be in direct opposition to what the family desires.     

In essence, what Harold Garfinkel has called a "degradation ceremony" takes place, where the person is stripped of their identity and the control that they can still exert.³  It has become painfully evident that this often occurs as soon as the diagnosis is made, at a time when the individual is still quite able to make his wishes known and make decisions for himself. 

Here is where the ethical dilemma exists, a dilemma that Kant would be very interested in as it relates to the categorical imperative. Society views the Alzheimer's population as an empty shell that is devoid of the essential human capacity to think, feel, or in other words, be human. Although many of these behaviors are often based on good intentions, as Kant states, even those that act on the premise of good will may be doing harm.^4,5 If the will to act is truly not good, then the action itself will be negative. Many people, upon hearing the diagnosis of Alzheimer's disease, fail to view the person as a human being, but rather as a defective person who can no longer carry out what all of us hold so dear: the ability for self-determination.

This is where we can learn from Kant, using his categorical imperative to ethically care for those that suffer from this terrible disease. In directing human action toward those that suffer from Alzheimer's disease we have to remember that regardless of the disease, they need to be treated as the end in themselves. In other words, the morally correct treatment or intervention is to first act toward them on the basis of their humanness. 

Treatment for those that suffer from Alzheimer's and dementia should uphold the universal principles and moral standards that we hold for all humanity. We need to remember that attempting to take on a proxy role immediately upon hearing the diagnosis subjugates the humanity that all individuals, including those that suffer from this disease, are entitled to. Although these individuals will definitely have special needs, especially as the disease progresses, we cannot use what is often thought to be good will to actually take away the quiddity of their lives.       

                                    References

1. Idziak JM.  Ethical dilemmas in long-term care. Dubuque, Iowa, Simon & Kolz Publishing, 2002.

2. Castell A. & Borchert DM. An introduction to Modern philosophy:  Examining the human condition, New York, NY, Macmillan publishing, 1983.

3.  Garfinkel, H. Conditions of successful degradation ceremonies. American Journal of Sociology, 1956;61(2): 420-424.

4.  Hallmman, MO. Traversing philosophical boundaries. Belmont, (Calif.): Wadsworth PublishingCo., 2003.

5.  Stumpf SE. Philosophy: History & Problems. New York, NY, McGraw-Hill Publishing, 1994.

   Dr. Brian Garavaglia is a long-term care administrator, gerontologist, educator and consultant. He has worked in health care for approximately 26 years and has worked in all phases of health care including acute, subacute and long-term care environments. His area of specialization is older adults and the long-term care environment. He has continued to research, publish and be an advocate for the older adult population as well as teach at various colleges within the Detroit-metropolitan area. His research interests are numerous, currently working on how stereotypes influence the diagnostic implications for dementia in the older adult long-term care population. He also has a strong interest in neuroscience and the neuro-social psychological factors related to aging as well as how social-gerontological issues affect the regulatory and political climate in long-term care.