Social Inequalities and Care for Older Adults: An Ethical Perspective

Verdecia TMJ¹*, Escalona PE¹ and Gomez LLA²

¹Department of Philosophy and History, University of Granma, Cuba ²Institute Preniversity, Manzanillo Education, Cuba Keywords: Social Inequalities; Older Adults; Care; Vulnerability; Dependency

Abbreviations

IDS: Institute of Development Studies; ISSC: International Social Science Council; OXFAM: Oxford Committee for Famine Relief; UNESCO: United Nations Educational, Scientific and Cultural Organization.

Introduction

At an international level, studies on social inequalities have reached a sustained stability, driven by the model of intelligibility of the social, which emphasizes concepts and dimensions of the research-decision-making interface, the capacity of social thought to connect with change, and the need to evaluate the concrete effects that the modifications experienced by public policies, induced by neoliberal or austerity reforms, have had on the problems they were intended to solve: inequality, poverty, unemployment and vulnerability. It is therefore widely recognized that inequalities experienced from the earliest years of life and throughout life undermine healthy ageing [1].

During the last decade, various reports reveal that social inequality, or more pertinently: social inequalities, have become a phenomenon with the magnitude of a global crisis with structural causes; where extreme inequality is identified as an avoidable phenomenon, the result of political and economic decisions that can therefore be reversed [2]. Therefore, ethical principles, as factors that guide people’s willingness to act, play a leading role in the intersectional management of this problem.

At the same time, the challenges that knowledge of social sciences and the definition of paths towards a more just and equitable world represent for the social sciences are pointed out [3]. The introduction of inequality in the 2030 Agenda for Sustainable Development presupposes a necessary commitment and the need for global action to address it, based on multiple Sustainable Development Goals, which place it as a central problem. This interest must be assumed responsibly in decision-making in the different areas, since important elements are at stake and are clearly at risk, making it necessary to find the most responsible and prudent way to act.

The study of social inequalities stands out, as a substantive characteristic, for its substantial complexity. Among other elements, for its multidimensional nature, which involves economic, social, political, cultural factors and the consequent synergies between them, articulated at different individual, relational and structural levels? [4] In addition, for the variety of processes and factors, historically conditioned, which in their interconnection give rise to multiple forms of inequities, disadvantages and asymmetries that must be ethically condemned. The recognition of this multidimensional and dynamic nature of inequalities requires finding approaches capable of interconnecting such dimensions and processes, the ethical perspective being a mediator par excellence.

Despite the plurality of approaches, visions and topics addressed, no research has been found that addresses the relationship between social inequalities and care of older adults from an ethical perspective, which constitutes the investigative contribution of the work now made public. This article focuses on the examination of the intersections between social inequalities and care of older adults from an ethical perspective. Through a multidimensional analysis, aspects such as health, access to services, social inclusion and the impact of public policies on this link are addressed. The particularities observed today are discussed, as well as their expressions in family and community interactions, and recommendations are proposed to improve the care and comprehensive management of this relationship based on certain ethical principles.

To carry out the study, a survey is made of the research that reveals equity gaps in the care of older adults, which were subjected to a content analysis from the ethical dimension of the issue. Examining social inequalities in the context of care for older adults, from the ethical perspective of their intersection, is key to predicting the possible impacts of intersections in the situation of asymmetries, which will allow the design and implementation of policies that guarantee access to rights and various services, and equity for all people as the basis of a better and more just world.

Social Inequalities and Care of Older Adults: Ethical Approach

It should be noted that when we refer to inequality, we are referring to the existence of a lack of balance between two or more people, between countries in a region or between regions of the world. Inequality has many manifestations, including social inequality. The latter refers to unfair and avoidable differences that occur between two people, within a group, a society, and occurs when a person receives asymmetrical treatment as a result of their social position, ethnicity, ideology, economic situation, religion, gender, the culture they come from or their sexual preferences, among other aspects [5, 6, 7].

Scientific production on social inequalities has revealed multiple equity gaps that are experienced by different situations: gender, age, skin color, territory, disability status, socioeconomic level, among others. Although the age dimension of inequality has not been so visible in research, it is considered that economic inequalities do not have a uniform distribution between different social groups, and especially between age cohorts [8].

One of the elements that affects the connection between social inequalities and care of older adults is participation [9]. The notion proposed by OXFAM indicates one of the dimensions of this process, related to power, as it poses participation as those activities that explicitly or implicitly seek to influence public debate and the distribution of power in a society. In this case, the impact on participation has a double connotation: a) to the people who care and, b) to the caregiver. This deprivation has an ethical content because the rights of these people are not respected; an issue exacerbated when it comes to two elderly people.

In this sense, it should be noted that social inequalities can be identified in two types: those where the asymmetries emerge explicitly, and others whose manifestations are more difficult to perceive or measure, but whose results reveal conditions of vulnerability for elderly people due to their situation of dependency. The persistence of social inequalities in relation to health, access to financial, cultural and social services is increasingly confirmed as a verifiable fact: people with a higher educational level, higher professional category, or higher income, have lower morbidity rates, a longer life expectancy and higher standards of living. Although social inequalities exist in all societies in the world, the intensity of these inequalities varies from one place to another, and there are notable differences within each country and between nations, with those with a low level of development being the most affected, which in addition becomes an example of inequalities in the international context.

From an ethical point of view, the effective management of social inequalities in the context of caring for older adults is justified by the essence of humanity based on respect and well-being for oneself, others, and society as a whole, a complicated task in a world in which values are being established based on economics, profit, and individual interest. These inequalities are expressed in a set of social problems that indicate the need for new leadership, focused on the common good, which demands above all comprehensive training for the rest of the people involved in caring for or living with older adults, which means the rest of society, which serves as a guide towards responsible reflection and action as professionals, citizens, family members, and caregivers.

The link between inequalities and older adult care is becoming increasingly apparent today, as the global phenomenon of ageing society has coincided with the commodification of social care, in some countries under conditions of economic austerity, and emphasis is placed on cost control in provision. At the same time, demographic developments have generated changes in the levels and types of support needs for social work, social care, and care in general; while professional values emphasise the promotion of service users’ rights to person-centred care and to the maximisation of their self-determination and control. Consequently, professionals face a range of ethical and professional dilemmas and challenges in negotiating their way through these competing priorities [10].

It is also dramatic how most of these inequalities tend to be linked. The probability of not receiving quality care is obviously greater for poor older adults, even from modest income groups, than for those from the middle class; the probability that their caregivers have a precarious, lower-paid job is higher for the poorest, women, blacks or indigenous people.

Here we are faced with an ethical dilemma related to two issues related to equity: the differential burdens of care between men and women, which generate gender inequality, and the inequity in the capacity to choose and access resources and support services according to educational and socioeconomic level, which poses an inequality of social class. The distribution of the responsibility of care between men and women, between family and State, constitutes a crucial debate that is based above all on solid ethical principles.

In addition, the issue contains a precious good: living in a society with justice, which has its roots in the social implementation of ethics. In line with the above, the characteristics of care must be observed, its magnitude in the context in which it occurs, and the profile of the caregivers, the work they do and the impact it has on their lives must be analyzed. The ethical analysis of the issue points to how different social determinants of inequalities, and specifically those related to habits and behaviors, occupation and living conditions, help to explain the relationship between educational inequalities and the self-perception of loneliness, poverty and helplessness.

Another element that emerges is the cost that women assume in their lives for being caregivers; which refers to terms of health, quality of life, access to employment, professional development, social relationships, availability of one’s own time and economic repercussions. Women with a lower educational level, without employment and from less privileged social classes make up the large group of caregivers in most nations. This requires that policies to support caregivers should take into account this unequal starting situation and be evaluated in terms of their impact on gender and social class inequality.

Here, another shortcoming of a health care service is revealed, especially that provided at home, which is mostly assumed by women worldwide; which, despite not being a new fact in the current context, takes on a new ethical connotation given by: the growing increase in the demand for care, the progressive decrease in the availability of “informal” caregivers, the reforms of health systems after the impact of COVID-19 and other welfare services. In this sense, the persistence and expansion of demographic aging and the greater survival of people with chronic diseases and disabilities not only increase the number of people who need care, but also the complexity and demand in its provision.

At the same time, changes in the structure and ways of family life place the question of the availability of caregivers in the foreground. Fertility and household size decrease, the mobility of its members increases, families adopt more diverse and complex forms of coexistence. A critical factor is the increasing incorporation of women into the labour market, despite which they continue to assume the majority of the responsibility of caring.

The third element is the evolution of the formal systems themselves. The reforms of the health services put emphasis on health care in the environment itself: early hospital discharge, outpatient surgery programmes, reforms of psychiatric care. Every day more people with serious illnesses, dependent on high technology or in a terminal situation are cared for at home. There is a shift of increasingly complex care towards the informal system, within a framework of containment of health expenditure and scant development of other social care services.

On the other hand, injustice characterizes the structuring of care, directly affecting its visibility and social recognition because it is unpaid work, without a price on the market, and this is confused with a lack of value. Care is based on affective and kinship relationships and belongs to the private sphere; these are “family matters” in which the rest of society is not involved. This takes place in the domestic sphere and, as such, remains hidden from the public arena. And, finally, it is a function assigned to women as part of the gender role; care, especially in relation to the health of people who need it, has historically been established as “a woman’s thing” at a global level.

The limits of care are difficult to define in terms of what is done, to whom, where and for how long. This complexity poses difficulties when it comes to gauging its magnitude. Most research takes as a starting point a type of dependent elderly person, from which their caregivers are identified. Care is carried out in a formal and informal manner. Despite the difficulties of comparability, there is a general agreement regarding the magnitude of informal care: formal services participate in a minority way in the continued care of dependent elderly people. Various studies confirm that the family is the main provider of care and sometimes constitutes the only source of care for older adults who need it. In addition to illness (chronic or acute) or disability, activity restrictions due to accident or hospitalization or limited autonomy of older adults are conditions that generate the need for care.

While it is true that the current context of humanity has as one of its characteristics the permanent changes in the social, cultural, political, technological, scientific, economic and educational spheres, dynamized in a certain way by globalization, which affect the daily life of human beings and, in particular, of older adults, who are at a greater disadvantage in the face of such transformations. It is in this sense that the rest of the people must meditate on the behavior assumed in the face of the inequalities present in the care of older adults.

In addition, ethically it is necessary to elucidate the range of responsibility regarding the decisions that are made, and on the effects or consequences that occur due to the procedures implemented, since individual actions affect the environment in which all people develop, especially the most vulnerable. In this sense, it must be understood that social inequalities have their roots in historical problems, which result, reproduce and structure from the social environment and which vary over time, all of which will make it possible to address this issue from the perspective of ethics and human values based on a world that is increasingly diverse, plural, but also more unequal.

Conclusions

Social inequalities are increasingly receiving special attention in their different forms of manifestation, with one of the most visible forms being those that manifest themselves in the care of older adults. One of the elements that affect the connection between social inequalities and the care of older adults is the participation of both the person being cared for and the person exercising the role of caregiver.

The marked aging of the population is emerging as one of the most marked demographic trends, which, together with social changes in families, the growing incorporation of women into the labor market and the reforms of health services themselves, are putting into question the availability of caregivers in the near future and are fuelling the debate on care, particularly that referring to older adults.

The category or condition of Caring is written, now as before, in the feminine; which in itself is a social inequality; because women not only assume the role of primary caregivers, women are also those who help other women in caregiving. They are responsible for heavier and more demanding tasks and spend more time caring than male caregivers. The unequal distribution of caregiving burdens between men and women generates clear gender inequality.

Faced with the bleak outlook revealed by the set of social inequalities present in the contexts of care for older adults, ethical conduct is identified as one of the main supports for effectively managing this problem. Without the adoption of solid ethical principles, such as: solidarity, responsibility, respect for differences, sensitivity, commitment, justice and equity, they cannot be resolved or overcome if we do not know how to resolve current ethical dilemmas and problems, ethical challenges in social, family and professional settings, based on the particularities of the context and the needs of humanity itself; which raises in the first place the responsible action with respect to the most dependent people, which includes children and older adults in the world.

Social inequalities outline a set of inequalities in the care of older adults, which delegitimize the aspiration to increasingly achieve fair and inclusive societies. In the context of care for older adults, social inequalities, under the ethical prism of their intersection, are key to predicting the possible impacts on the situation of asymmetries, which becomes essential to design and implement policies that guarantee access to rights and various services, and equity for all people, especially older adults; who deserve, after going through the life cycle, to live an ethically full end, with greater justice.