Our Thoughts

From Serving Iowa Elders for Over 20 Years

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Is Honesty Always the Best Policy?

Honesty is a universal value, applicable to the general population and to specific professions.  We all can understand what it means to be an honest person and behave honestly.

People in our area of human services have some major challenges when it comes to honesty in every situation.  Our peers have called them “geriatric fiblets.”  This “fibbing” is particularly troubling for me.  I value truth and honesty as highly as any personal value.  If you ask my family for the one thing that will set a usually mellow me fuming, they will all tell you “lying” or “dishonesty.”  I find life is challenging enough without being given deliberately misleading information.  Attempts to be truthful are a critical component of communication.  Without it, “Oh, what a tangled web we weave.”*

Yet, we find ourselves recommending judicious dishonesty when dealing with some cognitively impaired clients in some circumstances.  The rationale for lying to a client is easiest to understand by example.  Mr. and Mrs. A had a spectacular marriage of 75 years.  They were always honest with each other, as we expect all good couples to be.  During twenty of those years, Mrs. A’s mother had lived with them.  When Mrs. A began to lose her memory, she would look throughout the house for her aged mother.  She would come to Mr. A often to help her find “Mama.”  Mr. A understood well that his wife was confused and unable to remember many things.  He would try his best to present the truth to her, as he had for 75 years of a close and honest relationship.  He would tell her as gently as he could, “Honey, Mama died in 1998; and she’s in Glendale Cemetery.”  Mrs. A received this “news” by bursting into wracking sobs as if her beloved mother had just died this day.  It broke her heart to hear her mother was no longer with them.  She had the wherewithal to understand death and her personal loss but her memory could not retain the grieving she had completed decades earlier.  Mr. A was unwilling and even unable to lie to her.  His persistent honesty, though with stellar intentions, caused Mrs. A such pain, it bordered on cruelty.

In situations like this, we strongly suggest setting aside one’s impulse to be honest.  Our preference would be to tell Mrs. A that her mother was “fine but not home at the moment.”  If pressed, we would invent something that would pacify her worry but not break her heart.  Perhaps her mother was visiting a friend.  Simply changing the subject can be effective in some situations.  We can try looking for Mama together until Mrs. A can be distracted by some other concern around the house. Direct honesty sometimes has to be weighed against the pain and frustration it can cause.

A completely different situation arises when there is a mistake rather than a lie.  When someone says the day is Friday, while the rest of us know it is Tuesday, s/he isn’t really being dishonest.  Nonetheless, the error is intriguing.  Before simply correcting the mistake and moving on, pause to consider what the error may mean.  Does it mean the person is losing his or her sense of time?  Did she decide it was Friday because she had prematurely taken Wednesday’s and Thursday’s pills?  Is she still waiting for something she expected to happen on Tuesday?  Also, consider the effect of us making a simple correction.  If this person is making frequent factual errors, how will being told she is repeatedly wrong make her feel?  It is certainly hard on the ego and can make the person feel less confident at a time when she may be losing her ability to think clearly anyway.  We once had a client, Ms. D, who insisted her nurse was stealing her stockings.  Ms. D wore garter style stockings with many runs in them.  The nurses were insulted to think they would want such things, much less steal them.  There was no point in correcting Ms. D.  She would only argue more vehemently to protect her ego and her wobbly sense of reality.  When her stockings were missing, she couldn’t tolerate the idea that she was the guilty party herself.  Best to blame others.  Those who got wrongly accused could take comfort in the fact that their egos are less fragile than Ms. D’s.  Ms. D made a mistake about her missing hosiery, but correcting her would be a harmful error on our part.

Honesty is still the best policy for the vast majority of life’s communications, regardless of age and impairment.  However, when someone presents an inability to remember and cope with what the rest of us perceive to be the truth, we are offered an opportunity to step back and ask “why?”  The need to be shielded from some truths can be a consequence of cognitive change.  If the person’s cognitive capacity has become limited, as in the case of Mrs. A, it is up to the rest of us to learn to adapt to her “reality.”  We would not recommend that the death of Mrs. A’s mother be kept secret from her.  However, we do caution that pressing the cognitively impaired person to accept painful information may not be wise or necessary.  Protecting the elder’s emotional health is very much an expression of love and kindness.

*Quote from Sir Walter Scott, Marmion.

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Some thoughts on Ethics.

It seems appropriate that my first blog entry (Mary Alice) should be about ethics. Long ago I began my academic education in the philosophy department, with a particular foci on logic and ethics. Applying ethical principles has been a important value in my life. Now as a licensed social worker, I take several hours of continuing education in ethics biannually.

People don’t discuss ethics as much as they get outraged at the unethical. Unethical behavior makes headlines. We read accusations of dreadful conflicts of interest among financiers and bankers and politicians. There is nearly universal condemnation for being unethical. Yet, there is very little discussion of being ethical. This discussion is how I want to start my blogging adventure.

Merriam-Webster defines ethics as: “Rules of behavior based on ideas about what is morally good and bad.”

One would think that being ethical is pretty easy. People assume they know what is the “right” thing to do. We learn right from wrong as children. We learn The Golden Rule. We are taught, “Don’t poke your sister with a stick.” How hard can it be to continue to do “right” and avoid doing “wrong?” Hopefully, we adults have all stopped poking people with sticks.

The challenges for ethical behavior arise when life presents choices which are not so simple. “To poke or not to poke” becomes “which poke is less painful?” There are times when there are no “good” choices at all. Even more complications arise when people disagree on what is really good, sort of good, a little good, not very good, not too bad, etc. Is “sort of bad” better than “not too good?” What do we choose when your good is bad for me? When we start to look closely at real life situations, the right thing isn’t always so obvious.

Thanks to all the philosophers and ethicists over the centuries, we have some guidance on how to make the complicated choices. Like the dictionary says, ethics involves “rules” of behavior. Even in complicated situations, the Great thinkers guide us with rules and their reasonings about those rules. Some are aimed at humanity in general and some are developed for specific areas of human interaction.

As licensed social workers we are guided by the Code of Ethics of the National Association of Social Workers. This includes the principles that we profess as social workers and which underlie our approach to human interactions. As care managers, we have an overlapping Code of Ethics developed by The National Association of Geriatric Care Managers. You can read these in their entirely at http://www.socialworkers.org and http://www.caremanager.org.

These codes of ethics both include many obvious “rules,” like respect people, keep confidentiality, make good records, know our limitations, etc. However, there are a few “rules” that pose some interesting challenges for our style of practice. These will be the subject of my next few blog entries. Stay tuned.