The Conflicts of Eldercare Provide New Insight into the Nature of Values
Recently, sociologists have studied how people make value-based decisions when they are constricted by economic factors. They’ve documented how the meanings people assign to their market practices—for instance, how they decide what is appropriate to exchange for money—differ over time, across institutional contexts, and among different people. Sociologists have studied how the same people make decisions by invoking different moral criteria to orient their action in different contexts.
But Guillermina Altomonte, a doctoral candidate at the New School for Social Research, looked at the difficult ethical issues surrounding eldercare, and found another dimension to the relationships between economic incentives and moral reasoning. In “Exploiting Ambiguity: A Moral Polysemy Approach to Variation in Economic Practices,” published in the February issue of the American Sociological Review, Altomonte proposed that some values work as a “moral polysemy:” they can mean multiple things and therefore orient decisions in different directions under a single shared norm. In the case of a post-acute care unit, nurses, social workers, and other professionals used the value of “independence” to guide their professional judgment and actions regarding elderly patients, but what this meant changed from patient to patient and from situation to situation. Altomonte found that this ambiguity enabled the same actors to switch between different interpretations of independence in old age, therefore rationalizing the divergent organizational goals of post-acute care.
The case study itself is full of human drama. For almost two years, Altomonte observed and interviewed patients, their families, and their professional caretakers at a New York skilled-nursing facility. Altomonte describes the inherent contradictions between the economic incentive for skilled-nursing facilities to discharge patients quickly, especially if their Medicare or private insurance runs out, versus the mandate for “safe discharges” meaning that patients will not need to return to the facility. Much comes down to the widely-shared value of patient autonomy – but the tricky issue is determining what that really means, identifying whether going home actually contributes to patient autonomy, and negotiating between competing demands for speed and safety.
“This article argues that staff at a post-acute-care unit steer decisions toward one or the other goal by exploiting the moral polysemy of independent aging. This moral polysemy evokes multiple meanings of the hegemonic value of independence that are culturally and legally inscribed in U.S. society,” Altomonte wrote.
One patient who refused transfer to an assisted-living facility was convinced by a social worker to go to her sister’s home by the social worker describing her own workplace in negative terms and appealing to the patient’s desire for “creativity” and “life.” Another patient is actually discouraged from leaving because her nurse and social worker think she is too impulsive and will probably fall, so that the patient “ironically must prove her independence by acknowledging her dependence” on those who would protect her. Another interpretation of independence is demonstrated when a patient does not want to apply for Medicaid, and her caregivers insist that to be independent, she must depend on a government program to provide the help she needs and can’t afford at home. Yet another patient, who is reluctant to stand up by herself, is pressed harshly by her physical therapist to do so – in this case, providing less care so that the patient will take responsibility for recuperating her self-sufficiency.
“[T]he moral polysemy of independent aging that operates in post-acute care mobilizes connotations that become significant in old age precisely because they are threatened by old age. My findings show that the most central of these meanings is opposition to institutional care,” Altomonte writes. “Because it brought together the concepts of ‘home’ and ‘autonomy,’ institutional independence justified the organizational mission of discharging patients…Ideas about how elderly people should ‘do’ independence by relying on technologies, caregivers, and Medicaid came together in an interpretation of assisted autonomy that moralized extended care even if it contradicted economic imperatives of fast discharge. Conversely, interpreting independence as a constellation of duties, both individual and family-based, to remain self-reliant in old age moralized practices that lead to fast discharge.”
In real-life relationships, this research suggests, people can differ in an understanding of an accepted-but-ambiguous moral framework, and collaborate with each other going forward without necessarily agreeing, because they are all appealing to the same value. This makes for, as the author writes, “pragmatic rather than ideological compromise.” Jim does not have to change Sally’s mind about the value of independence; he does have to work with her to situationally define and reconcile what that means in terms of the work they do together.
The potential impact of this research extends beyond the complexities of eldercare and contributes to larger questions of economic and organizational sociology. As the author notes, the concept of moral polysemy questions a basic premise of economic sociology: “that clarifying the meanings of transactions is essential for people to successfully carry out these transactions. This reasoning has illuminated essential features of how actors interact in economic life, but this work has paid less attention to what happens when the parties involved have different understandings of the same value—which is often the case with rich and complex cultural concepts. My case shows it was essential for actors to agree that sending people home is the moral thing to do, but by foregrounding an ambiguous understanding of morality it also shows people can hold on to divergent meanings while participating in an exchange.”
Within the field of healthcare, which presents workers with increasing pressures to combine patients’ wellbeing with economic incentives to reduce spending, Altomonte concludes, “Future research should continue to explore the forms of cooperation and decision-making workers are adopting in response to these challenges.”
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The American Sociological Review is the flagship journal of the ASA. The research article described above is available by request for members of the media. For a copy of the full study, contact Johanna Olexy, ASA Senior Communications Associate, at (202) 247-9873 or firstname.lastname@example.org.