Most states require certain professionals or the community at large to report elder abuse to social services and/or law enforcement agencies. In passing a law on reporting elder abuse, legislators have been guided by the belief that older adults, such as children, need protection and assistance, are physically or cognitively frail and more vulnerable, are at risk of abuse, and may not be able to report on their own. Therefore, professionals and others should be required to contact social services and/or law enforcement agencies. Ethical violations related to elder abuse refer to the deprivation of autonomy, self-determination and charity of victims, their exposure to misconduct, injustice and paternalism. Mistreating older persons and denying them the right to autonomy and self-determination means that the person concerned is not allowed to make free and informed choices. Charity means working in someone`s best interest. Dick suggests that nurses should be aware of cultural beliefs and coping patterns of family members who neglect an older adult`s personal and environmental health needs, rather than viewing them as pathological outcomes (37). Yet, according to most studies, if older adults are unable to make decisions due to cognitive impairment, the task may be left to another person. This person must support the patient and be aware of their needs. Most regional councils for the elderly provide care services in which a group of competent people act as decision-makers for the elderly (5).
In cases where decisions are related to the patient`s performance, consultation with an interdisciplinary expert group is necessary and decisions should ultimately be made in favour of older people (10). Finally, for decision-making, the health care team can benefit from the ethical approach to communication, which is a participatory method that includes several phases: (a) the defense phase to clarify conditions and problems; (b) consultation; and (c) negotiations leading to an agreement (40). In cases of elder abuse, professionals may not agree on the least restrictive intervention needed to ensure protection and safety. For example, adult protection workers may listen to an elderly victim who wants to stay home and insist that no action be taken that will lead to a move. Health care providers working with the same person can assess the situation and determine whether the elderly patient needs to be transferred to a facility or dies. One of the legal and ethical challenges for any interdisciplinary team is to address these complex situations and develop a plan that focuses on the safety and needs of the older victim with as little loss of independence as possible for them and that aligns these competing considerations. Nurses as the first line of treatment and other members of the nursing team play an important role in this. Compiling or localizing clinical guidelines for the healthcare team not only influences their perspective on ethical issues, but also helps them work properly and choose the best functional option. Finally, clinical guidelines support the behaviour and performance of the healthcare team and serve as a criterion for assessing quality of care.
In terms of charity, an ethical violation in relation to elder abuse means that the patient`s well-being is completely neglected. In case of fault, it is a question of not taking the necessary measures. The opposite of this is the absence of wrongdoing, which means the principle of no harm. Ethical violation, in terms of paternalism, means restricting another person`s freedom. All this is a gross injustice inflicted on people for whom old age is a handicap. However, reporting abuse is another difficult issue. The discussion of reporting elder abuse is not limited to the social context, but requires awareness of medications, law enforcement and social services. All professionals who have relationships with elderly patients in terms of treatment and law enforcement should take an ethical responsibility to protect them from harm.
Different definitions of maltreatment over time have been provided (5). Elder abuse can refer to an act or lack of an appropriate act that causes harm or suffering to an older person, and this occurs in a relationship that usually requires trust and can only be done once or more times (1,2,6). Question: Is there comprehensive legislation on elder abuse? Lynch also discussed ethical issues surrounding informed consent to research studies and the decision-making capacity of older adults. She noted that after receiving information, an individual can give informed consent when making a choice, understand and appreciate issues, handle information rationally, and make a stable and consistent decision. Several considerations about what may impede an older adult`s ability to give informed consent include sensory deficits, reduced ability to ask questions, and values and beliefs about health care decisions. In the third chapter of the Constitution of the Islamic Republic of Iran, the importance of autonomy and human dignity was addressed. According to the Constitution, respect for human dignity is a principle accepted by the Islamic Republic of Iran, obliging the government to provide care services for all (54). Accordingly, care services should be based on respect for patients` rights and dignity. As a result, the patient must choose and decide freely.
The patient must be respected when using the care services on the basis of respect for the privacy of patients and confidentiality of information. In this context, a study by Davis et al. showed that the ability to make decisions is vital for older adults and that lack of autonomy leads to depression (51). To the surprise of many, there is also an ethical aspect to this question. Ethical issues related to elder abuse are usually related to conflicting social, cultural and religious reasons. These have been described below to provide more clarity on the whole topic. In addition, PSA laws aim to control elder abuse in family settings or institutions. Depending on the type of law, each country has a system for reporting elder abuse and social services to support victims and change conditions.
Nevertheless, the above-mentioned laws relate mainly to the abuse of disabled and vulnerable adults, rather than the abuse of the elderly (47). Violence committed by a family member or intimate partner is complex because older adults may have difficulty with the social, cultural and religious aspects of living with violent people (12). According to the College of Nurses of Ontario (CNO), ethical conflicts and challenges arise when two or more ethical values relevant to a particular situation require conflicting actions (13). Elder abuse causes physical harm, depression, increased hospital referrals, frequent hospitalizations and increased mortality (1,2,14,15). It also creates issues such as burnout and ethical burden for nurses and caregivers (16), who have a thorough and accurate understanding of the ethical concepts and challenges associated with elder abuse and should decide on the best intervention (17). Given the importance of this issue, this study aimed to examine the ethical challenges associated with elder abuse based on evidence-based ethical principles. Another issue related to brain function and health is the notion of competence. Jurisdiction is defined by law and determines whether a person is fit and qualified to testify or execute a legal document.
In the United States, the law assumes that all adults are competent and have decision-making capacity to make health decisions, unless the court decides otherwise. Lynch discussed ethical issues within the legal system regarding the ability of a vulnerable adult to testify in a case of elder abuse. She noted that a lack of competence could be used as a defense strategy to exclude testimonies from victims or witnesses of abuse. One study has shown that patient protection professionals need to keep in mind that if an older person decides to refuse services (independence) and continue to live in threatening conditions, logical thinking will be a necessity in critical circumstances (11). A 2003 study by Healy reported responses to a self-assessment by social service staff of ethical dilemmas regarding the decision-making capacity of older patients with cognitive impairment. In the section on safe living conditions in homes, participants indicated that they faced conflict when they had to force the person to go to a safe place or respect their decision to continue under existing conditions. In such cases, social workers face a decision-making challenge: refraining from intervening and respecting the person`s autonomy, or attempting to avoid harming the person and bringing the abuser into the justice system (49). Autonomy includes independent decision-making without restriction and respect for independence is a professional obligation (29). According to the American Nurses Association (ANA), autonomy means respect not only for patients` decision-making, but also for the method of decision-making (30), and patients have the right to participate in decisions that affect them (31).
