Reducing malnutrition in aged care: how ethics can help

There is evidence that between 30 and 50 per cent of residents in Australian residential age care establishments have malnutrition or under-nutrition, writes Professor Colin Thomson.
Evidence also shows that malnutrition is a predictor of morbidity and is associated with increased hospital admission and length of stay and increased falls and fractures.
Given this mounting evidence, both in Australia and elsewhere, and the rising numbers of residents in age care establishments, there are many proposals to reduce malnutrition. These recognise that a complex web of factors needs to be addressed. Such strategies like nutrition screening and periodic assessment, dietary supplements, staff training, menu flexibility, increased choice and mealtime assistance will assist, achievement of a reduction in malnutrition requires holistic and whole-of-staff approaches. However all of these measures will involve costs that will present budgetary challenges for establishments and government funding sources.
What contribution can ethics make to addressing and improving this significant need? In the last five decades, bioethics scholars have developed and refined the key ethical values and principles that can offer assistance. They can provide a basis in ethics for supporting – or opposing – interventions. At least three of these seem to have potential to offer arguments in support of interventions to reduce malnutrition among residents in aged care establishments.
Beneficence – acting to benefit others – has a specific meaning in relationships of care that would include that between providers of aged care and residents. Here, beneficence means an ethical obligation to act for the benefit of residents. In nutrition, the ethical principle of beneficence can be used support not merely adequate nutrition but a level of food provision that reduces the risks of malnutrition as well as nutritional assessment measures.
These will involve debate as to what is the benefit to residents that better nutrition is to achieve and what are the costs of that provision. Although cost-effectiveness analysis that measures the cost in monetary terms against benefits in non-monetary terms, for example, a reduction in malnutrition levels to 25%, is not an ethical tool, the need for such analysis arises from the ethical obligation of beneficence.
Respecting autonomy, commonly abbreviated to simply autonomy, means recognising that human beings have value in themselves. It is a broader obligation than respecting the capacity of individuals to make their own decisions - it extends to respecting their values and their culture. In nutrition, respecting autonomy would thus include providing for residents’ cultural diets, opportunities to exercise preferences in food and shorter menu rotations. There appears to be evidence that such measures are related to better nutrition.
Justice is an underlying ethical value and principle whenever there are questions about the distribution of scarce resources. Here, it is usually referred to as distributive justice and a choice needs to be made of the criteria for that distribution. Established criteria include: to each according an equal share, individual need, effort, contribution or merit. Of these, the measure of need - at least need to avoid malnutrition - would seem to offer the kind of ethical support for improvement in food provision.
In contexts of limited resources, there will also be debate about the level at which to deploy ethical arguments of distributive justice. Is that level a particular aged care establishment, the funding category to which that – and other establishments - belong or the overall State or national budget allocation of funds for aged care? If the ethical obligations of beneficence and respect for autonomy that an aged care establishment owes in providing nutrition to its residents are to be fulfilled, the debate will need to start at the establishment level: which ethical criterion of distributive justice informs its nutrition provision?
A criticism of ethics is that it does not always provide answers to problems. This is a partial misunderstanding. Ethics contributes to the resolution of problems by clarifying the ethical grounds, on which competing solutions rest and, in turn, provides, from among those grounds, an ethically defensible basis for the choice of a resolution. Nutrition in aged care establishments is a typically complex human situation in which ethics can offer constructive assistance.
Colin Thomson
BA, LLB, LLM (Sydney)
www.ehealthinfo.gov.au.
Colin Thomson is Professor in the Graduate School of Medicine at the University of Wollongong and is Academic Leader for Health Law and Ethics. He also works as a consultant.
He has held positions at the Faculty of Law, Australian National University (1972-1988), where he introduced teaching in medicine and law, and the Faculty of Law, University of Wollongong (1991-2002).
From 1988-91, he was a member of the Medical Research Ethics Committee of the National Health and Medical Research Council and, from 1998-2002, a member of its successor, the Australian Health Ethics Committee, and Chair of that committee from 2006-2009.
He is Associate Editor of the Journal of Bioethical Inquiry and is a joint author of Good Medical Practice: professionalism, ethics and law, 2010, Cambridge University Press.