bioethics in recent years. In the nursing home setting, because of the kinds of physical and mental limitations most residents face and because of the social functioning of a nursing home as an institution, autonomy and dependency cannot be seen as opposites. Instead, they must be seen as intertwined facets of one's life and one's state of being. Similarly, autonomy and community must be made mutually compatible in a nursing home setting if we are to get a full and realistic moral purchase on how life is actually lived there.
Second, we need to consider the difficult problem of justifiable limitations on individual freedom of choice and the institutional management of behavior. Problems of this type simply come up differently and have a different feel about them in a nursing home setting than they do in the acute care context, or in most other spheres of social life. And they come up every single day.
Finally, we need to reconsider the basic directions and purposes of our public and regulatory policies concerning nursing home care. There is a growing awareness that an exclusive focus on protection and adversarialism in nursing home regulation is sometimes self-defeating. The policies and the means of their enforcement can create such defensiveness and rigidity in nursing homes that what should be the common goal of everyone involved, namely, the well-being and care of individual residents, gets lost in the process.
The history of the modern nursing home has harsh beginnings, dating back to the nineteenth century almshouses and poorhouses that sheltered the destitute elderly. These institutions were places of both asylum and detention, housing a diverse population of the poor, the chronically disabled, and the mentally ill. Mid-nineteenth-century morality tended to see poverty and disability, even in old age, as signs of an undisciplined, improvident, even profligate life. The harshness of the poorhouse and the social ...