Posted: 09/05/2012 Hi. I'm Art Caplan in the Division of Medical Ethics at the New York University Langone Medical Center. Today I want to talk to you about a fascinating issue that concerns personal choice, freedom, and autonomy. I know that some of you are starting to think, "Uh-oh, here we go again. It must be about end-of-life care or about involvement in research ethics." No, this is a lot more basic, ordinary, and everyday.
A paper[1] came out recently that caught my eye. It argued that people in nursing homes ought to have the right to have sexual relations and that this is not something that doctors bring up with either the patients or the families when someone is getting ready to go to long-term care. It is a problem that I have been aware of, but the article reminded me that it is important to put this issue forward and talk about it -- something we don't like to talk about, which is sex in the elderly. I think a lot of us like to think that the elderly, whatever else they might be doing, are not having fun and romping around in the bedroom.Well, the data do not support that. Plenty of people are married and sometimes one of them has to go to assisted living or into a nursing home setting. That does not mean that their marriage has ended and that does not mean that their relationship and intimacy are over. They need to have a situation in which they can talk about how they are going to spend time with one another.
One of the big problems is that nursing homes are set up to afford people very little privacy for legal and safety reasons. There are almost always double rooms and it is hard to lock a door. There is no place to go. When you are talking about this with a patient or a family, you first need to broach the idea that romance might still be in the cards. Second, you have to talk to the administrators and see how they handle this sort of thing. Can they find a private spot? Can they lock a door? What is the attitude of the organization and the institution? All of these should be discussed.
What if the patient is not married? What if he goes to the nursing home and he finds someone that he likes? That happens, too. Are you going to handle a request for erectile dysfunction drugs? Are you going to do what it takes to facilitate sexual or romantic encounters? Intimacy can be achieved in a lot of ways without sex. That can be explained to people in nursing homes. I don't have a moral problem if somebody says, "I'm here. I have met somebody that I like and I would like to have a relationship." But children of those older parents might, and they need to be involved in the discussion so that they are not outraged, objecting, or trying to interfere in things that are not their business. We are talking about a competent adult.
The bottom line is this: We fret about how to give people autonomy when it comes to dialysis, a feeding tube, or pain medication if they are very ill and dying. Those are all great issues around autonomy. I suspect that a lot of the time, the people we are talking about don't have much autonomy left. They are too sick. What they care about are things like whether they can have visitors, whether they can go for a walk, or whether they can have romance. These take place much earlier in the nursing home or assisted-living setting, and that is where autonomy could really be put to good use.
My suggestion is that part of the emphasis when having discussions with elderly people -- particularly when the issue comes up about being taken care of in a nursing home -- should be that sex is a part of old age.
This is Art Caplan at the New York University Langone Medical Center. Thanks for listening.
References
- Tarzia L, Fetherstonhaugh D, Bauer M. Dementia, sexuality and consent in residential aged care facilities. J Med Ethics. 2012 Jun 25. [Epub ahead of print]
Medscape Internal Medicine © 2012 WebMD, LLC
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