With few exceptions—ethics and dementia, competency and decisional capacity, guardianship, and adult protective services—the intersection of mental health, aging, and ethics has received little attention. More broadly, considerations of ethics and mental health have focused on distributional questions, for example, priority setting for insured mental health benefits (Boyle & Callahan, 1995; Sabin & Daniels, 1994) or the ethical implications of diagnostic classifications (Sadler, Wiggins, & Schwartz, 1994), without regard to the possible relevance of age. Recently, efforts to understand the ethical implications of managed care have touched upon mental health services for older people (Wetle, 1993).
This chapter will move in other directions. It opens by describing a specific way of thinking about ethics, mental health, and aging. This perspective is broadly social in orientation and focuses on issues that transcend individual decision making. Thus the chapter's second section will address the historical context in which many of these social problems arose. Turning next to practical issues, the chapter will identify ethically sensitive issues in mental health care for the elderly. Next, it will raise and suggest answers to the question, what ought to be the ends of mental health care for the elderly? In conclusion, it will develop recommendations for mental health care grounded in normative ends. This chapter will not address questions that are well covered elsewhere, such as issues of competency or guardianship (see Generations, suppl. 1990, for an overview of these themes).
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