middle aged asian woman holding an older asian woman

Bioethics Forum Essay

Singapore Case Notes: In the Community, Who is Ethics Education For?

For previous posts on the Singapore Casebook project, a collaboration among the Centre for Biomedical Ethics at the National University of Singapore, The Hastings Center, and the Ethox Centre at the University of Oxford, see here and here .The first edition of this public, web-based casebook, “Making Difficult Decisions with Patients and Families,” was published in 2014. The second edition, “Care Transitions in Aging Societies,” will be published in 2017.

In February, our team held six workshops with Singaporean health care professionals to discuss the cases we’d developed, based on discussions during earlier visits, to illustrate common ethical challenges in the care of aging, often frail or chronically ill people in Singapore. Piloting workshops is always exciting, because we get to see what real people make of our fictional characters and situations. Do they seem “realistic” as well as “typical”?

One case is structured as a dialogue between an elderly woman determined to live independently despite deteriorating health and a case worker who is trying to figure out whether he should support his client’s choices or try to change her behavior. This case prompted participants in several workshops to ask the same question: What language are these people speaking? The characters’ names were Chinese – but would a young case worker speak the same dialect as a client who is 50 or 60 years his senior? Or should we imagine that the elderly woman had attended English schools as a child and was accustomed to speaking British-influenced English? Or did they both speak Singlish? Would the case worker call his client “ah po” (Grandma)? Or “Auntie,” the Singlish equivalent for addressing an elder in a friendly yet respectful way?

As we worked with our local colleagues to fine-tune the case narratives and get small, meaningful, local details right, we gained fresh insights into how members of different health care professions perceived our project’s goal. The first edition of the Singapore Casebook focused on medical decision-making and on doctors as moral agents. The second edition, with its broader focus on ethical challenges arising in an aging society, explores situations that involve illness and aging, therefore health, but not necessarily health care.

In Singapore, engagement with the ethical challenges of care and care work– arising for leaders and staff in community-based organizations or in collaborations with health care professionals, families, and foreign domestic workers– is new.  Singapore is home to many pilot programs in health care delivery for its aging population, but resources remain centered in hospitals or are allotted through care transitions originating in the hospital. The ethics of providing and receiving care “in the community” – to a frail or chronically ill person living at home, in a family member’s home, or in a nursing home – is a new area for bioethics here. Case-based ethics education, as a way of reflecting on and strengthening practice, is more familiar to physicians than to social workers and nurses, and may be unfamiliar to case workers, program administrators, and others. As our focus broadens from clinical and professional ethics, to organizational and social ethics, we ourselves are reflecting on how to adapt teaching and learning tools so they are useful and appealing to broader audiences.

This project is also raising intriguing questions about how to use realistic fictional narratives to help people new to ethics see and reflect on the moral dimensions of their daily work. For example, at what point does a person, by accepting a neighborly offer of help, become a client receiving “community care,” and object of scrutiny? As we imagined that fictional, realistic encounter between an old lady who is trying to live her life and an earnest, imperfect young case worker who is trying to do the right thing, we first had to imagine how these two people found each other. The “bedside” encounter is easy to see. Imagining the effort to keep things as they have been at home, as an aging person’s health changes, as a caregiver’s patience frays, is more difficult.  Considering how and why to support ethics teaching and learning in the community, close to the lives of aging people, is an ongoing question for our project team, and for health care ethics in aging societies.

Nancy Berlinger is a research scholar at The Hastings Center. Michael K. Gusmano is a research scholar at The Hastings Center and an associate professor of health policy in Rutgers University School of Public Health. Jacqueline Chin is an associate professor at the Centre for Biomedical Ethics of the Yong Loo Lin Medical School at the National University of Singapore. Michael Dunn is director of undergraduate medical ethics and law education at the Ethox Centre of the University of Oxford. The Singapore Casebook Project: Care Transitions is directed by Jacqueline Chin and is funded by the Lien Foundation.

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