We Are All Responsible: Ethics of Elder Care in COVID-19

By: Sarah Moses

May 1, 2020

Responding to: Religion and the COVID-19 Pandemic: Vulnerable Populations

We Are All Responsible: Ethics of Elder Care in COVID-19

When I teach my comparative religious ethics course, I have found that one of the moral insights my college students find most compelling is from Jewish thinker Abraham Heschel: “Few are guilty, but all are responsible” [1]. Heschel applied this argument to the 1968 My Lai massacre during the Vietnam War in his insistence that all Americans were responsible for ending the conflict. But Heschel’s insight, drawn from his reading of the Hebrew prophets, could be applied to the current situation of elderly people living in long-term care facilities which are being ravaged by the COVID-19 pandemic. In a press conference regarding Canterbury Rehabilitation and Healthcare Center in Richmond, VA, site of one of the highest death tolls nationally, medical director Dr. James Wright acknowledged it would be important to assess what steps the facility could have taken to better protect its residents. However, he went on to state: “It’s also important to see what we, as a society, could do differently, because this will not be the last untreatable virus to decimate our elders. When we, as a society, see that it’s appropriate to warehouse our elders, and to put them in small spaces, to underpay their staff so that there are chronic staffing shortages — I think if we see that as an adequate treatment of our elders, then we’re going to have a bad time. We are going to see this over and over again. We all opted for this type of environment for our elders” [emphasis mine]. Heschel’s call to universal responsibility together with Dr. Wright’s insight concerning societal accountability for the conditions in which elders live suggest that the COVID-19 crisis provides us an urgent opportunity to radically reshape elder care for the future.

In the United States about 1.5 million people live in nursing homes and about 1 million in assisted living. Furthermore, with the significant growth of the 65+ population projected through 2050, there will be an increase in the number of older Americans living in congregate care settings. While the majority of older Americans live in the community, we must recognize that those living in long-term care settings face acute vulnerability in this crisis. In fact, the grim picture of COVID-19’s devastation for these elderly is now painfully clear. The World Health Organization (WHO) now estimates that up to half of coronavirus deaths in Europe were residents of long-term care facilities. Disturbing stories of neglect and death have arisen in countries like Italy, Spain, and France: For example, on March 23 in Madrid, Spain, soldiers sent to disinfect a nursing home discovered dozens of elderly residents who had been left dead in their beds, abandoned by staff who themselves were sickened or feared being infected. 

Here in the United States a similar pattern is evident. The New York Times reports about one-fifth of COVID-19 deaths in the United States come from long-term care facilities, and at least 36,500 residents and employees nationally have contracted the virus. Since the first confirmed outbreak in Kirkland, Washington, deadly outbreaks have plagued nursing homes and assisted living facilities across the country, from Louisiana to Maryland to Indiana to New York. In hard-hit New York City, nursing homes account for one in four coronavirus deaths, and in one large nursing home in New Jersey, police discovered 17 bodies stacked up in a small morgue. These painful realities led one former New York state official to refer to nursing homes as “death pits.”

Watchdog groups are warning the true extent of virus infection and death is still likely undercounted as reporting from long-term care facilities has been inconsistent nationally. In fact, across the country family and friends of elderly residents have been frustrated by the inability to get accurate information about their loved ones and the conditions within the facilities where they live. While the Trump administration recently announced strengthened reporting requirements for long-term care facilities, compliance is still a challenge without enhanced surveillance and enforcement nationwide. As in Europe, long-term care administrators and elder care advocates have documented chronic staff shortages and a lack of access to testing and personal protective equipment, as these resources were allocated elsewhere. The situation is so dire that states like Maryland and Rhode Island are now bringing in National Guardsmen to shore up struggling facilities. As one nursing home executive in New York asked, “The story is not about whether there’s COVID-19 in the nursing homes. The story is, why aren’t they being treated with the same respect and the same resources that everyone else out there is?” 

Even in facilities without outbreaks, the measures recommended to protect vulnerable residents increases social isolation and loneliness for a population already marginalized from their communities. Following the outbreak in Kirkland, elder care facilities across the country banned all visitors, including family members; ended congregate activities such as religious services and communal meals; and in some cases prohibited residents from leaving their rooms. While such measures may be warranted from a safety perspective, as one observer put it, more isolation is not what older people need emotionally and psychologically. In fact, a report issued in February by the National Academies of Sciences, Engineering and Medicine warned of the negative psychological and health impact related to the social isolation and loneliness experienced by many older adults. Old age in and of itself doesn’t make a person lonely or isolated; but as the report explains, the current conditions within elder care facilities create a much higher risk for this population.

Understanding the vulnerability of elderly living within long-term care facilities is not complete without recognizing the intrinsic link between the condition of careworkers and the well-being of elders. Advocates for improved elder care have long identified chronic problems with the work conditions of direct careworkers, including CNA’s in nursing homes and homecare workers: low pay, lack of benefits such as paid sick leave, inadequate training, professional disrespect, and little opportunity for professional advancement [2]. These conditions lead to high levels of staff turnover, making it difficult to ensure a well-trained staff equipped to prevent the spread of infections. Lack of paid sick leave also results in staff coming to work sick and thus spreading illness to those under their care. Because of low wages, direct careworkers often pick up extra work in other facilities, thus increasing the likelihood of spreading a virus like COVID-19. The vulnerability of elderly living in long-term care facilities is linked to the vulnerability of careworkers caused by poor working conditions which disproportionately affect women and minorities who make up the bulk of long-term care workers.

While the pandemic’s impact on elderly people in long-term care facilities is heart-breaking, this suffering can awaken all of us to a new sense of shared moral responsibility. Drawing from the Jewish tradition, Heschel argued that moral responsibility is “the heart” of the dignity of the human person; it is “the capability of being called upon to answer” [3].  While only some of us have a loved one in a nursing home, we all should feel a deep sense of responsibility for creating a different culture and society around care for the frail elderly. While some nursing home administrators may be found criminally negligent in violating safety requirements, all of us are responsible for the society that has tolerated the warehousing of the elderly and the exploitation of low-wage care workers.

Perhaps the first step in taking responsibility, in claiming this core aspect of our human dignity, is to acknowledge that things can be different. Already such alternative models of elder care exist. For example, the Green House Project, founded in 2001, has partnered with senior care organizations across the United States to build small family size care homes with 10–12 residents, each having a private room and easy access to an outdoor patio. The Green House also has a revolutionary vision for staff, empowering direct careworkers, lowering staff turnover, and increasing professional opportunities. With over 15 years of experience since the first Green House homes were built, research has shown this model is financially feasible and produces better outcomes for staff and residents than traditional large institutions. Experts have reported the “staggering” financial loss COVID-19 is inflicting on the long-term care industry, especially for the 70% of facilities that are for-profit. However, given the chronic, systemic problems with this industry even before the pandemic, there should be no bail out for the nursing home industry as it exists. Instead, we must all take responsibility in this moment and advocate for federal and state policy and funding to radically remake long-term elder care in a way that truly promotes the well-being and dignity of elders and careworkers.

Religious communities in particular can play an important role in taking responsibility for vulnerable elderly. Given the intergenerational make-up of religious congregations, faith communities could even have a special role in fostering and modeling friendship and solidarity between generations. One example of this is an organization with which I have worked—The Community of Sant’Egidio. Founded in 1968, this international Christian lay community has served elderly people throughout the world with a model of intergenerational friendship in which care is provided to older people at home and in institutions. In some European cities, Sant’Egidio has also founded small family homes and co-housing arrangements in which frail elderly can receive residential care in a personalized manner. In addition to providing direct care, Sant’Egidio has exercised moral responsibility for the elderly by advocating for the abolition of traditional nursing homes and reallocating resources for providing care in the home. In the context of the COVID-19 crisis, for example, the Sant’Egidio chapter in the United States published an appeal calling for concrete actions to ensure the safety of elderly people living in care facilities and efforts to overcome social isolation. And despite the need for social distancing, Sant’Egidio communities have found concrete ways to maintain solidarity with elderly friends, such as writing cards and talking to residents through outside windows. Sant’Egidio seeks to form an alliance with people of goodwill to bring about a lasting shift in societal attitudes toward the elderly.

In a moving op-ed in the Washington Post, nursing home resident Brenda Dikes shared, “The coronavirus makes [living here] so much worse. I’ve been locked in my room, and living in this place doesn’t feel safe . . . How would you feel if you were next in line to get this virus--if you were in danger--and no one would tell you anything?” Heschel’s understanding of moral responsibility suggests that our individual dignity, and the measure of our society, resides in our capacity to be called upon to answer to the voices of those like Brenda Dikes. As Heschel himself declared at the first White House Conference on Aging in 1961, “But the affection and care for the old, the incurable, the helpless are the true gold mines of a culture” [4]. It is my hope that this tragic crisis will finally help us realize that care for and solidarity with vulnerable elderly persons is the responsibility of us all.

  1. ​Abraham Heschel, “Required: A Moral Ombundsman,” Moral Grandeur and Spiritual Audacity (New York: Farrar, Straus and Giroux, 1996), 220.
  2. For instance, Paul Osterman, Who Will Care for Us? Long-Term Care and the Long-Term Care Workforce (New York: Russell Sage Foundation, 2017).
  3. Heschel, “Required," 220.
  4. Abraham Heschel, “To Grow in Wisdom,” in The Insecurity of Freedom (New York: Farrar, Straus & Giroux, 1966), 72.

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