The concept of vulnerability in aged care: a systematic review of argument-based ethics literature

Abstract

Background Vulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept. Methods Using PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher’s Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology. Results Thirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults’ vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults’ vulnerability: understanding older adults’ vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures. Conclusions The way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human.

Vulnerability, ageism, and health: is it helpful to label older adults as a vulnerable group in health care?

“…In a recent systematic review of the literature on the concept of vulnerability in aged care, the meaning of vulnerability in the context of older adults and health has been analyzed from an ethical perspective. Thereby it is highlighted that vulnerability is value-laden and at the same time under-theorized as a concept (Sanchini et al 2022 ). Much more, terms such as frailty, dependence, or loss of autonomy are often used interchangeably with vulnerability (Levasseur et al 2022 ).…”

“…Such an undifferentiated view, in which vulnerability is interpreted as a lacking capacity “to make informed judgments for oneself, being socially or economically disadvantaged, or […] the result of other factors that contribute to a lack of autonomy” (Nuffield Council on Bioethics 2007 ), is pervasive. In particular, the literature identifies incapability of self-determination as a condition of vulnerability (Sanchini et al 2022 ). In turn, this understanding reflects a mostly deficit-oriented view of the topics concerned and an individualistic perception of autonomy.…”

“…Often older age and vulnerability are understood as being inherently linked to each other and, sometimes, older adults are even described and handled as a paradigmatic example of vulnerability; the main reason presented to explain this presumed connection is biological and cognitive decline in the context of ageing being connected to a higher risk of diseases (ten Have 2016 ). This is associated with an understanding that assumes a progressive loss of power and control when becoming older (Sanchini et al 2022 ). This view became also evident through a large-scale survey, in which especially younger people agreed to the statement that older age is characterized by frailty, vulnerability, and dependency.…”

When nurses' vulnerability challenges their moral integrity: A discursive paper

“…The protection of vulnerable groups and individuals has always been of particular importance in the context of nursing. Vulnerability is mainly discussed in research and practice with a focus on the patient (Sanchini et al, 2022; Sarvimäki & Stenbock‐Hult, 2016; Sellman, 2005; Wardrop et al, 2021) and extensive knowledge exists about its sources, including uncertainty and existential threats posed by illness (Schrems, 2020). Nurses, by contrast, are primarily considered through the lens of integrity in research and practice (Lach, 2019; LaSala, 2009).…”

Electronic Tracking Devices for People With Dementia: Content Analysis of Company Websites

“…Although all persons are vulnerable, certain individuals, groups, and populations experience a special vulnerability and are “more subject to possible harm and violence than others” [ 12 ]. In dealing with dementia and its challenges to physical, psychological, and social capabilities, persons with dementia and their families face a variety of particular vulnerabilities that are exacerbated or lessened by their social context (eg, level of accessible care and social support) [ 13 ].…”