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Chapter 2: Literature Review
Alzheimer’s or dementia in old age). Hofland (1994) had previously recognised that
the capacity to make decisions is integral to autonomy and stated that autonomy is
still relevant for older people with diminished cognitive capacity. Hofland (1994)
explained that making decisions is key to realising one’s autonomy and that the
capacity to do so varies along a continuum of cognitive ability as one ages.
Personalising daily routines by choosing what clothes to wear or expressing food
preferences are examples of simple decisions that most older people have the
capacity to make. Cook (2010) classifies residents’ decisions as micro or macro.
Micro refers to daily decisions about clothes and food, etc. Macro refers to decisions
about operations and medical interventions, etc.
“Decisional incapacity on some dimensions does not mean decisional
incapacity on all dimensions. The capacity to make a decision is
decision-specific.”
Hofland (1994, pp.31)
Hofland (1994: 31) explained that patients’ autonomy is threatened by professional
paternalism and “institutional self-interest”. Hofland (1994) suggested that when a
resident’s cognitive ability fades, as in the case of dementia, the caregiver must
reconfigure the balance between paternalism and autonomy, subsequently providing
beneficent care that is guided by respect for autonomy, dignity and personhood. Mill
(1975) explained that autonomy is about persons who are radically individualistic
and who determine their own beliefs, values, tastes, aspirations and actions in an
activity of individual free and rational will. The only legitimate reason for
interference in another’s actions is if those actions present clear and immediate harm
to another person’s equal liberty. Historically, health care was provided in a
paternalistic manner (Department of Health, 1968; O’Shea et al., 1991). However,
the changes that have taken place in society over time are now challenging the future
of healthcare provision to become more empowering and negotiated between
healthcare professional and client (Health (Nursing Homes) Act, 1990; McCormack,
2001; Ruddle et al., 1997). The meaning of autonomy becomes essential when one
considers the changes that are taking place in healthcare provision. Murphy et al.’s,
(2007) analysis described three phases in the approaches to residential care for the
older person in Ireland. Up to the late 1950s there was custodial care, which was care
dominated by routine and focused on the needs of the organisation rather than on the