Bioethical aspects of the autonomy of the elderly

This study was performed through a review of literature and it aims to describe bioethical issues involved in the autonomy of the elderly. This bibliographical survey was carried out through the recorded production of the following databases: Ibecs, Lilacs, Medline, Cochrane Library, and SciELO; besides of books that focus on the topic. This reflection is considered significant because the number of elderly has grown rapidly in recent years and studies have shown that this increase is concomitantly associated with a lack of respect for this population’s autonomy. It can be concluded that such principle should be founded on bioethical attitudes and respect for the elderly as autonomous people. It is therefore suggested that further studies should broaden the discussion about this subject, in order to guarantee a better quality of life for the elderly in a rapidly aging society.


Bioethical aspects of the autonomy of the elderly
In recent years, Brazil has demonstrated that its population profile indicates rapid change in the age structure, highlighting the progressive growth of the elderly population.The phenomenon is due mainly to the decline in fertility and increase in life expectancy, as major factors involved in this accelerated process of population aging 1 .
Information from the Brazilian Institute of Geography and Statistics (IBGE in Brazil) 2 show the enlargement of the top of the age pyramid, marked by the growth in the relative share of the population aged 65 years old and over: 4.8% in 1991, 5.9% in 2000 and 7.4% in 2010.Additionally, it can be noticed a higher incidence of diseases and physical deficits as well as in the psychological and social fields, so that more experienced years can be translated into years covered by diseases that lead to sequels and suffering for the elderly -besides suffering mistreatment, which favors further functional decline -, to the reduction of independence and autonomy, and especially to social isolation and deep sadness.
The reduction in functional capacity and independence of the elderly can result in negative consequences not only for him/herself, but also changes in lifestyle and burden on family caregivers 3 .In contrast, aging leads the individual to acceptance of reality, tolerance to physiological decline.This can be called psychic independence by increasing the understanding of the meaning of life, with increasingly higher values 4 .
Balance between psychological and biological aging is therefore the way to the meeting of autonomy and independence 4 .It is postulated that independent elderly people who have effective social interaction and are well-integrated to their families, may expand their ability to recover from health problems and improve their longevity.Thus, the loss in the autonomy of the elderly directly compromises their quality of life and the whole family dynamics 5 .
The valorization of the the elderly's autonomy, or not, permeates cultural aspects, as the indigenous cultures in Brazil and non-Western, for example, di-rect the community to the respect and obedience to elders, because of their intelligence, experience and wisdom gained over time.This is as the Russian proverb says: "Where the white hair is there is the reason".However, literature has neglected this aspect, not having been found studies that address the following aspect as we did the search for this research.
In the context of gerontology, when considering the autonomy, or the bioethical principle of respect for persons, it is discussed their competence in dealing with it and making decisions 6 , even before other controlling factors such as diseases, cognitive limitations, abuse, culture, or even the family.Introducing the backdrop of bioethics, science that contextualizes various subjects related to human existence and responsibility 7,8 , this article discusses a narrative review that focuses on bioethical issues involved in the elderly's autonomy.

Method
The approach to the subject was undertaken by means of a systematic survey of articles in indexed journals published in the last ten full years (2002-2012), which were filtered later to a superficial reading, leaving only the relevant ones to the topic under discussion.It was used the information searched in the following databases: the Cochrane Library, SciELO, MEDLINE, IBECS, Lilacs and books geared to the theme.For the research, descriptors were selected from DeCS (Descriptors in Health Sciences): bioethics; autonomy; elderly; health of the elderly.As the aim of the work was to retrieve studies that had one and/or other descriptors in the fields for which the search was being directed, we used the Boolean operators AND and OR.The final query allowed us to select 16 texts in Portuguese, English and Spanish which were analyzed so that one could complement the central idea of the other and thus allow us to build a new text including the leading discussions related to the elderly's autonomy on bioethical issues (Table 1).

Human aging and new challenges
The theme of human aging has often been studied in recent years, due to demographic and epidemiological transitions that occur worldwide.Despite the focus given to this issue, it is notoriously difficult to address the situation of the elderly in modern culture.This is because while science seeks alternatives to the conquest of the great dream of immortality, the economy reduces the elder to the condition of a useless old person, pure consumer of products that promote longevity.What it is observed is that population aging was not accompanied by social appreciation of the elderly.The status and power directed to the elderly in the past gave rise to the view of the elderly as a generator of pension expenses and a burden to family members who surround him.Within this entire context it emerges discussions in the field of geriatrics and gerontology to elucidate the true role of the elderly in modern society -driven by the utopia of perfect health 9 .
Aging is characterized by the expression of biopsychosocial events that occur over time and not with time, as some authors postulate.In this light, it is established that chronological age is not directly correlated with the biopsychosocial age, confirming the assumption that this process has an individual character, in which each elder being is unique and carries several peculiarities.The various chronic diseases that accompany the aging process are resulted from the increase in incidence of those risks, either by the biological process itself or by long periods of exposure to pathogens 10 .
In this context, it is important to understand that the term aging can take two different perspectives: senescence or senility.Senescence is characterized by healthy aging in which changes in organs and tissues occur synchronously.Senility is characterized by not healthy aging, in which it is observed associated pathological processes 11 .The development of chronic diseases and characteristics infirmities of this age group causes changes in lifestyle and in the family context, which consequently leads to the appearance of uncommon situations hitherto experienced in covering ethical issues.
The increasing life expectancy witnessed in the last 50 years 12 relates to the increase of chronic degenerative non-communicable diseases (NCD) and impaired functional capacity of the elderly.This factor contributes to decrease their quality of life, generating important implications within the fami-ly and social context, the health system and in the lives of aging people.In parallel, the conservation of functional capacity implies positively on their quality of life by allowing them to enjoy more independence even older 13 .
When there is awareness that healthy aging is substantiated from health promotion activities, from the universal access of the elderly to health services and social well-being throughout life, aging is characterized as an emerging theme in the field of bioethics, calling for reflection on the elderly, their association with other generations and their inclusion and participation processes in society 14 .To Fonseca et al 15 , the functional capacity is a very expressive unity reagarding health.
In Brazil, aging is occurring quite rapidly and differently compared to more developed countries.In order to reduce the burden of elderly's disability, benefiting large segments of this population, it is required, in addition to preventive and individual actions, reduction in social, educational inequalities and better institutional support.These measures should become a priority of public policy in the country, in order to better encourage this age group 16 .

Elderly's autonomy in the light of bioethics
Initially, it is important to revisit the concept of autonomy as a principle of bioethics, before applying it to the subject of this article.The appreciation of this concept in the context of the need to understand the ethical issues inherent in human experimentation 17 shows that the term relates to the human competence to legislate for itself, the ability to control, cope and make personal decisions in everyday life 6 .
Beauchamp and Childress employ the concept of autonomy to examine decision making in health care, defining the autonomous choice as the act of governing effectively and not simply the ability to rule 18 .The personal autonomy can be influenced by controlling factors, such as the excess use of medication, emotions, literacy, institutionalization, limitations to the level of sensory functions (hearing and visual), and mainly by mental capacity, enough rationality and intelligence 16,18 .It is postulated that the person with reduced autonomy may influence other individuals in some aspects, or simply may not have the power to act on their goals and desires 18 .To be autonomous and independently choose does not mean the same thing of respecting the autono-Bioethical aspects of the autonomy of the elderly mous person, i.e., to respect is to allow the right to self-government recognized -and the principle of autonomy expresses this right 17 .
However, for an action to be considered autonomous it must be executed without any manipulation or influences that reduce the protagonist's freedom of choice 19 .Importantly, the individual should be fully informed about the pros and cons of the decision to be made, in order to be able to understand and evaluate the information received.The act of consent must be genuinely voluntary and based on proper disclosure of information 16 .According to the Universal Declaration on Bioethics and Human Rights, from the United Nations Educational, Scientific and Cultural Organization 20 , in its Article 5, a person's autonomy must be respected as long as it respects the autonomy of others and takes responsibility for making decisions .
When discussing the reduction or loss of autonomy in a gerontogeriatric context, it is common to associate to the social or physical dependence, which often can induce a stereotypical perspective on the elderly, which reinforces the idea that every elderly dependent have compromised autonomy.This understanding helps to strengthen attitudes that disregard the elder as a participant of the existential process, able to decision making in guided autonomy.
Autonomy has been defined in the field of gerontology as the ability to make judgments and to act 15 , and can be seen from two perspectives: as an ethical task, for the elderly and as a moral requirement for the caregiver.The elder must face and take the process of senescence, when it comes to coping with the limitations and modifications, and, at the same time, be able to live their lives autonomously.However, trying this transformation process is usually not very easy for the elderly 4 ; some spontaneously lead this transition and with relative tranquility, while others require learning to be induced.
The caregiver, especially if a family member, is also seen under the impact of this process, many times.Either a spouse or a child, the caregiver suffers to understand the physical and psychological changes in the elderly, which in most cases ends by undoing little by little, the picture that had been built along the common life.Even in the full enjoyment of health, the elderly tend to lose mobility, visual acuity, hearing, and mental agility -among other attributes which they enjoyed with fullness in previous years.Thus, family care implies an ethical challenge.The commitment to contribute to the de-velopment of the autonomy of your elderly family member should encourage, where possible, decision making and initiative in matters relating to hygiene, health, occupation, relationships, even when the caregiver observes the decrease of the elderly's capacity and skills 9 .
To respond to this ethical challenge it is important to understand and transcend the moral values currently assigned to the elderly: physically and mentally decrepit beings totally deprived of their right to choose, and largely considered socially useless.It is crucial to realize that these ideas, like any other values are imposed by society and are not necessarily the truth.Such mythic constructions of aging and youth are perceived from the classical societies, culminating in a postmodern culture of horror to old age 21.It is then necessary to undress these (pre) concepts to enable ethical practice to guide everyday relationships with older people, based on the respect each other as an acting subject 7 .
And it is precisely because the elderly act as active subjects that, in some situations, they even support their families, offering them intergenerational cohabitation, which, in turn, enables the mutuality of care and helps them feeling integrated into family life and conquering the respect and acceptance of the youngest 22 .It is the same reason elderly and retired are the primarily responsible for family maintenance and support, because it is not uncommon to be the only family members who receive money regularly.
But even in situations where the elderly are not the owner of the residence or contributes decisively to the survival of the family group, it is important to strengthen the consciousness of their own autonomy and that a development is possible in the aging process 9,21 .Therefore, it is necessary that those around him treat him, to the extent of their possibities, as an autonomous being.Therefore, it is crucial that family members, caregivers and healthcare professionals eliminate infantilization in dealing with the elderly, notably observed phenomenon, highlighting the strong tendency to treat them as dependent, someone who cannot decide the best for his/her life.Similarly, it also considers that the installation of groups of living in old age is also a potentiating strategy for physical and mental health of those who participate in them, helping them to assume, with awareness and autonomy, the aging process and offering symbolic references that reinforce their value as persons and the search for new meanings to life 9 .

Bioethical aspects of the autonomy of the elderly
Thus, it becomes clear that to understand the elder in a broad perspective is necessary to consider its multidimensionality, understanding aspects of social, political, economic and cultural bioethics that will allow the analysis of the changes in relationships with people of this age group 23 .Modern moral precepts about aging are shown paradoxical: on one hand, they declare by legislation respect the elderly, on the other, it becomes clear the disregard for these elderly, as they are considered a burden to society.This paradoxical situation of respect versus neglect is reflected not only in how the elderly are perceived, but also in how they are treated and taken to behave.To be accepted, they need to abandon their principles of self-determination and fully accept other people's tutelage, as well as often being forced to assume behaviors which differ from their personality 24 .To induce independence of older people in a positive in his family circle, caregivers and society as a whole is to generate mutual understanding of the identity of persons in this age group and their livelihoods.It provide changes in attitudes and connotation of values that allow the elderly to direct his/her life according to their needs, desires, adaptations and personal achievements, since it is possible a connection with the productive age in the field of daily experiences 21,25.In this context, it is understood that to ensure autonomy over decision-making by the elderly as well as ensure mastery of physical skills, is to be ethical with the individual that is embedded in society and has vitality.For this it is essential to sensitize caregivers and society at large, whose members eventually will be familiar to older people, to develop greater awareness of the physiological limits of the natural aging process, avoiding removing from the individual the right to direct their own life, but equipping them to a new autonomous and safe way of life.

Final Considerations
The issue of autonomy has been quite prominent in discussions in the fields of gerontology and geriatrics.According to the National Health Policy for the Elderly (PNSPI in Brazil), it is essential that measures which cause active aging are enhanced, turning increasingly to valuing autonomy as an essential function.The increase in life expectancy featuring human aging is derived from advances in science and technology and presents ethical challenges that require the need to rethink the later stages of life.This reinterpretation of aging should have qualified professionals in order to care for the elder in all its dimensions, as well as be guided in the process of social awareness about aging.In this sense, bioethics shows to be an effective tool to promote reflection on both the thematic and qualified approach to people in this age group since it enables to equate and understand the change in the status and role of the elderly in recent decades, aiming thus rescuing dignity in aging.
The context analyzed, relating to various aspects of the autonomy of the elderly, allows us to identify that the elderly presents itself as the main character.It is thus important that health actions are discussed not only for them, but especially with them so as to preserve the elderly's autonomy and increment it.The quest for the right to act independently enables healthy and enjoyable longevity for the population that continues getting older, and also for those who are professionally responsible for protecting the elderly's health.

Table 1 .
List of selected papers, including their respective authors, journal and year of publication Bioethical aspects of the autonomy of the elderly