Doing

To understand what residents are able to do, we need to scrutinize their decisional and executive control over their lives in assisted living surroundings, i.e. their autonomy and agency. As we have seen, national guidelines for the care of older people in Finland, such as The National Framework for High-quality Services for Older People (Ministry of Social Affairs and Health 2008), stress autonomy, the right to determination, and making choices. Based on the previous chapter, the right to self-determination seems to be accepted as a major component of quality in elderly care.

As good as this maxim is regarding service production altogether, it is problematic as a guiding principle for delivering assisted living for older people, where they are most vulnerable (Agich 2003; Pirhonen & Pulkki 2016). As Agich (2003) put it, autonomy and freedom are the dominant and plausible values of liberal political perceptions, but we may have made a serious mistake when expanding their sphere to cover nursing and caring, too.

3.1.1 Autonomy

The autonomy of older people who receive care may be restricted by several factors related to their surroundings and themselves. People’s actions never take place in a vacuum, but human life is intertwined with facticity and connections and interactions with other people (Atkins 2006; Christman 2014; Sherwin & Winsby 2010). Human existence is intersectional and embodied by nature, as the feminist tradition emphasizes (Ells, Hunt & Chambers-Evans 2011; Käll & Zeiler 2014). This is especially true for older people residing in assisted living, since the facilities, even today, have some features of Goffman’s (1968, p. 17) total institutions: all aspects of life are conducted in the same place, many daily activities are carried out in the immediate company of others, activities are scheduled from above by a system of formal rulings, and the purpose of these activities is at least partly to fulfil the official aims of the institution. In addition, resident autonomy may also be reduced by paternalistic attitudes of the staff (Sherwin & Winsby 2010) and sometimes care-related decisions are judged by the motivations and goals of the helpers instead of the helped (Collopy 1988).

The preconditions for autonomous life in assisted living are also restricted by the residents’ diminishing functional abilities. According to Agich (2003, p. 1),

“individuals need long-term care because they suffer illnesses and incapacities that compromise their ability to function independently and choose rationally.”

Emphasizing rationality is especially dubious in an assisted living context since we know that cognitive illnesses, such as dementia, are the number one reason for older people to end up in residential care (Matthews & Denning 2002; Noro & Alastalo 2014; Wolinsky et al. 1993). Residents execute their diminishing functional abilities in situations which are de facto out of their control in many ways. This makes their autonomy highly relational.

The concept of relational autonomy (Atkins 2006; Christman 2014; Sherwin &

Winsby 2010) would fit assisted living better than other concepts, since it takes into account that individuals’ actions are inevitably connected to multiple relational factors, such as social relationships, personal characteristics, and the chances and restrictions of the agent’s environment. Prior research indicates that autonomy in assisted living is constant balancing between independence and dependence (Ball et al. 2004) and adjusting to changes in the residents’ abilities (Morgan et al. 2014).

Baltes and Baltes (1990) discussed a lifelong process of maximizing gains and minimizing losses by means of three processes: selection, optimization, and compensation (SOC). According to the SOC-theory, older people use multiple coping strategies, such as lowering standards and using aids, to maintain a feeling of control in their lives despite diminishing functional abilities (Freund & Baltes 1998;

Rothermund & Brandstäder 2003). In an earlier study on autonomy of community-dwelling nonagenarians (Pirhonen et al. 2016), we introduced the concept ability others to describe how nonagenarians highlighted their autonomy by checking it against the situation of those peers who had transferred into a care facility. Institutionalized people were seen as ability others since they had lost their independence due to diminishing abilities. The concept of relational autonomy has a strong affinity with the SOC-theory; they both acknowledge the importance of negotiation when an older person uses her remaining resources to maintain a good life.

3.1.2 Agency

Relational autonomy acknowledges that the environment always influences our decision making in one way or another. In sociological tradition, this individual-environment interaction has been discussed in theorizations about human agency (Giddens 1984; Jyrkämä 2008; Ritzer 2000). The classical, Giddensian interpretation of agency entails that on the one hand, social structures direct individual action, which then, on the other hand, reshapes the structures. Elder and Johnson (2003) define agency by stating that individuals construct their own life course through the choices they make and the actions they take within the opportunities and constraints of history and social circumstances. Defined like this, a close communion between agency and relational autonomy exists.

Although autonomy and agency operate in the same field of self-determination, there is a difference that challenges us to study them separately as elements of good human life. Autonomy and agency carry features of each other. As we saw, the concept relational autonomy acknowledges the influence of environment regarding our decision making (Atkins 2006; Christman 2014; Sherwin & Winsby 2010).

Agency focuses more on our opportunities to execute decisions within the limits of social or other structures around us than relational autonomy (Giddens 1984;

Jyrkämä 2008). The basic difference is that autonomy incorporates primarily decision making whereas agency deals with action taking. People make more or less autonomous decisions, while their success in the execution of those decisions dictates how agentic they are.

Once again, suspicion arises when we consider agency and older people with diminishing functional abilities residing in assisted living. Elder and Johnson above described agency as the “choices they make and actions they take”. As Wray (2004, p. 24) expresses it, “dominant Western conceptualizations of agency are often used

uncritically; individualistic notions of choice, autonomy, and in/dependence often pervade accounts of agency.” Frail older people seem to be at risk of becoming

“have-nots” in terms of agency. Indeed, Gilleard and Higgs (2010, p. 122) hold that residents of assisted living facilities have lost their cultural frame of reference regarding individual agency due to failure in self-management and transfer into round-the-clock care. These readings of agency are problematic when considering people with limited functional abilities, since they presuppose certain competences (Atkins 2006; Morgan et al. 2006) which frail older people often lack.

An obvious factor that has so far influenced our perceptions of agency is the triumph of activity regarding gerontological research. Both physical and social activity has become the major component of successful ageing (Baltes & Carstensen 1996; Rowe & Kahn 1997). According to Tulle (2008), physical activity is advocated as prevention against falls and the reduction of functional abilities, and it carries the potential of improving quality of life in old age, which produces cultural capital that older people gain by “staying fit”. Katz (2000) holds that activity has become such a paradigm of well-being in old age that questioning it would be considered unprofessional or even heretical. As important as activity is regarding both quality of life in old age and the economic resilience of society, we need to acknowledge again the vulnerability of human life. Agency is not necessarily active trade or reciprocity between the individual and structures. Agency is more about both an actor’s individual characteristics and her environment influencing chances to fulfill her aims.

Therefore, it answers Nussbaum’s (2011) question “What is this person able to do?”

for its part.