My mother is in her late 80s and lives alone in a house with a big fenced yard. She’s sharp, mobile and surrounded by friends. She has always lived with a dog, and she gave her last one a wonderful life until his recent death. She’s ready to welcome another older companion who fits her lifestyle.
When she recently tried to adopt, though, several rescues refused because of her age. A few of her younger friends — myself included — have offered to act as a front and adopt on her behalf. She sees this as unethical.
If a dog were to outlive her, I’d gladly take him or her in. And I can’t help thinking that the companionship, exercise and purpose a dog provides far outweigh the small deceit it might take to bring one into her home. Which is the more ethical course: honoring the system’s ageist rules, or bending those rules in service of compassion? — Name Withheld
From the Ethicist:
Given the shortage of homes for pets in shelters, a blanket ban on adoptions by older people seems bonkers. For one thing, a 25-year-old adopter is statistically more likely than an older adult to undergo the sort of life upheavals (job loss, relocation, marriage, breakups, etc.) that could make someone unable to keep an animal. For another, a suitable adopter who has advanced in years will have given thought to a succession plan should it become necessary. Part of what’s wrong with ageism is that it involves treating individuals according to group stereotypes.
I’m inclined to think that there’s a decent case for doing what you propose: It would benefit the dog, your mother and maybe you. But there’s an even better case for telling shelters that you’d be the designated backup adopter were your mother to become unable to care for the dog; if desired, you can sign a document to this effect. Many shelters accommodate these plans (in some cases as part of a “seniors for seniors” program, involving older pets); it lets them check a box and lets an older person get a rescue. As your mother probably told you at some point, lying, even for a good cause, is best avoided.
A Bonus Question
I was with my husband for over 40 years. When I discovered his sexual addiction, it was devastating. And scary as hell to find out what goes on in the mind of a sex addict. He wanted to stay married, but he continued lying. I ended the marriage.
Here is my ethical question: When people ask about my divorce, I answer that my husband had an addiction that he was not able to overcome and that it was not chemical. I want to be honest, and I do think there needs to be more discussion about sex addiction, which I think is on the rise. To say nothing seems wrong. But to give a full answer seems a bit shocking. I’m in my late 60s and don’t mind shocking people, but I wonder what is the most ethical response. — Name Withheld
From the Ethicist:
You don’t owe anybody a postmortem on your marriage. You can simply say that it wasn’t a healthy marriage any longer. But surely the core of the matter was that he wasn’t faithful, and he wasn’t honest about it; you couldn’t stay in a marriage where this continued. You can say so if you’re of a mind to.
Clinical language about compulsive behavior may help describe a pattern or help with treatment, but it doesn’t erase his agency or accountability. If you prefer the addiction frame, though, you could say he had a behavioral addiction; if you wanted to be more specific, you’re free to say he had a sexual addiction. But your story doesn’t need to be packaged for anyone else’s comfort, and your job isn’t to satisfy everyone’s curiosity.
Readers Respond
The previous question was from a reader who was debating whether to switch to a concierge-medicine practice for her health care. She wrote:
I am a 69-year-old woman in good health. The large medical practice I have been going to for more years than I can count is struggling to recruit and retain primary-care doctors and is short-staffed in general. Wait times for appointments have grown longer, the nurse practitioner I’ve seen most regularly will be retiring soon and I just don’t feel confident that I will receive the attention and care I will want, if and when my health takes a turn. … I recently learned of an internist and geriatric-care specialist who has opened a practice in my community. She has an excellent reputation and sounds like everything I could hope for in a doctor, especially at this stage of my life. The catch is that although she accepts my health insurance, she charges an annual membership fee in order to keep the practice small, which in turn allows her to provide personal, timely care. I am fortunate in that I can afford the membership fee, but I am torn about the ethics of being part of this growing concierge-medicine trend. … What is the right thing to do? — Name Withheld, Massachusetts
In his response, the Ethicist noted:
What you’re contemplating would have substantial benefits for you and a negligible effect on others. One fewer patient won’t affect a big clinic’s financials; if it had any marginal impact on the other patients, it might be in slightly reducing their wait times. So let’s think through your concern: that you’re participating in a harmful process that, at scale, leaves many people excluded from the better care and relegated to diminished services. … You may think, as I do, that our society fails to guarantee everyone the level of medical care they should receive. And medical practices, not just yours, do struggle to find and hold on to primary-care physicians. Among the reasons: Medicare, which effectively anchors compensation levels throughout the health-care system, reimburses physicians according to “relative value units,” and those are largely determined by an advisory committee dominated by specialists. Procedures are valued more than conversations. Although rule changes have recently narrowed the gap a bit, many primary-care clinics, to survive, make physicians see patients in rushed 15-minute slots, leaving them unable to deliver the level of care they’re trained to provide. That comes at a cost not only to patients but also to physicians. … A 2023 report found that a quarter of U.S. physicians were thinking about leaving clinical work altogether. The membership model may keep some of them in practice. … The point is that the growth of membership medicine should be viewed as a symptom, not the disease. … If you do want to try to do something about it, get involved in the politics of health care, or at least bear it in mind when you vote.
(Reread the full question and answer here.)
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I have a friend who is an internal-medicine physician and left her large clinic years ago to start a concierge-medicine practice. As the Ethicist suggested, she made the change so she could better serve her patients without the constraints her old employer put on her. It is also worth mentioning that she provides a sliding scale of membership fees, with some of her patients receiving her care for free. It might be worth the letter writer’s time to search for a doctor who employs this model of membership. Needless to say, my friend’s practice is thriving! — Susheela
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I feel the whole business of concierge doctors is a disgrace. My 99-year-old mother has lost one doctor she liked after another because they went “concierge.” The rich here can afford to keep their doctor, but most cannot. How can this ever be justified? — Jill
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My husband and I joined a concierge practice five years ago, after he suffered a heart attack. I had previously been a patient of this same physician, but I had left when she created her concierge practice because I had the same concerns as the letter writer. After my husband’s heart attack, however, we really needed the help and knowledge that her new practice would provide. I realize it is a privilege that most people don’t get, but I believe that it is a way for us to stay healthy and extend our useful lives. It doesn’t take away from anyone else’s care, but it does allow us, as active seniors, to be able to contribute our time to help others in our community. — Robin
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I’m a retired physician and have always regarded the term “concierge medicine” as an oxymoron. I agree with the Ethicist that patients who avail themselves of the opportunity to get superior medical care are not ethically challenged. But the physicians who provide that care sure are. The very concept of choosing patients based on their ability to pay extra for acceptable medical care is anathema to me. — Alan
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As income disparities have deepened over the past several decades, richer patients are more and more sheltered from the realities of medical care that their lower-income neighbors face. If a patient is experiencing substandard care, it is certainly their prerogative to leave that practice. But when wealthy people are insulated from the truth, I think it is overly optimistic to believe that they will advocate for change. — Rachel
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