Why Nursing-Home Incarceration Must End

On Wednesday of this week, the Auditor General of Ontario, Bonnie Lysyk, released her report on the catastrophic events that have occurred in Ontario nursing homes during the past pandemic year and the Ford Progressive Conservative government’s response to them. The report identified systemic underfunding, staff shortages, lack of PPE, lack of infection control, shared rooms with multiple occupants, and the failure of Ford’s government to adequately and appropriately respond to the situation in a timely way. The report also pointed out how the Ford government’s elimination of preemptive inspection of nursing homes before the pandemic exacerbated the crisis. None of these elements of the report was a surprise.

Not surprisingly, furthermore, the Ontario Minister of Long-term Care, Merrilee Fullerton, immediately deflected responsibility from the Ford government for the tragedy that has ensued in nursing homes during the pandemic, claiming, in response to the report (and as she has done repeatedly over the past year), that rather than worsen the situation in nursing homes, her ministry and the Ford government have attempted to correct decades of neglect of the nursing home sector.

In response to Fullerton and the Ontario Auditor General’s report itself, elder advocates and a nurses’ alliance have argued that the Ford government’s refusal to fine the operators of nursing homes for infractions enables the ghastly conditions in these places to continue unabated. As a panacea to the dire situation in nursing homes, gerontologists and advocates for seniors and elders have pushed for the Canadian federal government to develop “national standards” for so-called long-term care facilities, standards that would address funding, staffing, and living arrangements in these institutions.

The conditions in other Ontario residential “care” institutions that have been the sites of COVID-19 deaths, that is, the conditions in other institutions in which disabled people in Ontario are incarcerated have gone unnoticed and unaccounted for in the report and continue to be ignored by advocates for elders in nursing homes.

The development and implementation of national standards for nursing homes will of course entrench the institutionalization of elders and younger disabled people, a direction that disabled people and our allies oppose. In my forthcoming article “Philosophy of Disability, the Apparatus of Disability, and the Nursing Home-Industrial-Complex,” I point out that these advocates for national standards misunderstand the fundamentally carceral character of these institutions and the role that they play in the neoliberal government of populations deemed to be unproductive and disposable.

In general, that is, these seniors’ advocates and gerontologists, who increasingly call for national standards with respect to so-called long-term care institutions, lack a comprehensive political analysis of the institutions. In short, the implementation of national standards in nursing homes will serve to reinforce the carceral character of the nursing home-industrial-complex through a process of gentrification.

Nursing homes are what Goffman called “total institutions” whose efficiency requires the objectification and dehumanization of their inhabitants. As I explain in my forthcoming article:

The COVID-19 outbreaks that have occurred in nursing homes and similar congregate settings across Canada and globally are not due to an inherent characteristic of seniors, elders, and younger disabled people, that is, not due to an inherent vulnerability of the senior, elder, and disabled populations who live in these institutions that public ownership of them, better funding of them, and adequate staffing of them would have controlled or even prevented.

Rather, the thousands of COVID-19 cases and deaths in nursing homes and other so-called care institutions across the world, like the thousands of COVID-19 cases and deaths in prisons, are testament to both the vile nature of the institutions themselves and the carceral function that they increasingly serve in contemporary society. As Joseph Stramondo (2020) has argued, residential institutions where disabled people live should be defined in terms of the power relations that structure them and circulate within them: whether disabled people live in them with or without control (proxy control, if necessary) of the types of support and care that they receive, whether they live in them with or without control of when these types of support and care are provided, where they are provided, and by whom they are provided.

Nursing homes and other so-called care facilities in which seniors, elders, and younger disabled people are put, insofar as they are “total institutions” (Goffman 1961, p. xiii), do not enable such discretionary acts or even allow for the possibility of their execution. “In a total institution,” Erving Goffman noted, “minute segments of a person’s line of activity may be subjected to regulations and judgments by staff” (p. 38). In his classic 1961 text, Asylums, Goffman explained the idea of a “total institution” in this way:

“A total institution may be defined as a place of residence and work where a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life. Prisons serve as a clear example, providing we appreciate that what is prison-like about prisons is found in institutions whose members have broken no laws.” (p. xiii)

As total institutions, nursing homes and other congregate facilities (both for-profit or public) in which elders and younger disabled people are segregated constitute significant mechanisms of government, where the term government should be understood in the sense that Foucault adopted, that is, should be understood to refer to “the conduct of conduct,” to any mode of action, more or less considered and calculated, that is bound to structure the field of possible actions of oneself or another (Foucault, 1982). In nursing homes, Sara Luterman (2020) remarks, “[residents] depend on and are at the mercy of the staff. [Nursing home residents] do not choose with whom they live or what activities they can do on a given day.” On the contrary, Luterman writes, referring to the totalizing impetus and capacities of the nursing home-industrial complex, nursing homes and other institutions that confine elders and disabled people “allow for an economy of scale. Feeding, washing, and otherwise seeing to the needs of elderly and disabled residents all at once is more efficient than addressing those needs on an individual basis. But this efficiency,” Luterman asserts, “comes at the expense of human dignity.”

Nursing homes (whether for-profit or non-profit), with their scheduled bath days and bowel days; wake-up times and bedtimes; frugal meal planning and food rationing; locked wards; visitor restrictions; and other signposts of carceral logic are formulated upon asymmetrical relations of power that require compliance and homogeneity to ensure that their senior and disabled resident populations are rendered manageable. Indeed, the “handling of many human needs by the bureaucratic organization of whole blocks of people—whether or not this is a necessary or effective means of social organization in the circumstances—is the key fact of total institutions,” according to Goffman. People in total institutions are moved to action in “blocks” in this way, Goffman pointed out, so that personnel whose primary activities are observation and surveillance can more efficiently supervise them (Goffman, 1961, pp. 6-7; Mitchell and Snyder, 2015, p. 38).

To put the point another way, residents (inmates) of nursing homes are deprived of “freedom of non-domination” (Anderson, 2018, 91; Pettit, 2014, in Putnam, 2021), are the subjects of and subjected to the “arbitrary” power of nursing-home staff and the machinations of the nursing home-industrial-complex; that is, seniors, elders, and younger disabled people put in nursing homes and other “care” institutions are subject to a form of power that can be exercised over them at any given time, on any given day, at the behest or whim of any staff member of the institutions, a form of power that implicitly depends upon a certain obedience and deference from these resident inmates (or their proxy decision-makers), as well as abrogation of privacy and self-determination from them.

Complaints and reports of (for instance) rough or otherwise harsh treatment, of undesirable or inedible food, of unwashed clothing, of missing personal property, of breaches of privacy, or of sexual and physical abuse can (and do) result in reprisals from nursing-home staff and administration. In short, insofar as nursing homes and other so-called long-term care facilities in which seniors and disabled people are confined require of them (and their advocates) a certain docility, these spheres of domination contribute to the production of the carceral archipelago of modern societies, though they are not widely recognized and acknowledged as doing so. Indeed, claims to the contrary, that is, claims according to which nursing homes and similar institutions are sites of care and love constitute acts of structural gaslighting.

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