Ethical Issues in Caring for Older Persons in Sub-Saharan Africa: A Scoping Review

Ethical Issues in Caring for Older Persons in Sub-Saharan Africa: A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ethical Issues in Caring for Older Persons in Sub-Saharan Africa: A Scoping Review Abdulgafar Lekan Olawumi, Zainab Abdulkadir, Abdullahi Kabir Suleiman, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9190458/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Rapid population ageing in sub-Saharan Africa (SSA) is unfolding within fragile health systems, weak social protection, and limited geriatric and palliative services, creating ethical challenges in older adult care. This study critically reviews current literature and policy reports, synthesizes key themes, and proposes evidence-based recommendations for policy, practice, and research. Methods A comprehensive literature search examined ethical issues in caring for older adults in SSA across healthcare and social care settings. We searched biomedical, ethics, social science, and gray literature sources using population, ethics, care, and geographic terms. English-language studies from 2000 to 2025 addressing ethical dimensions of older adult care were included. Results We identified multiple ethical challenges that affect older adult care in SSA, including justice, equity, autonomy, dignity, vulnerability, abuse, and ageism. Healthcare-related concerns involve unmet needs, resource allocation dilemmas, limited palliative and end-of-life care, and age-biased clinical decisions. Socially, weakening family support systems create moral tensions for caregivers. Policy analyses emphasise rights-based, culturally sensitive, and equitable approaches, highlighting the need for integrated ethical, social, and systemic care strategies. Conclusions Addressing ethical issues in older care in SSA requires legally enshrined protections, health-system investments, public campaigns to counter ageism, supportive decision-making frameworks that respect cultural contexts and individual rights and strengthened research and surveillance. A right-based, culturally sensitive approach focused on the voices of older persons is essential. Ethics elder abuse older persons care resource allocation sub-Saharan Africa Figures Figure 1 Figure 2 INTRODUCTION Population ageing is a global phenomenon with important implications for health systems, social structures, and ethical practice. 1 , 2 In Sub-Saharan Africa (SSA), the proportion of older adults is increasing, albeit at a slower pace than in high-income countries, due to improvements in life expectancy and declining fertility rates. 2 , 3 While the absolute number of older persons in SSA remains lower than in Europe or North America, their health and social care needs are growing, often in contexts of fragile healthcare systems, limited geriatric expertise, and constrained resources. 1 – 4 Ethical challenges in the care of older adults in SSA emerge as healthcare providers, families, and policymakers navigate issues related to access, quality, and fairness. 4 These ethical considerations are multifaceted. Older adults often face chronic diseases such as hypertension, diabetes, and dementia, which require long-term patient-centered care. 5 Yet, health systems in SSA are often oriented toward acute care and maternal-child health, leaving older persons underserved. 1 , 6 Social norms, cultural expectations, and family dynamics further complicate the provision of ethical care. For example, autonomy and informed consent, foundational principles in Western bioethics, may conflict with communal decision-making practices prevalent in SSA. 7 , 8 The ethical tension arises between respecting individual rights and accommodating cultural norms, requiring clinicians and policymakers to navigate delicate moral terrain. 9 In addition, despite growing scholarly attention to ageing in SSA, ethical issues remain dispersed across disciplines and inadequately synthesized. 10 , 11 Existing reviews have largely focused on epidemiology, service delivery, or social support, with limited critical engagement with ethical dimensions. 10 – 14 A scoping review with critical analysis is therefore warranted to systematically map the available evidence, examine how ethical issues are framed, and identify gaps to inform research, policy, and practice. 15 , 16 The objectives of this scoping review are to map the range of ethical issues related to the care of older persons in SSA, examine how ethical principles such as autonomy, justice, beneficence, and respect for dignity are applied in different care contexts, and critically analyse the influence of cultural, social, legal, and health-system factors on ethical decision-making. The review will also identify evidence gaps and propose priorities for ethical research, policy, and practice in aging care. MATERIALS AND METHODS Ethical Frameworks Relevant to Geriatric Care in SSA Understanding ethical issues in older care requires grounding in bioethical theory. Several frameworks are particularly relevant: 1. Principlism : It is based on the four pillars of autonomy, beneficence, non-maleficence, and justice, which provides a practical approach to ethical decision-making in healthcare. 17 Autonomy Respecting older adults’ choices in healthcare decisions, including treatment refusal or advance directives, can conflict with familial authority in SSA contexts. 7 Beneficence and non-maleficence Clinicians must balance interventions that promote well-being while minimizing harm, particularly when resource constraints limit available treatments. 8 , 9 Justice Ethical allocation of scarce resources, such as medications, hospital beds, or specialized geriatric care, requires transparent and culturally sensitive policies. 9 Virtue ethics : Emphasizing character traits and moral dispositions, virtue ethics highlights the clinician’s responsibility to act with compassion, empathy, and integrity. 20 This approach is particularly useful in SSA, where formal protocols may be limited, and ethical practice relies heavily on professional judgment and relational care. Care ethics : Care ethics prioritizes relationships, interdependence, and responsiveness to the needs of vulnerable individuals. 10 Given the centrality of family and community in older care in SSA, care ethics provides a culturally resonant framework that complements principlism while addressing contextual realities. 10 , 11 Public health ethics : Ethical frameworks in public health emphasize population-level considerations, resource allocation, and equity. 9 , 10 In SSA, public health ethics is critical when addressing systemic challenges affecting older adults, such as access to vaccinations, chronic disease management, and social protection. 8 , 9 Registration The protocol for this scoping review was registered on the Open Science Framework (OSF) and is available at https://doi.org/10.17605/OSF.IO/9AXVW . Scope and approach We employed a systematic and transparent search strategy across multiple databases to identify relevant literature according to the PRISMA-ScR guidelines. 18 , 19 Search strategy We performed a comprehensive literature search to identify relevant studies addressing ethical issues in caring for older persons in SSA. The review focused on older adults as the population of interest, ethical and moral concerns as the core concept, and healthcare and social care settings within SSA (East, West, Central, and Southern Africa) as the context. The primary question guiding the search was: What ethical issues arise in the care of older persons in SSA, and how are these issues addressed within healthcare and social care systems? Electronic databases searched included PubMed/MEDLINE, Scopus, and Web of Science to capture biomedical and multidisciplinary literature. Given the regional focus, African-specific databases such as African Journals Online (AJOL), and African Index Medicus were also searched. We identified gray literature through targeted searches of reports and policy documents from the World Health Organization (WHO), United Nations agencies, HelpAge International, non-governmental organizations and relevant government sources. The search strategy combined terms related to older persons, ethical issues, care contexts, and geographic location. Terms describing the population included “older persons,” older people,” “older adults,” “elderly,” “ageing,” “aging,” and “geriatrics.” Ethical concepts were captured using keywords such as “ethics,” “bioethics,” “moral issues,” “ethical dilemmas,” “human rights,” “autonomy,” “dignity,” “justice,” “equity,” “ageism,” “elder abuse,” “neglect,” and “exploitation.” Care-related terms included “healthcare,” “health care,” “medical care,” “long-term care,” “social care,” “caregiving,” “nursing care,” and “community care.” Geographic identifiers included “Sub-Saharan Africa,” “Africa South of the Sahara,” and the names of individual countries within the region, such as Nigeria, Ghana, Kenya, South Africa, Ethiopia, Uganda, and Tanzania. Figure 1 In PubMed, both Medical Subject Headings (MeSH) and free-text terms were used to maximize retrieval. Similar keyword-based strategies were adapted for Scopus and Web of Science, using database-specific subject headings and Boolean operators, truncations and wildcards. Searches were limited to articles published in English from the year 2000 to 2025 to reflect contemporary ethical debates and healthcare contexts. Eligible studies included empirical qualitative and quantitative research, systematic and narrative reviews, ethical analyses, and policy papers that explicitly addressed ethical issues in the care of older adults in SSA. Studies were excluded if they focused exclusively on regions outside SSA, did not address ethical or moral dimensions of care, did not focus on older persons, or consisted solely of editorials without substantive ethical analysis. Study selection and data extraction Two reviewers independently screened the titles and abstracts of all identified studies to determine their relevance to the review topic. Studies considered potentially eligible were then retrieved for full-text assessment against the predefined inclusion and exclusion criteria. Any disagreements between the reviewers at any stage of the screening process were resolved through discussion and consensus; where necessary, a third reviewer was consulted to ensure objectivity and consistency in study selection. Data were extracted using a standardized data extraction form to ensure uniformity and completeness. The extracted information included details on authorship, year of publication, and study period, as well as the country and sub-region within Sub-Saharan Africa where the study was conducted. Additional variables included study design (e.g., qualitative, quantitative, or mixed methods), study setting (urban, rural, or mixed), and population group. Given the focus of this review, particular attention was paid to identifying and documenting key ethical issues related to the care of older persons. These included, but were not limited to, concerns around autonomy, informed consent, dignity, confidentiality, access to care, equity, cultural considerations, and end-of-life decision-making. Where reported, information on ethical frameworks, guidelines, or principles applied in the studies was also extracted. In cases where important information was missing, unclear, or insufficiently reported, corresponding authors were contacted for clarification or additional data. RESULT As shown in Fig. 2 , a total of 82 studies met the inclusion criteria for this scoping review, published between 2001 and 2025. The body of evidence comprised predominantly reviews, qualitative studies, cross-sectional studies, and policy reports focusing on older adults across SSA. Collectively, the findings reveal a wide range of ethical and moral concerns in the care of older adults, with recurrent themes of justice, equity, autonomy through consent and decision making, dignity, vulnerability, ageism, intergenerational responsibility, and culturally grounded ethical frameworks shaping care experiences. Within healthcare contexts, we found that service delivery for older adults in Nigeria and across SSA face multiple ethical challenges, particularly in decision-making, consent, palliative and end-of-life care (Table 1 ). In addition, culturally mediated decision making, limited palliative infrastructure, and inadequate professional training frequently undermine ethically-sound care. Qualitative studies from Nigeria by Doobay-Persaud et al. (2023) and Udeh et al. (2025), and a systematic review by Gysels et al. (2011), showed that communication barriers, family-dominated decisions, and poor symptom control often compromise autonomy and dignity at the end of life. 21 – 23 Powell et al. (2014) further highlighted the absence of comprehensive palliative care policies, reinforcing systemic inequities in access to compassionate care. 24 Hospital- and clinic-based studies reveal broader ethical vulnerabilities. Olawumi et al. (2021) documented high morbidity and poor nutritional status among hospitalized older adults in northern Nigeria, raising concerns about neglect and distributive justice. 5 Odusanya et al. (2018) and Olanrewaju et al. (2020) identified ageism, financial barriers, and fragmented services as persistent constraints to equitable access. 25 , 26 Knight et al. (2018) further demonstrated how older adults with HIV and non-communicable diseases (NCDs) navigate poorly coordinated services, highlighting failures in continuity and equity. 27 Ethical challenges in autonomy and informed decision-making are evident in consent, disclosure, and treatment prioritization. Ede et al. and Mussie et al. (2024) showed that cultural norms privileging family authority and clinician discretion limit individual autonomy, reflecting relational ethics, but risking marginalisation. 28 , 29 A report from Ethiopia by Tegegn et al. 2018 found that older patients value involvement in deprescribing, suggestive of tensions between clinical judgement, autonomy, and resource constraints. 30 In Uganda, Alupo et al. (2025) highlighted systemic and cultural barriers to anticipatory care based on low uptake of advance directives. 31 Access and stigma also remained critical concerns: Jolley et al. (2025) showed older adults with disabilities in Uganda navigate structural barriers to eye care, 32 while Wandera et al. (2025) identified stigma as an ethical barrier in the HIV care cascade. 33 Together, these findings demonstrate that ethical challenges in healthcare delivery for older adults in SSA extend beyond clinical encounters, and reflect deeply embedded structural, cultural, and policy-level constraints. Table 1 Ethical Issues in Care, Decision-Making, Consent, and End-of-Life Care Author(s) (Year) Region Study Type Population / Scope Ethical / Moral Focus Key Contributions to Ageing Ethics Doobay-Persaud et al. (2023). 21 Nigeria Qualitative study Health professionals, patients, older adults Palliative care ethics, dignity, communication Explores ethical challenges in symptom control, interprofessional communication, and delivery of culturally sensitive palliative care Powell et al. (2014). 24 Africa Commentary Patients, health systems Policy ethics, justice, access to palliative care Highlights ethical and policy challenges in scaling palliative care services in resource-limited settings Gysels et al. (2011). 22 SSA Systematic review (qualitative) Patients, families, healthcare providers End-of-life care, dignity, cultural ethics Synthesizes evidence on ethical issues in end-of-life care, including communication and cultural perspectives Udeh et al. (2025). 23 Nigeria Qualitative study Patients, healthcare providers End-of-life decision-making, autonomy, dignity Examines ethical dilemmas in end-of-life care including consent, truth-telling, and shared decision-making Tegegn et al. (2018). 30 Ethiopia Cross-sectional study Older patients Autonomy, deprescribing ethics Explores older patients’ perceptions of medication withdrawal and ethical considerations in clinical decision-making Odusanya et al. (2018). 25 Nigeria Narrative review Older adults Health system ethics, dignity, access to care Identifies systemic and ethical challenges affecting care quality and equity among older persons Olanrewaju et al. (2020). 26 Africa Narrative review Older adults Ageism, dignity, equity Examines how age-based discrimination affects access to healthcare and ethical care delivery Knight et al. (2018). 27 South Africa Qualitative study Older adults with HIV Equity, access, stigma Highlights barriers to healthcare access and ethical concerns related to stigma and multimorbidity Ede et al. (2024). 28 Nigeria Qualitative study Surgical patients (including older adults) Informed consent, autonomy Assesses ethical challenges in obtaining valid informed consent in resource-limited surgical settings Mussie et al. (2024). 29 Ethiopia Qualitative study Older patients, clinicians Disclosure ethics, autonomy Explores ethical tensions around truth-telling and information disclosure in elderly care Jolley et al. (2025). 32 Uganda Qualitative study Older adults with disabilities Access, equity, justice Examines ethical issues in access to eye care services among vulnerable older populations Wandera et al. (2025). 33 SSA Systematic review protocol Older adults with HIV Stigma, confidentiality, equity Investigates ethical implications of stigma across the HIV care continuum Alupo et al. (2025). 31 Uganda Mixed-methods study Older adults Autonomy, advance directives Explores awareness and ethical implications of advance care planning and decision-making In social care contexts across SSA, as shown in Table 2 , ethical challenges for older adults arise amid changing family structures, migration, poverty, and weakening informal support systems. 14 Evidence from Ghana, Malawi, and other SSA settings indicate that family-based care, traditionally central to elder support, is increasingly strained Narrative reviews from Ghana by Agyemang (2025) and Dovie (2019), and studies in Democratic Republic of Congo, by Adei et al. (2025), and Bikouta et al. (2015), document strong moral expectations on families and informal caregivers alongside economic hardship, urbanisation, and inter-generational change, resulting in neglect, reduced autonomy, and lower quality of care. 7 , 34 – 36 Hospital-based and community studies in Malawi 37 , and South Africa 38 , 39 , highlight risks of malnutrition, abuse, and caregiver burden, reflecting both household- and system-level vulnerabilities. 37 – 39 Regional and cross-national analyses, including works by Okolie et al. (2025), Aboderin (2025), HelpAge International (2011), Adamek et al. (2022), and Gedfew et al. (2024), identify gaps in social protection, prevalence of elder abuse, and limited institutional safeguards, situating ethical concerns within broader social and policy environments. 4 , 40 – 43 On the other hand, Jecker (2022) applied an inter-generational ethical perspective, framing moral obligations toward older adults within multi-generational and skipped-generation households, despite structural constraints. 44 Older adults’ lived experiences further illuminate these ethical challenges: qualitative studies from Uganda, 32 Nigeria, 45 and Ethiopia, 46 reported perceptions of vulnerability, loss of autonomy, and culturally incongruent care. Ethics-of-care approaches, emphasizing relational responsibility, dignity, and context-sensitive care, are also described in studies from South Africa, 47 and Ghana. 48 Collectively, the published evidence from Nigeria, Uganda, Ethiopia, Ghana, Malawi, and South Africa consistently link elder abuse and neglect to social inequality, caregiver stress, migration, food insecurity, and limited regulatory oversight. 49 – 67 Table 2 Social Care Ethics: Family Responsibility, Elder Abuse, Neglect, and Vulnerability Author(s) (Year) Region Study Type Population / Scope Ethical / Moral Focus Key Contributions to Aging Ethics Agyemang (2025). 7 Ghana Conceptual Older adults, families Family ethics, moral obligations Examines evolving family roles in elder care and the ethical implications of shifting caregiving responsibilities Dovie (2019). 34 Ghana Qualitative Older adults, families Family ethics, caregiving norms Highlights the role of traditional family systems and ethical obligations in supporting older persons Adei et al. (2025). 35 Ghana Cross-sectional Informal caregivers of older adults Caregiver burden, social responsibility Identifies predictors of caregiving strain and ethical concerns related to caregiver support and wellbeing Bikouta et al. (2015). 36 Congo Qualitative Young people, older adults Intergenerational ethics, respect Explores perceptions of ageing and moral attitudes toward older persons among younger populations Lukman et al. (2025). 14 Nigeria Conceptual Older adults Structural inequality, social justice Discusses how social determinants create ethical challenges in ageing and access to care Mphwanthe et al. (2025). 37 Malawi Cross-sectional Older adults Vulnerability, nutrition ethics Examines malnutrition and food insecurity as ethical concerns affecting older adults’ health Brear et al. (2025). 38 South Africa Mixed-methods Caregivers of older adults Care ethics, wellbeing Explores health and wellbeing of caregivers, highlighting ethical dimensions of caregiving burden Meel (2017). 39 South Africa Cross-sectional Older women Violence, justice, human rights Documents sexual violence against elderly women and highlights ethical issues of protection and justice HelpAge International (2011). 41 SSA Report Older adults Rights, vulnerability Provides evidence on systemic neglect and emphasizes ethical obligations for protection and policy response Adamek et al. (2022). 42 SSA Qualitative Older adults Social vulnerability, resilience Explores both challenges and strengths of older adults, emphasizing ethical need for supportive systems Okolie et al. (2025). 40 Nigeria Qualitative Older adults Abuse, caregiving ethics Distinguishes between caregiving and abuse, highlighting ethical grey areas in elder care Brear et al. (2024). 47 South Africa Qualitative Older adults, caregivers Ethics of care, quality of care Conceptualizes “good care” within informal caregiving networks and ethical responsibilities Awuviry-Newton et al. (2022). 48 SSA Review Caregivers, older adults Ethics of care, relational ethics Uses ethics of care framework to understand caregiving experiences Kelly et al. (2019).49 South Africa Qualitative Older adults Dignity, quality of care Highlights older persons’ experiences of neglect and perceived lack of respect in healthcare Gedfew et al. (2024). 43 SSA Systematic review & meta-analysis Older adults Elder abuse, neglect Synthesizes prevalence and forms of elder abuse, emphasizing need for ethical protection systems Mussie et al. (2022). 51 Eastern Africa Scoping review Older adults Ethical issues in care Provides comprehensive mapping of ethical challenges in elder care in the region Aboh et al. (2025). 50 SSA Scoping review Protocol Older adults Neglect, vulnerability Proposes systematic assessment of elder neglect and ethical implications Okigbo et al. (2025). 45 Nigeria / Diaspora Qualitative Caregivers Care ethics, transnational care Explores ethical dimensions of caregiving across borders, including emotional and financial strain Sossou et al. (2015). 52 Ghana Qualitative Older women Abuse, social justice Links elder abuse to gender inequality and human rights concerns Ferreira et al. (2008). 53 South Africa Qualitative Older adults Abuse, marginalization Highlights systemic neglect, exploitation, and ethical failures in protecting older persons Awuviry-Newton et al. (2020). 54 Ghana Qualitative Older adults Neglect, moral responsibility Explores perceptions and causes of elder neglect within communities Wamara (2022). 55 Uganda Qualitative Social workers Abuse, professional ethics Examines ethical responses and challenges in addressing elder abuse Wamara et al. (2021). 57 Uganda Qualitative Older adults Abuse, dignity Documents lived experiences of abuse and ethical need for voice and protection Wolde et al. (2022). 56 Ethiopia Cross-sectional Older adults Abuse, vulnerability Identifies prevalence and determinants of elder abuse Chane et al. (2015). 58 Ethiopia Qualitative Older adults Abuse, dignity, suffering Presents narratives of abuse and neglect, emphasizing ethical urgency Atim et al. (2023). 59 Uganda Cross-sectional Older adults Abuse, neglect Examines factors associated with elder abuse in community settings Okojie et al. (2022). 60 Nigeria Cross-sectional Older adults Abuse, inequality Compares rural–urban patterns of elder abuse Ojifinni et al. (2023). 61 Nigeria Qualitative Caregivers Abuse, caregiving ethics Explores caregiver perspectives and ethical dilemmas in elder abuse Okakah et al. (2025). 62 Nigeria Cross-sectional Older adults Abuse, vulnerability Assesses prevalence and predictors of elder abuse in rural settings Yussuf et al. (2014). 63 Nigeria Cross-sectional Older adults Abuse, neglect Documents patterns of elder abuse in Northern Nigeria Fajemilehin et al. (2007). 64 Nigeria Qualitative Older adults Neglect, poverty Highlights ethical implications of destitution among the elderly Cadmus et al. (2015). 65 Nigeria Qualitative Older adults Abuse, dignity Explores lived experiences and perceptions of abuse Cadmus et al. (2012). 66 Nigeria Cross-sectional Older women Abuse, gender ethics Examines prevalence and gendered dimensions of abuse Agunbiade (2019). 67 Nigeria Qualitative Older adults Abuse, prevention ethics Explores causes of abuse and strategies for prevention Table 3 illustrates how ethical approaches to ageing in SSA are shaped by global human rights norms, public health ethics, and locally grounded moral obligations, while revealing gaps in implementation, training, and system-level support for older adults. Empirical studies from SSA consistently showed that poverty, inequitable access to care, age-related discrimination, and health system fragmentation remain central ethical concerns shaping ageing experiences. 68 – 70 Global and regional policy frameworks Global and regional policy instruments, including the WHO Global Strategy on Ageing and Health (2017), the WHO AFRO Framework for Healthy Ageing (2022), and the United Nations World Population Ageing Report (2023), promote rights-based, equitable, and context-sensitive approaches to ageing. 2 , 71 , 72 These frameworks prioritize dignity, autonomy, and equity while advocating integration of health and social care systems. However, evidence from Ghana, Senegal, Nigeria, and Eswatini revealed implementation gaps, with older adults reporting unmet basic needs, financial hardship, and unequal utilisation of healthcare services, despite policy commitments to universal health coverage. 69 , 70 , 73 – 75 Ethics of research, policy, and health systems Expert reports and reviews by the National Research Council (NRC, 2006), 76 Prince et al. (2015), 77 Aboderin (2010; 2025), 3,4 Brock and Wikler (2006), 9 and Childress et al. (2002), 10 emphasized justice, distributive fairness, and ethical resource allocation in ageing societies. These ethical concerns are reflected in empirical studies showing socioeconomic inequalities, frailty-related vulnerability, and inequitable service provision among older adults in Ghana, Rwanda, Kenya, and Nigeria. 69 , 78 – 81 Studies further documented structural barriers such as fragmented primary care, inadequate workforce training, and low preventive service uptake, including vaccination among caregivers and healthcare workers. 75 , 82 Human rights, bioethics, and contextual moral frameworks Comparative rights analyses by Doron et al. (2019) introduce the International Older Persons’ Human Rights Index as a tool for ethical monitoring of elder care systems. 83 The role of inter-generational obligations, family responsibility, and moral duties toward older adults are highlighted by conceptual and case-based work that advance culturally grounded African bioethics. 13 , 84 These perspectives align with findings on ageism, workplace discrimination, and the moral consequences of poverty and multimorbidity in later life. 68 , 78 Foundational biomedical ethics texts by Beauchamp et al. (2019) and Brock and Wikler (2006) also stress the core principles of autonomy, beneficence, non-maleficence, and justice, that underpin ethical decision-making in geriatric practice across SSA. 9 , 17 Table 3 Moral and System-Level Ethical Frameworks, and Policy for Older Adults in SSA Author(s) (Year) Region Study Type Population / Scope Ethical / Moral Focus Key Contributions to Ageing Ethics Kola et al. (2019). 68 Nigeria Conceptual Older adults Poverty, distributive justice Challenges moral attribution of poverty and highlights ethical implications of economic vulnerability in old age Dei et al. (2018). 69 Ghana Cross-sectional Older adults Equity, healthcare access Examines inequities in healthcare utilisation, emphasizing ethical concerns around fairness Agyemang-Duah et al. (2019). 70 Ghana Qualitative Older adults Financial protection, access Explores ethical challenges in financing healthcare among poor older adults Mabuza et al. (2010). 73 Eswatini Qualitative Older adults Basic needs, dignity Identifies unmet basic needs and ethical implications for wellbeing and dignity Olawumi et al. (2023). 81 Nigeria Cross-sectional Older adults Functional health, equity Examines determinants of functional capacity, highlighting inequities affecting ageing outcomes WHO (2017). 71 Global Policy framework Older adults Rights-based care, dignity Provides global strategy promoting ethical, rights-based approaches to healthy ageing WHO AFRO (2022). 72 SSA Policy framework Older adults Equity, integrated care Outlines regional framework for ethical and equitable ageing care systems Chatterji et al. (2008). 85 Global Review Older populations Health equity, system ethics Discusses burden of disease and ethical implications for policy and care systems Taverne et al. (2023). 74 Senegal Qualitative Older adults Access, financial ethics Explores healthcare utilisation and ethical issues related to cost and access Ogunyemi et al. (2025). 75 Nigeria Qualitative Older adults Service provision, dignity Examines barriers to primary healthcare and ethical implications for quality care NRC (2006). 76 Global Expert report Older populations Research ethics, policy Provides recommendations for ethical research and policy development in ageing Prince et al. (2015). 77 Global Review Older populations Policy ethics, health systems Highlights burden of ageing and ethical need for responsive health systems Mba (2010). 86 Ghana Review Older adults Policy, demographic ethics Identifies research gaps and policy needs for ageing populations Aboderin (2010). 3 SSA Narrative review Older adults Equity, policy ethics Explores policy gaps and ethical challenges in ageing populations Aboderin (2025). 4 SSA Conceptual Older adults Justice, health systems Updates perspectives on ageing and ethical policy priorities Brock et al. (2006). 9 Global Book chapter Populations Resource allocation, justice Discusses ethical issues in allocation of healthcare resources Childress et al. (2002). 10 Global Conceptual Public health systems Public health ethics Defines ethical principles guiding population-level interventions Bayuo (2017). 87 Ghana Qualitative Older adults Access, dignity Explores healthcare utilisation experiences and ethical concerns Asiamah et al. (2024). 78 Ghana Cross-sectional Older adults Frailty, equity Examines functional decline and equity in ageing outcomes Jecker & Atuire (2022). 13 Africa Case-based analysis Older adults, families Contextual bioethics Advocates for culturally grounded African bioethics frameworks Jecker (2022). 44 Africa Conceptual Families, older adults Intergenerational ethics Explores moral obligations toward older adults in African contexts Kiplagat et al. (2025). 79 SSA Qualitative Providers, older adults with HIV Integrated care ethics Examines ethical challenges in integrating HIV and NCD care Dzando et al. (2025). 88 SSA Qualitative Older adults Lived experience, care ethics Synthesizes perceptions of ageing and care experiences Beauchamp & Childress (2019). 17 Global Conceptual Healthcare practice Biomedical ethics principles Establishes principles of autonomy, beneficence, non-maleficence, and justice Weise (2016). 84 Global Review Clinical practice Medical ethics Simplifies ethical principles for clinical decision-making Agyemang-Duah (2025). 92 Ghana Qualitative Caregivers, older adults Care ethics, wellbeing Explores caregiver experiences and ethical responsibilities Kalache et al. (2002). 93 Global Policy/Conceptual Older populations Healthy ageing, equity Emphasizes compression of morbidity and ethical policy priorities Monsudi et al. (2015). 89 SSA Narrative review Healthcare systems Medical ethics gaps Identifies deficiencies in ethical practice and training Atuire & Bull (2020). 90 SSA Commentary Health systems Crisis ethics Highlights ethical challenges intensified during pandemics Amberbir et al. (2025). 80 SSA Mixed-methods protocol Older adults Healthy ageing, system ethics Proposes strategies to address multimorbidity and ageing needs Nuffield Council on Bioethics (2001). 91 Global Ethics report Vulnerable populations Research ethics, justice Provides guidance on ethical conduct in health research Doron et al. (2019). 83 Global Comparative analysis Older adults Human rights Introduces framework for assessing rights of older persons Sibanda et al. (2023). 82 South Africa Cross-sectional Healthcare workers Professional ethics Examines ethical issues in vaccination practices among caregivers DISCUSSION This scoping review demonstrates that ethical challenges in the care of older adults in SSA are complex, interrelated, and deeply embedded in clinical, social, cultural, and structural contexts. Across the literature, five recurring ethical domains emerge: informed consent and decision-making capacity; end-of-life and palliative care; resource allocation and justice; elder abuse, neglect, and vulnerability; and cultural considerations under ethical pluralism. Together, these findings reveal systemic gaps that compromise autonomy, dignity, and equity for ageing populations in the region. Informed Consent and Decision-making Capacity Informed consent and decision-making capacity constitute persistent ethical challenges in the care of older adults in SSA, shaped by intersecting clinical, sociocultural, and structural constraints. While autonomy-based bioethical frameworks remain foundational, their application is frequently constrained in practice due to cognitive impairment, frailty, low literacy, and entrenched communal decision-making norms. 9 , 13 , 17 , 51 , 81 , 94 Evidence from Nigeria and Ghana suggest that clinicians often struggle to obtain informed consent, especially in acute care, surgical, and end-of-life settings. 21 28 , 95 In these contexts, consent processes are often abbreviated, poorly documented, or delegated to family members without formal capacity assessments. Such practices, while driven by time pressure and cultural expectations, risk undermining the autonomy of older adults and exposing them to paternalistic decision-making. 25 , 89 , 95 Qualitative studies further show that decision-making in SSA is rarely individualistic. Family hierarchies and inter-generational moral obligations strongly influence healthcare choices, particularly for older adults with cognitive decline or functional dependence. 7 , 29 , 34 , 44 Jecker’s inter-generational ethics framework argues that surrogate decision-making in African contexts should not be viewed solely as ethical failure, but as relational autonomy embedded within social responsibility. 44 However, without safeguards, this model may also enable coercion, concealment of diagnoses, or exclusion of older persons from meaningful participation. 49 , 51 , 96 – 97 Low health literacy and limited geriatric training among healthcare workers further compromise consent validity. 49 Studies from Ethiopia and Nigeria reveal clinicians’ reluctance to disclose full prognostic information to older patients, citing fears of distress or perceived inability to understand complex information. 21 , 28 , 51 , 89 , 95 While well-intentioned, such non-disclosure conflicts with ethical and rights-based standards articulated by the WHO and the Nuffield Council on Bioethics. 71 , 91 Overall, the literature suggests that ethically robust consent in SSA requires culturally responsive models that integrate capacity assessment, supported decision-making, and family engagement while prioritizing the dignity and expressed preferences of older adults. Strengthening geriatric ethics training, developing context-sensitive consent tools, and aligning clinical practice with rights-based frameworks are critical to addressing these challenges. End-of-Life Care and Palliative Ethics End-of-life care in SSA is characterized by substantial ethical challenges rooted in weak health system capacity, including limited availability of palliative care services, poor access to essential analgesics, and shortages of trained healthcare professionals. 22 , 24 These structural deficiencies result in inadequate symptom control and delayed initiation of palliative care, and compromise the ethical obligations of beneficence and non-maleficence, especially for frail and functionally dependent older adults. 21 Ethical dilemmas often arise when clinicians must decide between continuing life-prolonging interventions and transitioning to comfort-oriented care in the absence of clear prognostic guidance or institutional protocols. 99 , 100 Evidence from Nigeria and other SSA settings demonstrates frequent discordance between clinicians’ clinical assessments and families’ expectations, with families often favoring maximal intervention due to culturally-embedded beliefs surrounding hope, moral duty, and the social meaning of death. 24 , 101 Such tensions may contribute to over-treatment, delayed palliation, and moral distress among healthcare providers operating in resource-constrained environments. 101 Cultural norms that prioritize collective decision-making and filial responsibility further complicate end-of-life ethics, sometimes marginalizing older adults’ preferences, comfort, and experiential dignity. 13 , 36 The ethical complexity of end-of-life care is exacerbated by the limited uptake of advance care planning and the absence of clear legal and policy frameworks guiding surrogate decision-making in many SSA countries. 86 , 89 In this context, clinicians are often required to navigate ethically ambiguous decisions with little institutional or legal support. Guidance from the WHO emphasizes the integration of palliative care into primary healthcare systems and advocates for rights-based approaches that prioritize dignity, symptom relief, and culturally-responsive family engagement. 71 , 72 Collectively, the literature highlights the need for ethically grounded, context-sensitive end-of-life care models that reconcile clinical judgment, cultural values, and the fundamental right of older adults in SSA to a dignified death. Resource Allocation and Justice Resource limitations are a defining feature of many health systems in SSA, with ethical implications for justice and equitable healthcare delivery for older adults. Evidence from Nigeria and across SSA suggest that older persons experience persistent barriers to accessing healthcare services, essential medicines, and specialized geriatric care, reflecting structural inequities in resource distribution. 81 , 85 These constraints disproportionately affect older adults with multimorbidity, frailty, and functional limitations, worsening vulnerability within already resource-limited systems. 5 Such inequities raise concerns regarding distributive justice, social responsibility, and the moral obligations of health systems toward vulnerable populations. 9 , 10 Ethical frameworks emphasize fair, transparent, and needs-based allocation of scarce resources; however, studies consistently identify age-based discrimination (“ageism”) as a significant determinant of healthcare access for older adults in SSA. 26 Ageism manifests through overt neglect, financial exclusion, and subtle marginalization in clinical prioritization and referral pathways. 25 , 26 , 87 Such practices contravene the principles of justice and non-maleficence, as older adults may be denied interventions that preserve function, alleviate suffering, or improve quality of life. Ethical tensions related to resource allocation are particularly evident in palliative and end-of-life care. Limited infrastructure, shortages of trained personnel, and competing service priorities frequently compel clinicians to navigate difficult trade-offs between life-prolonging interventions and comfort-focused care, often in the absence of clear institutional guidance. 24 , 100 These challenges are exacerbated by the high burden of chronic disease and disability among older adults in SSA, which increases demand for long-term and resource-intensive care. 5 The literature further highlights that ethical approaches to resource allocation in SSA must be contextually grounded, accounting for sociocultural norms, health system constraints, and population-specific vulnerabilities. 90 , 69 Geriatric ethics in African settings requires balancing individual clinical need with collective welfare, while avoiding structural neglect of older persons. Policy-oriented analyses emphasize the need to integrate geriatric-focused strategies into broader health system reforms, including investment in human resources, training in ethical decision-making, and mechanisms to address entrenched inequities in access and quality of care. 9 , 10 , 93 In summary, resource allocation within SSA health systems represents a critical ethical challenge in which principles of justice and equity are frequently compromised. Addressing these challenges requires the deliberate integration of ethical frameworks into policy and practice, prioritization of older adults as a vulnerable population, and sustained investment in geriatric and palliative care infrastructure. Elder Abuse, Neglect, and Vulnerability Elder abuse and neglect in SSA represent significant ethical challenges that intersect with issues of justice, human rights, and societal responsibility. Older adults in SSA are disproportionately vulnerable due to social, economic, and familial pressures compounded by weak social protection systems. 3 , 41 , 85 , 88 , 95 The ethical responsibility to protect older adults extends beyond formal healthcare systems to informal care networks, which are often overstretched or under-resourced. 12 , 44 , 85 , 95 Chronic illnesses, functional disability, and cognitive impairment significantly exacerbate vulnerability, necessitating targeted safeguarding strategies. 5 , 44 , 102 Ethical frameworks emphasize the duty of care owed to older adults, highlighting the moral imperative to prevent harm and promote dignity, particularly in settings where ageism and societal neglect are prevalent. 26 , 96 Furthermore, the pervasive nature of elder abuse, ranging from physical and emotional maltreatment to financial exploitation, reflects broader structural inequities, including poverty, limited access to healthcare, and social marginalization. 3 , 41 , 85 These conditions create ethical dilemmas around allocation of resources, prioritization of vulnerable groups, and societal obligations to uphold the rights of older adults. The literature highlights the importance of a multi-level ethical response: integrating formal health interventions, legal protections, and community-based support systems to reduce elder vulnerability. In SSA, this involves balancing resource constraints with the moral imperative to protect and promote the dignity and wellbeing of older adults, reflecting a justice-oriented approach to ageing care. Cultural Considerations and Ethical Pluralism Sub-Saharan Africa encompasses a rich tapestry of cultural norms, family structures, and belief systems, all of which profoundly influence ethical perspectives and practices in the care of older adults. 3 , 88 , 85 Across all domains, cultural norms profoundly shape ethical practice in SSA. Care for older adults is embedded within family and communal structures, where collective responsibility often supersedes individual autonomy. Ethical pluralism: recognising the legitimacy of multiple moral frameworks, emerges as essential for reconciling biomedical ethics with local traditions. 4 , 14 , 44 Rather than viewing communal decision-making as inherently unethical, the evidence supports approaches that integrate relational autonomy with safeguards against marginalisation. 21 – 24 , 96 Culturally competent care requires policies and practices that support families while ensuring that older adults’ rights, dignity, and wellbeing remain central. 102 , 103 Community engagement, intergenerational dialogue, and locally adapted interventions are consistently identified as critical to ethically coherent ageing care in SSA. Recommendations Policy Implications Addressing ethical challenges in the care of older adults in SSA requires strengthened policy frameworks that integrate ethical principles with public health priorities: Ageing should be explicitly recognized as a major demographic and social transition with distinct healthcare and ethical implications. 3 , 14 Ethical prioritisation within policy should include the development of age-sensitive national health strategies that incorporate guidance on autonomy, informed consent, end-of-life care, and protection from abuse, while ensuring that healthcare resource allocation does not discriminate against older persons. 34 , 65 Policymakers should support the integration of geriatric and ethics training into medical and nursing curricula to enhance providers’ capacity to assess decision-making ability, manage ethical dilemmas, and communicate effectively with older adults and their families. 26 Strengthening legal protections for older persons is critical, including enforceable rights related to informed consent, abuse prevention, and access to healthcare. South Africa and Ghana have introduced older-persons legislation, but inconsistent implementation limits their impact, highlighting the need for stronger regulatory and enforcement mechanisms. 6 – 8 Community engagement and public awareness initiatives can reduce stigma surrounding ageing, cognitive decline, and end-of-life care, while strengthening caregiver support and improving older adults’ access to health and social services through existing community networks. 23 , 48 Research Implications Ethical ageing in SSA is constrained by limited empirical evidence on older populations, cultural influences on consent, and health system capacity. 54 , 58 , 81 , 97 Priority research areas include epidemiological studies to guide ethical resource allocation and service planning in ageing populations, and studies of multimorbidity, cognitive impairment, and functional decline. 52 , 58 , 102 Research is also needed to adapt and validate decision-making capacity assessment tools appropriate to SSA contexts, accounting for language, literacy, and cultural norms. 7 , 25 , 88 Comparative studies on ethical frameworks for resource allocation can inform transparent and culturally acceptable prioritization approaches in constrained systems. 9 Further work on community-based palliative care models and elder abuse prevention strategies is essential to strengthen ethical standards and protective mechanisms. 41 , 53 – 55 Clinical Practice Implications At the clinical level, ethical care requires patient-centered, culturally responsive approaches. Clinicians should adopt decision-making models that respect individual autonomy while acknowledging communal decision-making traditions. 17 Transparent triage processes, early integration of palliative care, and culturally competent communication with families and communities are critical to ensuring ethical, dignified care for older adults in resource-limited settings. 9 , 22 LIMITATION In this scoping review, we acknowledge some limitations. Restriction to only English-language studies is a threat to language bias. Our findings should be interpreted as descriptive rather than conclusive since the main aim of scoping is to map the current state of knowledge rather than to determine effect sizes or study quality. In spite of these limitations, this review provides a foundational overview of the field ethics in the care of older adults in SSA and highlights important knowledge gaps that warrant future research. CONCLUSION In this scoping review, we found that multifaceted ethical challenges shape the care of older adults in SSA. Key concerns include informed consent, end-of-life care, equitable resource allocation, protection from abuse, and the need for culturally grounded ethical pluralism. Addressing these issues requires integrated approaches that align policy frameworks, professional ethics, family engagement, and cultural competence across healthcare and social care settings. We also found that ethical ageing in SSA depends on bridging clinical ethics, public health ethics, and social justice perspectives. Strengthening ethical care will therefore require rights-based policies, culturally responsive models of care, and shared accountability among families, communities, health systems, and the state to protect the dignity, rights, and well-being of older adults. Declarations ETHICAL CONSIDERATIONS This study was approved as exempt from ethical review by the Research Ethics Committee of Aminu Kano Teaching Hospital, Kano, Nigeria. This is because it was a scoping review of published literature and involved no human participants or identifiable data. Consent for publication : Not applicable Availability of data and materials: All data generated or analysed during the study are available and included in this manuscript. Competing interests: The authors declare no competing interest whatsoever in preparing this article. Funding: This work was partly supported by the Fogarty International Center (FIC) of the U.S. National Institutes of Health (NIH) award number 1R25TW012715. The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIH, the Department of Health and Human Services, or the government of the United States of America. Authors’ contribution: All authors contributed significantly to this manuscript. Olawumi A.L led the conceptualization, study design, methodology, data analysis, drafting of the manuscript, and served as the corresponding author with overall responsibility for the work. Abdulkadir Z. and Suleiman A.K contributed to conceptualization, methodology development, data synthesis, and drafting of the discussion. Umar Z.A, Grema B.A, Michael G.C, Mohammed A.A, Abdullahi U.F, Mahmud M.B, Ibraheem A.S, Muhammad A.D, and Badamasi A, participated in data collection, literature search, data extraction, quality assessment, and interpretation of findings. Grema B.A, and Badamasi A provided specialist input into clinical interpretation and ethical considerations. Gezawa I.D, Borodo M.M., and Aliyu M.H. provided senior academic oversight, critically reviewed the manuscript for intellectual content, and guided interpretation of results. 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Doron I, Cox C, Spanier B. Comparing Older Persons' Human Rights: Exploratory Study of the International Older Persons' Human Rights Index (IOPHRI). Gerontologist. 2019;59(4):625–34. 10.1093/geront/gny080 . Weise MV. Medical Ethics Made Easy. Prof Case Manag. 2016;21(2):88–94. 10.1097/NCM.0000000000000151 . Chatterji S, Kowal P, Mathers C, Naidoo N, Verdes E, Smith JP, et al. The health of aging populations in developing countries. Lancet. 2008;372(9640):847–57. Mba CJ. Population ageing in Ghana: research gaps and policy directions. J Aging Soc Policy. 2010;22(2):153–71. Bayuo J. Experiences with out-patient hospital service utilisation among older persons in the Asante Akyem North District-Ghana. BMC Health Serv Res. 2017;17(1):652. 10.1186/s12913-017-2604-6 . Dzando G, Ward P, Mwanri L, Asante D, Okyere E, Ambagtsheer RC. Aging in Sub-Saharan Africa: A qualitative synthesis of older people's perceptions and experiences using the ecological systems theory. Geriatr Nurs. 2025;66(Pt C):103663. 10.1016/j.gerinurse.2025.103663 . Monsudi KF, Oladele TO, Nasir AA, Ayanniyi AA. Medical ethics in sub-Sahara Africa: closing the gaps. Afr Health Sci. 2015;15(2):673–81. 10.4314/ahs.v15i2.47 . Atuire CA, Bull S. COVID-19 heightens the need for ethical considerations in Africa’s health systems. Dev World Bioeth. 2020;20(4):187–90. Nuffield Council on Bioethics. The ethics of research related to healthcare in developing countries. London: Nuffield Council on Bioethics. 2001. [cited 2025 December 10]. Available from: https://www.nuffieldbioethics.org/wp-content/uploads/Ethics-of-research-related-to-healthcare-in-developing-countries.pdf Agyemang-Duah W. Towards good health and wellbeing: understanding health conditions and healthcare needs among informal caregivers of older adults in Ghana. J Health Popul Nutr. 2025;44(1):415. 10.1186/s41043-025-01131-7 . Kalache A, Aboderin I, Hoskins I. Compression of morbidity and active ageing: key priorities for public health policy in the 21st century. Bull World Health Organ. 2002;80(3):243–4. Essomba NMJ, Mba MRM, Kameni EL, Tchebegna P, Lema MFD, Tabue-Teguo M. Prevalence of frailty and association with intrinsic capacity decline among community-dwelling older people in Cameroon: a cross-sectional study. BMC Geriatr. 2025;25(1):335. 10.1186/s12877-025-06011-7 . Grema BA, Tanimu ST, Michael GC, Aliyu I, Aji SA, Takai IU et al. Informed Consent: The Surgical Patient's Experience in a Tertiary Hospital in Northwest Nigeria. West Afr J Med. 2022;(5):471–8. Mitchell E, Walker R. Global ageing: successes, challenges and opportunities. Br J Hosp Med (Lond). 2020;81(2):1–9. 10.12968/hmed.2019.0377 . Zelalem A, Gebremariam Kotecho M. Challenges of Aging in Rural Ethiopia: Old Age Is like the Sunset: It Brings Disrespect and Challenges . J Gerontol Soc Work. 2020;63(8):893–916. 10.1080/01634372.2020.1814475 . Shlobin NA, Sheldon M, Bernstein M. Ethics of Transitioning from Curative Care to Palliative Care: Potential Conflicts of Interest Using the Example of Neurosurgery. World Neurosurg. 2022;168:139–45. 10.1016/j.wneu.2022.10.003 . Lucente FE. Ethical challenges in geriatric care. Otolaryngol Head Neck Surg. 2009;140(6):809–11. 10.1016/j.otohns.2009.01.033 . Campbell CL, Williams IC, Orr T. Factors that impact end-of-life decision making in African Americans with advanced cancer. J Hosp Palliat Nurs. 2011;41(1):277–8. Hurst SA. Vulnerability in research and health care; describing the elephant in the room? Bioethics. 2008;22(4):191–202. 10.1111/j.1467-8519.2008.00631.x . Gbadegesin S, Wendler D. Protecting communities in health research from exploitation. Bioethics. 2006;20(5):248–53. 10.1111/j.1467-8519.2006.00501.x . Bateman C. Old age care - relatives 'at the mercy' of homes. S Afr Med J. 2012;102(5):278–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviewers invited by journal 31 Mar, 2026 Editor invited by journal 24 Mar, 2026 Editor assigned by journal 23 Mar, 2026 Submission checks completed at journal 23 Mar, 2026 First submitted to journal 22 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9190458","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619247742,"identity":"bbc2e0df-dae2-47b4-ac5d-188de886d3ea","order_by":0,"name":"Abdulgafar Lekan Olawumi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABJklEQVRIiWNgGAWjYDACdjApwWDAkMB4gIFBDijSABQwsMCthRmhhQGoxZiBgecASIsEIS0MSFokEiCG4AL8zMzPpHlzLOTN2XMMDn6pMZA3n/n86oYfBRIM/O3dCdi0SDazmUnzbpMw3NnzxuCwzDEDwzm3c8pu9gAdJnHm7AZsWgwOM5jdBmph3HAjx+CwBNsfxhnSOWk3eIBaDCRycWhh/wbSYg/R8s/AfobkmbSbf/Bq4QHbkgjScvBjm0HiDAn2Y7fx2SLZzFP+c+42ieSdPc8KDjP2GSTP4Mlhuy1jIMGDyy/87O2bDd5uq7Pdzp688eGPbwa2M9iPP7v55o+NHH97L1YtKICZB0zxGIBJgspBgPEHmGJ/QJTqUTAKRsEoGDEAAEjaZA2M0+oIAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Abdulgafar","middleName":"Lekan","lastName":"Olawumi","suffix":""},{"id":619247745,"identity":"de82809a-42a6-41b9-bc0f-82756e646011","order_by":1,"name":"Zainab Abdulkadir","email":"","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zainab","middleName":"","lastName":"Abdulkadir","suffix":""},{"id":619247752,"identity":"19a2a0ca-af8e-419a-b88a-b53b301e85b6","order_by":2,"name":"Abdullahi Kabir Suleiman","email":"","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdullahi","middleName":"Kabir","lastName":"Suleiman","suffix":""},{"id":619247756,"identity":"1068267e-d68a-4a62-bf03-eebb8dcc60b8","order_by":3,"name":"Zainab Abdulazeez Umar","email":"","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zainab","middleName":"Abdulazeez","lastName":"Umar","suffix":""},{"id":619247757,"identity":"152df9a6-a8c1-44ea-b5f0-f59c476fec4a","order_by":4,"name":"Bukar Alhaji Grema","email":"","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bukar","middleName":"Alhaji","lastName":"Grema","suffix":""},{"id":619247760,"identity":"630abee9-5a85-4116-8ddf-0b5244471be1","order_by":5,"name":"Godpower Chinedu Michael","email":"","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Godpower","middleName":"Chinedu","lastName":"Michael","suffix":""},{"id":619247761,"identity":"f55528f5-c904-49ee-a39e-662a49fcb581","order_by":6,"name":"Abiso Abubakar Mohammed","email":"","orcid":"","institution":"Department of Family Medicine, University of Maiduguri Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abiso","middleName":"Abubakar","lastName":"Mohammed","suffix":""},{"id":619247762,"identity":"43323f37-d6d5-408a-bcb9-220fa37618fa","order_by":7,"name":"Umar Faruk Abdullahi","email":"","orcid":"","institution":"Department of Internal Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Umar","middleName":"Faruk","lastName":"Abdullahi","suffix":""},{"id":619247766,"identity":"29238643-9b01-472b-903a-de111b1ff7e5","order_by":8,"name":"Mahmud Baba Mahmud","email":"","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mahmud","middleName":"Baba","lastName":"Mahmud","suffix":""},{"id":619247769,"identity":"decfa026-1db5-4080-8ad1-1716f36465c8","order_by":9,"name":"Abdulrauf Segun Ibraheem","email":"","orcid":"","institution":"Department of Family Medicine, Federal Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdulrauf","middleName":"Segun","lastName":"Ibraheem","suffix":""},{"id":619247772,"identity":"7fb7173d-9ec3-47b7-8b38-86c9dfb42fa3","order_by":10,"name":"Amina Danladi Muhammad","email":"","orcid":"","institution":"Department of Family Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Amina","middleName":"Danladi","lastName":"Muhammad","suffix":""},{"id":619247775,"identity":"17a790ce-468e-4800-b884-ab6c058a9fe4","order_by":11,"name":"Abba Abba Badamasi","email":"","orcid":"","institution":"Department of Family Medicine, National Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abba","middleName":"Abba","lastName":"Badamasi","suffix":""},{"id":619247777,"identity":"a5203f29-4bf9-4e81-9479-e3783076eb94","order_by":12,"name":"Ibrahim Danjummai Gezawa","email":"","orcid":"","institution":"Department of Internal Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Danjummai","lastName":"Gezawa","suffix":""},{"id":619247778,"identity":"bd7ec95e-1719-4cb9-8d1c-d078647cb0cd","order_by":13,"name":"Muktar Hassan Aliyu","email":"","orcid":"","institution":"Vanderbilt Institute for Global Health, Vanderbilt University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Muktar","middleName":"Hassan","lastName":"Aliyu","suffix":""},{"id":619247783,"identity":"c11fb74e-e8be-47f0-8618-3c8fd99e30da","order_by":14,"name":"Muhammad Musa Borodo","email":"","orcid":"","institution":"Department of Internal Medicine, Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Musa","lastName":"Borodo","suffix":""}],"badges":[],"createdAt":"2026-03-22 10:09:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9190458/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9190458/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106603618,"identity":"5dfe893c-306c-439d-a226-f5a63d302ae2","added_by":"auto","created_at":"2026-04-10 10:43:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144953,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic distribution of studies included in this review across Africa.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9190458/v1/c808799d416b520e8f6015f0.jpg"},{"id":106603620,"identity":"c2020b48-08fc-4f16-8243-80b28ae7d55c","added_by":"auto","created_at":"2026-04-10 10:43:07","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":85084,"visible":true,"origin":"","legend":"\u003cp\u003eThe PRISMA-ScR flow diagram illustrates the study selection process in the scoping review, showing how studies were identified, screened, and assessed for inclusion or exclusion.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9190458/v1/a4894cde7e22557fe1f15ae2.jpg"},{"id":106728716,"identity":"c50d986d-08ce-4dba-a815-ccfef5b0f0c6","added_by":"auto","created_at":"2026-04-12 18:44:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1981646,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9190458/v1/24340a1c-d9a5-49f9-b14e-a2a215faf405.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEthical Issues in Caring for Older Persons in Sub-Saharan Africa: A Scoping Review\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePopulation ageing is a global phenomenon with important implications for health systems, social structures, and ethical practice.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In Sub-Saharan Africa (SSA), the proportion of older adults is increasing, albeit at a slower pace than in high-income countries, due to improvements in life expectancy and declining fertility rates.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e While the absolute number of older persons in SSA remains lower than in Europe or North America, their health and social care needs are growing, often in contexts of fragile healthcare systems, limited geriatric expertise, and constrained resources.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEthical challenges in the care of older adults in SSA emerge as healthcare providers, families, and policymakers navigate issues related to access, quality, and fairness.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e These ethical considerations are multifaceted. Older adults often face chronic diseases such as hypertension, diabetes, and dementia, which require long-term patient-centered care.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Yet, health systems in SSA are often oriented toward acute care and maternal-child health, leaving older persons underserved.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Social norms, cultural expectations, and family dynamics further complicate the provision of ethical care. For example, autonomy and informed consent, foundational principles in Western bioethics, may conflict with communal decision-making practices prevalent in SSA.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The ethical tension arises between respecting individual rights and accommodating cultural norms, requiring clinicians and policymakers to navigate delicate moral terrain.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In addition, despite growing scholarly attention to ageing in SSA, ethical issues remain dispersed across disciplines and inadequately synthesized.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Existing reviews have largely focused on epidemiology, service delivery, or social support, with limited critical engagement with ethical dimensions.\u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e A scoping review with critical analysis is therefore warranted to systematically map the available evidence, examine how ethical issues are framed, and identify gaps to inform research, policy, and practice.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe objectives of this scoping review are to map the range of ethical issues related to the care of older persons in SSA, examine how ethical principles such as autonomy, justice, beneficence, and respect for dignity are applied in different care contexts, and critically analyse the influence of cultural, social, legal, and health-system factors on ethical decision-making. The review will also identify evidence gaps and propose priorities for ethical research, policy, and practice in aging care.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthical Frameworks Relevant to Geriatric Care in SSA\u003c/h2\u003e \u003cp\u003eUnderstanding ethical issues in older care requires grounding in bioethical theory. Several frameworks are particularly relevant:\u003c/p\u003e \u003cp\u003e \u003cb\u003e1. Principlism\u003c/b\u003e: It is based on the four pillars of autonomy, beneficence, non-maleficence, and justice, which provides a practical approach to ethical decision-making in healthcare.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAutonomy\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eRespecting older adults’ choices in healthcare decisions, including treatment refusal or advance directives, can conflict with familial authority in SSA contexts.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eBeneficence and non-maleficence\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eClinicians must balance interventions that promote well-being while minimizing harm, particularly when resource constraints limit available treatments.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eJustice\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eEthical allocation of scarce resources, such as medications, hospital beds, or specialized geriatric care, requires transparent and culturally sensitive policies.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eVirtue ethics\u003c/b\u003e: Emphasizing character traits and moral dispositions, virtue ethics highlights the clinician’s responsibility to act with compassion, empathy, and integrity.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e This approach is particularly useful in SSA, where formal protocols may be limited, and ethical practice relies heavily on professional judgment and relational care.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCare ethics\u003c/b\u003e: Care ethics prioritizes relationships, interdependence, and responsiveness to the needs of vulnerable individuals.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Given the centrality of family and community in older care in SSA, care ethics provides a culturally resonant framework that complements principlism while addressing contextual realities.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePublic health ethics\u003c/b\u003e: Ethical frameworks in public health emphasize population-level considerations, resource allocation, and equity.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In SSA, public health ethics is critical when addressing systemic challenges affecting older adults, such as access to vaccinations, chronic disease management, and social protection.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRegistration\u003c/h3\u003e\n\u003cp\u003eThe protocol for this scoping review was registered on the Open Science Framework (OSF) and is available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.17605/OSF.IO/9AXVW\u003c/span\u003e\u003cspan class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eScope and approach\u003c/h3\u003e\n\u003cp\u003eWe employed a systematic and transparent search strategy across multiple databases to identify relevant literature according to the PRISMA-ScR guidelines.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eSearch strategy\u003c/h3\u003e\n\u003cp\u003eWe performed a comprehensive literature search to identify relevant studies addressing ethical issues in caring for older persons in SSA. The review focused on older adults as the population of interest, ethical and moral concerns as the core concept, and healthcare and social care settings within SSA (East, West, Central, and Southern Africa) as the context. The primary question guiding the search was: What ethical issues arise in the care of older persons in SSA, and how are these issues addressed within healthcare and social care systems?\u003c/p\u003e \u003cp\u003eElectronic databases searched included PubMed/MEDLINE, Scopus, and Web of Science to capture biomedical and multidisciplinary literature. Given the regional focus, African-specific databases such as African Journals Online (AJOL), and African Index Medicus were also searched. We identified gray literature through targeted searches of reports and policy documents from the World Health Organization (WHO), United Nations agencies, HelpAge International, non-governmental organizations and relevant government sources. The search strategy combined terms related to older persons, ethical issues, care contexts, and geographic location. Terms describing the population included “older persons,” older people,” “older adults,” “elderly,” “ageing,” “aging,” and “geriatrics.” Ethical concepts were captured using keywords such as “ethics,” “bioethics,” “moral issues,” “ethical dilemmas,” “human rights,” “autonomy,” “dignity,” “justice,” “equity,” “ageism,” “elder abuse,” “neglect,” and “exploitation.” Care-related terms included “healthcare,” “health care,” “medical care,” “long-term care,” “social care,” “caregiving,” “nursing care,” and “community care.” Geographic identifiers included “Sub-Saharan Africa,” “Africa South of the Sahara,” and the names of individual countries within the region, such as Nigeria, Ghana, Kenya, South Africa, Ethiopia, Uganda, and Tanzania. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003eIn PubMed, both Medical Subject Headings (MeSH) and free-text terms were used to maximize retrieval. Similar keyword-based strategies were adapted for Scopus and Web of Science, using database-specific subject headings and Boolean operators, truncations and wildcards. Searches were limited to articles published in English from the year 2000 to 2025 to reflect contemporary ethical debates and healthcare contexts. Eligible studies included empirical qualitative and quantitative research, systematic and narrative reviews, ethical analyses, and policy papers that explicitly addressed ethical issues in the care of older adults in SSA. Studies were excluded if they focused exclusively on regions outside SSA, did not address ethical or moral dimensions of care, did not focus on older persons, or consisted solely of editorials without substantive ethical analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eStudy selection and data extraction\u003c/h3\u003e\n\u003cp\u003eTwo reviewers independently screened the titles and abstracts of all identified studies to determine their relevance to the review topic. Studies considered potentially eligible were then retrieved for full-text assessment against the predefined inclusion and exclusion criteria. Any disagreements between the reviewers at any stage of the screening process were resolved through discussion and consensus; where necessary, a third reviewer was consulted to ensure objectivity and consistency in study selection. Data were extracted using a standardized data extraction form to ensure uniformity and completeness. The extracted information included details on authorship, year of publication, and study period, as well as the country and sub-region within Sub-Saharan Africa where the study was conducted. Additional variables included study design (e.g., qualitative, quantitative, or mixed methods), study setting (urban, rural, or mixed), and population group. Given the focus of this review, particular attention was paid to identifying and documenting key ethical issues related to the care of older persons. These included, but were not limited to, concerns around autonomy, informed consent, dignity, confidentiality, access to care, equity, cultural considerations, and end-of-life decision-making. Where reported, information on ethical frameworks, guidelines, or principles applied in the studies was also extracted. In cases where important information was missing, unclear, or insufficiently reported, corresponding authors were contacted for clarification or additional data.\u003c/p\u003e "},{"header":"RESULT","content":"\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, a total of 82 studies met the inclusion criteria for this scoping review, published between 2001 and 2025. The body of evidence comprised predominantly reviews, qualitative studies, cross-sectional studies, and policy reports focusing on older adults across SSA. Collectively, the findings reveal a wide range of ethical and moral concerns in the care of older adults, with recurrent themes of justice, equity, autonomy through consent and decision making, dignity, vulnerability, ageism, intergenerational responsibility, and culturally grounded ethical frameworks shaping care experiences.\u003c/p\u003e\u003cp\u003eWithin healthcare contexts, we found that service delivery for older adults in Nigeria and across SSA face multiple ethical challenges, particularly in decision-making, consent, palliative and end-of-life care (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition, culturally mediated decision making, limited palliative infrastructure, and inadequate professional training frequently undermine ethically-sound care. Qualitative studies from Nigeria by Doobay-Persaud et al. (2023) and Udeh et al. (2025), and a systematic review by Gysels et al. (2011), showed that communication barriers, family-dominated decisions, and poor symptom control often compromise autonomy and dignity at the end of life.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Powell et al. (2014) further highlighted the absence of comprehensive palliative care policies, reinforcing systemic inequities in access to compassionate care.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Hospital- and clinic-based studies reveal broader ethical vulnerabilities. Olawumi et al. (2021) documented high morbidity and poor nutritional status among hospitalized older adults in northern Nigeria, raising concerns about neglect and distributive justice.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Odusanya et al. (2018) and Olanrewaju et al. (2020) identified ageism, financial barriers, and fragmented services as persistent constraints to equitable access.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Knight et al. (2018) further demonstrated how older adults with HIV and non-communicable diseases (NCDs) navigate poorly coordinated services, highlighting failures in continuity and equity.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Ethical challenges in autonomy and informed decision-making are evident in consent, disclosure, and treatment prioritization. Ede et al. and Mussie et al. (2024) showed that cultural norms privileging family authority and clinician discretion limit individual autonomy, reflecting relational ethics, but risking marginalisation.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e A report from Ethiopia by Tegegn et al. 2018 found that older patients value involvement in deprescribing, suggestive of tensions between clinical judgement, autonomy, and resource constraints.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e In Uganda, Alupo et al. (2025) highlighted systemic and cultural barriers to anticipatory care based on low uptake of advance directives.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Access and stigma also remained critical concerns: Jolley et al. (2025) showed older adults with disabilities in Uganda navigate structural barriers to eye care,\u003csup\u003e32\u003c/sup\u003e while Wandera et al. (2025) identified stigma as an ethical barrier in the HIV care cascade.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Together, these findings demonstrate that ethical challenges in healthcare delivery for older adults in SSA extend beyond clinical encounters, and reflect deeply embedded structural, cultural, and policy-level constraints.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEthical Issues in Care, Decision-Making, Consent, and End-of-Life Care\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eAuthor(s) (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eStudy Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003ePopulation / Scope\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eEthical / Moral Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eKey Contributions to Ageing Ethics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDoobay-Persaud et al. (2023).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth professionals, patients, older adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePalliative care ethics, dignity, communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores ethical challenges in symptom control, interprofessional communication, and delivery of culturally sensitive palliative care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePowell et al. (2014).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAfrica\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCommentary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePatients, health systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePolicy ethics, justice, access to palliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHighlights ethical and policy challenges in scaling palliative care services in resource-limited settings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGysels et al. (2011).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSystematic review (qualitative)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePatients, families, healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEnd-of-life care, dignity, cultural ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSynthesizes evidence on ethical issues in end-of-life care, including communication and cultural perspectives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eUdeh et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePatients, healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEnd-of-life decision-making, autonomy, dignity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines ethical dilemmas in end-of-life care including consent, truth-telling, and shared decision-making\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTegegn et al. (2018).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAutonomy, deprescribing ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores older patients’ perceptions of medication withdrawal and ethical considerations in clinical decision-making\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOdusanya et al. (2018).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNarrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth system ethics, dignity, access to care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIdentifies systemic and ethical challenges affecting care quality and equity among older persons\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlanrewaju et al. (2020).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAfrica\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNarrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAgeism, dignity, equity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines how age-based discrimination affects access to healthcare and ethical care delivery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eKnight et al. (2018).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults with HIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEquity, access, stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHighlights barriers to healthcare access and ethical concerns related to stigma and multimorbidity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEde et al. (2024).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSurgical patients (including older adults)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInformed consent, autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAssesses ethical challenges in obtaining valid informed consent in resource-limited surgical settings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMussie et al. (2024).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder patients, clinicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDisclosure ethics, autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores ethical tensions around truth-telling and information disclosure in elderly care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eJolley et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults with disabilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAccess, equity, justice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines ethical issues in access to eye care services among vulnerable older populations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eWandera et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSystematic review protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults with HIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStigma, confidentiality, equity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInvestigates ethical implications of stigma across the HIV care continuum\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAlupo et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMixed-methods study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAutonomy, advance directives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores awareness and ethical implications of advance care planning and decision-making\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003eIn social care contexts across SSA, as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, ethical challenges for older adults arise amid changing family structures, migration, poverty, and weakening informal support systems.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Evidence from Ghana, Malawi, and other SSA settings indicate that family-based care, traditionally central to elder support, is increasingly strained Narrative reviews from Ghana by Agyemang (2025) and Dovie (2019), and studies in Democratic Republic of Congo, by Adei et al. (2025), and Bikouta et al. (2015), document strong moral expectations on families and informal caregivers alongside economic hardship, urbanisation, and inter-generational change, resulting in neglect, reduced autonomy, and lower quality of care.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Hospital-based and community studies in Malawi\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003c/sup\u003e and South Africa \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e, highlight risks of malnutrition, abuse, and caregiver burden, reflecting both household- and system-level vulnerabilities.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Regional and cross-national analyses, including works by Okolie et al. (2025), Aboderin (2025), HelpAge International (2011), Adamek et al. (2022), and Gedfew et al. (2024), identify gaps in social protection, prevalence of elder abuse, and limited institutional safeguards, situating ethical concerns within broader social and policy environments.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOn the other hand, Jecker (2022) applied an inter-generational ethical perspective, framing moral obligations toward older adults within multi-generational and skipped-generation households, despite structural constraints.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Older adults’ lived experiences further illuminate these ethical challenges: qualitative studies from Uganda,\u003csup\u003e32\u003c/sup\u003e Nigeria,\u003csup\u003e45\u003c/sup\u003e and Ethiopia,\u003csup\u003e46\u003c/sup\u003e reported perceptions of vulnerability, loss of autonomy, and culturally incongruent care. Ethics-of-care approaches, emphasizing relational responsibility, dignity, and context-sensitive care, are also described in studies from South Africa,\u003csup\u003e47\u003c/sup\u003e and Ghana.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Collectively, the published evidence from Nigeria, Uganda, Ethiopia, Ghana, Malawi, and South Africa consistently link elder abuse and neglect to social inequality, caregiver stress, migration, food insecurity, and limited regulatory oversight.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocial Care Ethics: Family Responsibility, Elder Abuse, Neglect, and Vulnerability\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eAuthor(s) (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eStudy Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003ePopulation / Scope\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eEthical / Moral Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eKey Contributions to Aging Ethics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAgyemang (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConceptual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults, families\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFamily ethics, moral obligations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines evolving family roles in elder care and the ethical implications of shifting caregiving responsibilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDovie (2019).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults, families\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFamily ethics, caregiving norms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHighlights the role of traditional family systems and ethical obligations in supporting older persons\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAdei et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInformal caregivers of older adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCaregiver burden, social responsibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIdentifies predictors of caregiving strain and ethical concerns related to caregiver support and wellbeing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBikouta et al. (2015).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCongo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eYoung people, older adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIntergenerational ethics, respect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores perceptions of ageing and moral attitudes toward older persons among younger populations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLukman et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConceptual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStructural inequality, social justice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDiscusses how social determinants create ethical challenges in ageing and access to care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMphwanthe et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eVulnerability, nutrition ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines malnutrition and food insecurity as ethical concerns affecting older adults’ health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBrear et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMixed-methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCaregivers of older adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCare ethics, wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores health and wellbeing of caregivers, highlighting ethical dimensions of caregiving burden\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMeel (2017).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eViolence, justice, human rights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDocuments sexual violence against elderly women and highlights ethical issues of protection and justice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHelpAge International (2011).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eReport\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRights, vulnerability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProvides evidence on systemic neglect and emphasizes ethical obligations for protection and policy response\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAdamek et al. (2022).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSocial vulnerability, resilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores both challenges and strengths of older adults, emphasizing ethical need for supportive systems\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOkolie et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAbuse, caregiving ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDistinguishes between caregiving and abuse, highlighting ethical grey areas in elder care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBrear et al. (2024).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults, caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEthics of care, quality of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConceptualizes “good care” within informal caregiving networks and ethical responsibilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAwuviry-Newton et al. 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(2015).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAbuse, dignity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores lived experiences and perceptions of abuse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCadmus et al. (2012).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAbuse, gender ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines prevalence and gendered dimensions of abuse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAgunbiade (2019).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAbuse, prevention ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores causes of abuse and strategies for prevention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates how ethical approaches to ageing in SSA are shaped by global human rights norms, public health ethics, and locally grounded moral obligations, while revealing gaps in implementation, training, and system-level support for older adults. Empirical studies from SSA consistently showed that poverty, inequitable access to care, age-related discrimination, and health system fragmentation remain central ethical concerns shaping ageing experiences.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eGlobal and regional policy frameworks\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eGlobal and regional policy instruments, including the WHO Global Strategy on Ageing and Health (2017), the WHO AFRO Framework for Healthy Ageing (2022), and the United Nations World Population Ageing Report (2023), promote rights-based, equitable, and context-sensitive approaches to ageing.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e These frameworks prioritize dignity, autonomy, and equity while advocating integration of health and social care systems. However, evidence from Ghana, Senegal, Nigeria, and Eswatini revealed implementation gaps, with older adults reporting unmet basic needs, financial hardship, and unequal utilisation of healthcare services, despite policy commitments to universal health coverage.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eEthics of research, policy, and health systems\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eExpert reports and reviews by the National Research Council (NRC, 2006),\u003csup\u003e76\u003c/sup\u003e Prince et al. (2015),\u003csup\u003e77\u003c/sup\u003e Aboderin (2010; 2025),\u003csup\u003e3,4\u003c/sup\u003e Brock and Wikler (2006),\u003csup\u003e9\u003c/sup\u003e and Childress et al. (2002),\u003csup\u003e10\u003c/sup\u003e emphasized justice, distributive fairness, and ethical resource allocation in ageing societies. These ethical concerns are reflected in empirical studies showing socioeconomic inequalities, frailty-related vulnerability, and inequitable service provision among older adults in Ghana, Rwanda, Kenya, and Nigeria.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e78\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e Studies further documented structural barriers such as fragmented primary care, inadequate workforce training, and low preventive service uptake, including vaccination among caregivers and healthcare workers.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e82\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eHuman rights, bioethics, and contextual moral frameworks\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eComparative rights analyses by Doron et al. (2019) introduce the International Older Persons’ Human Rights Index as a tool for ethical monitoring of elder care systems.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e The role of inter-generational obligations, family responsibility, and moral duties toward older adults are highlighted by conceptual and case-based work that advance culturally grounded African bioethics.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e84\u003c/span\u003e\u003c/sup\u003e These perspectives align with findings on ageism, workplace discrimination, and the moral consequences of poverty and multimorbidity in later life.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e Foundational biomedical ethics texts by Beauchamp et al. (2019) and Brock and Wikler (2006) also stress the core principles of autonomy, beneficence, non-maleficence, and justice, that underpin ethical decision-making in geriatric practice across SSA.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab3\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMoral and System-Level Ethical Frameworks, and Policy for Older Adults in SSA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eAuthor(s) (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eStudy Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003ePopulation / Scope\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eEthical / Moral Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eKey Contributions to Ageing Ethics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eKola et al. (2019).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eConceptual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePoverty, distributive justice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eChallenges moral attribution of poverty and highlights ethical implications of economic vulnerability in old age\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDei et al. (2018).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEquity, healthcare access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines inequities in healthcare utilisation, emphasizing ethical concerns around fairness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAgyemang-Duah et al. (2019).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFinancial protection, access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores ethical challenges in financing healthcare among poor older adults\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMabuza et al. (2010).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEswatini\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBasic needs, dignity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIdentifies unmet basic needs and ethical implications for wellbeing and dignity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlawumi et al. (2023).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFunctional health, equity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines determinants of functional capacity, highlighting inequities affecting ageing outcomes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eWHO (2017).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e71\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGlobal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePolicy framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRights-based care, dignity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProvides global strategy promoting ethical, rights-based approaches to healthy ageing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eWHO AFRO (2022).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePolicy framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEquity, integrated care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOutlines regional framework for ethical and equitable ageing care systems\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eChatterji et al. (2008).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGlobal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder populations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth equity, system ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDiscusses burden of disease and ethical implications for policy and care systems\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTaverne et al. (2023).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSenegal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAccess, financial ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExplores healthcare utilisation and ethical issues related to cost and access\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOgunyemi et al. (2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eService provision, dignity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines barriers to primary healthcare and ethical implications for quality care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNRC (2006).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e76\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGlobal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExpert report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder populations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eResearch ethics, policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProvides recommendations for ethical research and policy development in ageing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePrince et al. 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(2025).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e80\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMixed-methods protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealthy ageing, system ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProposes strategies to address multimorbidity and ageing needs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNuffield Council on Bioethics (2001).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGlobal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEthics report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eVulnerable populations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eResearch ethics, justice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProvides guidance on ethical conduct in health research\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDoron et al. (2019).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGlobal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eComparative analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOlder adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHuman rights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eIntroduces framework for assessing rights of older persons\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSibanda et al. (2023).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e82\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealthcare workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eProfessional ethics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExamines ethical issues in vaccination practices among caregivers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis scoping review demonstrates that ethical challenges in the care of older adults in SSA are complex, interrelated, and deeply embedded in clinical, social, cultural, and structural contexts. Across the literature, five recurring ethical domains emerge: informed consent and decision-making capacity; end-of-life and palliative care; resource allocation and justice; elder abuse, neglect, and vulnerability; and cultural considerations under ethical pluralism. Together, these findings reveal systemic gaps that compromise autonomy, dignity, and equity for ageing populations in the region.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed Consent and Decision-making Capacity \u003c/strong\u003e\u003c/p\u003e \u003cp\u003eInformed consent and decision-making capacity constitute persistent ethical challenges in the care of older adults in SSA, shaped by intersecting clinical, sociocultural, and structural constraints. While autonomy-based bioethical frameworks remain foundational, their application is frequently constrained in practice due to cognitive impairment, frailty, low literacy, and entrenched communal decision-making norms.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e Evidence from Nigeria and Ghana suggest that clinicians often struggle to obtain informed consent, especially in acute care, surgical, and end-of-life settings.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/sup\u003e In these contexts, consent processes are often abbreviated, poorly documented, or delegated to family members without formal capacity assessments. Such practices, while driven by time pressure and cultural expectations, risk undermining the autonomy of older adults and exposing them to paternalistic decision-making.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eQualitative studies further show that decision-making in SSA is rarely individualistic. Family hierarchies and inter-generational moral obligations strongly influence healthcare choices, particularly for older adults with cognitive decline or functional dependence.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Jecker\u0026rsquo;s inter-generational ethics framework argues that surrogate decision-making in African contexts should not be viewed solely as ethical failure, but as relational autonomy embedded within social responsibility.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e However, without safeguards, this model may also enable coercion, concealment of diagnoses, or exclusion of older persons from meaningful participation.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e\u003c/sup\u003e Low health literacy and limited geriatric training among healthcare workers further compromise consent validity.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e Studies from Ethiopia and Nigeria reveal clinicians\u0026rsquo; reluctance to disclose full prognostic information to older patients, citing fears of distress or perceived inability to understand complex information.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e,\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/sup\u003e While well-intentioned, such non-disclosure conflicts with ethical and rights-based standards articulated by the WHO and the Nuffield Council on Bioethics.\u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e Overall, the literature suggests that ethically robust consent in SSA requires culturally responsive models that integrate capacity assessment, supported decision-making, and family engagement while prioritizing the dignity and expressed preferences of older adults. Strengthening geriatric ethics training, developing context-sensitive consent tools, and aligning clinical practice with rights-based frameworks are critical to addressing these challenges.\u003c/p\u003e\n\u003ch3\u003eEnd-of-Life Care and Palliative Ethics\u003c/h3\u003e\n\u003cp\u003eEnd-of-life care in SSA is characterized by substantial ethical challenges rooted in weak health system capacity, including limited availability of palliative care services, poor access to essential analgesics, and shortages of trained healthcare professionals.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e These structural deficiencies result in inadequate symptom control and delayed initiation of palliative care, and compromise the ethical obligations of beneficence and non-maleficence, especially for frail and functionally dependent older adults.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Ethical dilemmas often arise when clinicians must decide between continuing life-prolonging interventions and transitioning to comfort-oriented care in the absence of clear prognostic guidance or institutional protocols.\u003csup\u003e\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e\u003c/sup\u003e Evidence from Nigeria and other SSA settings demonstrates frequent discordance between clinicians\u0026rsquo; clinical assessments and families\u0026rsquo; expectations, with families often favoring maximal intervention due to culturally-embedded beliefs surrounding hope, moral duty, and the social meaning of death.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u003c/sup\u003e Such tensions may contribute to over-treatment, delayed palliation, and moral distress among healthcare providers operating in resource-constrained environments.\u003csup\u003e\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCultural norms that prioritize collective decision-making and filial responsibility further complicate end-of-life ethics, sometimes marginalizing older adults\u0026rsquo; preferences, comfort, and experiential dignity.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e The ethical complexity of end-of-life care is exacerbated by the limited uptake of advance care planning and the absence of clear legal and policy frameworks guiding surrogate decision-making in many SSA countries.\u003csup\u003e\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e,\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u003c/sup\u003e In this context, clinicians are often required to navigate ethically ambiguous decisions with little institutional or legal support. Guidance from the WHO emphasizes the integration of palliative care into primary healthcare systems and advocates for rights-based approaches that prioritize dignity, symptom relief, and culturally-responsive family engagement.\u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e Collectively, the literature highlights the need for ethically grounded, context-sensitive end-of-life care models that reconcile clinical judgment, cultural values, and the fundamental right of older adults in SSA to a dignified death.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eResource Allocation and Justice\u003c/h2\u003e \u003cp\u003eResource limitations are a defining feature of many health systems in SSA, with ethical implications for justice and equitable healthcare delivery for older adults. Evidence from Nigeria and across SSA suggest that older persons experience persistent barriers to accessing healthcare services, essential medicines, and specialized geriatric care, reflecting structural inequities in resource distribution.\u003csup\u003e\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e These constraints disproportionately affect older adults with multimorbidity, frailty, and functional limitations, worsening vulnerability within already resource-limited systems.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Such inequities raise concerns regarding distributive justice, social responsibility, and the moral obligations of health systems toward vulnerable populations.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEthical frameworks emphasize fair, transparent, and needs-based allocation of scarce resources; however, studies consistently identify age-based discrimination (\u0026ldquo;ageism\u0026rdquo;) as a significant determinant of healthcare access for older adults in SSA.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Ageism manifests through overt neglect, financial exclusion, and subtle marginalization in clinical prioritization and referral pathways.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u003c/sup\u003e Such practices contravene the principles of justice and non-maleficence, as older adults may be denied interventions that preserve function, alleviate suffering, or improve quality of life.\u003c/p\u003e \u003cp\u003eEthical tensions related to resource allocation are particularly evident in palliative and end-of-life care. Limited infrastructure, shortages of trained personnel, and competing service priorities frequently compel clinicians to navigate difficult trade-offs between life-prolonging interventions and comfort-focused care, often in the absence of clear institutional guidance.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e\u003c/sup\u003e These challenges are exacerbated by the high burden of chronic disease and disability among older adults in SSA, which increases demand for long-term and resource-intensive care.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe literature further highlights that ethical approaches to resource allocation in SSA must be contextually grounded, accounting for sociocultural norms, health system constraints, and population-specific vulnerabilities.\u003csup\u003e\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e Geriatric ethics in African settings requires balancing individual clinical need with collective welfare, while avoiding structural neglect of older persons. Policy-oriented analyses emphasize the need to integrate geriatric-focused strategies into broader health system reforms, including investment in human resources, training in ethical decision-making, and mechanisms to address entrenched inequities in access and quality of care.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn summary, resource allocation within SSA health systems represents a critical ethical challenge in which principles of justice and equity are frequently compromised. Addressing these challenges requires the deliberate integration of ethical frameworks into policy and practice, prioritization of older adults as a vulnerable population, and sustained investment in geriatric and palliative care infrastructure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eElder Abuse, Neglect, and Vulnerability\u003c/h2\u003e \u003cp\u003eElder abuse and neglect in SSA represent significant ethical challenges that intersect with issues of justice, human rights, and societal responsibility. Older adults in SSA are disproportionately vulnerable due to social, economic, and familial pressures compounded by weak social protection systems.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/sup\u003e The ethical responsibility to protect older adults extends beyond formal healthcare systems to informal care networks, which are often overstretched or under-resourced.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e,\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/sup\u003e Chronic illnesses, functional disability, and cognitive impairment significantly exacerbate vulnerability, necessitating targeted safeguarding strategies.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e\u003c/sup\u003e Ethical frameworks emphasize the duty of care owed to older adults, highlighting the moral imperative to prevent harm and promote dignity, particularly in settings where ageism and societal neglect are prevalent.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e\u003c/sup\u003e Furthermore, the pervasive nature of elder abuse, ranging from physical and emotional maltreatment to financial exploitation, reflects broader structural inequities, including poverty, limited access to healthcare, and social marginalization.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e These conditions create ethical dilemmas around allocation of resources, prioritization of vulnerable groups, and societal obligations to uphold the rights of older adults.\u003c/p\u003e \u003cp\u003eThe literature highlights the importance of a multi-level ethical response: integrating formal health interventions, legal protections, and community-based support systems to reduce elder vulnerability. In SSA, this involves balancing resource constraints with the moral imperative to protect and promote the dignity and wellbeing of older adults, reflecting a justice-oriented approach to ageing care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCultural Considerations and Ethical Pluralism\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSub-Saharan Africa encompasses a rich tapestry of cultural norms, family structures, and belief systems, all of which profoundly influence ethical perspectives and practices in the care of older adults.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e,\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e Across all domains, cultural norms profoundly shape ethical practice in SSA. Care for older adults is embedded within family and communal structures, where collective responsibility often supersedes individual autonomy. Ethical pluralism: recognising the legitimacy of multiple moral frameworks, emerges as essential for reconciling biomedical ethics with local traditions.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Rather than viewing communal decision-making as inherently unethical, the evidence supports approaches that integrate relational autonomy with safeguards against marginalisation.\u003csup\u003e\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e\u003c/sup\u003e Culturally competent care requires policies and practices that support families while ensuring that older adults\u0026rsquo; rights, dignity, and wellbeing remain central.\u003csup\u003e\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e,\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e\u003c/sup\u003e Community engagement, intergenerational dialogue, and locally adapted interventions are consistently identified as critical to ethically coherent ageing care in SSA.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003ePolicy Implications\u003c/h2\u003e \u003cp\u003eAddressing ethical challenges in the care of older adults in SSA requires strengthened policy frameworks that integrate ethical principles with public health priorities:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAgeing should be explicitly recognized as a major demographic and social transition with distinct healthcare and ethical implications.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEthical prioritisation within policy should include the development of age-sensitive national health strategies that incorporate guidance on autonomy, informed consent, end-of-life care, and protection from abuse, while ensuring that healthcare resource allocation does not discriminate against older persons.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePolicymakers should support the integration of geriatric and ethics training into medical and nursing curricula to enhance providers\u0026rsquo; capacity to assess decision-making ability, manage ethical dilemmas, and communicate effectively with older adults and their families.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStrengthening legal protections for older persons is critical, including enforceable rights related to informed consent, abuse prevention, and access to healthcare. South Africa and Ghana have introduced older-persons legislation, but inconsistent implementation limits their impact, highlighting the need for stronger regulatory and enforcement mechanisms.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCommunity engagement and public awareness initiatives can reduce stigma surrounding ageing, cognitive decline, and end-of-life care, while strengthening caregiver support and improving older adults\u0026rsquo; access to health and social services through existing community networks.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResearch Implications\u003c/h2\u003e \u003cp\u003eEthical ageing in SSA is constrained by limited empirical evidence on older populations, cultural influences on consent, and health system capacity.\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e\u003c/sup\u003e Priority research areas include epidemiological studies to guide ethical resource allocation and service planning in ageing populations, and studies of multimorbidity, cognitive impairment, and functional decline.\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e\u003c/sup\u003e Research is also needed to adapt and validate decision-making capacity assessment tools appropriate to SSA contexts, accounting for language, literacy, and cultural norms.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u003c/sup\u003e Comparative studies on ethical frameworks for resource allocation can inform transparent and culturally acceptable prioritization approaches in constrained systems.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Further work on community-based palliative care models and elder abuse prevention strategies is essential to strengthen ethical standards and protective mechanisms.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eClinical Practice Implications\u003c/h2\u003e \u003cp\u003eAt the clinical level, ethical care requires patient-centered, culturally responsive approaches. Clinicians should adopt decision-making models that respect individual autonomy while acknowledging communal decision-making traditions.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Transparent triage processes, early integration of palliative care, and culturally competent communication with families and communities are critical to ensuring ethical, dignified care for older adults in resource-limited settings.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATION\u003c/h2\u003e \u003cp\u003eIn this scoping review, we acknowledge some limitations. Restriction to only English-language studies is a threat to language bias. Our findings should be interpreted as descriptive rather than conclusive since the main aim of scoping is to map the current state of knowledge rather than to determine effect sizes or study quality. In spite of these limitations, this review provides a foundational overview of the field ethics in the care of older adults in SSA and highlights important knowledge gaps that warrant future research.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn this scoping review, we found that multifaceted ethical challenges shape the care of older adults in SSA. Key concerns include informed consent, end-of-life care, equitable resource allocation, protection from abuse, and the need for culturally grounded ethical pluralism. Addressing these issues requires integrated approaches that align policy frameworks, professional ethics, family engagement, and cultural competence across healthcare and social care settings. We also found that ethical ageing in SSA depends on bridging clinical ethics, public health ethics, and social justice perspectives. Strengthening ethical care will therefore require rights-based policies, culturally responsive models of care, and shared accountability among families, communities, health systems, and the state to protect the dignity, rights, and well-being of older adults.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICAL CONSIDERATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved as exempt from ethical review by the Research Ethics Committee of Aminu Kano Teaching Hospital, Kano, Nigeria.\u0026nbsp;This is because it was a scoping review of published literature and involved no human participants or identifiable data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cem\u003e:\u003c/em\u003e\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data generated or analysed during the study are available and included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare no competing interest whatsoever in preparing this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This work was partly supported by the Fogarty International Center (FIC) of the U.S. National Institutes of Health (NIH) award number 1R25TW012715. The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIH, the Department of Health and Human Services, or the government of the United States of America.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed significantly to this manuscript. \u003cstrong\u003eOlawumi A.L\u003c/strong\u003e led the conceptualization, study design, methodology, data analysis, drafting of the manuscript, and served as the corresponding author with overall responsibility for the work. \u003cstrong\u003eAbdulkadir Z.\u003c/strong\u003e and \u003cstrong\u003eSuleiman A.K\u003c/strong\u003e contributed to conceptualization, methodology development, data synthesis, and drafting of the discussion. \u003cstrong\u003eUmar Z.A, Grema B.A, Michael G.C, Mohammed A.A, Abdullahi U.F, Mahmud M.B, Ibraheem A.S, Muhammad A.D, and Badamasi A,\u003c/strong\u003e participated in data collection, literature search, data extraction, quality assessment, and interpretation of findings. \u003cstrong\u003eGrema B.A,\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003eBadamasi A\u003c/strong\u003e provided specialist input into clinical interpretation and ethical considerations. \u003cstrong\u003eGezawa I.D, Borodo M.M., and Aliyu M.H.\u003c/strong\u003e provided senior academic oversight, critically reviewed the manuscript for intellectual content, and guided interpretation of results. \u003cstrong\u003eAliyu M.H,\u0026nbsp;\u003c/strong\u003eadditionally provided global health and methodological expertise. All authors reviewed, revised, and approved the final manuscript and agreed to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTapon F. Defining Sub-Saharan Africa and the Countries in It. [accessed 2025 November 10]. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://francistapon.com/Travels/Africa/define-sub-saharan-africa-and-the-countries-in-it\u003c/span\u003e\u003cspan address=\"https://francistapon.com/Travels/Africa/define-sub-saharan-africa-and-the-countries-in-it\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations. World Population Ageing 2023: Challenges and opportunities of population ageing in the least developed countries. [cited 2025 November 24]. 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Bioethics. 2006;20(5):248\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1467-8519.2006.00501.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1467-8519.2006.00501.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBateman C. Old age care - relatives 'at the mercy' of homes. S Afr Med J. 2012;102(5):278\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ethics, elder abuse, older persons care, resource allocation, sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-9190458/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9190458/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRapid population ageing in sub-Saharan Africa (SSA) is unfolding within fragile health systems, weak social protection, and limited geriatric and palliative services, creating ethical challenges in older adult care. This study critically reviews current literature and policy reports, synthesizes key themes, and proposes evidence-based recommendations for policy, practice, and research.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA comprehensive literature search examined ethical issues in caring for older adults in SSA across healthcare and social care settings. We searched biomedical, ethics, social science, and gray literature sources using population, ethics, care, and geographic terms. English-language studies from 2000 to 2025 addressing ethical dimensions of older adult care were included.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified multiple ethical challenges that affect older adult care in SSA, including justice, equity, autonomy, dignity, vulnerability, abuse, and ageism. Healthcare-related concerns involve unmet needs, resource allocation dilemmas, limited palliative and end-of-life care, and age-biased clinical decisions. Socially, weakening family support systems create moral tensions for caregivers. Policy analyses emphasise rights-based, culturally sensitive, and equitable approaches, highlighting the need for integrated ethical, social, and systemic care strategies.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAddressing ethical issues in older care in SSA requires legally enshrined protections, health-system investments, public campaigns to counter ageism, supportive decision-making frameworks that respect cultural contexts and individual rights and strengthened research and surveillance. A right-based, culturally sensitive approach focused on the voices of older persons is essential.\u003c/p\u003e","manuscriptTitle":"Ethical Issues in Caring for Older Persons in Sub-Saharan Africa: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-10 10:42:00","doi":"10.21203/rs.3.rs-9190458/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"42167116233978913128763321010533147597","date":"2026-05-12T14:27:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37932720089084829956943244488890127584","date":"2026-05-04T13:17:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T03:00:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-24T05:17:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-23T04:15:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-23T04:14:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2026-03-22T09:59:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99377797-ff01-414f-9c82-0707f933d57e","owner":[],"postedDate":"April 10th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"42167116233978913128763321010533147597","date":"2026-05-12T14:27:47+00:00","index":37,"fulltext":""},{"type":"reviewerAgreed","content":"37932720089084829956943244488890127584","date":"2026-05-04T13:17:32+00:00","index":32,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-10T10:42:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-10 10:42:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9190458","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9190458","identity":"rs-9190458","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}