Autonomy, dignity and human rights in situations of dependency in older age

Human rights are universal and belong to every person throughout the life course. They do not diminish with age, disability, illness or increasing reliance on the care and support of others. Yet, situations of dependency are often the circumstances in which the equal enjoyment of human rights is most severely tested. As support needs increase, older persons may encounter barriers to autonomy, participation and inclusion that are not inherent in dependency itself, but arise from the ways in which societies, institutions and legal systems respond to their needs for care and support. Understanding and addressing these barriers is therefore one of the central human rights challenges of ageing societies.

Population ageing is transforming societies across every region of the world. Increasing numbers of older persons are living longer while also experiencing frailty, chronic illness, physical disability, cognitive impairment or other circumstances that may require varying degrees of support. These developments reinforce the need to address situations of dependency through a human rights framework that safeguards autonomy, dignity, participation and equality.

The present report examines autonomy, dignity and the enjoyment of human rights in situations of dependency in older age. It proceeds from the recognition that increasing reliance on care and support does not diminish personhood, legal capacity or entitlement to the equal enjoyment of human rights, and should never be interpreted as doing so. Rather, situations of dependency provide a critical test of whether existing human rights protections remain fully effective when support needs increase, and demand that we examine how existing human rights can be more effectively realized in such circumstances. It therefore shifts the focus from dependency itself to the legal, social and institutional conditions that enable older persons to continue exercising their human rights on an equal basis with others.

This report is informed by more than 110 written inputs received from States, national human rights institutions, civil society organizations, organizations of older persons, organizations of persons with disabilities, professional associations, academic institutions and individual experts from all regions of the world. Together, they constitute a broad body of evidence drawn from different legal systems, cultural traditions, socioeconomic contexts and lived experiences. They reveal a remarkable degree of international convergence regarding the principal human rights challenges arising in situations of dependency in older age and the direction of travel needed for future reforms.

The consultation found that the greatest threats to autonomy, dignity, participation and equality often arise not from situations of dependency, but from the ways in which societies respond to needs for care and support. Ageism, paternalism, fragmented systems, inaccessible environments, unnecessary institutionalization, inadequate community-based support and the persistent gap between legal recognition and practical implementation continue to prevent many older persons from enjoying their human rights on an equal basis with others. Contributors consistently affirmed that care and support must enable rather than replace autonomy; that community-based support should be preferred wherever appropriate; that institutional care should never result solely from the absence of appropriate community alternatives; that ageism remains the principal structural barrier to the equal enjoyment of human rights; and that the quality of care systems should be assessed not only by the services they provide, but also by the extent to which they enable older persons to maintain autonomy, dignity, participation and equality in everyday life.

Inputs also revealed different perspectives regarding the use of the term “dependency”. Some contributors expressed concern that the term may reinforce deficit-based understandings of older age, and suggested alternative expressions centred on support needs or interdependence. The present report acknowledges these perspectives, yet retains the concept of dependency because the term reflects a normal dimension of the human experience that should be neither denied nor stigmatized. Dependency is understood here not as a diminished personal status or reduced legal capacity, but as a situation in which a person’s needs for care and support interact with the surrounding social, legal and institutional environments. This understanding shifts attention away from perceived deficits of the individual towards the responsibilities of States and other duty bearers to ensure that situations of dependency become circumstances in which autonomy, dignity, participation and equality receive stronger – not weaker – protection.

This report builds upon the existing international human rights framework and seeks to contribute to its interpretation and implementation in situations of dependency in older age. In ageing societies, ensuring that increasing support needs are addressed through a human rights framework is becoming essential not only for the protection of individual rights, but also for inclusive development, social cohesion, and the achievement of the 2030 Agenda for Sustainable Development. Situations of dependency reveal whether laws, policies and institutions continue to uphold autonomy, dignity, participation and equality when individuals require greater support to exercise their rights.

The report first reviews the relevant international human rights framework before examining the implications of situations of dependency for autonomy, dignity, participation and inclusion. It then analyses the principal structural barriers to the equal enjoyment of human rights, examines rights-realizing systems, and concludes with recommendations for States. Throughout the report, situations of dependency are understood not as a justification for limiting rights, but as circumstances in which the effective enjoyment of human rights requires renewed commitment from States and other duty bearers.

The conclusion of this examination is that the principal challenge is not the recognition of universal rights, but the implementation of those rights in addressing the lived realities of older persons. Existing international human rights law already provides a foundational normative framework, albeit one that has not been adequately applied to the distinct human rights violations and abuses experienced by older persons. The decisive question is thus whether laws, institutions, public policies and professional practice are currently capable of translating universally recognized human rights into the everyday lives of older persons who require care and support, or what additional legislative and policy frameworks are necessary at the national and international levels to ensure that they do so.

To address this challenge, the report proposes reinforcing the concept of rights-realizing systems. Such systems organize healthcare, long-term care, social protection, housing and related services around the effective enjoyment of human rights rather than around institutional convenience or service delivery alone. They support autonomy rather than substituting for it, strengthen participation instead of diminishing it, and enable older persons to remain active members of their families and communities for as long as possible and in accordance with their wishes, rights and support needs. This approach aligns with what the United Nations High Commissioner for Human Rights has referred to as the obligation of States to realize a human rights economy, which must invest in care and support systems that are anchored in human rights.

In summary, situations of dependency should not be regarded as exceptional circumstances in which human rights become less applicable. On the contrary, situations in which older persons need care and support reveal whether societies are prepared to uphold the universality of human rights throughout the life course, without discrimination based on age. Ultimately, dependency is not the point at which human rights become weaker. It is the point at which societies demonstrate whether they truly believe that human rights belong to everyone, throughout the whole of life.

International human rights law provides a substantial normative foundation for protecting the rights of older persons in situations of dependency. The Universal Declaration of Human Rights affirms that all human beings are born free and equal in dignity and rights. These principles are further developed in the core international human rights treaties, which recognize the universality, indivisibility and interdependence of all human rights and require their enjoyment without discrimination. These guarantees apply throughout the life course and are not diminished by age, disability, frailty, illness, cognitive impairment or increasing reliance on support.

Those obligations are reinforced by the United Nations Principles for Older Persons, and by the Madrid International Plan of Action on Ageing, which continue to constitute an important conceptual and policy framework, although they are not a substitute for binding international human rights obligations. The existing framework of international human rights law remains fragmented, and in some regards has fallen short of providing a coherent, comprehensive framework on the human rights of older persons.

International human rights standards have been substantially developed in laws, policies, practices, and the recommendations of United Nations treaty bodies and special procedures, which are highly relevant to older persons’ full enjoyment of their human rights in situations of dependency. Existing international human rights law recognizes a range of rights that assume particular importance when support needs increase. These include, among others, equality and non-discrimination; legal capacity; privacy, home and family life; social security; an adequate standard of living; adequate housing; accessibility; and participation in family, community, cultural, political and public life. Together with the overarching principles of dignity, autonomy, participation, inclusion and accountability, these rights provide the normative basis for assessing whether laws, policies, support systems and institutional practices adequately protect older persons when their support needs increase.

Two principal challenges remain. Firstly, existing human rights obligations are often not effectively implemented in situations of dependency. Older persons continue to encounter barriers to the equal enjoyment of their rights because laws, policies and services are often designed without sufficient attention to the realities of increasing support needs, or based on assumptions about independence, family availability or institutional care, rather than being designed around autonomy with support. Secondly, the current international framework remains fragmented and uneven in its explicit treatment of older persons, including in relation to legal capacity, community inclusion, ageism, access to remedies, and the rights of older persons whose experiences are not adequately or explicitly addressed by existing treaty frameworks. The task is therefore not to establish new categories of rights, but to ensure that existing rights remain fully effective when individuals require greater support, while also identifying issues that may require further normative clarification.

Among existing international instruments, the Convention on the Rights of Persons with Disabilities has made a particularly important contribution to the interpretation of human rights where individuals require support in exercising their rights. Its provisions demonstrate that support needs are compatible with autonomy, agency, participation and equality – when there are safeguards ensuring respect for the rights, will and preferences of the person, including equality and non-discrimination, accessibility, legal capacity, supported decision-making, independent living and community inclusion. Although not all older persons in situations of dependency fall within the scope of the Convention, its principles provide valuable guidance for interpreting existing human rights standards whenever support is required to exercise rights effectively. The Convention is directly applicable to older persons with disabilities, including those with physical, sensory, intellectual, psychosocial or cognitive impairments who face attitudinal or environmental barriers. Care should nevertheless be taken not to collapse older age into disability: some older persons in situations of dependency may not identify as, or fall within legal definitions of, persons with disabilities, and age-based barriers, ageism and age-specific forms of exclusion require specific attention.

The interpretation of these principles has been progressively developed through the work of United Nations human rights mechanisms, including the Independent Expert on the enjoyment of all human rights by older persons, the Office of the United Nations High Commissioner for Human Rights, treaty bodies and other relevant special procedure mandate holders. Previous reports under the mandate have addressed issues directly relevant to this inquiry, including autonomy and care, ageism, violence, legal capacity, housing, social protection, emergencies, social exclusion and participation in technological change. Collectively, this work confirms that dependency must not be equated with incapacity, loss of personhood or diminished entitlement to rights. It also shows that rights-based care and support must be available, accessible, acceptable, affordable and of good quality; must respect the older person’s will, preferences, privacy and family and community relationships; and must include effective safeguards, monitoring, participation and remedies.

Normative developments at the regional and international levels further demonstrate growing recognition that older persons face distinct barriers to the equal enjoyment of human rights. The Inter-American Convention on Protecting the Human Rights of Older Persons expressly reaffirms the universality, indivisibility and interdependence of all human rights and fundamental freedoms, prohibits age discrimination, and recognizes older persons’ rights to dignity, independence, autonomy, health, safety, integration and active participation. The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Older Persons in Africa addresses, among other issues, discrimination, access to justice, decision-making, social protection, protection from abuse, care and support, residential care, older women, older persons with disabilities, situations of risk, health, education, participation and accessibility. These regional instruments do not displace universal standards, but they provide important reference points for clarifying rights in older age. At the international level, the establishment of the open-ended intergovernmental working group to elaborate a legally binding instrument on the human rights of older persons reflects the growing commitment of States to strengthen protection of older persons’ rights, and to close identified protection gaps.

The present report builds upon this normative framework. It does not seek to create a separate category of lesser or exceptional rights for older persons in situations of dependency. Rather, it examines how the full range of existing civil, political, economic, social and cultural rights should be interpreted and implemented when older persons require support in daily life, decision-making, communication, mobility, healthcare, social participation or personal care. It also considers how the experience of dependency exposes protection gaps, including the need for clearer standards on autonomy with support, legal capacity, community-based care and support, freedom from coercion and institutionalization, protection of family and informal caregivers without transferring State obligations to families, and effective accountability. The submissions received in response to the call for inputs point both to the urgency of implementing existing obligations and to the need for greater normative coherence.

International human rights law recognizes that all persons enjoy the same rights and fundamental freedoms throughout the life course. The question addressed in the present report is not whether older persons in situations of dependency possess these rights, but how those rights should be understood and realized when support needs increase. Situations of dependency require renewed attention to how autonomy, dignity, participation and inclusion are protected in law, policy and practice.

Ensuring the effective enjoyment of human rights in situations of dependency requires States not only to refrain from interfering with the exercise of rights, but also to take positive measures to respect, protect and fulfil rights. This includes establishing legal and policy frameworks, regulating and overseeing public and private providers of care and support, and ensuring that systems are designed to enable, rather than replace, the exercise of autonomy, dignity, participation and inclusion.

Situations of dependency frequently give rise to an apparent tension between autonomy and support. The need for assistance is often interpreted as evidence that autonomy has been diminished or lost, leading to greater reliance on substitute decision-making, institutional routines or protective interventions. However, increasing support needs do not necessarily reduce an individual’s capacity to express values, preferences and choices. Rather, they require different ways of ensuring that autonomy can continue to be exercised effectively. Human rights therefore require States not only to respect individual freedom, but also to create the legal, institutional and practical conditions necessary for older persons to exercise autonomy effectively despite increasing support needs.

Creating these conditions requires more than avoiding interference. It requires recognizing individual wishes and preferences, ensuring accessible information and communication, providing opportunities to participate in decisions affecting the person’s own life, and avoiding assumptions that increasing support needs automatically justify greater control by others. Meaningful expression of will and preferences is often made possible through relationships, communication, trust and other forms of support that enable older persons to participate effectively in decisions affecting their lives. Support should be organized around the person, rather than the person around the support that is available. This requires States to ensure that laws, policies and services are designed to give effect to the wishes, preferences and rights of the individual, rather than administrative convenience or imperatives.

In practice, this approach requires moving, wherever possible, from substitute decision-making towards supported decision-making. Appropriate measures may include accessible information, communication support, trusted supporters, assistive technologies and advance care planning. The need for assistance in implementing a decision should never be interpreted as an inability to make that decision. Rather, such support enables individuals to express their wishes and preferences and to participate meaningfully in decisions concerning their health, care, living arrangements, finances and everyday lives. The objective is not to transfer decision-making to others, but to provide the assistance necessary for individuals to make their own decisions and continue participating meaningfully in decisions affecting their lives.

Autonomy and support are not opposing concepts. Properly organized support enables individuals to continue directing their own lives despite increasing support needs. Conversely, support that disregards individual wishes, preferences or participation risks undermining the very autonomy it seeks to protect. The erosion of autonomy is itself a mechanism through which human rights may be undermined. A human rights approach therefore measures the quality of support not only by the services provided, but also by the extent to which it enables individuals to remain active participants in decisions affecting their own lives, in accordance with their wishes, preferences and values. States must therefore regulate, resource and oversee support systems in ways that enable, rather than replace, the exercise of autonomy.

Situations of dependency frequently give rise to an equally pervasive misconception: that increasing reliance on the support of others diminishes human dignity. Older persons who require support do not lose their dignity because they become dependent. Rather, dignity is threatened when dependency is accompanied by ageism, neglect, exclusion, coercion or abandonment. The central human rights challenge therefore lies not in dependency itself, but in ensuring that every person continues to be recognized and treated as a person of equal worth, regardless of the nature or extent of the support required.

Human dignity is inherent and universal. It does not depend upon health, productivity, independence or functional capacity; nor is it diminished by age, disability, frailty, cognitive impairment or the need for support. Situations of dependency therefore do not reduce personhood or weaken entitlement to the equal enjoyment of human rights. On the contrary, they require renewed commitment to ensuring that every individual continues to be recognized, respected and treated as a person of equal worth. Respect for human dignity also requires recognizing that personhood and agency remain intact even where cognition becomes vulnerable, fluctuating or impaired, and that older persons may continue to express their wishes, preferences and identity through diverse forms of verbal and non-verbal communication. States therefore remain under the obligation to respect, protect and fulfil the human rights of older persons, irrespective of age, disability, frailty, cognitive impairment or the nature and extent of their support needs.

Situations of dependency do not diminish an individual’s capacity to contribute to family and community life. Older persons continue to care for family members, maintain social relationships, and contribute to their communities despite increasing support needs. During humanitarian crises and armed conflicts, many also assume essential caregiving responsibilities while experiencing significant hardship themselves. Failure to recognize these continuing contributions diminishes not only older persons themselves, but also society’s understanding of ageing. A human rights approach therefore rejects assumptions that dependency renders individuals passive recipients of care, and instead affirms their continuing status as equal members of society.

One of the greatest risks associated with situations of dependency is abandonment. The opposite of dependency is not independence, since human beings remain interdependent throughout the life course. The true opposite of dependency is abandonment: the failure of individuals, communities and institutions to provide the support necessary for every person to continue enjoying human rights on an equal basis with others. Preventing abandonment is therefore not simply a matter of social policy or compassion. It is a human rights obligation of States to ensure that older persons in situations of dependency can enjoy their human rights on an equal basis with others.

A human rights approach therefore requires that situations of dependency never be regarded as circumstances in which diminished dignity is presumed or rights are weakened. Rather, they call for renewed commitment to recognizing the equal worth of every person and to organizing support in ways that respect identity, preserve relationships and enable continued participation in society. Human dignity is not protected by reducing autonomy in the name of protection, nor by limiting participation in the name of care. It is protected when support enables people to continue living the lives they value, according to identity, relationships and choices, on an equal basis with others. This also requires recognizing that places where older persons receive long-term care are not merely facilities providing services, but also the homes in which they continue to exercise their rights, maintain relationships and express their identity.

Participation is often one of the first dimensions of human rights to be affected when individuals experience increasing support needs. Older persons may gradually become excluded from decisions, relationships and activities that had previously formed part of their everyday lives. One of the greatest fears expressed by many older persons is not dependency itself, but becoming unheard, unseen and excluded once support needs increase. Measures introduced in the name of protection may unintentionally result in withdrawal from family, community and public life, while concerns about safety or efficiency may reduce opportunities for social engagement. Such exclusion is not an inevitable consequence of dependency, but the result of legal, institutional, environmental and attitudinal barriers that prevent older persons from remaining active participants in society.

Participation is not merely a desirable social objective or an element of good care. It is a fundamental dimension of the equal enjoyment of human rights. The opportunity to participate in decisions, maintain relationships, engage in community life and continue contributing according to one’s own wishes and abilities reflects the equal recognition of every person as a member of society. Situations of dependency therefore do not diminish the right to participate. Rather, they require that greater efforts be made to remove barriers that prevent participation and to create opportunities for continued inclusion.

Participation is expressed in many different ways throughout older age, including making decisions about one’s own life, maintaining relationships, contributing to community life, engaging in cultural and civic activities, and sharing knowledge and experience with others. Autonomy is realized not only through isolated decisions, but also through the continuing ability of older persons to shape the everyday course of their lives, relationships and future, with appropriate support where needed. Although its form and extent may vary according to individual circumstances, the right to participate does not diminish because support needs increase. Human rights standards require that older persons continue to be recognized not only as recipients of care, but also as individuals who contribute to the social, cultural and economic life of their communities.

Meaningful participation depends upon environments that enable rather than restrict inclusion. Accessible housing, transport, public spaces, information, digital technologies and community-based services are essential for the effective enjoyment of human rights. Participation cannot depend solely upon individual effort. It requires States to remove physical, social, institutional and attitudinal barriers that prevent older persons from remaining connected to their families, communities and the wider society. Creating inclusive environments is therefore not simply a matter of good social policy, but an essential human rights obligation. This requires States to adopt legal, policy and practical measures that enable older persons to participate in society on an equal basis with others.

Participation is not an optional dimension of ageing well, nor a benefit that depends upon health or independence. It is an essential expression of equal personhood and the equal enjoyment of human rights. Situations of dependency therefore require greater efforts to enable participation in family, community, cultural and public life. A human rights approach measures the quality of support not by the care it provides, but by the extent to which it enables individuals to remain connected, included and actively engaged in the lives they value. States should therefore design and assess policies, services and care arrangements by the extent to which they enable older persons to remain connected, included and active participants in the lives they value.

Situations of dependency do not in themselves diminish human rights. Yet, older persons in situations of dependency continue to encounter serious obstacles to the equal enjoyment of those rights. These obstacles arise not from dependency itself, but from structural barriers embedded in laws, policies, institutions, social attitudes and systems of support. Understanding and addressing these barriers is therefore essential to ensuring that human rights can be realized effectively in practice.

Structural barriers are those features of laws, policies, institutions, social practices and attitudes that systematically prevent older persons from enjoying their human rights on an equal basis with others. Unlike individual acts of discrimination or isolated failures, structural barriers are embedded in the ways societies organize support, allocate resources and exercise public authority. Their cumulative effect is to restrict autonomy, diminish participation, undermine dignity and increase the risk of neglect, coercion and abandonment.

Ageism is not simply one structural barrier among many. It is the underlying social and cultural framework through which situations of dependency are frequently understood, interpreted and responded to.

Ageism influences not only how older persons are perceived, but also how their rights are interpreted and implemented. Assumptions that older persons are inherently frail, incapable of making decisions, resistant to change or primarily recipients of care may lead to paternalistic laws, policies and practices that restrict autonomy, limit participation and diminish opportunities for independent living. Such barriers do not arise from dependency itself, but from age-based assumptions that shape institutional responses to dependency.

Ageism is not expressed only through overt discrimination or negative stereotypes. It frequently manifests itself through benevolent paternalism: the assumption that older persons should be protected rather than enabled to exercise their rights. Policies and practices introduced in the name of safety, care or efficiency may unintentionally limit autonomy, restrict participation and justify substitute decision-making without adequate regard for the wishes, preferences and rights of the individual. Ageism may also be expressed through seemingly benevolent forms of communication and everyday interactions that diminish older persons’ identity, agency or equal status, including infantilizing language and other paternalistic forms of treatment. Ageism also operates in a second, less recognized form: the devaluation of older persons who experience frailty, disability, cognitive impairment or increasing support needs, as though dependency itself diminished personhood or entitlement to rights. Such paternalistic approaches, although often well intentioned, may themselves become structural barriers to the equal enjoyment of human rights. Ageism may also become internalized. Lifelong exposure to negative stereotypes about ageing can lead some older persons to expect less, ask for less, or accept restrictions on their autonomy that would otherwise be challenged. A human rights approach therefore requires not only removing external barriers, but also recognizing and countering the internalized effects of ageism.

These assumptions are reflected in laws, policies and institutional practices. Age-based restrictions, inflexible eligibility criteria, inaccessible environments, fragmented services and inadequate investment in community-based support may all limit the ability of older persons to exercise their rights on an equal basis with others. Accessibility should be understood not only as the removal of physical barriers, but also as the application of universal design principles that enable older persons to exercise autonomy, participate fully in society and access services on an equal basis with others. These barriers are rarely the result of deliberate discrimination. More often, they arise because systems are designed around assumptions of incapacity, diminished autonomy or reduced social value rather than around the equal rights of older persons.

Eliminating ageism therefore requires more than promoting positive images of ageing or raising public awareness. It requires recognizing ageism as a structural human rights barrier that affects the interpretation, implementation and enjoyment of rights across laws, policies and institutions. A human rights approach therefore requires States to ensure that measures affecting older persons are systematically reviewed through a human rights lens so that protection, care and support strengthen – rather than diminish – autonomy, dignity, participation and equality.

Ageism rarely operates in isolation. Older persons in situations of dependency often experience multiple and intersecting forms of discrimination that reinforce one another and compound barriers to the equal enjoyment of human rights. Poverty, disability, gender and other factors may each contribute to exclusion and disadvantage. When combined with increasing support needs, these intersecting barriers create cumulative patterns of disadvantage that cannot be understood or addressed through an age lens alone.

Structural discrimination is not the simple accrual of multiple disadvantages. It is the interaction of barriers that mutually reinforce one another and progressively restrict the effective enjoyment of human rights. Structural discrimination may also arise through administrative procedures and digital systems that unintentionally exclude older persons from accessing social protection, healthcare, justice and other essential services, particularly where eligibility depends on administrative or technological requirements that many older persons are unable to meet. Legal, economic, social and environmental barriers often accumulate throughout the life course, producing patterns of exclusion that cannot be addressed through isolated policy responses. A human rights approach therefore requires States to recognize and respond to the cumulative and intersecting nature of structural discrimination.

The cumulative effects of structural discrimination become particularly evident in situations of dependency. Older persons frequently encounter barriers across multiple domains of everyday life, including access to healthcare, long-term care, housing, social protection, justice, digital services and community life. These barriers reinforce one another, creating patterns of exclusion that cannot be overcome through isolated interventions. Ensuring the equal enjoyment of human rights therefore requires coordinated, rights-realizing systems that recognize and address the cumulative effects of structural discrimination.

Human rights are exercised by individuals as an integrated whole. Yet, evidence received consistently demonstrated that the systems responsible for protecting and realizing those rights are frequently fragmented. Healthcare, long-term care, social protection, housing, justice and community services often operate within separate legal, administrative and financial frameworks, each addressing only part of the individual’s circumstances. The result is that responsibility for the person as a whole may become diffused, leaving important human rights needs insufficiently addressed.

Fragmentation affects not only the organization of services but also the effective protection of human rights. When responsibilities are divided across multiple sectors, institutions and levels of government, no single actor assumes responsibility for ensuring that older persons are able to enjoy their rights as an integrated whole. Gaps in coordination, continuity and accountability often leave older persons and their families to navigate complex and disconnected systems without adequate support. As a result, responsibility for overcoming fragmentation is effectively shifted from public institutions to those who are often least able to bear it.

A human rights approach therefore requires more than better coordination between services. It requires systems that are organized around the person rather than around institutional mandates or administrative boundaries. States should ensure that healthcare, long-term care, social protection, housing and other sectors operate in ways that support the integrated enjoyment of human rights, recognizing that autonomy, dignity, participation and inclusion cannot be realized through fragmented responses.

Structural barriers ultimately have human consequences. When ageism, structural discrimination and fragmented systems remain unaddressed, they create conditions in which neglect, coercion and abandonment become more likely, less visible, and less prone to be prevented, monitored or remedied. The consultation revealed a remarkable degree of convergence on this point. Moreover, these outcomes are rarely isolated incidents. Rather, they often reflect systemic failures to organize and regulate care and support in ways that respect, protect and fulfil the human rights of older persons.

Neglect is among the most pervasive yet least visible consequences of structural barriers in situations of dependency. Neglect may result not only from individual acts or omissions, but also from inadequate legislation, insufficient investment, workforce shortages, fragmented services and the absence of effective oversight and accountability. The consultation also identified self-neglect as an emerging human rights concern, particularly where severe social isolation, cognitive impairment or other vulnerabilities place older persons at serious risk despite the absence of an identifiable perpetrator. In such circumstances, a human rights approach requires responses that respect the person’s rights, will and preferences while ensuring that appropriate support and protection remain available. In these circumstances, neglect becomes not only a personal tragedy, but also a manifestation of systemic failure to ensure the equal enjoyment of human rights. Responses to self-neglect should not be used to justify coercive intervention where less restrictive, supportive measures are available.

Coercion represents another important consequence of structural barriers in situations of dependency. Coercive practices often arise when protection, safety or administrative convenience are permitted to override autonomy, participation and informed choice. Restrictive measures, involuntary interventions, unnecessary institutionalization and substitute decision-making may all be justified as protective responses, yet they risk undermining the very rights they seek to safeguard. A human rights approach therefore requires that protective measures enable, rather than replace, the exercise of rights, and that any limitations on individual freedom remain lawful, necessary, proportionate and subject to effective safeguards, oversight and access to remedies.

The most profound consequence of these structural barriers is abandonment. Abandonment does not occur only when care is absent. It also occurs when support is insufficient, fragmented or organized in ways that prevent older persons from exercising their rights on an equal basis with others. Abandonment may arise despite the existence of services, where those services fail to respond to the person’s needs, wishes and circumstances in a coordinated and rights-based manner. It may also arise during transitions between healthcare, rehabilitation, long-term care and community support, where older persons are discharged from hospital or transferred between services without timely access to appropriate follow-up care, leaving individuals and their families to bear responsibilities that should be assumed by coordinated public systems. From a human rights perspective, abandonment is not measured by whether care is provided, but by whether older persons are enabled to enjoy their rights fully and on an equal basis with others.

The structural barriers examined in this section demonstrate that violations of the human rights of older persons in situations of dependency are rarely the result of dependency itself. More often, they arise from the ways in which societies organize laws, policies, institutions and systems of care and support. Removing these barriers therefore requires more than isolated reforms or additional services. It requires rights-realizing systems that place the person, rather than the institution, at the centre of decision-making, support and accountability. The following section therefore examines how rights-realizing systems can enable the effective enjoyment of human rights in situations of dependency.

The preceding sections demonstrate that the challenge is not to establish that older persons in situations of dependency are rights holders entitled to the full and equal enjoyment of all human rights. Existing international human rights law provides a substantial normative foundation for their protection. At the same time, the experiences described in this report reveal that this framework is not always sufficiently coherent, explicit or operationalized in relation to the realities of increasing support needs, including in areas such as autonomy with support, legal capacity and informed consent, community-based care and support, protection from coercion and institutionalization, and accountability in care settings. These issues are directly relevant to ongoing discussions on a legally binding instrument on the human rights of older persons. The effective enjoyment of human rights depends both on the clarification and consistent interpretation of existing standards and on the institutional architecture through which those rights are translated into everyday practice. The central challenge is therefore to organize rights-realizing systems capable of making human rights effective in the daily lives of older persons. Such systems place the individual, rather than institutions, services or administrative convenience, at the centre of decision-making, and organize care, support and public action around the person’s dignity, will and preferences, relationships, participation and inclusion. In rights-realizing systems, care and support are not treated as alternatives to autonomy, dignity, participation and inclusion, but as means through which these rights are exercised and secured when support needs increase.

Rights-realizing systems place human rights at the centre of policy development, service design and service delivery. Rather than focusing primarily on needs, risks or service provision, they organize support around the person’s rights, wishes, preferences and life goals. They recognize that the ability of older persons to exercise autonomy depends not only on individual capacity, but also on the accessibility, availability and effective coordination of health, long-term care, social protection, housing, justice and community services. Their purpose is to ensure that older persons remain active participants in shaping their own lives, rather than passive subjects of decisions made by others. Institutional arrangements should therefore be assessed both by the services they provide and by the meaningful choices they make available.

Translating this approach into practice requires a shift from service-centred approaches to person-centred approaches explicitly grounded in human rights principles. Rights-realizing systems should provide a continuum of home-, family- and community-based support that enables older persons to remain in familiar environments for as long as this is consistent with their wishes, rights and support needs. Institutionalization should remain an exceptional measure of last resort and should never become the default response to increasing support needs where appropriate community-based alternatives are available. Decisions should be guided not only by clinical assessments, administrative criteria or organizational routines, but also by the individual’s rights, wishes, preferences and life goals. Where decisions affecting eligibility, assessment, resource allocation or access to services are supported by automated or algorithmic processes, these should remain transparent, subject to meaningful human oversight, and able to be reviewed and challenged. In this way, care and support cease to be objectives in themselves and become the means through which autonomy, dignity, participation and inclusion are realized in everyday life.

Rights-realizing systems require not only legal and institutional reform, but also a human rights culture in which autonomy, dignity, participation and inclusion guide everyday decision-making across healthcare, long-term care, social protection and other public services. Such a culture recognizes that the equal enjoyment of human rights depends both on what laws require, and also on how decisions are made, how services are organized and how older persons are treated in their daily interactions with professionals and institutions. The quality of rights-realizing systems should therefore be assessed not only through the availability or quality of services, but also through their impact on the effective enjoyment of human rights in everyday life, including respect for autonomy, dignity, meaningful participation, privacy, family and community relationships, and freedom from coercion or unnecessary restrictions. This requires professional practice that is relationship-based, strengths-based and person-centred, supported by education and training, interdisciplinary collaboration, adequate staffing and resources, effective accountability mechanisms, and the meaningful participation of older persons and their representative organizations in the design, implementation and evaluation of laws, policies and services. Without these elements, legal recognition and institutional reform alone are unlikely to translate into meaningful improvements in the everyday enjoyment of human rights by older persons.

Ultimately, rights-realizing systems must not only improve the delivery of care and support; they must also ensure that older persons in situations of dependency continue to enjoy their human rights as equal members of society. Such systems recognize that increasing support needs do not diminish personhood or citizenship. Rather, they require societies to organize support in ways that enable every individual to continue to exercise autonomy, maintain relationships, participate in community life and live with dignity on an equal basis with others. The true measure of a society’s commitment to human rights lies not in how it responds to independence, but in how it upholds autonomy, dignity, participation and equality when people become dependent on the care and support of others.

Dependency reveals the true measure of a society’s commitment to human rights. The significance of dependency extends far beyond the organization of health or social care. Situations of dependency reveal how societies understand human dignity, autonomy, equality and solidarity, and demonstrate whether States continue to protect individuals’ human rights when increased care and support become necessary. The true measure of a society’s commitment to human rights therefore lies in how it enables every person to continue living with dignity, autonomy, participation and equality when support from others becomes part of everyday life.

Dependency is not a limitation of human rights, but a test of their effective implementation. The first and perhaps most important conclusion emerging from this inquiry is that situations of dependency do not diminish the human rights of older persons. Contributors from different regions and legal traditions consistently rejected the assumption that increasing needs for care and support reduce personhood, legal status or entitlement to rights. Rather, situations of dependency reveal whether existing human rights continue to be respected, protected and fulfilled when support needs increase. The central human rights question is therefore whether societies organize support in ways that enable those rights to be effectively exercised.

The principal barriers identified are structural rather than individual. Violations of autonomy, dignity, participation and equality arise less from dependency itself than from the ways in which societies respond to dependency. Ageism, paternalism, fragmented systems, inaccessible environments, inadequate community support, digital exclusion and institutional cultures that prioritize organizational convenience over individual choice were repeatedly identified as the principal barriers to the equal enjoyment of rights. These findings confirm that dependency should be understood as a human rights issue requiring systemic responses rather than individual adjustment. A second major finding is the broad international consensus that autonomy does not diminish simply because support needs increase. On the contrary, properly organized support enables older persons to continue exercising autonomy despite physical frailty, disability or cognitive impairment. Across a wide range of legal systems and policy traditions, contributors consistently favoured supported decision-making, accessible communication and personalized support over substitute decision-making. The purpose of support is not to replace individual choice but to enable its continued exercise.

The future of long-term care lies in rights-based, community-oriented support. It is vital to enable older persons to remain in their homes and communities wherever possible and desired, and in a fashion consistent with their wishes and support needs. Although institutional care will remain a needed option for some individuals – and residential care reform, regulation and quality remain vital – many inputs identified the need to strengthen community-based services, home care, family support and integrated systems that preserve relationships, participation and continuity of life. The objective is not simply to relocate care around institutions, but to organize support around the person.

Older persons’ full enjoyment of human rights requires systems capable of respecting, protecting and fulfilling those rights. The central challenge lies not in recognizing that older persons in situations of dependency are rights holders, but in ensuring that their rights are made effective in practice. Existing international human rights law provides a substantial normative foundation, although situations of dependency reveal areas where standards require greater coherence, specificity and operationalization. The decisive question is whether laws, institutions, professional practice and public policies are capable of translating those standards into everyday reality. Human rights become meaningful only through coordinated, accountable and person-centred systems that enable older persons to continue exercising their rights throughout situations of dependency.

Based on the preceding conclusions, the Independent Expert recommends the following measures to strengthen the international human rights framework and its implementation in law, policy and practice to address the gaps identified above.

States should participate actively and constructively in the intergovernmental working group process to elaborate a legally binding instrument on the human rights of older persons, ensuring that the instrument addresses the specific protection gaps exposed by situations of dependency, including autonomy with support, care and support, legal capacity, community inclusion, ageism, accountability and remedies.

States should ensure that all laws, policies and practices concerning older persons in situations of dependency are grounded in the equal enjoyment of human rights. Dependency should never be used as a justification for reducing personhood, legal capacity, autonomy, dignity, participation or any other human right. Support should be organized in ways that enable older persons to continue exercising their rights on an equal basis with others, in accordance with their will, preferences and life goals.

States should establish legal, policy and practical measures that enable older persons to exercise autonomy in situations of dependency, including through supported decision-making, accessible information and communication, advance planning where desired, and other forms of support that respect the person’s will, preferences and rights. Support should be provided to enable the exercise of autonomy before any restrictive measures affecting decision-making are considered, and any such measures should remain exceptional, lawful, proportionate and subject to effective safeguards.

States should develop integrated systems of home-, family- and community-based support that enable older persons to remain in their homes and communities for as long as this is consistent with their wishes, rights and support needs. Institutional care should remain an exceptional measure of choice and last resort and should never result solely from the absence, inaccessibility or inadequacy of community-based alternatives.

States should organize healthcare, long-term care, social protection, housing and other relevant services as integrated, rights-realizing systems that place the person, rather than institutions or administrative structures, at the centre of decision-making. Such systems should ensure continuity of support, effective coordination across sectors and levels of government, and timely access to services that respond to the person’s individual rights, wishes, preferences and life goals. States should further ensure that responsibility for coordinating support rests with public systems rather than being transferred to older persons and their families.

States should adopt comprehensive measures to prevent and eliminate ageism in laws, policies, institutions and society. This should include reviewing legislation, administrative practices and institutional cultures to ensure that older persons are not subjected to discrimination, paternalism, unnecessary restrictions on autonomy or exclusion from decision-making solely because of age or increasing support needs. States should also promote realistic and diverse images of ageing and ensure that public communication, professional practice and everyday interactions respect the dignity, agency and equal status of older persons.

States should ensure that all persons involved in providing healthcare, long-term care and support receive adequate education, training and continuing professional development in human rights, supported decision-making, person-centred practice, communication, dementia, mental health, the prevention of abuse and ageism, and the protection of autonomy, dignity and participation. States should also foster professional cultures in which these principles become an integral part of everyday practice rather than aspirational standards.

States should establish effective systems of accountability, monitoring and independent oversight to ensure that the human rights of older persons are respected in all settings where care and support are provided. Such systems should include accessible complaints mechanisms, independent inspections, effective remedies and regular evaluation of whether laws, policies and services enable the equal enjoyment of human rights in practice. Monitoring should assess not only the availability or quality of services, but also their impact on the autonomy, dignity, participation, privacy, inclusion and equality of older persons.

States should ensure that physical, digital, communication and social environments are accessible to older persons in situations of dependency, enabling them to exercise their rights on an equal basis with others. Accessibility should be prioritized in housing, transport, public spaces, information, communication, digital services and administrative procedures, and appropriate non-digital alternatives should remain available for those who require them. Accessibility should be understood to include not only the removal of barriers, but also the creation of environments that enable older persons to continue participating in family, community, cultural and public life.

States should ensure the meaningful participation of older persons and their representative organizations in the development, implementation, monitoring and evaluation of laws, policies and programmes affecting them. Decisions concerning older persons should not be made without the meaningful participation of older persons themselves. Such participation should be timely, accessible, adequately supported and based on the recognition that older persons are rights holders whose knowledge, experience and perspectives are indispensable to the design of effective public policy.

States should ensure that all future reforms concerning ageing, health, long-term care, housing, social protection and related public policies are designed, implemented and evaluated through a human rights framework that recognizes older persons as equal rights holders throughout situations of dependency. States should continue to strengthen international cooperation, exchange good practices and support the progressive development and effective implementation of international human rights standards relating to older persons.