References
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behavioral sciences (pp. 1-34). Cambridge, England: Cambridge University Press.
Bergman, L, Eklund, G., & Magnusson, D. (1994). Studying individual
development: Problems and methods. In D. Magnusson, L. Berman, C.
Rudinger, & B. Torestad (Eds.), Problems and methods in longitudinal
research: Stability and change (pp. 1-27). Cambridge, England: Cambridge University Press.
Burks, B. S., Jensen, D. W., & Terman, L. M. (1930). The promise of youth:
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Butler, R. N. (1963). The life review: An interpretation of reminiscence in
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Elder, C. H., Jr., & Clipp, E. (1989). Combat experience and emotional
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Elder, G. H., Jr., & Pavalko, E. (1993). Work careers in men's later years:
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Social Sciences, 48, S180-S191.
Elder, G. H., Jr., Shanahan, M., & Clipp, E. (1994). When war comes to
men's lives: Life course patterns in family, work, and health. Psychology and Aging, 9, 5-16.
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Rosow, I. (1978). What is a cohort and why? Human Development, 21, 6575.
Terman, L. M. (1925). Mental and physical traits of a thousand gifted
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University Press.
CARING FOR THE CHRONICALLY ILL ELDERLY: ETHICAL CHALLENGES
Bringing the Hospital Home: Ethical and Social Implications of High-Tech Home Care, edited by John D. Arras.
Johns Hopkins University Press, Baltimore, 1995, 259
pp., $40.00 (cloth).
The Moral Challenge of Alzheimer Disease, by Stephen C.
Post. Johns Hopkins University Press, Baltimore, 1995,
142 pp., $29.95 (cloth).
These books address questions of vital concern to health
professionals and lay persons involved in caring for geriatric patients. Bringing The Hospital Home, edited by John
Arras, asks, What are the moral and social costs of providing high-tech interventions in the home environment? For
example, how can we ensure the quality of high-tech
services in the home? Do persons receiving home care
retain greater autonomy, dignity, and comfort in a familiar
environment, or become more vulnerable to abuse, loss of
privacy, and juvenile regression? The Moral Challenge of
Alzheimer Disease asks: What is the value and significance
of human life when mental faculties erode or are lost
altogether? For example, when patients in the terminal
stages of Alzheimer Disease (AD) are mute, bedridden,
incontinent of bladder and bowel, and possess unmeasurable intellectual function, should we prolong their lives?
Can we ethically hasten their deaths? How can we best care
for persons with dementia? For example, should family
members use physical or chemical restraints to control the
behavior of demented patients? The authors provide solid
analysis of these, and other, important questions.
Bringing the Hospital Home is the outgrowth of a yearlong research project on "The Technological Tether: Ethical and Social Implications of High-Tech Home Care" carried out at the Division of Bioethics and Health Policy of
Montefiore Medical Center-Albert Einstein College of
Medicine. The project brought together clinical, scholarly
and policy experts, and lay persons involved in giving or
receiving high-tech home care. Contributors to the volume include members of this original working group and
separately commissioned papers from leading figures in
philosophy, bioethics, health economics, law, health policy, public health, social work, nursing, psychiatry, geriatrics, pediatrics, oncology, education, and grief counseling. Arras, the book's editor, is a philosopher and
bioethicist. He introduces the book with the observation
that over the past decade or so, important boundaries
between home and hospital have eroded, with the "hypermedicalization of the home" transforming the "heretofore private sphere of family and friends" (p. 2).
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The twin perspectives of scholarly analysis and hands-on
experience are evident throughout most of the fourteen
essays that constitute the book, which makes frequent
reference to specific cases. The volume's two main parts
also reflect this dual theme: Part I deals with "The Technologies and Their Effects on Patients and Families"; Part II
takes up "Philosophical and Policy Perspectives on HighTech Home Care."
The first part of Bringing the Hospital Home provides the
lay person with accessible descriptions of the high-tech
treatments that are the currency of modern home care. It
reports on the history of respirators and total parenteral
nutrition in the home, technologically dependent children, technologies providing intravenous access, pain
control, hydration and nutrition, drug infusion, and respiratory care for cancer patients, and long-term and hightech care for persons with HIV Infection/AIDS. A few essays touch on the personal and social meanings attached
to giving or receiving high-tech home care. Comparing the
journey of parents who care for technology-dependent
children to the trials of Odysseus, Arthur Kohrman writes
that parents' experiences resemble Odysseus's encounter
with Circe, "the enchantress who changes humans into
beasts, a metaphor for the transformation of a child into a
potentially frightening new species of being" (p. 62).
Two sections address geriatric home care. The first, by
Lidia Pousada, acquaints the reader with home care interventions the elderly use, such as decubitus care, urinary
tract catheterization, nutritional support, peritoneal dialysis, and home oxygen use. The second, more ambitious,
paper by Jeanie Kayser-Jones, uses case studies of two
terminally ill elderly patients managing high-tech home
care to argue for improved communication to facilitate
decision making, improve the quality of care, increase
trust and satisfaction with care, and possibly reduce the
cost of care by preventing rehospitalization. Although
many essays in this part of the volume emphasize burdens
that home care imposes, others conclude that home care's
advantages outweigh its disadvantages. Thus, a particularly strong essay by a nurse (Sherrie R. Schachter) and
physician (Jimmie C. Holland) argues that benefits, such as
contact and closeness, control over decisions, and diminution of future regrets make home care the best option for
many patients and families.
The book's stronger, second part contains a more sophisticated analysis of home care, exploring central philosophical, ethical, social and policy questions. Contributors
include Nel Noddings, William Ruddick, Marshall Kapp,
The Gerontologist
Rosalie Kane, Peter Arno and colleagues, and Norman Daniels. Part two will be of interest to a broader audience: not
only lay persons, but also health professionals and
scholars in ethics, law, and policy. Among the most impressive essays in the volume is philosopher William Ruddick's deconstruction of widespread stereotypes of home
and hospital, noting that "hospitals may prove more hospitable than some patients' homes," not only for those
whose social and economic circumstances make home an
unwelcome or abusive place, but for any ill person for
whom illness and treatment transforms "even spacious
quarters and caring family relationships into hospital-like
conditions . . . los[ing] their familiarity . . . intimacies and
. . . trust" (p. 168). Also strong is an essay by Noddings,
who critiques the concept of caregiving obligations and
proposes the alternative idea of networks of moral support. Kane offers expert analysis of the difficulties associated with defining and applying criteria for quality assurance in the home care setting. Other essays address dying
at home in a high tech environment, the economic impact
of high-tech home care, and achieving justice in access to
high-tech home care.
The Moral Challenge of Alzheimer Disease, by Stephen
C. Post, starts with the bold assertion that "the ethics of
dementia attach no moral relevance to mental acuity or
decline. The value of a human being is not diminished by
even profound forgetfulness; we must assume equal
moral seating and awaken a new beneficence . . . " (p. 3). It
defends this claim, first, by "attentive listening to the
voices of people with dementia" (p. 17), reviewing the
stories of elderly people whose lives were affected by
progressive, irreversible dementia. Post next draws on the
judeo-Christian tradition, which holds that the moral status and dignity of people should not be assessed "in
relation to social value, productivity, and rationality, but in
relation to the deity, and is therefore absolute" (p. 34). The
author worries that an exclusionary and hypercognitive
secular Western culture is inhospitable to persons with
Alzheimer disease, and describes the veneer of respect for
such persons as thin.
The longer, second half of the book shifts focus and
considers the practical ethical quandaries involved in caring for persons with AD. Post considers the ethics of
behavior control in the context of family caregiving, pre-
symptomatic testing, the quality versus the sanctity of life,
and assisted suicide and euthanasia. These chapters generally break little new ground, but provide a competent
overview of the topics. The kinds of conclusions the author draws often state the obvious, and fail to address
more thorny problems. Thus, discussing behavior control
in the context of family caregiving, Post concludes that art,
music, dance therapy, organized ambulation, and environmental modification are preferable to medication or physical constraints. Assessing the prospect of prenatal testing
for familial Alzheimer disease, the author cautions that
imperfect creatures can teach important lessons about
"the meaning of equality and commitment" (p. 92).
Among the most provocative chapters of the book is one
that challenges inhumane attempts to prolong the lives of
persons with advanced Alzheimer disease. Post defends a
human-centered quality of life ethic that discourages treatments producing mental or physical pain. Appealing to
this ethic, Post justifies omission of many forms of lifeprolonging treatment, yet is also compelled to conclude
that prolonging permanently unconscious life is mandatory if, for example, family members find meaning in a
patient's unconscious existence. Unfortunately, the author does not address the implications of such pronouncements for the autonomy and integrity of health professionals, who would presumably be required to act contrary to
conscience and to professional standards of care by engaging in heroic acts to extend the lives of permanently unconscious patients.
Readers of both Bringing the Hospital Home and The
Moral Challenge of Alzheimer Disease will be richly rewarded and frequently challenged. Both books are well
suited for students in bioethics, philosophy, and health
law since they assume no prior medical background. Ethics
portions of the books will be of interest to health professionals facing practical ethical decisions about patient
care. Lay persons who give or receive care will find these
books challenging, but relevant and generally accessible.
Nancy S. Jecker, PhD
Associate Professor of Medical Ethics, Philosophy, and Law
University of Washington
Box 357120
Seattle, Washington 98195-7120
ALL GERONTOLOGY IS DIVIDED INTO 500 ARTICLES
The Encyclopedia of Aging, edited by George L. Maddox,
Springer Publishing Company, New York, 1995, 1,216
pp., $159 (cloth).
One of these days, a technology for reviewing an encyclopedia will emerge. For the present, each reviewer develops a personal approach, one which rarely includes a
cover-to-cover reading. This reviewer approached the task
in four ways: a prior selection of 30 topics in order to
determine whether these or related entries could be
found; an attempt to categorize the topics contained in a
random 200 pages in order to determine the content emphasis; a reading of a random consecutive 100 pages in
order to judge the quality of the entries; and pure browsing. All of these perspectives furnish information on the
extent to which this second edition met its goals.
In the front materials, the editor-in-chief, George Maddox, frames the general goal as that of providing "definitive statements . . . about the processes of aging" (p. xiii).
In order to perform such a task, the Encyclopedia was
Vol.36, No. 4,1996
designed to be interdisciplinary — to be intelligible to the
educated lay person and nonexpert as well as helpful to
the expert, to contribute an extensive bibliography on the
gerontology of the past couple of decades, and to represent the international aspects of aging. These goals form a
convenient outline for a critical review.
How Definitive Are the Statements about Aging?
The adequacy of coverage and the basic quality of the
articles are the relevant issues for this criterion. In selecting 30 topics to be located, a single reviewer's biases
become evident, despite the attempt to range broadly in
choosing them. A total of 26 were locatable either directly,
by cross-referencing, or by easily retrieved synonyms; an
87% hit rate seems most commendable. For whatever interest there may be, there was no entry for diagnosisrelated groups (DRGs), alternatives to institutions (community alternative), or transfer income. The absence of an
entry for emotion (or affect) is the only one that qualifies as
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