Book Review

Family Support for the Elderly: The International Experience

Ethics in an Aging Society

N Engl J Med 1993; 329:66July 1, 1993

Article

Family Support for the Elderly: The International Experience
Edited by Hal Kendig, Akiko Hashimoto, and Larry C. Coppard. 323 pp. New York, Oxford University Press, 1992. $70. ISBN: 0-19-262173-4

Ethics in an Aging Society
By Harry R. Moody. 288 pp. Baltimore, Johns Hopkins University Press, 1992. $40. ISBN: 0-8018-4323-5

How do we care for the elderly? How should we care for the elderly? These two books examine these questions, providing some insights yet raising more issues of concern for professionals who provide care, administer programs, or develop policy for elderly populations.

Family Support for the Elderly, produced by the World Health Organization Global Programme for Health of the Elderly, is a collection of reports describing how family support for the elderly is influenced by the aging of the population and by social and economic change around the world. The international, intercultural perspective of the effort results in a fascinating picture of how the well-being of older people is addressed in diverse societies. In the opening chapters, contributors examine the broad forces influencing the lives of the elderly and their families. The process of caretaking is examined within its cultural context, and the demographics of aging and family support are reviewed. This is followed by a practical evaluation of possible resources for the elderly in the light of available economic assistance. The effects of public health and social policy on caretaking structures are examined in different settings.

Of most interest is the presentation of the demographics of aging, family structure, caretaking patterns, formal support services, financial support, and public policies that define care of the elderly in such different places as Sweden and the Netherlands, Israel and Turkey, Mexico and Brazil, Japan and China, English-speaking nations, and the islands of the Pacific. Comparisons of industrialized nations and less economically advanced countries provide evidence that caring for the elderly is a universal challenge. This book's heavy reliance on tables to present data is initially distracting, but as the complexity and variability of care are revealed, these formal summaries help focus attention on the ways in which each nation attempts to manage social responsibility within its own economic, political, and cultural limitations.

Ethics in an Aging Society challenges the dominant model of bioethics as it is applied to common, everyday ethical problems facing those caring for the frail elderly. Moody suggests that the commonly revered rights of competency, consent, and confidentiality do not reflect the true interests of many geriatric patients. He favors instead a different perspective, the communicative ethics of critical theory. This form of analysis recognizes that ethical thought reflects a political, economic, and social context. Moody proposes an ideal standard of communication that would allow truthful, free, and open deliberation in place of what he sees as distorted communication about choices not truly available to patients and caretakers. For example, he questions whether the emphasis on informed consent obscures the true interests of nursing home patients, whose chief need may be maintaining their dignity. He also explores the illusion of patient autonomy, suggesting, for example, that a higher standard for patients with a dementing illness should be respect for self, instead of impractical discussions about complex advance directives.

Throughout this book, Moody encourages a shift in attention to the ideal of human dignity as he discusses the ethics of long-term care, care of those with dementia, and the complex challenge of “rational suicide” on the grounds of old age. His focus on justice between generations and intergenerational solidarity leads him to explore the value of fairness and the conflict between the common good and the individual good. Moody's questioning and reassessment of the bioethics of geriatric care will provoke thoughtful argument. His writing will help redirect attention from the dramatic, event-centered dilemmas at the end of life, to more prosaic, ongoing, daily problems that involve little drama but define the quality of life for the frail elderly.

Both books broaden our perspectives on aging and make it difficult to sustain common assumptions about the right way to care for aging persons. Family Support for the Elderly illustrates the universality of issues related to caring for the elderly, while demonstrating the uniqueness of each society's handling of these responsibilities. Ethics in an Aging Society presents new ways of understanding the tensions among the elderly, their caretakers, and society and makes clearer the moral values hidden in common decisions about the aging and the aged in society.

Katherine A. Hesse, M.D.
Mount Auburn Hospital, Cambridge, MA 02238