Book Review

Dementia and Aging: Ethics, Values, and Policy Choices

N Engl J Med 1993; 329:67July 1, 1993

Article

Dementia and Aging: Ethics, Values, and Policy Choices
Edited by Robert H. Binstock, Stephen G. Post, and Peter J. Whitehouse. 184 pp. Baltimore, Johns Hopkins University Press, 1992. $18.95. ISBN: 0-8018-4545-9

Dementia poses an enormous ethical problem to U.S. society and to other societies and cultures in the world. The “old old” are the fastest-growing segment of our population, and dementia is alarmingly prevalent in this group. The most common dementias are inevitably fatal after there has been a decade or more of progressive intellectual and physical deterioration. The great majority of patients with dementia spend their final years in nursing homes, bed-bound, incontinent, unable to recognize their family members, and unaware even of their own identities. The issues such patients raise are extreme versions of problems we now face in many areas of our health care delivery system -- the prioritizing and rationing of care, competence in making decisions about personal health, and the role of economics in shaping health care policy.

Binstock et al. have rendered a great service in bringing together essays written by people from diverse fields who have expertise in ethics and health care policy as they apply to dementia and aging. The essays are of uniformly high quality; each has a distinct point of view, but together they provide a cohesive, multifaceted view of a critical group of problems.

The book is divided into three sections. The first contains four chapters on dementia from a medical and care-giving perspective. The essay by Richard Martin and Stephen Post offers a unique view of care giving as an ultimate act of self-sacrifice, in which the care giver provides care to someone unable to reciprocate or even to know that care is being delivered. A central issue discussed in this section is the definition of personhood and whether diseases such as dementia compromise a patient's claim to personhood. The second section contains four chapters on treatment decisions, advance directives, and euthanasia. These selections are particularly timely, given the recent enthusiasm for advance directives. Serious questions are raised about whether decisions made while the patient is mentally competent need necessarily apply when the patient has become demented and has entered a different state of being. The final section contains three chapters on public policy with regard to dementia. The chapter by Daniel Callahan and the chapter by Robert Binstock and Thomas Murray present a point-counterpoint dialogue on whether curative and life-sustaining (and expensive) interventions should be withheld from patients with dementia. Both perspectives are eloquently and persuasively argued.

This book does not answer the ethical and policy questions that challenge our society as the epidemic of dementia continues to engulf us. It does provide diverse, cogently argued points of view from people who have given these problems serious thought. Interest in the book will not be limited to physicians; members of the many professions serving the elderly will appreciate it. It would make an excellent set of readings for seminars and discussion groups.

Jeffrey L. Cummings, M.D.
UCLA School of Medicine, Los Angeles, CA 90024