Book Review

A World Growing Old: The coming health care challenges

N Engl J Med 1996; 335:757-758September 5, 1996

Article

A World Growing Old: The coming health care challenges
(Hastings Center Studies in Ethics.) Edited by Daniel Callahan, Ruud H.J. ter Meulen, and Eva Topinková. 175 pp. Washington, D.C., Georgetown University Press, 1995. $42.50. ISBN: 0-87840-591-7

This monograph deals with the present and projected health care problems facing the elderly according to U.S. and Western European students of the subject. The outgrowth of a two-year research project organized by the Institute for Bioethics, Maastricht, the Netherlands, and the Hastings Center in the United States, this book is also a volume in the Hastings Center Studies in Ethics series.

Geriatrics is one of those problematic fields in which there is a plethora of statistics but a dearth of solutions. In this book we learn that the population over 65 in the Netherlands will increase by 14 percent between 1990 and 2000; that 31 percent of the elderly are admitted to an intensive care unit in the United Kingdom, whereas 44 percent are admitted in the United States; and that “the current average caregiver to the elderly [in the United States] is forty-five years old, female, and married. Among children who are primary caregivers, daughters outnumber sons three to one.” The discordance between precise projections and fuzzy answers is not new in geriatrics. Indeed, one wonders how many of the early statisticians warning us of the coming crush of elderly persons are now themselves housed in the less than satisfactory facilities they hoped might improve as a result of their Cassandra-like prophecies.

The book is roughly divided into an introduction, four sections, and a concluding essay. The four sections address broad philosophical issues involving the elderly. Three chapters include a discussion of life extension as a research and social goal. There is an attempt to analyze and project the probable health care needs and bills in the Netherlands and Germany as they change with the increasing population of elderly persons. The section includes current facts and problems involving the health care of the elderly in Sweden, the Netherlands, the United Kingdom, and Germany, with subjects ranging from surgical procedures on the elderly to the importance of the life history in geriatric care. Finally, the conundrum of family care — so desirable yet so costly to the care givers in terms of physical and financial and emotional health — is addressed in chapters on the Czech Republic and the United States.

The quality of the chapters varies considerably. This is a very uneven book. The strongest essays are those by Moody (“The Meaning of Old Age: Scenarios for the Future”), Leidl (“Effects of Population Aging on Health Care Expenditure Financing”), Topinková (“Family Caregiving for the Elderly”), and Brakman (“Adult Daughter Caregivers”). They stimulate thought and are carefully written. Although one may not agree with Moody's assertions about the strengths and weaknesses of his four possible scenarios for the future of an aging society (prolongation of morbidity, health promotion, life extension, and recovery of what Moody calls the “life-world”), he has given much attention to them and provides useful references. Like other essays in this book, Moody's gives the reader the impression it was excessively condensed. The two students of family care giving paint a disturbing portrait of the sacrifice involved in caring for an aging relative (usually a parent). I know several colleagues whose lives have been irrevocably constrained by the need to take care of their parents throughout adulthood and even past retirement.

The concluding chapter, “What Do We Owe the Elderly?,” a supplement to a 1994 Hastings Center report, contains six key recommendations with supporting arguments. These are well worth reading, especially the last three: “The burden upon women in the care of the elderly that has marked informal caregiving in the past cannot and should not be sustained,” “Active efforts should be undertaken to help the elderly to organize politically and to define and articulate their major needs collectively,” “A public dialogue on the significance of old age in the common life of society should be advanced through educational programs, the media, and joint governmental–private efforts.” It is clear to me that the ambivalence that members of virtually all societies feel toward their future infirm selves must be addressed with openness, education, and compassion if books such as this are not to be published yearly ad infinitum.

Richard M. Ratzan, M.D.
University of Connecticut School of Medicine, Farmington, CT 06030