Book Review

Challenges of an Aging Society: Ethical Dilemmas, Political Issues

N Engl J Med 2008; 358:1311-1312March 20, 2008

Article

Challenges of an Aging Society: Ethical Dilemmas, Political Issues
Edited by Rachel A. Pruchno and Michael A. Smyer. 448 pp. Baltimore, Johns Hopkins University Press, 2007. $49.95. ISBN: 978-0-8018-8648-5

Despite the large body of literature on ethics in health care that addresses individual cases, ethics at the bedside, and justice in the distribution of health care, book-length treatments of philosophical and ethical issues that are related to the experience of aging and an aging society are rare. Given the prominence of elderly people as patients and as consumers of health care resources, one can back into exploring ethics and aging through topical treatments of informed consent, end-of-life care, decisional competence, family caregiving, Alzheimer's disease, rationing of health care, and long-term care. But it is a losing proposition to approach ethics and aging as an isolated subject matter — the topic is inevitably multidisciplinary and extraordinarily broad, and it requires consideration of how all people are connected in society and across the life span.

This book is an attempt to focus on the implications of old age and of our aging society. The contributors include distinguished scholars of aging from the social sciences and the humanities. The editors have organized the book around three general topics: individual autonomy, responsibility within families, and distributive justice within and across generations. As with most edited books, the content is uneven and the plotline is somewhat difficult to discern, but some of the individual chapters are superb.

Part I, comprising four chapters built around the theme of autonomy, is probably the most salient to clinicians. It includes Nancy Dubler's authoritative summary of legal issues in end-of-life decisions, with her interesting suggestion that much of the case law is dependent on “the fiction of individual choice” and her direct challenge to physicians “not to be cowed by the law when it is wrong” and to become actively engaged in the policy debates. Another highlight in this section is Monsignor Charles Fahey's discussion of the ethics of long-term care. Over the past decade, he has developed an original viewpoint about the ethical demands of determining the appropriate response to what he calls the “progressive intermittent frailty” that characterizes much of old age. Despite where this chapter is positioned in the book, Fahey's formulations speak against the application of a narrow ethic of autonomy to guide care of the elderly.

Part II consists of three chapters on family responsibility, and all are well worth reading. Norella Putney, Vern Bengtson, and Melanie Wakeman anchor the section with a virtuoso review of national and international research on family trends (much of it developed by Bengtson and his colleagues over decades) and a thoughtful consideration of the implications of these trends. Martha Holstein's discussion of long-term care, feminism, and the ethics of solidarity provides a fresh perspective and a convincing argument about the problems in a system that “demands impoverishment before public dollars are available.” The section concludes with a short chapter by H. Rick Moody, which is entertaining because it opens with a case manager's report on King Lear, presented as a case of premature divestiture of resources and miscarriage of filial responsibility. In this thought-provoking essay, Moody calls for experts on aging to move beyond outrage at inflammatory rhetoric on intergenerational warfare to a careful consideration of the inevitable competition for resources.

The five chapters in part III move the discussion from responsibility within individual families to the politics and policies of generational responsibility. The mixed offerings are considerations of the desirable blurring of what are commonly compartmentalized as the three stages of life — education, employment, and retirement and recreation. The section includes a chapter in which philosopher Ronald Manheimer formulates a rationale for public investment in lifelong education for older people. Robert Binstock's chapter describes how the “era of compassionate ageism,” with stereotypical depictions of the elderly as frail but deserving, has been replaced by an era in which the stereotypical depiction of the elderly is of greedy geezers demanding resources from children. He proposes a strategy for building a public and political constituency for public programs that exhibit responsibility across the generations.

Part IV, comprising three chapters that are analyses of Social Security reform and two chapters that are critiques of Medicare Part D, fits poorly into the general plan of the book. The chapter by Peter Diamond and Peter Orszag is a 50-page summary of their own 2003 book, Saving Social Security: A Balanced Approach (Washington, DC: Brookings Institution Press), which is referenced extensively in the two preceding chapters on Social Security. The fact that the chapter by Diamond and Orszag appears last in the sequence will be jarring to anyone reading the book sequentially. The policy analyses of Medicare Part D are informative but inevitably have a short shelf life.

In sum, this book contains some interesting original material as well as a useful synthesis of the literature. It does not present a singular viewpoint about the nature and challenges of an aging society, few readers are likely to respond to its entirety, and it does not lead to a call to action in either clinical practice or policy. But there is something in it for almost everyone.

Rosalie A. Kane, Ph.D.
University of Minnesota School of Public Health, Minneapolis, MN 55455
kanex002@umn.edu