The Dependent Elderly: Autonomy, Justice and Quality of Care. - book reviews

Age and Ageing,  March, 1994  by Cornelius Katona

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The Dependent Elderly: Autonomy, Fustice and Quality of Care Edited by Luke Gormally

Cambridge, Cambridge University Press: 1992. 202 pp. Price [pound]24.95.

This book consists of revised versions of papers delivered at two conferences organized by Luke Gormally for the 1990 meeting of the European Association of Centres of Medical Ethics. There are 14 contributions from 10 authors: four of them (Hildick-Smith, Horan, Mulley and Stout) are geriatricians. There is, sadly, no contribution from an old-age psychiatrist. Of the remainder, the majority have backgrounds in philosophy (Banner, Boyle, Finnis, Gormally) with representation also from the law (Finnis, Keown) and health economics (Hunter).

As might be expected, the medical papers reflect the best of current clinical practice. Horan describes the practical difficulties, in terms both of consent issues and decisions about witholding artificial nutrition, of treating and feeding the debilitated elderly. The need to respect informed patient choice NOT to be treated is well presented, with the crucial caveat of ruling out coexistent depression. Mulley and Stout are both splendidly scathing in describing the lack of any genuine policy framework in the UK for long-term care of the elderly and the poor prospect that the research information required for formulating such policy (in terms of objective measures of need and of quality of life) will be obtained. Hildick-Smith provides an anecdotal account of the practicalities of providing good long-term care that includes a moving description of how her own religious belief has informed her practice.

To the majority of Age and Ageing readers, however, the main potential interest of this book should lie in the non-medical contributions. To my mind, the best of these is Keown's account of the mess that Dutch euthanasia law has led to, with substantial movement down the slippery slope towards non-voluntary killing in cases where doctor-perceived quality of life is low. This is complemented by Gormally's account of the similar slippery slope in contemporary philosophy through the claim that a person needs 'the wherewithal to make things matter to them' in order to possess a 'serious right to life'. A similar concern is expressed in Gormally's other (somewhat long and dense) discussion of 'The Living Will'. Boyle provides an elegant refutation of the idea that age per se should be a criterion for not providing treatment; his other essay, on the American debate on artificial nutrition and hydration is considerably drier and of less practical application. Banner's chapter on QALYs in the context of ageing is overlong but argues well that such measures will inevitably be biased against interventions (in the elderly and in terminal care) that fail to prolong life substantially. This is useful ammunition in our arguments for equitable resource allocation. Hunter's paper on prospects for long-term care has been overtaken by events: it speculates about the impending Community Care Act which has been implemented by the time of this review.

There is a clear need for a synthesis between theoretical ethical formulations and the practical provision of care for elderly chronically ill people. This book is important for attempting such a synthesis and (perhaps inevitably) disappointing for failing fully to achieve it.

CORNELIUS KATONA

Professor of Psychiatry of the Elderly, University College London

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