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Ageing, Autonomy and Resources
  1. Julian C Hughes
  1. Consultant in Old Age Psychiatry, Centre for the Health of the Elderly, Newcastle General Hospital, Newcastle upon Tyne, NE4 6BE

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    Edited by A Harry Lesser, Aldershot, Ashgate, 1999, x + 245 pages, £39.45 (hb).

    We should be passionate about the elderly. This book contains, albeit with the occasional lull, some passion, adroit philosophical argument and fascinating social and political insights. It originates from a conference in 1992 and, despite talk of Mrs Thatcher, the book has aged well. The first half deals with autonomy in the elderly; whilst the second considers the allocation of scarce resources. The shift from ethics, via clinical practice, to economics and politics is effected with little effort, precisely because of the book's passion. For it deals with real problems that affect individuals and nations.

    I wonder if autonomy was a Thatcherite notion?! We loved it in the individualistic 1980s, but its appeal has lessened. It does not solve all our problems and is, perhaps, a hindrance to some elderly people. Dunn links it to being human and to human needs. I am sure autonomy relates to being human, but (as Lamb recognises) so does dependency. The human need, for love, respect and dignity, is more strongly indicative of our dependency than of our autonomy. The real focus here, I suggest, should be on the person, not on autonomy.

    Hostler provides a rigorous analysis of personal development and what it might mean in old age. It is worth noting his important final point, that our models might determine the facts we can see. Models can be limiting, whereas our everyday concepts have more breadth. And Chadwick suggests, surely rightly, that “ageing” is multifaceted. It struck me that we need deeper unpacking of the notions being considered: what can we say about the person, about models, or the everyday use of concepts?

    Gavin Fairbairn's clear use of everyday concepts, however, is counterintuitive, if not perverse. Allowing someone to die, he says deals death. Well, they certainly die if we allow them; and death is a consequence of our allowing them. But in what sense do we deal them death? They just die. Furthermore, according to Fairbairn, killing might venerate life. Sure, it might end suffering, but only by ending life. It perverts language, however, to suggest that aiming to end life somehow respects it. This is to venerate death and that will not go down well in the dock.

    I was more impressed by the clinical insights of Winner and Herzberg. I take comfort from Winner's assertion that: “A good clinical service is one that has a small but definite incidence of discharges that go wrong” (page 65). We should be on the side of vulnerable elderly people, even if this involves some risks. Especially if, as Herzberg describes, the alternative is to sit forlornly “staring blankly at a budgerigar or television” (page 73).

    Attfield repeats his point, made previously in this journal, that our moral obligations in medical ethics have an international aspect. The point seems cogent, but its punch is softened by inequity at home. Paul Johnson teases out the complications surrounding lack of fairness in the distribution of economic resources. As we await the report by the royal commission on long term care, his discussion of intergenerational transfers is illuminating, if disconcerting. Seemingly, what it is right to do might just have to reflect what is possible. But that conclusion deserves more philosophical scrutiny. As Cribb asserts, moral and political decisions on this macro level are decisions about what kind of society we want to live in. This will depend upon individual concrete choices. What we should not do, however, is choose “to devalue the latter part of a normal life span” (Leaman, page 186).

    Institutions which deal with the elderly should certainly invest in this book. The issues it deals with are crucial: not least of all, the issue of ageism. In his own chapter, Lesser convincingly declares that, in dealing with questions concerning the rationing of treatment, although the effects of ageing might be relevant, chronological age is not. He concludes, passionately and appropriately: “we should be tough-minded and unsentimental, and resist the temptation to do what will almost certainly do no good, simply because we feel we must do something. But we should not pretend that easing or extending a person's final years, or months, or even days, is ‘doing no good!’” (page 211).