GOING AGAINST THE STREAM:
Ethical Aspects of Ageing and Care
by Peter Jeffery
(Gracewing, 2001, 282pp, $37.95. Available from AD Books)
Father Peter Jeffrey, Professor of Moral Theology at the Missionary Institute London, has produced a well researched, articulate and persuasive book, which provides a sound framework upon which to think about and build a strong ethical, medical and societal view of caring for the elderly.
He states plain facts: the world's population is ageing, families in Western nations are breaking up, resources for care are diminishing, and low-paid workers with little or no training will be looking after people who enter nursing homes. Those who are lucky may be looked after in an institution whose spiritual dimension values people as individuals; if not, those ending up in government care, may not be treated as real persons.
A central argument in Going Against the Stream is the ethical basis for foregoing treatment. Jeffrey argues that decisions, in order to be ethical and compassionate, must be based on the need to avoid disproportionate treatment. He voices concern that using "substituted judgments" or criteria such as "best interests" and "quality of life", might not necessarily show respect for life as they may be subjective.
The author believes that we need to have a more sophisticated understanding of "quality of life" - one that recognises and understands that quality of life is not in essence a measurable quantity, but rather that elements of quality of life may still be maintained and manifest even in severe disability, dementia, or in terminal illness.
Respectful autonomy, Jeffrey suggests, could readily become a form of selfishness. Here he highlights an ethic of "authentic autonomy" found in "the web of relationships of the person". Considering this, autonomy is not simply "self-mastery" or respect for a person, but when considering the moral life also involves an idea of the interconnection of a person.
What this means is that autonomy must acknowledge "the essential social nature of the person and recognise dependence as a non- accidental feature of the human condition".
These days, the definition of old age has risen by ten years, with elderly now referring to those aged 75 and above. It is this group, Jeffrey says, who need our particular focus - in terms of institutional help - rather than those in the 65-75 category.
This does not however refer to nursing homes alone, but also to services which enable people to stay in their own home as long as possible. The other aspect to care for the elderly goes beyond resources. Jeffrey argues: "To achieve a proper level of care a revolution in the attitude of both government and medicine is necessary. Building new facilities is not sufficient; a new philosophy of care is needed - a philosophy that returns to its Judaeo-Christian roots and adopts Corporal Works of Mercy".
This radical approach "going against the streamâ" entails rejection of the capitalistic idea that people should look after themselves, calling for authentic autonomy and true respect of the old and weak by the medical field. This necessarily demands that euthanasia "be seen for what it really is, a way of avoiding caring for the weak, vulnerable older person by ending people's lives."
Jeffrey reminds us that society and health care workers need to value the experiences of the elderly, and recognise their own contribution to their care of which gives them dignity and acknowledges the curses of old age such as loneliness, anxiety, fear and forgetfulness. Care for the elderly entails not just "professionalism" but also being mindful that "care as the gift of oneself demands heart" - and this heart or compassion is crucial to professionalism in order for it to become a fully human attitude.
In concluding his book, Jeffrey argues poignantly, that there is a critical need to re-value life itself - "not for what it gives, but for what it is". The challenge to respecting life should be combined with an approach which accepts the human condition and knowing when it is no longer appropriate to preserve life, determined by the burden of maintaining life.
His three appendices are very useful: (i) To treat or not to treat: the debate, (ii) The position of the Catholic Church, and (iii) An ethical framework for clinical decision- making at the end of life.
This book would be a very useful reference for those involved in care of the elderly - not to mention the elderly themselves.