Peter JEFFREY, Going Against the Stream: Ethical Aspects of Ageing and Care. Collegeville:The Liturgical Press, 2001. pp. 282. pb. ISBN 0-8146-2801-X.
Reviewed by Dolores L. CHRISTIE, CTSA/John Carroll University, UNIVERSITY HEIGHTS, OH 44118

As one might expect, this book deals with such issues as the cost of health care for the ageing, rationing, autonomy, aggressive treatment versus neglect, autonomy in the face of nursing home placement, palliation, advance directives, and assistance in dying. It addresses common myths about aging and confronts some of the major problems facing this generation.

The author frames his discussion in language suggestive of a Catholic view of the human person, as detailed in Gaudium et Spes: made in the image of God, having and possessing value, spiritual and material (limited), part of a community of persons who must be considered in the decision-making process. His conclusions reflect accurately the positions of mainstream Catholic thinking, including those put forth in the American bishops' Ethical and Religious Directives for Catholic Health Care Services; which underscore the dignity of persons, the responsibility to consider the proportionate good posed by medical interventions as well as their proportionate burden. Jeffrey reminds the reader that decisions should be particular to the case and to the personal values of the patient, with a clear prohibition against direct action aimed at taking a human life. He asserts correctly that it is not immoral to discontinue interventions that do not promote the health and wellbeing of patients, and that resuscitation in the elderly is almost always futile. To his credit and the advancement of the discourse, Jeffrey highlights the communal dimensions of elderly autonomy in facing life and death, concerns which are often absent in many contemporary discussions of end-of-life issues, particularly in the American conversation.

This reviewer had some minor bones to pick with the book. Jeffrey's vision of an ideal future world for the elderly—wonderfully equipped and staffed nursing homes—reflects more a sterile approach to the how life should conclude than a satisfying reality. It is a vision with a narrow viewing audience, since even by his statistics less than half the population will end their days in long-term care. Sometimes Jeffrey condenses his arguments into an either-or approach. The issues are much more complex than such a polarized model suggests. Just as "pro-choice" and "pro-life" do not spell out sufficiently the nuances of the abortion debate, "pro-totally aggressive treatment" and "pro-euthanasia" do not elaborate sufficiently the complicated concerns surrounding the dying. While Jeffrey's development of ideas is sometimes very careful and appropriate, there are instances where he paints with too broad a brush and ends up with somewhat murky caricature rather than a good analysis. Reducing "death with dignity" arguments to manipulative ploys of those who wish to promote euthanasia, for example, is not a fair representation of the complex issue.

There are many good things about the book. Particularly helpful is the section in his chapter, "Opening the Final Door," which details the process of dying. Ultimately, care of the elderly should be a ministry to persons, what the author says is "caring about" rather than simply "caring for." The former connotes a sensitivity to issues of dignity and caring, rather than an emphasis on the physical and efficient.

The appendices review the debate on the duty to treat or not treat, the position of the Catholic tradition on withholding or withdrawing treatment and an ethical framework for decision-making at life's end. This last is one of the most helpful sections of the book. Three principles for an ethical framework for end-of-life decision-making are offered. They include respect for the inherent dignity of every person, cognizance of the concrete state of this patient and his or her needs, and the affirmation of both the intrinsic value of the person and the necessary mortality that is part of all life.

For American readers Jeffrey's perspective and sometimes his turn of phrase will make the text slightly off-putting. Nevertheless, the author's focus renders this book suitable reading in the area of geriatrics and end of life. While there has been a recent proliferation of books which deal with end-of-life topics, not all situate their arguments in the dignity of the human person and the essential relatedness of human beings. For that reason alone, the book should be taken seriously.

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