Ethics in an Aging Society.

Harry R. Moody, Baltimore: Johns Hopkins University Press, 1992, 1996. 188pp. $16.95 (paper).

As the elderly population grows and medical advances increase longevity, questions about methods and limits of prolonging life, treatment of nursing-home populations, and fair allocation of funds among generations have become more insistent. Harry Moody addresses these issues in Ethics in an Aging Society. His thesis is that moral foundationalism with its ideals of autonomy and justice is inadequate to meet the ethical challenge of an aging society. "Instead of an ethics of rules and principles, we need a communicative ethics based on civil discourse both in the small community and in national politics" (12).

The moral principles usually invoked in medical ethics - beneficence, autonomy, and justice - are not always appropriate to geriatric health care. Beneficence involves the temptation of paternalism. Autonomy is often an illusion since many of the elderly are not mentally competent. And justice is ambiguous because of the many different parties involved (patient, family, doctors, laws). Moody then turns to the complexities of nursing-home care and the distribution of funds among generations and suggests that negotiated consent and open communication are more applicable to these problems.

Ethics in an a Aging Society is successful on a number of counts. First, it presents historical context and the complexity of ethical problems facing an aging society. Through references to studies by various experts and to a survey Moody conducted of physicians, nurses, and social workers at long-term care facilities in New York, it exposes the difficulties peculiar to geriatric health care. Secondly, it criticizes the moral ideals of liberalism. Moody rightly understands that mere autonomy - freedom of choice - is an insufficient moral principle. What is needed is reference to the common good, to "relationship, solidarity" (87). Since the model of means-to-end rationality dominant in today's scientific and technological world cannot handle difficult ethical questions, he recommends a "deliberative rationality" which takes into account people for their own sake (83). Thirdly, Moody's moral stance on controversial issues is sound. He argues against direct euthanasia (48), against age-based "rational" suicide (84-88), against covert actions by governments (197), and against rationing of funds merely on the basis of age (204). In these cases he draws on the ideal of human dignity, the virtues, and the common good.

The book's weakness is its lack of cogent moral foundations. Open communication as a normative ideal is insufficient to ground moral argument for the same reason Moody gives for the insufficiency of autonomy and justice (as defined by the liberal tradition): lack of real ethical content. Autonomy as a political ideal cannot tell us what we ought to do or refrain from doing. The goodness of a moral act is not measured by the freedom with which it is done, but by the object chosen and the intention of the agent. Equally, the social-contract idea of justice as self-serving compromise - my interests are furthered by refraining from harming others - does not explain what one ought or ought not to choose. If my "correct" treatment of others is merely a means to the end of my self-interest, such treatment is dispensable if a better means is found. Like the goodness of freedom, the goodness of the communication depends on what the communication is about or where it is going. A society which freely drifts toward active euthanasia would presumably be wrong according to Moody, but on what grounds?

The foundations of moral responsibility are not in liberty, or compromise, or communication, but in that traditional morality (often referred to as natural law) espoused by the pagans Plato, Aristotle, and Cicero and found in the ten commandments and Christian ethics (not to mention Confucianism, Taoism, and Buddhism). Autonomy and justice, properly understood, are part of this tradition. Kant says that autonomy ("self-given law") is fundamental to morality. Modern liberalism has held on to the ideal of liberty. But even more central to autonomy is the idea of law - something that holds universally for all people. The essence of this law is that every human being should be treated as an end, with dignity and respect. As to justice, prior to rights talk there must be reference to basic human goods. You have a right to life because life is a fundamental human good; you have a right to be told the truth because knowledge and friendship (orderly social life) are fundamental human goods. Human beings flourish by participating in human goods and they are harmed when these goods are denied them. These moral principles are general and do not spell out what we ought to do in particular cases, but they serve as negative guides: a choice or policy which directly violates them is wrong and should not be implemented.

Since every ethical judgment involves principle and facts, Moody's professed emphasis on facts- ranging from particularities about patient, procedure, institution, and expense to generalities about culture, political power, and budgets - is well taken. Without principle, however, no particular judgment can be justified. If it were not generally wrong to make decisions about the worth of human life based on the accident of time (the age of a person), then rationing funds based solely on age (which Moody rejects) would not be wrong. And if all moral principles are negotiable, there is no ultimate justification for the highly commendable task of negotiations for the sake of improving the conditions of geriatric care and the fair allocation of funds among generations.

MONTAGUE BROWN