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Reviews and Notes: Geriatrics: Autonomy and Long-Term Care

Autonomy and Long-Term Care George J. Agich. 197 pages. New York: Oxford University Press; 1993. $35.00. Autonomy is perhaps the youngest of the four prima facie values that constitute the major concerns of medical ethicists today. The paradigm circumstance of informed consent necessarily led us to consider autonomy in the context of decisions and actions. For most of us, the notion of long-term care connotes severe limitations of mental activity and mobility, making autonomy and long-term care seem mutually exclusive or perhaps oxymoronic. Not so, argues Dr. Agich. He modestly contends that his treatise explores the circumstances of long-term care and the notions of autonomy as a special circumstance. You will find that this book does much more than that. It is, I believe, the most important contribution to the maturation of our thinking about autonomy that has yet been offered. A robust idea of autonomy requires us to move from the liberal notion of decisions and actions to consider autonomy as a state of affairs. Autonomy needs to account for and accommodate the variable conditions of the human experience. The liberal theory of autonomy that Agich castigates might well allow you to feel good about the defense of a negative-rights idea of autonomy, but it can still leave the patient drooling and restrained in her wheelchair. As he develops this argument, you may be concerned that he is leading to a back-door defense of increasing paternalism. He then presents a brief section on paternalism and parentalism that is worth extracting and applying on its own. The title suggests an audience more limited in scope than is appropriate. Those who labor in long-term care or who are responsible for interface with long-term care will be rewarded, but so too will a broad audience of health professionals and ethicists. The clear, sometimes lyrical writing makes the reading easy. The message is very important. Autonomy. is found in the nooks and crannies of everyday experience in the social world and not in the idealized paradigm of choice or decision making that so dominates ethical analysis