The President's Council Calls for Prudence

Long-term care policy needs something more than business as usual, and it needs it soon. The ordinary policy-making process is not effectively addressing the long-term care needs of our aging society. "Fiddling while Rome burns" is what comes to mind. Demographic trends indicate a steadily growing demand for long-term care services that will peak around midcentury and overwhelm the current system. The question is not whether but how the system will have to change in order to meet these needs.

The occasionally exasperating but fundamentally important recent report from the President's Council on Bioethics focuses on the moral imagination needed to face up to the social and personal challenges of debilitating chronic illness. Taking Care: Ethical Caregiving in Our Aging Society is short on policy recommendations and pretty much lacking in any new structural vision for the American long-term care system. Taking Alzheimer disease and other dementias as its core example—I should say "master trope," for this is an elegant and complex rhetorical document—the report delivers on the promise that the Council will be different from its predecessor bioethics commissions. It brings together registers from literature, the classics, history, and a philosophy more Aristotelian than analytic. Before you get far, both Seneca and Xenophon have been quoted to good effect. Is this a government document?

Yes and no. Often it has the synthetic feel of a white paper. It begins with a helpful factual overview of the demographic trends and other aspects of the aging society that should properly alarm and motivate the reader. Even amid the facts and figures, however, it offers a refreshing departure from much of the social scientific and medical literature on aging because it intrepidly attempts to say what is distinctive about aging and old age. It refuses the conceit of viewing the former as a curable "disease." Using a life cycle model (which reminds me of Erik Erikson, though he is not cited), it brashly expands on the proper qualities and virtues of the last chapter of our lives—the last leg of the voyage.

Taking Care then makes an odd detour into a discussion of advance directives—living wills are no good; proxy appointments are better. There is little new or very helpful here, and this is indicative of one of the flaws of the book—namely, its excessive preoccupation with end of life treatment issues, when what is really needed is much more exploration of the quotidian work of caregiving in the context of the inexorable transformations associated with chronic illness. We seldom get such a visible treatment of long-term care in bioethics; let us bring aspects of the lived experience of caregiving and care receiving out into the open and fight about feeding tubes some other time.

The heart of the work is two long chapters on the ethics of caregiving. Here both substance and style—what is said and how it is said—are crucial and inseparable. Readers with an analytic bent will find much to fault. Clear conceptual definitions, distinctions, and theoretical parsimony are not the main concerns of this presentation. What the Council is seeking, I take it, is an appropriate metaphorical language and moral orientation or sensibility with which to approach the human reality of dependency, the loss of self-identity, the affirmation and effacement of receiving care, and the affirmation and ordeal of giving it. Why should we care at all? What makes human life morally valuable when the self-awareness required for happiness or unhappiness in the utilitarian tradition, or the autonomy and the claim-rights of the contractarian tradition, are of no avail? How to give proper expression to the human good and human flourishing when there are few if any "life-plans" left to pursue and when the experience of time becomes the daily round in the nursing home instead of a straight path stretching ahead toward the future? What lies beyond "interests," contracts, and even reciprocity in human relationships?

The report concludes with a final section offering recommendations. Having provided an ethical preface, it calls upon the federal government to launch a new...