Field Notes

Running out of time. My friend Maureen and I have essentially lapped the world in our quarter century of runs around Brooklyn. We refer to these weekly exertions as our (very cheap) therapy sessions. For her, the past five years of therapy have largely involved the challenges of taking care of her eighty-year-old mother, who has Alzheimer disease. Maureen, a nurse, grew up in Brooklyn, and she and her three sisters—all working mothers—live close to their mother. Mrs. S. still lives in the home she raised them in, with her husband of fifty-nine years. But even four loving daughters and a devoted spouse are just barely enough to meet the physical, emotional, and financial caretaking demands her mother requires.

Becoming caregivers to an aging parent is something almost all of us will have to do someday—just as we can all expect to need caregiving ourselves in the future. Very few of us will receive the care that Maureen's mother is getting, however. "We're all old people in training," geriatrician and Hastings Center fellow Joanne Lynn said at "Aging America: A Reform Agenda for Living Well and Dying Well," a Hastings Center Capitol Hill briefing we held in May. "In our current system, what that means is that—unless you've got three daughters or daughters-in-law—you should count on being an old person in a nursing home," Joanne warned. (Bad news for me; with two sons and no daughters-in-law in sight, I guess I better start shopping for a nursing home.) Philip Ellis, a senior analyst at the Congressional Budget Office, noted that the aging of America, death after years with a chronic illness, and the soaring costs of care translate into a stark economic crisis. He called health care the "nation's core fiscal challenge."

As the wheels of democracy turn and an opportunity for change presents itself, the Center is drawing attention to the ethical dimensions of this crisis in several ways. The recent briefing is one example; we'll have others like it over the next year. We're also developing a project on values in health care reform, and Dan Callahan's forthcoming book, Taming the Beloved Beast, addresses health care technology costs. Nancy Berlinger is heading up the revision of the Hastings Center Guidelines for End-of-Life Care.

The bioethical issues engage the broader policy world. Reforming endof life care, like health reform in general, is more than just getting everyone good care. It is tightly integrated with other social issues not normally under the bioethics umbrella, such as fair wages, education for caregivers, and childcare support so that women are able to serve as professional caregivers.

This makes me wonder about the boundaries of bioethics. At the Center, we try to avoid balkanizing the bioethics field into ever narrower slices—nanoethics, neuroethics, synbioethics, genethics. On the contrary, when it comes to health policy, we should consider an expansive view in which we inform ethical debates that go beyond medicine and biotechnology to education, economics, and wages. On this view, bioethics—a multidisciplinary field, after all—is like the hub of a wheel with spokes that reach in many directions. As such, on one of our next runs, I'd like to tell Maureen about how bioethics recognizes and promotes the comprehensive social changes needed to manage the spectrum of end-of-life issues.