Dependence and Autonomy in Old Age: An Ethical Framework for Long-Term Care. George J Agich. Cambridge: Cambridge University Press, 2003, pp. 207, £26.95 (PB) ISBN: 0-521-00920-0.

Rachael Gooberman-Hill

This book is a revised edition of Autonomy and Long-Term Care (1993). From the viewpoint of bioethics, Agich examines the concept of autonomy in long-term care of older people. Specifically, he critiques the liberal view of autonomy as based on independence and self-determination, suggesting instead that in contexts of long-term care, it is better to work with a concept of ‘actual autonomy’. This is the lived experience of autonomy in circumstances where interdependence, rather than independence, takes place.

The arguments in this book are woven from evidence drawn from existing literature. Chapters One and Two discuss existing theories of autonomy. In this section, Agich concludes that the usual political/legal concept of autonomy is inadequate if applied to real-life situations. While such notions of autonomy stress negative freedom—the right to be left alone—Agich reminds us that in real situations, especially in long-term care, people only achieve autonomy through or because of interaction with others. To work through this argument, the following chapter draws on empirical evidence from a range of sources. This sets the tone for the rest of the book's linking of theory with evidence. For instance, Chapter Three includes a review of the literature on stereotypes and expectations of older age. Chapter Four further explores the concept of ‘actual autonomy’, although it is not until Chapter Five that there is more protracted discussion of long-term care. In this chapter, Agich draws on phenomenological philosophy, using space, time, communication, and affectivity as a thematic framework for exploring and conceptualizing central issues for autonomy in long-term care. Phenomenology is a branch of philosophy that emphasizes the need to focus on the ‘lived experience’ of its subjects. So, Agich suggests that if older people experience fatigue, then that fatigue should prompt caregivers to consider the emotional (affective) character of fatigue as well as just its physical characteristics. Through such arguments, Agich shows us how negative freedom is not key to actual autonomy in contexts of long-term care. Finally, Agich uses work by David Morgan in a long-term care institution for older people. His interpretation of Morgan's material is intended to illustrate how the routines and decision-making of everyday life are connected to ‘moral action’. This, he suggests, is largely ignored by a bioethics that focuses on unusual situations. Autonomy, he argues is a process of ‘being in the world’ rather than a state. Hence, autonomy has to be understood in the context of real circumstances rather than as an abstract value.

When the original version of this book was published in 1993 it may have facilitated new ways of thinking about autonomy. Although it no longer seems groundbreaking to suggest that liberal notions of autonomy (independence, negative freedom) do not easily apply to certain spheres such as long-term care, Agich's arguments can still enhance how we think about the circumstances of dependency. Furthermore, his use of phenomenology provides a framework for analysis. However, as a note of caution, many of those who employ phenomenological approaches stress the need for extremely close familiarity with the circumstances under analysis. Although admittedly not the aim of his work, had Agich conducted more first-hand research rather than relying on other published material, then readers might find his arguments more grounded and approachable.

This new edition is intended for a wider audience than the original. Hence, it has been updated and reworded in places. It would have been good to see even more rewriting, as this book remains a scholarly work probably best suited to those with a serious interest in ethics. This said, Agich's book provides us with a synthesis of the literature about autonomy, dependence, and independence in the context of care. It also serves as a robust addition to that body of literature.





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