Robert H. Binstock, Stephen G. Post, and Peter J. Whitehouse; eds. 184 pages. Baltimore: Johns Hopkins University Press; 1992. $50.00 hardcover, $18.95 paperback.

The successes of medical science and improvements in public health over the last century have led to the rapid growth of the elderly population in the United States and other Western countries. Prevention and treatment of chronic disease has become the focus of much of modern medicine. Among the chronic diseases that afflict us, perhaps none are more devastating on both personal and societal levels than the dementing syndromes, of which Alzheimer disease is the most common. Although tremendous gains have been made in our understanding of the causes of dementia, there is little likelihood of a cure in the near future. The need to confront the ethical and moral dilemmas that surface while providing care for this growing population of patients is apparent, especially given the economic constraints envisioned for our health care system. This book is intended as a starting point for understanding the experience of dementia for patients and caregivers, the range and complexity of moral and ethical discussion, and some of the health policy options under consideration.

The book is divided into three sections that cover various aspects of Alzheimer disease. In the first section, the reader is given an overview of the basic biomedical facts of the disease, along with personal insights into the experience of afflicted persons and their caregivers. The second section discusses treatment decisions, advance directives, and euthanasia. The final section is devoted to alternative proposals for policy development, along with an overview of current initiatives. Taken as a whole, the book intends to lead the reader from a consideration of the specific concerns of the individual to broader considerations of the moral and ethical principles on which health policy should be based.

The most powerful chapters of the first section include those containing personal descriptions of patients with Alzheimer disease: one by a neurologist who poignantly describes the feelings and concerns of a patient who is aware of his diagnosis and another by a medical ethicist whose experiences with a family member suffering from dementia lends added perspective to his writing.

The second section will be of most interest to practicing physicians. For example, the limited usefulness of advance directives in clinical decision making is highlighted by several authors. One makes a plea for the use of objective measures when determining the appropriate action for a given patient, whereas another encourages the discussion of advance directives as a way of enhancing communication among patients, caregivers, and clinicians. The last two chapters in this section deal with euthanasia as an option for patients with end-stage Alzheimer disease. A case scenario in the final chapter gives us one vision of how euthanasia might actually be practiced. The authors in the last section agree on the need for fundamental change in the way our health system provides care to the elderly and chronically ill. The divergent views as to how this might be accomplished are likely to form the basis of much of the current discussion on health care reform.

The diversity of thought and opinions represented in this book is its major strength. The contributing authors are for the most part acknowledged experts in their respective fields; the chapters are well written and edited. Each section provides insights into an important aspect of Alzheimer disease; the book presents a fairly coherent picture of the disease and its implications for patients, caregivers, clinicians, and society. Opposing views on euthanasia and alternative proposals for health care reform are fairly presented. The reader is left with a better understanding of the complex and evolving nature of decision-making required in the care of patients with Alzheimer disease. This book should interest health professionals and students from a broad range of disciplines. There are no simple solutions to the questions raised in this short book; rather, it admirably serves as a starting point for discussions and actions that will determine the kind of care we provide for our elders and ultimately ourselves in the coming century.