Charles W. Lidz, Lynn Fischer, and Robert M. Arnold. 195 pages. New York: Oxford University Press; 1992. $37.95.

The autonomy of persons admitted to long-term care facilities is often diminished by the very need to seek institutional lodging. Indeed, this is usually less than an autonomous choice. Through their depiction of institutional life, the authors of this book show further erosion of autonomy. They describe a research project that examines the fate of patients in nursing homes and independent residents of one such facility, scrutinizing the factors influencing autonomy.

What is autonomy and why should it be pursued? Exploring the facets of this concept, the authors consider autonomy to include free actions that are voluntary and intentional, that result from effective deliberation, and that are consistent with life patterns. The peripheral element of privacy is also cited.

The authors indicate that because of the diminished mental or physical capacity of patients receiving long-term care, limitations of free action and deliberation can be justified. However, patients or residents should be assisted in engaging in activity consistent with previous life patterns. They should be encouraged to hold onto their identity.

Why should we encourage autonomy? The authors cite ethical and legal precedents that support the intrinsic worth of self-determination. Further, they agree that persons are usually the best judges of what is in their best interest. But when diminished capacity is present, respect for our common humanity and dignity is the only way to acknowledge autonomy.

In the medicalized nursing home environment, occupants are patients who are traditionally passive and directed by the staff. But in the independent-living area, the staff encourages residents to pursue, within limits, their own activities. There, independence makes the staff's job easier. In both facilities, the authors conclude that compliance, not assertive behavior, is encouraged in the interest of institutional efficiency.

For the uninitiated, this introduction to a long-term care environment points out the commingling of the demented with the incrementally disabled, and the practical difficulties encountered with the institutionalization of what is mostly older persons. We must read between the lines to discern the result of low wages for line staff whose major concern is control. In addition, the book does not directly explore resident sexuality, which could have been addressed with the authors' description of the impossibility of privacy.

The fundamental issue that the authors identify in the preface is what might be done to improve the autonomy of the elderly in long-term care institutions. They acknowledge the practical difficulties encountered in institutions where concerns for health, safety, and efficiency must be balanced with promotion of autonomy. Nevertheless, the authors' suggestions are drawn from their own observations, and they indicate that implementing them may require a minor revolution. But if they can be instituted, they would enhance the life of the increasing number of persons who will spend many years in long-term-care facilities.