It is expected, when the figures are available, that expenditures for home care in the United States in 1995 will be shown to have exceeded $27 billion. With 17 000 agencies delivering services to approximately 7 million persons, home care is the fastest growing segment of the health services industry. Bring the Hospital Home examines the newest aspect of this expansion: the frenetic transfer of technology to the home. This change has created substantial gaps between technical prowess and discernment of the humane, just, and efficient use of technology. Sending patients home to manage and monitor complicated equipment and materials that require special knowledge, skill, and composure can cause them harm.

This book is the result of a year-long project executed by expert clinicians, scholars, and policy analysts, and it considers the effect of a boom in portable technology. In addition to deliberating about important questions of access, equity, standards of quality, and consequences for families, this group also met with patients, family members, and involved friends who shared their experiences with high-tech home care.

The first chapter provides an excellent distillation of the main points of consensus reached in this timely debate. The rest of the book is divided into two sections: "Technologies and Their Effects on Patients" and "Philosophical and Policy Perspectives on High-Tech Home Care." The chapters in the first section examine the use of infusion therapies, feeding tubes, dialysis, ventilators, and various monitoring systems in children, patients with cancer, persons with human immunodeficiency virus infection and the acquired immunodeficiency syndrome, the terminally ill, and the elderly. Although this section provides a comprehensive overview, the redundancy and references to other chapters characteristic of a multiauthor text are tedious at times.

The second section of the book considers principled solutions to complex issues, opportunities both to care and to exploit that are created by high-tech home care. Bringing the hospital home creates new clinical challenges and ethical dilemmas. The standard ethical analysis of indications for care, calculus of benefit and burden, and fully informed consent take on new meaning when the family is counseled on these matters by high-tech companies intent on amassing great profits or hospitals anxious to save money through early discharge. Thoughtful consideration is also given to the disproportionate burdens placed on women by this domestication of care, the inequity of systematically excluding the elderly from access to a full range of high-tech care, and the absence of alternative institutional solutions to meeting needs for high-tech care. All of these enlighten the new reality of living at home. Remarkably absent from the book is an in-depth analysis of social class and high-tech home care. At a time when millions have no insurance, providing access to care requires more than the presentation of middle-class issues and problems. In an otherwise excellent book, home care for those with inadequate housing, insufficient food, and an inability to purchase prescribed medications should be given more than a brief acknowledgment.

This book is to be recommended for its handling of the ethical and social implications of high-tech home care. It will, one hopes, encourage patients and their caregivers to participate actively in the creation of family-friendly, cost-effective, equitable, high-quality approaches to technology. Although this collaborative project was initiated before the current onslaught of managed care, it serves notice to every clinician that many moral, social, and policy changes are yet to come.