Contents LETTER OF TRANSMITTAL TO THE PRESIDENT ix MEMBERS OF THE PRESIDENT’S COUNCIL ON BIOETHICS xiii COUNCIL STAFF AND CONSULTANTS xv PREFACE xvii 1. DILEMMAS OF ANAGINGSOCIETY1 I. Aging and Contemporary Society4 A. The Aging Society5 B. The Trajectory of Chronic Illness and Death11 C. The Availability of Caregivers15 1. The Present Realities of Caregiving16 2. The Future Availability of Caregivers17 3. A Caregiving Crisis?19 II. Individual Aging and the Lifecycle21 A. Biological Nature and Environment24 B. The Presence or Absence of Loved Ones25 C. Wealth and Poverty26 D. Vocation and Avocation27 E. Male or Female28 F. Mind and Body29 G. A Person’s View of Death31 H. Conclusion: Modernity and the Lifecycle32 III. Dementia and the Human Person34 A. The Phases of Alzheimer’s Disease36 B. Cause and Remedy38 C. Alzheimer’s Disease and Human Experience41 IV. Aging and the Common Good46 Endnotes49 2. THELIMITEDWISDOM OFADVANCEDIRECTIVES53 I. Defining Key Terms56 II. The Emergence of Advance Directives in Policy and Law58 III. The Principles and Aims of Advance Instruction Directives67 IV. Living Wills in Practice: Evaluating Success and Failure70 V. Conceptual and Moral Limits of Choosing in Advance80 A. The Problem of “Informed Consent”81 B. Prior Wishes and Present Welfare82 C. Personal Identity and the Obligations of Care85 VI. Beyond Living Wills: The Wisdom and Limits of Proxy Directives and Advance Care Planning89 Endnotes91 3. THEETHICS OFCAREGIVING: GENERALPRINCIPLES95 I. Defining the Subject100 II. Human Contexts of Caregiving: Life, Death, and Modern Medicine102 A. The Worth of Human Lives103 B. The Meaning of Human Deaths108 C. Modern Medicine113 III. The Ethics of Caregiving118 A. The Goals of Caregiving120 1. Respect for the Person’s Prior Wishes and Ideals120 2. The Well-Being of the Family123 3. The Good of Society125 4. Best Care for the Person Now Here128 B. Moral Guidelines130 1. Ordinary and Extraordinary Care131 2. Acts of Commission and Acts of Omission133 a. Never beginning treatment versus ceasing/removing a treatment-in- process135 b. Active killing versus letting die136 3. Doing and Accomplishing: Motives, Intended Deeds, and Goals140 4. Burdens of Treatment and Burdens of Disease144 C. Moral Boundaries147 Endnotes150 4. ETHICALCAREGIVING: PRINCIPLE AND PRUDENCE INHARDCASES151 I. Deciding for Oneself and Deciding for Others154 II. The Significance of Age-Related Dementia and Its Stages164 III. The Well-Being of the Patient171 A. Dementia and Well-Being172 B. The