Our attitudes toward aging change in that “old” depends on where you are. When I was 16, and my sister Nancy was 29, I suddenly realized, to my horror, that one of us was about to be 30. I went around saying to everyone, “Poor Nancy, she's almost 40,” because to me at that time, 30 and 40 were about the same. Later, when Nancy was 40, she said she didn't mind because, according to me, she had been 40 for a decade.

The ethics of decision making for the critically ill elderly is an area of concern for all those involved in the decision-making process. The number of participants involved in decision making around end-of-life issues may be many: treatment and care decisions often bring together not only the patient and the physician, but the family, an extended medical care team, and impartial members of a hospital or institutional ethics committee. In addition, treatment and care decisions made at the end of life occur in a variety of settings, not just the acute care hospital. Elderly patients who are critically ill, or in the final days or weeks of life, are found in intensive care or medical units of hospitals, in hospital and nursing home based hospice programs, in long-term care settings such as skilled nursing facilities, or at home, where they are tended by family caregivers. Differences in patterns of decision making regarding the care and treatment of critically ill older adults can be found across these settings, and decisions often vary according to the roles of the participants.

This article focuses on the elderly patient with a progressive and irreversible dementia, most often of the Alzheimer type. However dementia, the decline in mental function from a previous state, can occur in all ages. For example, if Alzheimer's disease (AD) is the dementia of the elderly, increasingly AIDS is the dementia of many who are relatively young. I will not present the major ethical issues relating to dementia care following the progression of disease from the mild to the severe stages, for I have done this elsewhere. Among the issues included are: presymptomatic testing, both psychological and genetic; responsible diag- nostic disclosure and use of support groups; restrictions on driving and other activities; preemptive assisted suicide; advance directives for research and treatment; quality of life in relation to the use of life-extending technologies; and euthanasia.

Populations around the world are aging at a very fast rate, so much so that care for the elderly will soon rupture even the most carefully planned, enlightened care provisions societies can offer. The demographics in advanced countries demonstrate this dilemma, even without projections based on antiaging medications that may be possible in the near future, and a healthier lifestyle that has preoccupied the yuppies for about 10 years.

In healthcare, it should be a primary requirement that we define accurately what we are trying to do. The necessity for this intensifies when we are under stress, a part of which is caused by increased technological ingenuity outstripping the general ability to pay for it. Dealing with human beings and their problems, we are person and event oriented; our creed has always been and is the best that can be done for an individual, at a point in time. Increasingly, we must modify this traditional approach by viewing episodic care of the individual as a part of two continua, of the individual in relation to their life span, and of the individual in relation to the community and healthcare system to which all belong. We are not skilled or practised in defining our overall aims.

Many Japanese American Buddhist families in the San Jose, California area observe a series of late life celebrations in honor of their elders. The sixty-first, the seven-tieth, the seventy-seventh, and eighty-eighth birthdays are celebrated with special flourish. These celebrations mark milestones in life and underscore the respect and gratitude elders are accorded by the family and community. At these gatherings the talk among family and guests invariably turns to the life of the elder and they wonder how the elder was able to survive and even flourish amid the hard- ships and setbacks during his or her long life. Indeed, long-lived elders do seem to have a presence of being that can only come from many years of living. The idea of kyogai, “one's station in life,” is especially revered in the elder. Ordinarily, kyogai refers to one's place in society. Kyogai also suggests the spiritual maturity of being able to live with equanimity and ease in a transient and interdependent world. For Shiryu Morita (1912– ), a leading Japanese sho-artist or calligrapher and student of Buddhist thought and practice, kyogai is both a spiritual and an aesthetic quality. I reflect on Morita's notion of kyogai within the context of the Buddha's attitude toward aging and elders. I offer my reflections as a Buddholo- gist interested in elder ethics and as a Buddhist priest concerned with caring for and empowering elders. I begin with a description of the Buddha's attitude toward aging and elders outlined in the Sutta-Nipata, an early Buddhist document. The “Salla Sutta” in the Sutta-Nipata outlines the Buddha's attitude toward old age, elders and elder tasks. Old age is linked to the question of death and the unease of living in a transient world, in the passages cited below (p. 68).1

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma.

The increasing incidence of ethical dilemmas in long-term care settings, in concert with recommendations from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, has prompted long-term care institutions to develop mechanisms to address these concerns. Some facilities have chosen to set up an ethics committee, although estimates obtained in the past few years indicate that only between 2 and 27% of institutional long-term care settings have such committees. Ethics committees are responsible for assisting staff, residents, and families with the resolution of ethi- cal concerns, and typically engage in policy review and development, case review, and education. Such committees usually count among their membership representatives from a variety of disciplines, with family members, patients, and representatives from patient advocacy groups supplementing the professional component of the committee.

Healthcare Providers advising patient surrogates on the appropriateness of continued care for comatose patients have often been sharply criticized for coercive behavior toward patient surrogates; with failing to provide them with adequate information; and for a general failure to adequately cinsider the cimplex needs and hopes of patients, their surrogates, and caregivers. Because decisions on the continuation or withdrawal of care (for example where tube feeding or respiratory assistance are required for nonresponsive patients) often need the legal approval of surrogates the failure of both medical personnel and patient families to understand each other's priorities may lead to ethical and interpersonal conflict.

I work at a research institute where the staff spends its time thinking about ethical issues that arise with progress in medicine, the life sciences, and technology. After such thinking, we make public policy recommendations. We pride ourselves in the diversity of our staff: there is a doctor, a lawyer, a linguistic anthropologist, a political scientist, a theologian, some philosophers, and so on. Both men and women do research and we are religiously diverse: Catholics, Jews, Protestants, and atheists

In September 1994, the New York Times carried a front page article declaring healthcare reform dead in Congress. The obituary on healthcare followed a Congressional decision not to pursue the issue further in 1994. Although Congress and the President will likely revisit healthcare reform during 1995, the choices may be between various incremental steps, rather than substantive changes to bring about universal coverage.

It is now 110 years since the first reported medical use of donor insemination (DI). Despite its somewhat doubtful beginnings and its chequered history, especially up until the 1970s, DI has become a well accepted and utilised part of most infertility treatment services. An American survey in 1988 reported that approximately 80,000 women a year undergo the procedure, and that over 30,000 children are born each year. The only figures from the United Kingdom cover a 5-month period between August 1 and December 31, 1991, and show that 4,260 patients were treated with DI during this period. The treatment was carried out in 85 different centres.