Perhaps the change of title says it all. This is the revised edition of Agich’s Autonomy and Long Term Care, which was itself a seminal work. The new title gives us the main drift: if autonomy is important in old age, so too is dependence. Indeed, in the actual world in which Agich is keen to locate his study, autonomy and dependence intermingle as inescapable features of old age for real people. As he says: “Maintaining a sense of autonomous wellbeing (...) is consistent with dependencies on medication or professional care if those dependencies help to maintain a more basic sense of functional integrity in those areas of life that individuals value” .The present book retains and renews its standing as a first rate work in the field of philosophical medical ethics. It aims “to sketch a framework for respecting autonomy in long term care”, rather than to work out practical guidelines . Nevertheless, its strength lies in Agich’s ability to move from the real world of often dependent older people to the philosophical underpinnings of our thinking about how we care for them. In so doing, Agich mounts a powerful attack on what he sees as a prevailing tendency in bioethics. It is the tendency to define autonomy “primarily in terms of a concept of human persons as rational, independent agents and decision makers, who are assumed to be competent and who can be understood without serious reference to society or history” . As he says: “Influenced by liberal theory, autonomy is often treated in bioethics as a concept that primarily applies to the public realm …. (shrink)

An educational provision for young children with autism that offers intensive behavioural intervention based on the principles of Applied Behaviour Analysis (ABA), within an early years mainstream school setting in the UK, is described. The ABA Class at Westwood School is a collaborative project between the School of Psychology, Bangor University, two Local Education Authorities in North East Wales (Flintshire and Wrexham) and the local NHS Trust. Using two case examples, two important features of mainstream education for children with autism (...) are considered: access to the National Curriculum, and inclusion with peers in mainstream settings. Standardised test data on outcomes for these children over the initial 12 months of their educational placements are also provided. (shrink)

This book is challenging and sets itself up as “going against the stream”. But which stream? Perhaps there is a distinction between the stream in medical ethics and the stream in clinical practice. One impressive feature of the book is the detail of the references and footnotes. This gives me the impression that Jeffery is swimming in the stream of academic medical ethics. It is also true that he has first hand experience of clinical practice, but I suspect it is (...) the flow towards euthanasia in the literature that alarms him (page 10). Whereas in practice, however slow moving and stagnant in so many places, my perception is that the tide runs towards person centred care based on a compassionate commitment to meeting individual needs. In the National Health Service (NHS) nursing home for people with severe dementia with which I am involved, the talk is not of euthanasia, but of engendering the sort of holistic view and palliation found in hospices. One substantial argument put forward by Jeffery concerns the ethical basis for foregoing treatment. He argues that decisions, in order to be ethical and compassionate, must be based on the need to avoid disproportionate treatment. His concern is that using “substituted judgments” or criteria such as “best interests” and “quality of life” might not necessarily show respect for life and might be subjective. Instead, “disproportionate treatment” stresses the …. (shrink)