In 1852 Florence Nightingale wrote, “It is valuable to have one place in the hospital where postoperative and other patients needing close attention can be watched”. Almost 100 years later, an American “anesthesia study commission” concluded that one-third of postoperative deaths in the first 24 hours could have been prevented by better nursing care. Yet it is only in the last 25 years that designated intensive care units have become a feature of acute hospitals in developed countries. In the United States, intensive care beds now comprise 15% of acute beds, and they cost at least two to three times more than ordinary ward beds. Over half the difference between “activity and treatment” in hospitals in the United States and in the United Kingdom is attributed to the much lower provision of intensive care in Britain (1), where such units comprise only 1% of acute hospital beds. Selection for intensive care is therefore more stringent than in the United States, as it is for other high technology procedures (e.g., coronary artery surgery and renal dialysis). However, even in the United States there is now reluctant recognition not only that health care as a whole has to be rationed, but also that unlimited access to high technology medicine is not always in the best interests of patients and their families. In particular the cost-benefit ratio of intensive care for certain types of patients has recently come under scrutiny at an NIH Consensus Development Conference (2) and at the Massachusetts General Hospital (3).

Of the many ways to conceptualize the relationship between modern medicine and moral principles, by far the most reassuring is the idea that technically good and morally good medical care are one and the same. There are no contradictions, in other words, between the claims of moral obligation and the canons of scientific medical practice. In a trivial sense, this is undoubtedly correct. It is immoral to profess medical competence that one does not have. Ethical medicine presupposes technical knowledge and skill. But what of the far stronger proposition that authentic technical competence inevitably generates ethical practice? As might be expected in complicated human affairs, this statement is only partially true.

Professor Brian Jennett has written a thoughtful and comprehensive article on Intensive Care for the Elderly, mainly from the British and North American perspective. In my commentary I shall try to look at the issue from a Scandinavian perspective, especially a Swedish one.

Although a relative latecomer in the industrialization process, Japan has managed to catch up with the more advanced nations and become a major competitor in the international marketplace for goods and services. As a result of their excellent economic performance and rapid technological development, the Japanese people enjoy a level of general well-being that is among the highest in the world. This is especially true with respect to health status. In terms of most commonly accepted indicators, Japan compares quite favorably with other industrial nations. Indeed, the life expectancy for males of 74.20 years and that for females of 79.78 years in 1984 were the highest in the world.

The kidneys are the body's main organs of excretion. They are, however, subject to serious, progressive, and irreversible deterioration, and as a result, to a decreased ability to extract poisonous wastes and excess fluids from the blood. Almost invariably, this condition proceeds to the point where it is termed end-stage renal failure (ESRF). As the name suggests, ESRF is fatal.

Tom Halper is not the only American who has been looking at the rationing of renal replacement therapy in the United Kingdom. All are appalled at the denial of effective lifesaving therapy to elderly and high-risk patients, such as diabetics, with end stage renal failure (1). Some realize that the rationing practiced in the United Kingdom today may have to be applied in other countries tomorrow (2). Medical resources are not unlimited (3).

That the United Kingdom has comparatively low figures for acceptance of patients over the age of 55 for renal replacement therapy is remarkable, because, on a comparative basis, the United Kingdom is not a poor country and many U.K. nephrologists were pioneers in the technical and medical development of he-modialysis. While most nephrologists in the United Kingdom agree that age per se is not a valid criterion to be used for excluding patients, the “hard” use of age as a rigid line demarcating those to be treated from those to be denied treatment predominates. Professor Halper has made a very thorough analysis of which factors at the macroallocative as well as the microallocative level are responsible for this. It would have been of interest to know how the health system in the United Kingdom deals with other categories of elderly, severely ill patients (e.g., patients with malignant diseases), for whom immediate surgery may be life-saving, but the long-term prognosis is questionable. Are such patients also denied treatment in the United Kingdom because of age?

The term orthopedics was introduced in 1741 by Nicolas André in Paris for “the Art of Prevention and Correction of Deformities in Children” and for 200 years orthopedic institutions were mainly concerned with locomotor problems in children and young adults. After World War II, however, the majority of orthopedic patients were not children. Devas (6) has coined the expression “geriatric orthopedics”, a semantic contradiction which highlights that we now face an increasing volume of elderly patients in whom the locomotor system causes severe problems. For example, in my own institution an orthopedic wing built in 1928 contained 135 beds, the majority of which were occupied by children. Today 10 beds suffice for our orthopedic children. Half of all orthopedic beds in Sweden are used for hip surgery in the very old.

The association between a slow pulse and fainting episodes dates back to Mor-gagni's original description in 1761, when he discussed two elderly men whose pulses were very slow and who suffered from epileptic seizures. Subsequent reports by Adams in 1827 and Stokes in 1846 substantiated that the slow heart rate was caused by degenerative changes in the heart and not by a disorder of the brain.

When first introduced in the early 1950s, the pacemaker was driven by a battery-powered impulse generator that was large and cumbersome (Figure 1). The introduction of transistors later in the 1950s made it possible to build a generator small enough for implantation beneath the skin (Figure 2), allowing patients to walk about freely.

During the last decade, microsurgical improvements have developed extremely rapidly in eye surgery. The use of operating microscopes has opened this field to a wide range of technical innovations such as finger suture materials, more sophisticated instruments, and new implants. The result has been better rehabilitation of patients, whose vision was impaired by opacities in the refracting media of the eye. The most frequent cause of poor vision in the elderly is cataract, which is an opacification of the lens in the eye. Most people older than 70 years will have some cataract, with about 30% having opacities that markedly reduce visual acuity and often produce glare phenomena in at least one eye (see Figure 1). There is at present no medical treatment for cataract.

During the last few years evidence has accumulated that fetal neurons, implanted into the depth of the brain in adult rats, can reestablish damaged connections in the host brain and substitute functionally for elements lost or damaged as a result of a preceding lesion. This research work has led to the realization that, contrary to traditional views, the adult mammalian CNS has a potential to incorporate new neuronal elements into already established neuronal circuitry and that such implanted neurons can modify the function and behavior of the recipient. For a long time it was thought that the remarkable regenerative and functional potential of CNS tissue grafts that had been demonstrated in cold-blooded vertebrates reflected a fundamental difference in the regenerative properties of central nervous tissue between cold-blooded vertebrates and mammals. During the last few years it has become evident however, that at least certain types of intracerebral neural grafts can perfoum just as well in developing and mammals as in developing or adult submammalian vertebrates.

Of all the diseases afflicting the elderly, the degenerative brain disorder, known as Alzheimer's disease, may be the crudest because it kills its victims twice. The mind dies first. The patients display decreased knowledge of recent events, both about their own personal lives and the world around them. Decreased performance is manifested in demanding situations at work, traveling, and managing personal finances. These symptoms are commonly accompanied by anxiety, denial, social withdrawal, and loss of initiative. The patients' performances on psychometric tests are well below average, yet they may be able to function safely in a limited familiar environment with familiar routines.

Aging is generally regarded as a reduction of physical, psychological, and social resources. This reduction is due to two processes that operate simultaneously during the life of an individual. One of these processes is the basic biological changes which take place within the individual and are probably programmed by genetic factors. The other is change due to environmental factors, such as air pollution, noise, poor working conditions, and eating habits, social and psychological factors such as attitudes and norms, and technological factors which can enhance adaptation or cause a decline in social or psychological resources. According to present knowledge, biological age changes are irreversible. However, it should be possible to reverse the environmental changes either through short-term interventions among individuals and the community, or by long-term interventions in the society.

Coronary artery bypass graft surgery (CABGS) has become an important procedure for the treatment of coronary heart disease. Over 100,000 of these surgical procedures are performed each year (1) at an aggregate cost of about $2 billion (2). Despite its current widespread acceptance, this major surgical innovation has generated considerable controversy concerning its effectiveness (3), and there still remains substantial confusion in assessing its overall impact (4).

Acute cerebrovascular disease (CBVD) has an annual incidence of 100–300 per 100,000 inhabitants in the industrialized countries (1,2). CBVD occurs mainly in the elderly. Acute mortality is around 15%. Disablement and decreased quality of life are common consequences. Institutionalized care will be needed after the acute phase for around one-third of the patients (3). Considering the volume of patients and the growing proportion of elderly persons in most countries, stroke poses a major problem for health care. An effective diagnostic work-up as the base for therapy to improve the situation is, therefore, a matter of great public concern, for humanitarian as well as economic reasons.