It has long been thought that theories based on equations of motion possessing derivatives of order higher than second are not unitary. Specifically, they are thought to possess unphysical ghost states with negative norm. However, it turns out that the appropriate Hilbert space for such theories had not been correctly constructed, and when the theory is formulated properly [Bender and Mannheim, PRL 100, 110402 (2008). (arXiv:0706.0207 [hep-th]] there are no ghost states at all and time evolution is fully unitary. Unitarity can be established for theories based on both second and fourth order derivatives, and for theories based on fourth order derivatives alone. In this latter case the Hamiltonian is a non-diagonalizable, Jordan-block operator which possesses fewer eigenstates than eigenvalues. Despite the lack of completeness of the energy eigenstates, a consistent, unitary quantum mechanics for the theory can still be formulated [Bender and Mannheim, PRD 78, 025022 (2008). (arXiv:0807.2607 [hep-th]).] The implications of these results for the construction of a consistent theory of quantum gravity in four spacetime dimensions will be briefly discussed.