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Doctors and Dying

“I intend to live forever. So far, so good.”

- Steven Wright

The humor in many of comedian Steven Wright’s famous one-liners is that they are simultaneously familiar and absurd. At some level we all know that we are going to die, but as long as we are still alive (or a loved-one is alive) we can cling to the irrational hope, the impossible denial, that death remains a distant abstract concept, not an near inevitability.

We all need to come to terms with death in our own private way, but often those terms are not private because they drive our use (for ourselves or others) of increasingly expensive health care. Two essays over the last year by doctors explored this issue, noting that when doctors face their own mortality they often make different health care decisions for themselves than the general public.

In February of 2012, Dr. Ken Murray wrote an essay in The Wall Street Journal – Why Doctors Die Differently. His primary thesis was that doctors choose less end-of-life care for themselves than the average patient. They do so largely because they are intimately familiar with the futility of much of what we do for patients who are likely going to die anyway. As one example, CPR has a success rate of about 8%, with only 3% of people receiving it going on to have a near-normal quality of life. Those numbers are pretty grim. Meanwhile, TV depictions of CPR are successful 75% of the time with 67% returning to normal life. Sometimes the person wakes up during the CPR, is fine, and then goes on to thwart a terrorist attack without missing a beat.

For the general public, receiving CPR means surviving and going on with life. For doctors, receiving CPR means prolonging the inevitable and just adding unnecessary additional pain and suffering in the process.

Even when told the numbers many people will cling to that 3%. Physicians live it, however. They see first-hand the outcomes and it is real to them.

A second essay by Richard Senelick from last year, Why Dying is Different for Doctors, focused on being comfortable with one’s own mortality. His point is that the more familiar an individual is with death the more they have likely come to terms with their own death. This allows people to “die with dignity.” He did cite two studies, but they did not support his premise. One Israeli survey showed no variation by specialty correlating exposure to death and personal anxiety about death. The second study he claimed did show a relationship, actually didn’t. It showed:

The results confirmed an inverse relationship between the use of repression and overt report of death anxiety for the physicians tested. Frequency of exposure to death seemed to have no effect on defensive style. The physicians most frequently exposed to death (internists) did not employ the most repression, as expected.

Anxiety over death did decrease with age, but that is a general trend not unique to physicians. Of the two hypotheses above, familiarity with the futility of certain care, rather than decreased anxiety about death, seems to have the more compelling case.

Unfortunately, there isn’t much more published about the attitudes of physicians toward their own end-of-life care. Physicians are far more likely to have made advanced directives – Murray cites an article indicating that 64% of physicians compared to 20% of the general public have made advanced directives (instructions for what to do and not do if they are gravely ill and unable to communicate their desires).

Issues of death, advanced directives, and futile care are increasingly important as the cost of health care continues to rise and is generally considered to be unsustainable. I was extremely disappointed to see, during the debate about Obamacare, that these critical issues were effectively sidelined by painting them with the politically unpalatable label of “death panels.” This term exploited one barrier to effective end-of-life counseling and advanced directives, lack of trust of the system.

Doctors and certain other health-care workers know first-hand that some interventions are not likely to be worth it in some situations, and can comfortably choose to forgo expensive and painful interventions that are truly futile. Their families who trust them also make similar decisions. But for the general public, without first-hand knowledge, they have to have enough trust in their doctors, the hospital, and the system to believe that when they are being told that a certain intervention is not worth it that this is a fair assessment.

Some comments to Murray’s article reflects this attitude, for example:

In other words, 99%, can you please die quickly? the rich need those machines.

I have personally encountered such pushback – families who fear that the system is willing to sacrifice their loved one in order to save money. In fact, there is a kernel of truth to this. It is ruinous to everyone if, as a society, we spend health care dollars we cannot afford on care that every specialist involved knows to be futile, or to have only the tiniest sliver of a chance of an outcome that is something other than horrible. People don’t think about society when they are making such decisions for loved ones, however. It’s also the physician’s job to advocate for their patient, not society. Discussions focus, therefore, and as they should, on what is best for the patient.

As a society, however, we do need to balance what is optimal for individuals and what is best for society, which is really just about considering all individuals. To a degree we are dealing with a zero-sum game in that health care resources are being rationed and increasingly will need to be rationed. Spending health care dollars on futile care for the dying will take resources away from others who are more likely to benefit.

Right now there is no good mechanism to avoid truly futile care, other than individual physicians counseling families and patients in each situation. To be fair, much of the time, in my experience, people make very reasonable decisions and generally follow the advice of their physicians. It doesn’t take many exceptions, however, to spend billions on futile care. Utterly worthless interventions should be the low-hanging fruit in terms of reducing health care costs, but it seems to be off the table.

It seems that more study is needed into how people (including doctors and other health care workers) make decisions about end of life care. The system does need to do a better job overall in confronting these uncomfortable issues.  Doctors need to discuss these issues more consistently with their patients, more of whom should have advanced directives. Even worse than merely futile care is futile care the patient does not want, but we are obligated to give because that was never documented.

These are all difficult, controversial, and even painful topics to discuss, but we can no longer afford to avoid them.

Posted in: Politics and Regulation

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115 thoughts on “Doctors and Dying

  1. DugganSC says:

    With, of course, one of the fears regarding the fixed recompensation scheme with the current health care where hospitals would only be given so much money for a condition is that hospitals will hit that figure and suddenly become reluctant to do anything further for the patient. To some degree, we have something like that in the current system where insurance typically has an upper limit and, due to the hideously high costs of some therapy (inflated ones in some cases, with double and triple charging and common supplies like gauze pads, tests, and aspirin charged at 20-30x markup), that limit is reached very quickly whereupon patients have to decide whether it’s worth going into massive debt just to survive another year.

    I recently read “Bitter Pill: Why Medical Bills are Killing Us” from Time’s website. I’ll admit that it might be influencing my thinking a bit at the moment.

  2. Janet says:

    I have already seen enough people I have known opting for absolutely futile care to know that I am not going to do that. In all cases these people were religious (some traditionally and some more “alternatively”) and believed in an afterlife of some kind–and yet they pushed hard for pointless intervention because they would not relinquish “hope”. In every case the patient was receiving publicly-funded care as all other resources had been exhausted, and of course, the last months were the most expensive.

    It may be crass to criticize them, but all but one of these cases involved people who had used CAM for cancer, then turned to standard care when it was much too late, but they insisted and were able to get it anyway. It took a fair amount of doctor-shopping in one case. These people remain in complete denial and have no remorse for what their “beliefs” have cost society, as described by Beyerstein in his essay at Quackwatch.

    The only possible solution is very long term and it is education. I will not live to see it–with or without pointless intervention.

  3. evilrobotxoxo says:

    When I was an intern on an internal medicine service at a fancy private hospital, I think over half of what I did was utterly futile, prolonging death instead of prolonging life. The ICUs were full to capacity with patients in their 80s and 90s with metastatic cancer (whose life was being unnecessarily prolonged), so we had floor patients on pressors with Q1hour urine output checks and etc. It was awful. Of course, virtually everyone was full code, meaning we were supposed to provide CPR or intubation to everyone. I think part of this was because of the religious makeup of the population the hospital served, which was insistent that we “do everything,” even though we were always trying to convince the patients’ families to allow us to withdraw care.

    About half-way through the year, we were supposed to make the annual internship T-shirt, and all of us were supposed to send in entries for a contest to determine what would be printed on the shirt. A few of my entries were:

    “______ Hospital: fighting the good death since 1862″

    “______ Hospital: where DNR is a four-letter word”

    “______ Hospital: world-class medical care in a world-class city*.

    * If the person wearing this T-shirt is found unresponsive, they are not under any circumstances to be brought to _____ Hospital”

  4. windriven says:

    An old adage holds that everyone wants to go to heaven … but nobody wants to die.

    I hope that Dr. Novella’s excellent post this morning spurs a spate of other posts and comments about the future of health care and health care financing in this country.

    Unrealistic expectations among the general public is certainly a serious problem. Everybody wants grandma to live forever.

    Equally troublesome is the almost total lack of transparency in health care delivery prices and costs. Hospital bills, for instance, are ridiculous exercises in creative writing. The prices listed on hospital invoices (for instance $28 for a nasal cannula that the hospital buys for less than a buck) are only paid by poor schmucks with no insurance and a sense of moral obligation to pay their bills. Insurance companies are discounted down to normal and reasonable markups.

    Hospitals argue, rightly, that they bear a serious burden of uncompensated care (though why this should be disproportionately passed on to those without insurance never seems to be explained). In any event, where accounting and reporting are used to obscure rather than illuminate, trouble is sure to lurk. The financial services industry is the poster child for this verity.

    Perhaps Jann Bellamy could explore the impact of litigation on malpractice and products liability insurance, and on the secondary effect of defensive medicine. Dr. Crislip might discuss again the financial impact of simple infection control practices (i.e. routine handwashing, gloving, etc.). And I would really like to see (though probably well beyond the scope of SBM) a comparison of cost and quality between the VA system and a large hospital holding company.

  5. Scott says:

    As a society, however, we do need to balance what is optimal for individuals and what is best for society, which is really just about considering all individuals. To a degree we are dealing with a zero-sum game in that health care resources are being rationed and increasingly will need to be rationed. Spending health care dollars on futile care for the dying will take resources away from others who are more likely to benefit.

    Well said. Unfortunately, many people don’t believe that resources are in fact limited. I recall one conversation where I pointed out what the share of US GDP going to health care is doing, and that we just couldn’t afford to provide all possible care to everyone. The response? “I refuse to believe that. No civilized country can limit access to health care.” (Exact quote.)

    For myself, I agree with you. Given that health care resources are limited, IMO we as a society have an affirmative moral obligation to make sure we spend our communal resources wisely – meaning that we get the most bang for the collective buck. Cost-efficiency is a critical consideration which must not be swept under the rug. (Of course, anyone who’s paying for it out of pocket rather than communal resources can spend their own money however they like, regardless of how cost-inefficient it might be.)

  6. WilliamLawrenceUtridge says:

    The prices listed on hospital invoices (for instance $28 for a nasal cannula that the hospital buys for less than a buck) are only paid by poor schmucks with no insurance and a sense of moral obligation to pay their bills. Insurance companies are discounted down to normal and reasonable markups.

    Hospitals argue, rightly, that they bear a serious burden of uncompensated care (though why this should be disproportionately passed on to those without insurance never seems to be explained). In any event, where accounting and reporting are used to obscure rather than illuminate, trouble is sure to lurk. The financial services industry is the poster child for this verity.

    In part it may be because insurance companies are guaranteed to pay their bill (so you don’t have to subsidize the cost of non-paymenet in the cases of these accounts) and because of economies of scale similar to when you get a discount buying service packages in advance. You can amortize the cost of cathetar and care over dozens, if not hundreds of patients who pay through the same insurer. Meanwhile, you’ve essentially no guarantee someone without insurance will pay the bill, so that may be $1 for the cathetar and $1 for the average 27 people without insurance who don’t ever reimburse the hospital. Insurance companies probably have clauses built-in that they can’t be billed or subsidize these sorts of costs, only the direct costs of care and consumables. They’re for-profit companies after all, with a lot of money invested in ensuring they maintain healthy profit margins. Nobody is making that same argument for the uninsured. Probably part of the reason the US has such high healthcare costs, once you have a national system that tracks and reimburses universally you worry less about these things because they’re paid through taxes rather than individual billing.

    Just guesses. You take a couple courses on accounting and economics, you start to see how the appearance of pure evil might be masking sensible decision-making for the company involved (sensible as long as you ignore externalities, moral hazard and free rider problems – though I’m sure I’m mis-applying several economic principles).

    A really interesting addition to the SBM stable of occasional writers would be a medical economist that looks at issues like this. Scott Gavura’s analysis of what goes into the cost of developing a drug was very interesting, and again turns companies from charicatures of moustache-twirling villains into much more interesting characters with incentives and drivers we don’t necessarily see. A comparable figure for health systems overall would be interesting.

  7. cervantes says:

    Two essays on this general issue in JAMA today, including Why the Ethics of Parsimonious Medicine Is Not the Ethics of Rationing. Nothing really profound or new here, I would say. Everybody in the world knows this except the U.S. public and politicians. The rest of the civilized world has come to terms with it.

  8. Duggan – to clarify, I do not think that hospital bean counters with knowledge of when the reimbursement limit has been met should be making life-and-death care decisions.

    Rather, a review committee of doctors, nurses, lawyers, and ethicists with training and expertise in these issues could be available to quickly review cases in which the health care team and the family/patient are having differences of opinion. Many hospitals already have such ethics committees, but they could be specifically utilized to review cases of alleged futile care.

    A soft outcome would be for the committee to make recommendations – whether or not the care is truly futile, for example. I am familiar with cases in which the patient was literally dead, but the hospital was forced to continue care.

    A firmer outcome would be to empower such committees to make actual decisions, not just recommendations. For example, they could decide that further care is no longer ethical or appropriate. As it stands now, the default legal position is to do whatever the family wants, and it would take a court order to override their wishes (which no hospital wants to do). But imagine if the committee could determine care futile, meaning that the default is now to withdraw care and the family would have to get a court order to prevent it. We would then need to make sure that a legal structure was in place to allow for quick and just decisions in such cases. (If the legal battle takes even a few weeks, which is nothing, then the whole point of the exercise is largely lost.)

    Of course what I am describing is literally a “death panel.” It’s politically untouchable right now. We may have to wait for health care costs to utterly destroy our economy before such ideas will become politically palatable.

  9. weing says:

    I would propose a similar panel of experts to review care to determine futility. I would not advocate discontinuing care, however. The family would be notified that, as a result of their findings, further care is futile and no longer covered by Medicare and they are responsible for payment for further care, upfront. They can then decide whether grandma really wanted her dying prolonged.

  10. windriven says:

    @WLU

    ” You can amortize the cost of cathetar and care over dozens, if not hundreds of patients who pay through the same insurer.”

    I’ll bring my own catheter rather than share with dozens or hundreds of others. ;-)

    We aren’t talking about the difference between, say, list price for the uninsured and a 25% discount for big insurers. We’re talking about uninsured being billed at markups that would never pass muster in any other industry. It is part of the reason that so many uninsured file bankruptcy when faced with a major medical emergency. Then the hospital gets squat.

    Again, my argument is simply that hospital accounting and reporting should be transparent and should enlighten rather than obscure. Dark things happen in dark shadows far more frequently than they do in the full light of day.

  11. Scott says:

    I’m with weing. The distinction should not be between whether or not care is provided, but about who pays for it. Insurance companies, Medicare, and Medicaid would not be obliged to pay for any care such a panel advises against. But if the family wishes to pay out of pocket, that’s their prerogative.

    I see no justification for barring care on cost considerations, when the individual paying the cost is the one wishing to proceed with care.

  12. CrookedTimber says:

    A very interesting topic and discussion. I recently listened to the Radiolab short on this topic where they have a discussion with Dr. Murray and others. The breakdown of exactly which treatments doctors eschew was enlightening to me as a lay person. I also didn’t know CPR was THAT unsuccessful! If anyone is interested it is worth a listen.
    http://www.radiolab.org/blogs/radiolab-blog/2013/jan/15/bitter-end/

  13. Weing and Scott – two issues.

    In many cases you are right and it goes without saying – you can pay for private care. But for the vast majority of people this is a distinction without a difference because we are talking about hundreds of thousands or millions of dollars worth of care. This also creates an uncomfortable situation in which families would have to pay up front or put money in escrow – it won’t help anyone if they wrack up millions in care then file bankruptcy.

    However, you can also argue that beyond a certain point futile care in unethical, even when you put the costs aside. Doing invasive procedures to someone that have no possibility of helping them, some consider to be abuse.

    The question is – can and should doctors refuse to deliver futile care on ethical grounds (again, costs aside). This is tricky. We always prefer to get the family on board so that everyone is comfortable, and this is usually the case. The exceptions can be serious problems, however.

  14. pharmavixen says:

    The whole death panel thing was part of a massive and organized campaign to discredit single-payor health care, the “socialized medicine” used by all industrialized countries in the world except the US. Here in Canada, we were surprised to learn from American Republican commentators that we had death panels, a widely-circulated falsehood easily discredited by even a cursory google.

    A dispassionate discussion of end-of-life care is impossible in an environment where health care executives are reaping profits in the billions while people in Europe and Canada enjoy comparable, if not better, health outcomes at considerably lower costs.

  15. weing says:

    “This also creates an uncomfortable situation in which families would have to pay up front or put money in escrow – it won’t help anyone if they wrack up millions in care then file bankruptcy.”

    What do they do with student loans in these situations? They are not wiped out by bankruptcy.

    I agree, it is unethical to deliver futile medical interventions. I don’t consider it “care” in these situations. Doctors are in a bind as they may be accused of abandonment. Usually we have to give the family 30 days to find another physician, so the waste would continue anyway. We need safe harbor laws. Doubt if we’ll get them.

  16. Calli Arcale says:

    windriven:

    Hospitals argue, rightly, that they bear a serious burden of uncompensated care (though why this should be disproportionately passed on to those without insurance never seems to be explained).

    There is a very simple reason. It’s not a good one, but it’s all there is. It’s because there is no one else they *can* pass it on to, other than charitable donations. EMTALA obligates them to provide critical care to the indigent. Insurance companies do not want to overpay and have the finanical clout to negotiate specific rates. Government funding simply ain’t gonna happen, outside of Medicaid and Medicare, which operate like insurance anyway in that they also will do everything in their power to avoid being billed extra just because some poor schmuck got run over outside the hospital and had to be stabilized free of charge. That leaves only two places the money can come from: charitable donations and fee increases for those who can afford to pay (if only barely) but lack the collective bargaining power of an insurance company.

    This isn’t good, but it’s inevitable under the current system.

    I like your suggestions for exploring the cost problem more. Right now, the system is so hopelessly inconsistent and obfuscated both intentionally and through incompetence that it’s really impossible to get a useful baseline of how much things *should* cost. This should be fixable, but I think it would take government intervention and some very serious discussion that doesn’t devolve into fear of death panels. And consequently, I am doubtful it’ll happen anytime soon. Hopefully individual hospitals will take it upon themselves to get more organized, but I am not optimistic of that either; if they haven’t by now, what will motivate them to do so in the future?

    One thing that I think is often overlooked in the cost question is the cost to the patient. The cost of futile care isn’t paid only by the hospital or the community or the insurer. It is also paid directly by the patient, in the form of co-insurance, skilled nursing care outside of the hospital that excedes what Medicare will reimburse, and so forth. This can come to quite a large sum. It is not that unusual for end-of-life care to completely deplete someone’s estate — and to do so well before they die. If you wanted to leave an inheritance for your kids, it may not be possible if you (or your kids, while you’re incapacitated) demand resuscitation whenever possible. You may even leave them with debt. And then there is the question of expending all of your resources before you die — what will you continue to live on when all your funds have gone to your medical care? If you are resuscitated, but do not fully recover, and must now move into a nursing home, the normal path is to expend all of your financial resources so that you now qualify for state assistance. You will be on welfare. And at this point, you will HAVE to be in a nursing home, since leaving the home will terminate your medical assistance money. Our nation has a lot of severely overcrowded nursing homes, many with deplorable conditions, but if you can’t afford assisted living, there won’t be any alternative. And this problem will only get worse; the current structure for financial assistance of the elderly drives increasing use of inadequately funded and badly run nursing homes. Even people who could live with their children may have to stay in the homes, because their assistance ends if they leave and their children can’t afford to give them the care they need on their own.

    This was the future my grandfather dreaded, when he decided that his symptoms of pancreatic cancer were not something he wanted to follow up on. He didn’t even want a biopsy to diagnose it. He didn’t think it was worth it, and he dreaded the idea of becoming a burden to anyone. No autopsy was performed after he eventually died under hospice care, but the progression was consistent with untreated pancreatic cancer, and he went with grace and dignity in the end. Perhaps relevant to this article, he was a general surgeon who had worked in the military and a small-town hospital, and had of course seen his share of death. What he chose wouldn’t be the right choice for everyone, but I am convinced it was the right choice for him; he was very content in his decision. It isn’t the choice being made for my maternal grandparents, but their situation is more complex. They have not had any clearcut medical events that would lead the decision one way or the other. Just a slow deterioration. Where is the line between relieving their discomfort by treating their conditions and extending their agony by treating their conditions? Hard to say. But I do know it’s been very expensive; the family is even looking at selling their house to pay for it.

    So when a doctor says “it is too expensive to keep treating you”, it isn’t just the cost to society. There is the cost to the patient as well, and we need to stop ignoring that.

  17. daughternumberthree says:

    With two parents, two in-laws, and many aunts and uncles currently in their early 80s and many in various stages of decline toward death, these questions are on my mind often. A few scenarios:

    An aunt of mine, in her late 70s, was diagnosed with pancreatic cancer last October. She and close family decided to do a course of chemotherapy, which had no effect. But it did cost Medicare/all of us some amount of money and cause her unnecessary discomfort, thought it “bought” her no more time. She then elected to do hospice at home and died a week ago. I know it is easy for me to say, but if it had been me with that diagnosis at her age (and knowing even the limited amount I know about her health history of smoking, etc.) I would have said no to any treatment.

    My father-in-law was felled by a severe stroke at 81. Until that time, you would have thought he was 65 at most, and he was very active even for that age. Despite physical and speech therapy, he has not been able to recover to anywhere near his former health. Particularly, his short-term memory is bad enough that he can’t watch a television show and follow the plot. Recently, his memory has gone downhill even more rapidly, he is disoriented and beginning to not remember names and faces, and has become incontinent. After a week in the hospital, he is now back in a rehab hospital, confused about why, unable to enjoy even the minimal social interactions that setting provides. Where is the dignity that I know his pre-stroke self would have wanted?

    My own parents face a range of huge physical challenges, but have their mental faculties and no immediate death-causing threats, such as cancer. But their world has been squeezed down to their small home and the doctor’s appointments they have to struggle to get to.

    When something acute does happen to one of them or to my father-in-law, why is there any requirement to treat it at all? How can we begin to talk about this as families? I feel terrible bringing it up and would hugely welcome the so-called “death panels” that were once part of the Affordable Care Act, because it would make us talk about it.

  18. Brandt says:

    I think that it should be “advance directives” and not “advanced”.

  19. jmb58 says:

    I wonder about the validity of the idea that hospitals mark up drugs and equipment 20x or more. As a physician I have sat on various committees at various hospitals and I don’t see it. I know my current hospital doesn’t do it and charges close to cost. The uninsured actually get a discount. I’d be interested in some objective data.

    I have certainly seen my fair share of futile or near-futile care. Many times families want a surgery performed but have a change of heart after seeing their loved one in the ICU for a few days. I try to paint a picture for them, but it is difficult to appreciate until you see your family member with all the machines and tubes.

    The resource issue is real. Blood products are a perfect example. I currently work in a small city and I have given all the blood available (more than 30 units) to one trauma patient I knew had almost no chance of survival.

    On the other hand, my partner had a teenage trauma patient recently that I helped care for. I thought the patient had no chance of survival, much less a meaningful recovery. Had I been on a hospital panel I would have voted to deem the care futile. The patient has since made an amazing recovery to near normal function. One of the most surprising cases I have ever seen. But it made me wonder, what chance of recovery is worth the effort and resources?

    A futility panal would certainly help with the health care resource problem, but there would be the rare (maybe extremely rare) patient deemed futile that would have recovered. I think I can accept that. Thoughts?

  20. windriven says:

    @pharmavixen

    I would agree with your assertion. Americans of all political stripes suffer delusions about the quality, cost and efficiency of the American system and inchoate fears about alternatives. Our federal government has earned some skepticism about its ability to manage large programs effectively and efficiently. But that is a theoretical fear. That the current system is marginally effective and grossly inefficient is demonstrable.

    On the other hand, back in the 80s I used OHIP* as it then existed, anecdotally in speeches I gave to industry groups about the likely impact of DRGs** and steps that could be taken to mitigate unwelcome effects. At that time there were more MRI imagers (or CATs, its been a long time and the details are foggy) in LA county than in the entire nation of Canada. I related the story of a hospital in Toronto that rented its scanner out for veterinary use in off-hours. A story was related in (as I recall) The Sun newspaper about a man who needed a scan waiting some ridiculous time for a slot while his dog was scanned almost immediately. The upshot was that the hospital stopped renting out the scanner. Oy.

    In any event, the path to a single payer system in this country will be arduous and very, very long. My personal view is that we should shunt some Medicare patients to the VA system (with appropriate bumps in funding) and compare and contrast cost and quality with similar populations treated in private hospitals. But while that might be illuminating it only hints at one possible solution.

    *Ontario Health Insurance Program
    ** Diagnosis Related Groups, a payment scheme adopted by Medicare in the early 80s

  21. DugganSC says:

    @Steven:
    Thank you for addressing my comment. One would certainly hope that the doctors wouldn’t be influenced by the bean-counters. But, as has been mentioned on other entries in this blog, physicians face a lot of outside influences from drug companies to hospital boards, and not everyone will have the strength of will to tell the hospital accountant to take his cost/risk estimate and shove it.

    @Calli Arcale:
    Interesting. I hadn’t thought of it in that sort of risk analysis. I will say, though, that if they’re padding to account for expenses they can’t account for elsewhere, they may be doing a bit too good of a job, given the record profits some of these hospitals are showing. Honestly, it kind of reminds me of the RIAA bit where they claimed billions in lost profits from pirating to justify their witchhunt while they showed record profits. Hmm… you know, there might be a strong parallel over that. I wonder how much of their “lost money” from treating emergency poverty cases gets racked up under the inflated chargemaster values rather than something more fair like the Medicare values much like how the RIAA claimed their losses based on the idea that every person caught pirating a CD had stolen hundreds at an inflated price that no one ever paid…

    @jmb58:
    Take a look at http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/6/. Unfortunately, they chose pictures of everything but the overcharges they’re citing from the guy’s bills. Hopefully, these guys are the exception. Unfortunately, I know that the local hospital (which has bought up every other medical practice in the area and is currently fighting to only accept insurance from the company tied to them, allowing them to control both sides of the equation) has been caught doing similar marking up. And if you follow that article, they cite several other cases, many of well-known hospitals. Part of the issue is that these are the “chargemaster” values, which is many times what insurance companies pay, and generally a hundred to a thousand times what the Medicare value is, so most people never see these charges, only the people least able to pay them.

  22. pharmavixen says:

    @ Windriven

    Your proposal for some evidence-based research into the relative costs of different payment systems would help defuse arguments from those naysayers who protest that evidence for healthcare payment reform from Europe and Canada isn’t applicable to the US. But the real problem is the enormous profitability of the US system, and in turn the resources that the people who reap these profits have to protect the status quo.

    An interesting bit of arithmetic: the OECD 2010 comparison of health care costs in OECD countries finds that Americans spend $8,233 USD per capita, compared with $4,445 for Canada. (The OECD average is $3,268, but I’m making the assumption that a comparison with Canada is more pertinent because of cultural similarities, and we share an economy as well as a continent with you guys.)

    So $8233-$4445 = $3788 USD, the difference between Canada in the US in healthcare costs. I’m assuming the difference in 2013 is similar to these 2010 numbers, and multiply by the US population currently, 315,404,403 (from the world population clock as of Feb. 27, 2013 @ 18:12 UTC).

    That’s a total of $1,194,751,878,564 USD in reduced costs per annum. No more profits in the tens of millions for individuals, and the cost reduction doesn’t necessarily come from front line health care since other studies have found that a large proportion of these cost differences are administrative. (Granted, your drug costs are also higher, so reform in that area would also be needed.) And the resulting healthcare system covers everybody.

    Here’s the OECD document my numbers come from: http://www.oecd.org/health/health-systems/BriefingNoteCANADA2012.pdf

  23. Quill says:

    Physicians are far more likely to have made advanced directives – Murray cites an article indicating that 64% of physicians compared to 20% of the general public have made advanced directives (instructions for what to do and not do if they are gravely ill and unable to communicate their desires).

    I urge everyone to have advance care directive (or whatever the precise term is in your state) for yourself. Preferably yesterday. Most hospitals have fill-in-the-blank forms that allow you to specify your wishes especially and including end-of-life care. You may never need it but if you do it will spare your loved ones, friends and society a world of hurt and pain if they know your wishes before you are unable to tell them.

    Do it to be kind to yourself, knowing your wishes will be known or do it to avoid a “death panel” selling you to The Board of Soylent — matters not to me, but please do it.

  24. WilliamLawrenceUtridge says:

    I’ll bring my own catheter rather than share with dozens or hundreds of others.

    Pft, that seems excessive. I’m sure they wash it real good :)

    We aren’t talking about the difference between, say, list price for the uninsured and a 25% discount for big insurers. We’re talking about uninsured being billed at markups that would never pass muster in any other industry. It is part of the reason that so many uninsured file bankruptcy when faced with a major medical emergency. Then the hospital gets squat.

    …thus forcing hospitals to raise the cost of goods and services to cover the lost costs. It seems like a vicious cycle (and one that, as a Canadian, seems easily solved by having a national health care system). From an economic perspective, it seems horribly, horribly justified (which is one of the reasons why economics is known as the “dismal science”).

    Again, my argument is simply that hospital accounting and reporting should be transparent and should enlighten rather than obscure. Dark things happen in dark shadows far more frequently than they do in the full light of day.

    Again, as a Canadian I don’t know what the American system is like (my references are House, ER and Scrubs). Is it genuinely so opaque, so secretive, or is it more that decisions are made in-house and thus don’t tend to show up on the internet? Could you get the answer if you asked the right person? Or would they refuse to tell you? And would the answer be meaningful or inflammatory? What looks horrifying on paper can be the result of the cold but necessary calculations needed to keep a business viable. People decry the presence of sponsors at scientific conferences, but the reality is the Annual Meeting of Foo Studiers International may very well not happen at all if Foo, Inc. didn’t kick in a couple hundred thousand bucks (which they wouldn’t kick in if they couldn’t put up a very large banner saying, essentially, “BUY FOO, FROM FOO, INC!”).

    @daughternumberthree
    I had an idea for this – implanted poison capsule that is reset on a day-to-day basis. If you ever forget to reset the timer, it releases the poison and you die peacefully in your sleep (I haven’t identified the poison yet). You establish various controls (the ability to permanently disable it in the case of some accident or some such, it is automatically turned off if you enter a coma due to trauma, power of attorney to turn it off in certain circumstances, etc.) but otherwise – your conscious, thinking, coherent self makes a decision that essentially peacefully ends your life when you are no longer conscious, thoughtful and coherent enough to make the decision. The sad part about dementia is, when you are in a position where you would want to say “that’s it, I’m done, I’m ready to die” you can no longer make that very decision.

  25. Scott says:

    @ jmb:

    I see it every time I get a statement from my insurance company describing the charges for a particular procedure. The price charged by the hospital/lab/office is shown, as is the price actually paid (or passed on to me via deductible, as the case may be). The difference is normally around a factor of 10.

    If the price charged were even in the ballpark of costs, the business in question would be losing huge amounts of money on each interaction. Since they are still operational, this is not happening. So, the prices must indeed be massively marked up.

    I suppose it’s conceivable that *nobody* actually pays them, which just raises the obvious question of why they make up a completely fictional and meaningless number. But the markup is definitely there IMX. (Or IMA, as you prefer – In My Anecdote.)

  26. mousethatroared says:

    Quill “I urge everyone to have advance care directive (or whatever the precise term is in your state) for yourself. Preferably yesterday. Most hospitals have fill-in-the-blank forms that allow you to specify your wishes especially and including end-of-life care.”

    I tried the form from our PCP office, but they didn’t have a box for “Zombie Reanimation”. :(

    In all honesty I did look at such a form, but it was very confusing…I felt like I was making a choice between “really I don’t want to bother anyone, just let me die if I have anything worse than a hangnail” or “Keep me alive by any means possible regardless of cost or negative consequences.”

    Really, I’d rather just say “Listen to my husband, he understands what I want.”

  27. Quill says:

    “Really, I’d rather just say ‘Listen to my husband, he understands what I want.’”

    Jann Bellamy can certainly provide better comments, but as I understand it, this may not be legally sufficient depending on what state you live in. Your wishes as expressed to your husband may or may not count in terms of what a hospital is obligated to do or not do. This also assumes your husband is capable of speaking with doctors about these things, something that might not for example happen in a bad car accident involving both of you.

    Most hospitals and many PCP places will have someone in place to explain things to you or refer to you a free source of good information (again it depends on what state you live in.)

    Many people don’t think about these things until they can’t and then the burdens –legal, medical, moral and ethical– fall to someone else. One of the reasons I urge people to get this done is that I was one of those people upon whom a burden fell and it is something I wish on no other person.

    I do agree, though, that the lack of Zombie Reanimation as a preferred wish is very thoughtless. ;-)

  28. mousethatroared says:

    Those are good points Quill. I guess I am letting my paperwork phobia get in the way of making the right decision. I should check with one of our hospitals and see if they can explain things. Thanks for the information.

  29. Calli Arcale says:

    On top of the “husband might not be around to communicate your wishes” problem, this is even true of advance directives. Advance directives are great — but only if people know about them. If you are walking around downtown and get hit by a bus, the EMTs who respond aren’t going to check your ID, contact your lawyer, and determine the contents of your advance care directive before deciding whether or not to administer CPR. They’re just gonna start the CPR and worry about the paperwork later. For this reason, some folks have taken to having it tattooed on their chests. ;-)

  30. mousethatroared says:

    Calli Arcale “They’re just gonna start the CPR and worry about the paperwork later. For this reason, some folks have taken to having it tattooed on their chests.”

    I’m pretty sure having an advance directive tattooed on my chest would kill the mood in romance situations.

  31. Harriet Hall says:

    In addition to the advance care directives, we have signed durable powers of attorney for health and finances. My husband will be able to make those decisions for me if I am incapacitated, and my daughter if we are both incapacitated.

  32. Narad says:

    I have already seen enough people I have known opting for absolutely futile care to know that I am not going to do that. In all cases these people were religious (some traditionally and some more “alternatively”) and believed in an afterlife of some kind–and yet they pushed hard for pointless intervention because they would not relinquish “hope”.

    I would be cautious in trying to implicitly denigrate religious motivations. I had a friend who was an observant Jew who was diagnosed with colon cancer that had metastasized to his liver. Hospice was recommended. Being young, however, with a newly started family, he opted for aggressive chemo. The only strategy I can imagine here would be shrinking the tumors to the extent that the colon could be resected and hoping to hang on long enough for a liver transplant. He was, technically, not a goses, but pikuach nefesh is strong stuff.

    Sadly, he did not make it to the start of the chemo, and a not-insubstantial part of the world is the lesser for it.

  33. Narad says:

    I think that it should be “advance directives” and not “advanced”.

    I will again put on my editorial beret. There is nothing wrong with adjectival “advanced.” Indeed, one could argue that it is superior to “advance” in this context, as the action by definition has already occurred, in the past.

  34. windriven says:

    @Calli Arcale

    Three cheers for your grandfather!

    The path to solving the healthcare problem is so rocky and arduous that I despair of it every being resolved. Interest groups always throw up bogeymen: greedy doctors, rapacious insurers, death panels, pushing grandma off a cliff. Politicians, gutless to the core, nibble at the edges and then proclaim victory. It is an unpopular stance but that is even how I view Obamacare; all sturm und drang with precious little in the way of real reform.

    The reality is the reforming healthcare in the US is monumentally complex. It will take some very new thinking and that is a rare commodity in public circles. And to be perfectly honest, lots of people are getting a nice lick on the ice cream cone that represents 20% of GDP. Reducing that to, say, 12% means a lot less lick. That won’t happen without one hell of a fight.

  35. windriven says:

    @pharmavixen

    “But the real problem is the enormous profitability of the US system, and in turn the resources that the people who reap these profits have to protect the status quo.”

    Bingo. Couldn’t agree more.

  36. windriven says:

    @WLU

    “I had an idea for this – implanted poison capsule that is reset on a day-to-day basis.”

    Interesting. I played with writing a short story using a similar theme; my idea was a device rather than a capsule and the delay was 72 hours rather than 24. I’d opt for it in a heartbeat.

    And yes, opacity is a real problem even for hospital CFOs. Hospitals are like any other large business – they are unwieldy and reporting and controls often evolved over time a piece here and a piece there … then just sort of became SOP while the complexity of the institution mushroomed. I am reminded of the Three Stooges episode where the boys are working as plumbers and start adding stems of pipe to reroute a simple leak until the basement is a maze of pipes and one leak has become a flood. Bottom line is it is often difficult to understand where cost contributions originate much less how to control them.

  37. windriven says:

    @Narad

    ” There is nothing wrong with adjectival “advanced.” Indeed, one could argue that it is superior to “advance” in this context,”

    And one could argue that it is markedly inferior to “advance” in this context. But let’s not go there! I’m afraid we’ll attract the grammar freaks and this will evolve into a Harriet Hall – style* blood bath where the any notion of end of life care is lost in a paroxysm of projectile bile-spewing ;-)

    *With all due respect to Dr. Hall who deserved none of the invective that was directed her way.

  38. mousethatroared says:

    WLU – “I had an idea for this – implanted poison capsule that is reset on a day-to-day basis. If you ever forget to reset the timer, it releases the poison and you die peacefully in your sleep”

    WLU – You just killed about half the artists I know. You’ll end up living in world of perpetually sunshiney people decorated with kitten and clown paintings and it’ll serve you right. :)

  39. Brandt says:

    @ Narad & WIndriven

    “I will again put on my editorial beret. There is nothing wrong with adjectival “advanced.” Indeed, one could argue that it is superior to “advance” in this context, as the action by definition has already occurred, in the past.”

    “And one could argue that it is markedly inferior to “advance” in this context. But let’s not go there! I’m afraid we’ll attract the grammar freaks and this will evolve into a Harriet Hall – style* blood bath where the any notion of end of life care is lost in a paroxysm of projectile bile-spewing”

    As an elder law attorney who has prepared many advance directives and no advanced directives (they tend to be quite basic) I am not making a comment on the grammar, which is no doubt correct, but rather pointing out the correct terminology for a set of specific legal instruments that are referenced in this post.

  40. windriven says:

    @Brandt

    Domo arigato.

  41. Narad says:

    pointing out the correct terminology for a set of specific legal instruments

    Hey, I didn’t start it. And I will drop it. But here I get to say 22 CFR 72.30 (yes, I know, just the title; I can find state law). Legalese varies so wildly in decrepitude of terminology that it’s hard to assign categories of “correct,” which I say as someone who worked in a text-manipulating position for the empire of Joe Flom for seven years. It’s the semantics that count.

  42. WilliamLawrenceUtridge says:

    Interesting. I played with writing a short story using a similar theme; my idea was a device rather than a capsule and the delay was 72 hours rather than 24. I’d opt for it in a heartbeat.

    Just don’t link it to your heartbeat, no point having a poison capsule that goes off when your heart stops…

    To add some details, the timer would expire (ahahaha) after more than 24 hours; I’d even venture a week. There would be a warning signal, some sort of vibration, chime or perhaps mild shock. Perhaps the poison is kept contained by a constant charge, and when the battery runs down, it is released. In this case, you substitute charging the battery (with a 3-7 day lifespan) for resetting the timer. It would need to be relatively long-lived, with some sort of obvious indication it had been activated (perhaps the capsule itself deflates). The point is, you build in safeguards such that it’s very easy to ensure it stays off but still serves its purpose when the cognitive decline is sufficiently advanced. Plus, since it’s “armed” through conscious decision, it’d probably have some sort of legal defensibility.

    Naturally the possibilities for fiction are nigh-endless, an extremely compelling plot device for murder or thriller stories. Mash it up with a zombie apocalypse and you’ve got large numbers of people dying when the power goes off, creating the opportunity for reanimation from inside your safehouse.

    You just killed about half the artists I know

    Hm…is there any way to substitute “hippies” in that phrase? I just finished Science Left Behind and it got my dander up for antivaccinationists. And hippies, obviously…

    And yes, opacity is a real problem even for hospital CFOs. Hospitals are like any other large business – they are unwieldy and reporting and controls often evolved over time a piece here and a piece there … then just sort of became SOP while the complexity of the institution mushroomed. I am reminded of the Three Stooges episode where the boys are working as plumbers and start adding stems of pipe to reroute a simple leak until the basement is a maze of pipes and one leak has become a flood. Bottom line is it is often difficult to understand where cost contributions originate much less how to control them.

    Actually, most large businesses are incentivized to reduce costs (or raise profits). Massive amounts of time and money go into private industry becoming more streamlined with fewer unnecessary controls. The ideal profit-driven industry produces a product that is wanted at a cost that is affordable.

    Curiously, this does seem to break down in my mental caricature of a hospital. Possibly because they represent one of those hideous hybrid creatures that combines the worst of the private with the worst of the public. I still go back to a federal health care option going at least a long way towards addressing many of these concerns. But perhaps that is utopian.

  43. Brandt says:

    @ windriven – do itashimashite mr. roboto

    @ Narad – I imagine that you performed a google search for “advanced directive” which brought up the correct term “advance directive” but you chose to search instead for “advanced” which even then returned hits for “advance” requiring you to go through several pages to find a page with the term in a federal regulation (which you probably know is not law and is most likley in error). At this point you very well know what the correct term is and I’m sure Joe Flom did as well. You may have even looked up the difference between the adjectives “advance” and “advanced” which makes it all the more clear. And you said you would drop it – which you didn’t – and now we have all this nonsense at the end of this post.

  44. JJ Borgman says:

    Utopian, William?

    I’ve long regretted our collective inability to pragmatically face our mortality and, to a person, end-of-life issues.

    Some salient considerations are pointed out in this post and subsequent comments. Universal healthcare, or shall I say non-profit healthcare, is part of the solution to rising healthcare costs. So is lifestyle education and training. Sadly, we will not deal sufficiently with mortality until we have been overwhelmed by our failure to do so.

    I give it a generation, maybe two, until there is a broad push for death with dignity and other actions that will curtail this current state of medical affairs.

    I do not think it is or can be a utopian construct for very long.

  45. windriven says:

    @WLU

    “Actually, most large businesses are incentivized to reduce costs (or raise profits).”

    Yes, I’ve run several. And indeed American hospitals are adept at raising profits. But the structure of healthcare reimbursement doesn’t always mean that is achieved by reducing costs.

    One of the hardest things to do as an executive is to get high quality information in a large organization. Top managers of large firms have to accept summary information; none of us has the time to drill down to bedrock in every department. You incentivize middle managers … but be careful what you ask for. By that I mean developing incentive programs is often an exercise in unintended consequences.

    ” The ideal profit-driven industry produces a product that is wanted at a cost that is affordable. ”
    You assume a free market economy. The healthcare system in the US is not in any sense of the words a free market.

    ” I still go back to a federal health care option going at least a long way towards addressing many of these concerns.”

    I don’t necessarily disagree. But the devil is in the details. Simply moving to a federal system does not guarantee a better system. In fact no one in the US is even suggesting a federal system (e.g. UK model). The closest they come is a single payer system that would still allow most hospitals to be private enterprises.

  46. Chris says:

    WLU:

    Hm…is there any way to substitute “hippies” in that phrase? I just finished Science Left Behind and it got my dander up for antivaccinationists. And hippies, obviously…

    I just put that book and Chris Mooney’s latest book on the Republican brain on the “for later” shelf on my library account. Neither is available, but I am trying to get through Mutants, and A Cabinet of Medical Curiosities is in transit for me to pick up. I do want to finish reading them first. (I just finished The Violinist Thumb, and both of those books were mentioned).

  47. rmgw says:

    And at the other end of life, has anyone else noticed a divide between our (genuine) delight and congratulations over the announcement of a friend or loved one’s pregnancy or birth, whilst a small voice inside says “What sort of world will the new arrival have to deal with?” “Shouldn’t people be trying to cut down the greedy, consumer-society numbers?”. What we say and do in these situations of birth and death have more to do with stereotypical social reactions than with hard facts (whatever they are) . Not surprising society finds it hard to reconcile theory and practice.

  48. BillyJoe says:

    Scott,

    “Of course, anyone who’s paying for it out of pocket rather than communal resources can spend their own money however they like, regardless of how cost-inefficient it might be”

    That sounds like a double standard to me. One for the rich and one for the poor. In my opinion, it shouldn’t matter. One rule for all. Besides, those paying for it out of their own pockets, are also using up resources in hospital beds, medical manpower etc, that could be better used elsewhere. I don’t think this is justifiable.

  49. mousethatroared says:

    WLU – No, you can’t substitute hippies for artists* (mock frown). There is a logic problem there. If all hippies think they are artists, But many good artists are not hippies, then will killing half the artist reduce the number of hippies?

    Actually my point was related to depression (At the time it seemed rather obvious, but in retrospect, perhaps it was a leap). That it sounds like your default to death system would make suicide incredibly easy for folks suffering from depression. Also (if my comment about kitten and clown paintings was equally opaque) many of those folks are valuable to me and society and I’d rather we try to keep them around until their mood lifts or they get treatment.

    *From my experience artists are no more inclined to be anti-vax than the general public, but then many of my friends are still working in technology, so they are not the crunchy granola -livng off the grid types you may be thinking of.

  50. BillyJoe says:

    Australia spends 9.4% GDP on health, and no one goes bankrupt paying medical bills.

    Example:
    In the last few years, my mother, who is without private health insurance, has had a left THR, and resection of colon cancer, and has just had a call-up for a right THR (her colon cancer is probably terminal because it was locally advanced, but she is limited to a wheelchair because of severe right hip pain, so they are doing this for pain relief for the last few years of her life). She has not bad to pay a single cent for this care.

    So, I don’t know what is wrong with health care in America, or how to fix it, but it is definitely broke.

  51. mousethatroared says:

    rmgw
    “has anyone else noticed a divide between our (genuine) delight and congratulations over the announcement of a friend or loved one’s pregnancy or birth, whilst a small voice inside says “What sort of world will the new arrival have to deal with?” “Shouldn’t people be trying to cut down the greedy, consumer-society numbers?”. ”

    Nope, I never noticed that. In fact, when I hear that someone expecting, I’m just happy for them, “greedy, consumer-society” never enters my mind.

  52. BillyJoe says:

    On death.

    I believe that deep down, nobody really believes in god or an afterlife. Otherwise, why the frantic struggle to keep living if dying means going to Heaven? I have seen deeply and devoutly religious people panic at the thought of death. I believe that people believe in god and heaven on a very superficial level but, hit them with a real life and death situation and their deep unbelief in their superficial belief is immediately exposed.

    Of course, I speak from personal experience as a previously devout catholic who did once face a situation where my life was about to end until it was fortuitously saved by seemingly the only person in a room full of friends who actually knew what to do, whilst everyone else looked at me with shocked and horrified expressions as they realised that they were about to witness the death of this person who was turning deep blue right in front of their very eyes.

    I now no longer believe in god or an afterlife with the same conviction with which I don’t believe in faeries and hobgoblins. And my fear of death is actually less as a result (I don’t even practise preventative health, except by default). In my opinion, the most panicky thought of all is that of living for all of eternity, with the full realisation of what that actually means. However, I would like to live a fair bit longer….so far so good. :)

  53. windriven says:

    @BillyJoe

    “And my fear of death is actually less as a result”

    This is an interesting phenomenon that I have noted as well. I cannot think of a single atheist friend who dreads death. I wonder if anyone has studied the relationship between religiosity and necrophobia?

  54. DevoutCatalyst says:

    I doubt it breaks down that simply. From an abstract,

    “Based on previous work and the results of factor analysis, 8 fear of death dimensions are proposed: fear of the dying process, fear of the dead, fear of being destroyed, fear for significant others, fear of the unknown, fear of conscious death, fear for body after death, and fear of premature death.”

    I can see fear in myself based on my circumstance as caregiver for someone who has few pleasant options for his remaining life were I to leave just now. Once that impediment is gone, I fear only pain.

    I know born again folk who show no fear of death, seem to welcome it. Just got off the phone last night with a Jehovah’s Witness friend whose mom passed Friday and he was distraught. It felt good ministering to a religious person, it’s the atheist thing to do.

    I think a clear sense of atheism does give solace. Just not yet is all I ask of dog.

  55. mousethatroared says:

    My athiest father was much more in denial about and fearful of his death than my devote Catholic father-in-law. Possibly confirmation or selection bias might be at play here.

    But all in all, I’m not really sure how helpful it is to look at anecdotal or even solid evidence that determines whether christians or atheists have a greater tendency to fear dying. An individual’s life experiences and biology probably encompass a lot more than being christian or athiest. Why not look at whether accountants, engineers or teachers fear dying more?

  56. BillyJoe – I don’t see any problem with letting people pay privately for extra services that society is not willing to provide. This is not using up resources if they are paying for it (it’s not like the system is limited by hospital beds). In fact, private payers help subsidize the system so that it is more affordable for everyone else.

  57. Janet says:

    @Narad

    “I would be cautious in trying to implicitly denigrate religious motivations. ”

    I don’t see that I did that at all, especially the “denigrate” part. Religious belief is what it is, I accept that. I studied Anthrpology and know a bit about the human propensity for religion. My comment was offered as an explanation, not as denigration.

  58. Calli Arcale says:

    BillyJoe:

    I believe that deep down, nobody really believes in god or an afterlife. Otherwise, why the frantic struggle to keep living if dying means going to Heaven?

    Well, if we look just at Christians, most of them believe that you actually are guaranteed only an afterlife. You are *not* guaranteed Heaven. So one fearing death might be less suffering a crisis of faith than a guilty conscience, if you follow my meaning. Many Christians resolve the question of how a just God would permit evil to exist by concluding that since justice isn’t served here, it must be served in the afterlife instead. This is actually a very popular philosophy in many religions, and Christianity certainly didn’t originate it. The Egyptians believed your heart would be literally weighed against the feather of truth (Ma’at). If it was heavier, it would be thrown to Sobek, the crocodile-headed devourer of souls. Buddhists and Hindus believe in reincarnation, with your status in the next life determined by how you behaved in this life. If you’ve behaved badly, your next life will be unpleasant in order to atone for that.

    And then there is always the selfish aspect of not wanting to leave the world you know and love, and the mystery of exactly how excruciating this whole dying process is going to be, and a frustrating lack of specificity for how the whole afterlife thing works out in most Scriptures. The play “Our Town” reflects one school of Christian thought on the topic — that we don’t actually go to Heaven when we die, but at the Second Coming. Until then, we just have to wait around in death, so there really isn’t a good reason to rush through life. And even if you believe you go straight to Heaven as long as you’ve done the rituals, a lot of denominations require that you strive to live a long and healthy life, and consider suicide such a serious crime that it would bar you from Heaven entirely. So you can’t really take a person’s reluctance to die as evidence of poor faith.

    The idea of using a dying person’s fear as evidence of their lack of faith is, to me, as offensive as the old expression that “there are no atheists in foxholes”. Besides, fear isn’t rational anyway. I’m terrified of spiders. Even teensy ones. This is totally irrational and has nothing to do with my actual sentiments towards the creatures, which I consider to be tremendously essential to the environment. But a part of my brain just wants to gibber in a corner whenever it sees them.

    In the current season of Doctor Who, they ran a really awesome episode called “A Town Called Mercy”. It was done as a Western, and awesomely, they filmed it in Almeira, Spain, in a fake Western town that has been standing for decades, used for all the Sergio Leone films. It was great. But . . . spoilers ahead. I’ll try to keep them mild. The town is harboring an alien named Kahler-Jex. He’s rigged up electricity for the town (using his tiny spaceship as a generator) and has been acting as their doctor, saving their lives during a cholera outbreak. And now an alien cyborg is hunting him down for war crimes, holding the entire town hostage until they give him up. He has a conversation with the Doctor in which he explains his reluctance to give himself up, even though it would save the town:

    “In my culture, we believe that when you die your spirit has to climb a mountain, carrying with it all the souls you wronged in your lifetime. Imagine the weight I will have to lift; the monsters I created, the people they killed. Issac. He was my friend. Now his soul will be in my arms, too. And you see now why I fear death.”

    I’m not sure how apt it is to the conversation, but it was a really cool episode, and this particular exchange had some awesome acting in it. I highly recommend it.

  59. Calli Arcale says:

    DevoutCatalyst:

    It felt good ministering to a religious person, it’s the atheist thing to do.

    I hope someday we as a species will reach the point where we all realize that this is the *human* thing to do. To minister to one another, regardless of our affiliations or personal characteristics.

  60. DevoutCatalyst says:

    I agree, Calli.

  61. Scott says:

    @ BillyJoe:

    I suppose you could call it a double standard. But the only other alternative is to say “this is too expensive to spend communal resources on, so we won’t allow you to spend your own money on it either.” Which makes no sense whatsoever. Denying someone health care for no reason other that than other people didn’t get the same? I don’t think you could ever justify that.

    The “they’re using up other resources” argument doesn’t work, like Dr. Novella said – if it’s true then they aren’t actually bearing the full cost of the treatment. Hence, charge them enough more to make up for that.

    I will additionally note that, AFAIK, the publicly-funded health care systems in the world are not exclusive. The state will fund the standard level, but folks with more money can purchase private care. I gather from your comments above that you’re from Australia – is that not the case there?

  62. WilliamLawrenceUtridge says:

    @windriven

    I’m reading the Time article recommended by Duggan in the first comment, and I’m seeing that my assumptions are indeed rather flawed. The devil is indeed in the details, it’s hard to do something as complicated as healthcare properly.

    @Chris

    My library has neither :( Science Left Behind is essentially a published set of blog posts, and you can tell. I think I finished it in 3-4 days worth of bussing. Mooney’s book is on my for later list as well, but I believe SLB actuall calls out Mooney specifically for his assumptions about Republicants being the only transgressors against science.

    WLU – No, you can’t substitute hippies for artists* (mock frown). There is a logic problem there. If all hippies think they are artists, But many good artists are not hippies, then will killing half the artist reduce the number of hippies?

    I should indeed be frowned at, art is in the category of “things I’m not good at and thus must disparage to justify my poor performance”. Carol Tavris would have things to say about me. This is why we should all think about our prejudices before justifying them.

    Actually my point was related to depression (At the time it seemed rather obvious, but in retrospect, perhaps it was a leap). That it sounds like your default to death system would make suicide incredibly easy for folks suffering from depression. Also (if my comment about kitten and clown paintings was equally opaque) many of those folks are valuable to me and society and I’d rather we try to keep them around until their mood lifts or they get treatment.

    That would obviously have to be one of the controls put into place – an age limit would make sense (though, Logan’s Run), a diagnosis of pre-dementia would be another. No matter what, I think JJ Borgman’s “broad push for death with dignity” would be a necessary precursor to this ever being practical (in the sense of “readily available and socially acceptable”).

    From my experience artists are no more inclined to be anti-vax than the general public, but then many of my friends are still working in technology, so they are not the crunchy granola -livng off the grid types you may be thinking of.

    Like most stereotypes, my beliefs about artists and hippies are caricatures bearing virtually no resemblance to reality. That’s why most villains are fictional. For that matter, wasn’t one of the criticisms of the hippie movement that they grew up and became yuppies?

    I believe that deep down, nobody really believes in god or an afterlife. Otherwise, why the frantic struggle to keep living if dying means going to Heaven? I have seen deeply and devoutly religious people panic at the thought of death. I believe that people believe in god and heaven on a very superficial level but, hit them with a real life and death situation and their deep unbelief in their superficial belief is immediately exposed.

    Because religious belief is a conscious belief, one that works with the highly advanced systems of memory and reasoning that appeared late in our evolution. Fear of death (and pain) are much more primal, and require no learning, teaching or prompting. That’s my facile reasoning :)

    Though doubtless I will struggle against actually dying, I don’t fear what comes afterwards. But I exercise, eat lots of veggies and try to enjoy myself to prolong the time I get on this most interesting of planets. My two greatest regrets about death (that don’t involve missing my wife, delightful bundle of fun and malice that she is – hi honey, I know you are reading! Don’t ever die!) are that I won’t get to finish all the books I want to read, and that I don’t get to see what comes next. Do China and India go to war? Do we run out of oil before we discover an alternativer? Is there an internal ramp within the Great Pyramid? Who killed Kennedy? Is Bahrain really Dilmun? Where are the origins of the Harappan civilization? How does The Walking Dead end (comic, not TV series)? Will vat meat taste good? Will Taiwan stop calling itself the “Republic of China”? Do North Koreans ever get a leader who isn’t a complete nutjob monster? Does the world become more or less religious over time? What happens to Saudi Arabia when the oil runs out? Will my children’s children’s children have children? Will their lives look anything like mine? Do we reach the singularity? Is the universe really expanding? What the eff is dark matter, anyway? Will Italy ever mass produce a car worth driving? Will we ever invent a space elevator?

    Fortunately after I die, I won’t be around to worry about it. I hope people miss me when I’m gone, because that means I wasn’t a total shit.

  63. mousethatroared says:

    WLU – I think I came across as more serious than I was. Your problem was not stereotypes, it was that you choose the wrong stereotypes. You are suppose to believe that artists are hip (not hippies) cool, quirky, cutting edge, tortured souls, with a passion for new knowledge…we put a lot of effort into promoting those stereotypes, cause they are good for business. :)

    Also, how you talk about your wife is very cute. ;)

  64. BillyJoe says:

    Steven,

    “BillyJoe – I don’t see any problem with letting people pay privately for extra services that society is not willing to provide. This is not using up resources if they are paying for it (it’s not like the system is limited by hospital beds)”

    I’m assuming that the public health system provides all the services that a consensus of the relevant medical experts assesses as being worth doing. That would leave only the private health system doing things that really do not make any difference to outcomes. The problem here is that this does use up resources. Apart from hospitals, there is medical manpower. There is not an unlimited supply. As a specific local example, it is impossible to see a urologist in a public hospital within a twelve months, and the waiting time for surgery is about another two years (I’m referring here to non-emergency/elective surgery). The problem, apparently, is that not enough medicos want to be urologists and those that do become urologists go into private practice where they do unnecessary surgery such as ordering PSAs and removing prostates, leaving insufficient urologist for the public system.

    “In fact, private payers help subsidize the system so that it is more affordable for everyone else”

    I agree, and that is how it works in Australia. The point is that, if private practitioners did only those hings that are worthwhile doing, it would serve the public system even better and, then, everyone would be better off. Apart from that, I don’t think there is any excuse for doctors doing procedures and ordering investigations that are unnecessary just because there is a patient demand. There must be good medical reasons for doing them and that should apply equally to the private system.

  65. icewings27 says:

    @Calli – I am in my 40s and terrified of death and dying. My wishes, as communicated to my husband, have always been, “Do everything possible to extend my life regardless of its affect on the quality of life”.

    Thank you for adding a little perspective. Do I want to pass on the expense of doing so to my son and his future children? Do I want my loved ones to remember my last days as being full of interventions, suffering, and futility? Hmmmm. Much to ponder.

    @jmb – Regarding the teenage miracle patient: I certainly hope that hospitals set different levels of acceptable intervention for young patients vs. elderly. Meaning, if an 18-year-old comes in unresponsive, work your ASSES off to save him. Intervene! Meanwhile, if an 81-year-old comes in similarly deprived of vital signs, do a few basic things and then let him go.

    Does anyone know how hospitals tend to address the minimal acceptable amount of intervention, based on the age of the patient?

    I sincerely hope I have many years of life left. However, I am going to write an advanced directive. I still believe that, at my age and current level of health, I should be allowed to request a lot of intervention. But, I need to consider the larger picture of how it affects not just me, but my family, insurance costs, and the healthcare system at large. Thank you for this article, Steve. You really got me thinking!

  66. windriven says:

    @icewings27

    “I am going to write an advanced (sic) directive. I still believe that, at my age and current level of health, I should be allowed to request a lot of intervention. But, I need to consider the larger picture of how it affects not just me, but my family, insurance costs, and the healthcare system at large.”

    Have you considered a durable power of attorney? If you have someone in your life with whom you are very close and who you trust to act in your best interests, that may be a better solution than an advance directive. The problem with advance directives is that situations change, your age and health change, your views change, and it is both a pain in the butt and a little morbid to rewrite your advance directive every 6 months.

  67. Narad says:

    Buddhists and Hindus believe in reincarnation, with your status in the next life determined by how you behaved in this life.

    Careful. There is no metaphysical Self in Buddhism, just a construction of causality. It’s perfectly possible within the framework to maintain that “death” and “rebirth” are nothing more than a constantly ongoing pair of phenomena.

  68. WilliamLawrenceUtridge says:

    WLU – I think I came across as more serious than I was. Your problem was not stereotypes, it was that you choose the wrong stereotypes. You are suppose to believe that artists are hip (not hippies) cool, quirky, cutting edge, tortured souls, with a passion for new knowledge…we put a lot of effort into promoting those stereotypes, cause they are good for business.

    I can totally get on board by refocusing my stereotypes. The important thing is to keep a hateful fire burning deep in your belly. The specifics of who you hate really don’t matter. I’ll update stereotypes.dll and reboot before going to bed tonight.

    Also, how you talk about your wife is very cute.

    One must be careful. One must poke enough to get a rise, without having her tiny fists of rage be unleashed on one’s kidneys. It is a subtle, elaborate game of bluffs, risks and victory.

    And of course, tiger blood.

  69. mousethatroared says:

    WLU – hehe – whatever works.

  70. windriven says:

    @WLU

    ” It is a subtle, elaborate game of bluffs, risks and victory.”

    Ohhhhh … you’ll pay for that conceit!

  71. Narad says:

    @Brandt

    And you said you would drop it – which you didn’t – and now we have all this nonsense at the end of this post.

    You imagine a bit more than is warranted. I’m perfectly willing to take it to E-mail if you would like: narad.trabant@gmail.com.

  72. Narad says:

    Fortunately after I die, I won’t be around to worry about it.

    This position unfortunately can also be used as a rationalization for suicide.

  73. mousethatroared says:

    WLU “Fortunately after I die, I won’t be around to worry about it.”
    Narad “This position unfortunately can also be used as a rationalization for suicide.”

    pfft – everyone knows suicides get assigned government jobs in the afterlife.

  74. Narad says:

    @Janet

    “I would be cautious in trying to implicitly denigrate religious motivations. ”

    I don’t see that I did that at all, especially the “denigrate” part. Religious belief is what it is, I accept that. I studied Anthrpology and know a bit about the human propensity for religion. My comment was offered as an explanation, not as denigration.

    I apologize for reading more into “in all cases these people were religious” than was intended. I do, however, stand by the assertion that belief in, for example, olam ha-ba doesn’t itself represent a solid foundation upon which to criticize the pursuit of what is rationally understood to be almost certainly “futile care.”

  75. Narad says:

    pfft – everyone knows suicides get assigned government jobs in the afterlife.

    Yah, but then everybody’s got to wait around for http://www.youtube.com/watch?v=a9DGvsTBPmQ>Jonathan Richman to show up.

  76. Narad says:

    Curse-a you, Buckaroo No-Preview. Here.

  77. WilliamLawrenceUtridge says:

    @windriven

    Ohhhhh … you’ll pay for that conceit

    I’ve already been informed that the tiny fists are primed, to be deployed at an uncertain future date. My punishment is foreordained. She doesn’t want me to tell you about it. I have just been informed that I shall pay for this as well. Truly, it is an exemplar of a feed-forward mechanism.

  78. WilliamLawrenceUtridge says:

    @narad

    This position unfortunately can also be used as a rationalization for suicide.

    It’s also a rationalization for treating the world and the people that live in it with care and love, and to spend one’s time wisely because it’s all you have. I’ll step out on a limb and venture that people who commit suicide don’t really need “the ultimate pointlessness of existence” as a reason to commit suicide, I’m guessing there are other factors in their lives that are pushing them in that particular direction.

    My logic, reasoning and prose fails in the face of suicide, which makes me sad. In many ways we are lucky the drive to survive is so strong, since there’s not much I can think of to rationally convince someone of the worth of living. Having volunteered at a distress line, it normally wasn’t a rational discussion.

  79. mousethatroared says:

    Narad – I had not considered how Jonathan Richman might feature in. :)

  80. mousethatroared says:

    WLU “I’ll step out on a limb and venture that people who commit suicide don’t really need “the ultimate pointlessness of existence” as a reason to commit suicide”

    I think it’s more pragmatic than that. If you are miserable you want it to end. Ceasing to exist is a more attractive alternative than an unknown, probably bad, afterlife.

    But I don’t think there’s much way around it, people tend to believe what they believe. There’s lots of ways you can rationalize things.

  81. Narad says:

    In many ways we are lucky the drive to survive is so strong, since there’s not much I can think of to rationally convince someone of the worth of living.

    Yah. I’m sure there are some who hang on only because of an understanding of the pain it would bring to others, as well as, in some cases, the unfairness involved (e.g., a burden on elderly parents). Or just that they don’t trust others to take care of the beings or, even, things that they still do care about as they would. Once these cares begin to erode, the situation is dire.

    I salute you for having worked a distress line; I don’t think I have the requisite communication skills. In the several suicide attempts I’ve been confronted with over the years (some symbolic, some quite real), the only thing I know to do is to act immediately and relentlessly. This at least is in my skill set.

  82. BillyJoe says:

    Scott,

    You are looking at it from the point of view of someone with enough funds to purchase whatever they want in the health system, good, bad, or indifferent. I’m talking about medical professionals providing those services. I’m saying that I don’t think it’s justifiable for medical professionals to provide services that are bad or indifferent just because a health consumer demands those services and has the money to pay for it. For example, would you work in, or set up, a clinic providing exercise ECGs to anyone who wants one (when there’s no evidence that this is a useful thing to do)? Do you think it’s a wise use of limited resources?

    I think I answered your other questions in my response to Steven Novella.

  83. BillyJoe says:

    Calli,

    Do Christians really fear death because they might end up in hell? But then why are they committing mortal sins? I mean, if they really believed in hell, why would they ever risk eternal suffering for a moment of sin here on Earth? The only reason I can think of is that, deep down, they don’t really believe in eternal hellfire.

    And I wasn’t suggesting that religious people should suicide to get to heaven sooner because, as you say, that would actually get them into hell. I was clearly taking about religious people faced with the threat of death.

    “The idea of using a dying person’s fear as evidence of their lack of faith is, to me, as offensive as the old expression that “there are no atheists in foxholes”.”

    I was not trying to be offensive, I was merely trying to explain why a devoutly religious person who believes he will go to heaven when he dies would fear death when suddenly faced with that prospect, and strive strenuously to avoid it! If he really believes heaven is infinitely so much better than life here on Earth, why panic when your time has come to go there? Why not embrace it with open arms?

  84. BillyJoe says:

    WLU,

    “Because religious belief is a conscious belief, one that works with the highly advanced systems of memory and reasoning that appeared late in our evolution. Fear of death (and pain) are much more primal, and require no learning, teaching or prompting”

    Hmmm…but that’s like saying their faith is not strong enough! ;)

  85. Narad says:

    Do Christians really fear death because they might end up in hell? But then why are they committing mortal sins?

    “Mortal sin” is mostly a concept that exists within the Catholic and Orthodox traditions. But, yes, I’ve had this question posed in immediate terms by a Christian-by-association in really bad shape. I think there may have been some desire for an idealized Hell as a form of atonement for actions on earth. This outcome was avoided.

  86. mousethatroared says:

    BillyJoe “I was not trying to be offensive, I was merely trying to explain why a devoutly religious person who believes he will go to heaven when he dies would fear death when suddenly faced with that prospect, and strive strenuously to avoid it! If he really believes heaven is infinitely so much better than life here on Earth, why panic when your time has come to go there? Why not embrace it with open arms”

    Why are you assuming that fear responses to reason?

  87. Scott says:

    I’m assuming that the public health system provides all the services that a consensus of the relevant medical experts assesses as being worth doing. That would leave only the private health system doing things that really do not make any difference to outcomes.

    This is a false assumption. There are many things which would make a difference to outcomes, which are nonetheless judged too expensive for the benefit provided. It’s those things we’re talking about here.

  88. WilliamLawrenceUtridge says:

    I salute you for having worked a distress line; I don’t think I have the requisite communication skills. In the several suicide attempts I’ve been confronted with over the years (some symbolic, some quite real), the only thing I know to do is to act immediately and relentlessly. This at least is in my skill set.

    It’s actually rather the opposite – you don’t need communication skills, you need listening skills. The ones who call in usually aren’t the ones who just up and kill themselves – they’re the ones who want to be talked out of it. Usually it entailed not saying much, just listening. You also get a lot of training, including a handy mnemonic:

    CPR – current plan? Previous attempts? Resources? If they have a current plan, it increases the risk of actual suicide/death. If they have made previous attempts, it increases the risk as well. If they have resources to draw upon, it decreases the risk.

    I don’t think what I did was particularly spectacular. It mostly consisted of staying awake on the overnight shift and saying “uh-huh” a lot. Not to trivialize it, just that I think most people could do it if they were put in a similar situation. I doubt I brought any special skills with me.

  89. BillyJoe says:

    Michelle,

    “Why are you assuming that fear responds to reason?”

    You are living in a house that you can reach only by trudging up twenty stairs, dead ants and maggots are continually falling down from the pine lined ceiling which houses a dozen possums with their entourage of rats that you can hear every night scratching inside the walls on which every night you can see spiders and cockroaches scuttling, and it’s so dark inside the house during the day that you have to have the lights on. Down in the valley there is a house with no stairs to climb, bright and airy inside, cool and shady outside, a bedroom for each of the kids, a sparking new kitchen and two bathrooms, surround verandahs, and a pool and a spa in a tropical garden.

    All you have to do is die.

    Metaphorically you would “die to go there”, but would you actually physically die to get there? Of course not. You would have to believe with all your heart and soul that death would bring that reward and there’s no reason for you to believe that. The Hell’s Gate people were probably an exception to the general rule that people really do not trust their belief in the afterlife. They strenuously strive to stay alive here on Earth because that’s a sure thing. They really do not want to risk the great unknown beyond death which they, deep down, do not believe is real.

    What I am saying is that their superficial belief in an afterlife, when faced with a life a death situation, is easily overcome by their deep disbelief. They have talked themselves into a belief but, deep down, they do not believe a word of it. WLU could be correct, though. It could be that the primitive fear takes precedence over consciously ingrained beliefs in such situations.

  90. mousethatroared says:

    BillyJoe – It looks like you are building a fictional “devote christian” and writing the story of his life and beliefs. Then based on this fictional character and story you are judging whether his belief is superficial. Then you are generalizing that judgement to attempt to argue that christian belief may be superficial.

    Hmmm….I think there’s a word for that.

    And you haven’t answered my question. Why do you assume that fear responds to reason?

    If I am afraid of flying does it mean that I only “superficially believe” that pilots are well trained, that science has proven that airplanes can fly and that my plane has adequate safety standards?

    I feel like you are building an argument based on the concept of fear without adequate knowledge of why people experience fear, the biology of fear or what stimuli or methods alleviate fear or anxiety. Why would you do that? It looks like your are starting with your conclusion and looking for “evidence” to support it.

  91. Stuartg says:

    Partly WRT the “miracle teens”

    I work over a wide field of medicine – emergency, acute, rehabilitation and palliative – and have to deal with many patients who are likely to die no matter the level of intervention. In many cases advance directives or durable power of attorney can be a major help in guidance as to how to treat the seriously ill or dying patient.

    I don’t see many teenagers where similar decisions of treatment level have to be made, usually passing them (the teenage patients, as well as the decisions) on to specialists in the field. Following a single event, I now question my ability to help make life/death/resuscitation decisions in teenagers (warning: anecdote follows).

    My own teenage offspring had a full cardiorespiratory arrest following coning, due to raised intracranial pressure from an astrocytoma. In similar situations in the elderly I would advise against active treatment, with absolutely no hesitation.

    At the time of the arrest I was unable to be contacted – driving through the night to try to get there – and the team decided on full resuscitation measures. Five years down track my offspring has no MRI evidence of recurrence, is approaching the end of their university degree, and plays at above average level in their chosen team sport. If I had been able to be contacted, would a healthy, productive life have been lost?

    I now raise the question: should doctors be involved in the resuscitate/do not resuscitate decisions involving members of their own family? Particularly with children or teenagers? Is it possible to become too accepting of the inevitable outcome of life and not resuscitate when there is reasonable expectation of a good outcome? Or become the opposite where maximum effort is made for every patient, no matter the prognosis, because of a single “miracle” patient?

    I think I have sorted things for myself, but I believe that all health care professionals should consider these questions well in advance of any urgent requirements to answer them.

  92. BillyJoe says:

    Michelle,

    I don’t think fear of flying is an apt analogy. Why do people fear flying? For some it is the feeling of claustrophobia. For others it simply the feeling of being constrained (they can’t get off whenever they wish). Others fear being suspended in mid air. Still others fear the take off or the landing. I don’t think the basis of anyone’s fear of flying is untrained pilots or that the science is wrong. But suppose that IS the basis of a particular person’s fear of flying. A reasonable analogy to the fear of death would be that god is the pilot. The problem is that there would be no way to convince that person that the pilot is god.

    But, you are right. I have not done any study on religious belief in the afterlife or why people who believe in an afterlife fear death. It is indeed based on personal experience. When I was a devout catholic, I would sometimes hope to be suddenly struck dead right after going to the confessional. That would be a sure path to heaven. But, when I really thought about it, I didn’t actually want to die right here and now right after confessing all my sins. It seems I would rather keep on living and risk dying at a later time when bad timing could see me end up in hell.

    And I watched both my religiously devout father and his religiously devout best mate die about a year apart, both of lung cancer. Unfortunately their demeanour in facing death belied their belief in god and an afterlife. It was painful to see the panic that overcame them during several false alarms when death seemed immanent before they actually passed away. Perhaps is was just the overpowering influence of the primitive brain on the conscious thinking brain.

    But, in my experience, it is difficult to pick a devoutly religious person in real life because they seem to respond just like anyone else in similar situations. You would not guess they are living this life on loan to the next. In my youth, no one would guess I was devoutly religious until they saw my bedroom (I am no longer embarrassed because I am a totally different person now). In my present life, no one would guess that I am an atheist until they see my library. I guess what I am trying to say is that, except for extreme examples, there does not seem to much difference in the way people who do or do not believe in an afterlife go about their daily lives. This makes me question that belief.

    BTW, when I say “superficial belief” and “deep unbelief”, all I mean is that there is a persistent subterranean disbelief below the surface appearance of ingrained belief. I don’t necessarily mean that believers haven’t thought about their belief deeply.

  93. mousethatroared says:

    @BillyJoe – Well I can certainly relate. It is March 1st and here in my state, I not only doubt that spring will come – I’m almost certain that it won’t. I can’t even purchase a rose bush based on a promise of delivery for planting time…it’s just seems too futile. :)

  94. BillyJoe says:

    But you’re wrong, Michelle, you see* it was March 2nd when you posted your comment and, actually, it’s autumn where I stand in my shoes, even though we’ve just had three days of winter and the following seven promise to be days of summer if the weather vane is to be believed.

    *Jethro Tull reference:
    http://www.lyricsfreak.com/j/jethro+tull/solitaire_20071104.html

  95. mousethatroared says:

    BillyJoe – pfft – Winter, sminter. I doubt you actually have winter. At the worst you probably have a really long November/March season.

  96. Island Annie says:

    Here is another aspect of the issue that has not been explored. This is the idea that you are “fighting” your fatal disease. My husband died of Mesothelioma, the surgeon told us he would be dead in two years no matter what treatment or non-treatment we chose. We chose non-treatment, just drugs for pain. On the Mesothelioma websites I visited, patients were going to all kinds of extremes, and mostly had pretty miserable lives, and died within two years anyway. My husband had a pretty good two years, only deteriorating quickly the last month of his life. What bothered me was this unspoken accusation that we did not “fight” this cancer. So, to use all the resources of the medical system, even to no avail, was preferable to accepting the inevitable.

  97. BillyJoe says:

    Annie,

    I empathise. I don’t want my epitaph to be “he finally lost his battle with cancer”.
    I also will not accept any investigations or treatments without clear evidence of benefit.
    (Note: as far as I know, I do not have cancer at the present time)

  98. WilliamLawrenceUtridge says:

    Here is another aspect of the issue that has not been explored. This is the idea that you are “fighting” your fatal disease. My husband died of Mesothelioma, the surgeon told us he would be dead in two years no matter what treatment or non-treatment we chose. We chose non-treatment, just drugs for pain. On the Mesothelioma websites I visited, patients were going to all kinds of extremes, and mostly had pretty miserable lives, and died within two years anyway. My husband had a pretty good two years, only deteriorating quickly the last month of his life. What bothered me was this unspoken accusation that we did not “fight” this cancer. So, to use all the resources of the medical system, even to no avail, was preferable to accepting the inevitable.

    I just finished a book, Pink Ribbon Blues by Gayle Sulik. Though about breast cancer, it has a similar theme – that there is a dominant theme within the cancer community that one must fight, that there is only one right way to deal with cancer with all other stories or approaches being marginalized. Kind of a depressing book, but very interesting.

  99. kathy says:

    How one approaches something like cancer is dependant on the sort of person you are, surely? My brother’s wife, who is a street fighter in all departments, battled breast cancer tooth and nail and won out. On the other hand my father, after one effort that didn’t pan out, spent his last couple of years with cancer just doing what he wanted, which was mainly watching TV as far as I could tell. Different folks, different strokes, even in a single family.

    Luckily none of us had fights about how to to approach the disease. That can cause much heart-burning in a family. It wasn’t pleasant watching my Dad go downhill without a struggle, but he’d made his choice and he was quite calm about the consequences.

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