This is why culture stays with us . . . or economics of death

Death anxiety is a primary motivational force that drives much of our behavior. It puts our defenses on high alert, and we make strenuous efforts to repress or deny the unwelcome truth of our inevitable end. The way each of us denies death not only affects life in its broadest sense but also influences the way we behave in organizations. Death anxiety underlies much executive behavior and action. However, traditional motivational theories do not acknowledge the influence of death anxiety on our behavior. Although they attempt to help us better understand employee motivation, they are not sufficiently inclusive. This article takes a clinical lens to explore death anxiety as a motivational force, how it affects behavior in organizations, and how we metabolize the feelings death evokes. In addition, I examine the various ways we deal with our knowledge of death. Some of us go into overdrive in trying to suppress it, while others fall into a state of resignation and depression. To deal with the ultimate narcissistic injury that death represents, we resort to a variety of immortality strategies to create permanent or enduring meaning. Furthermore, from an organizational perspective, three maladaptive responses to death anxiety are explored: the manic defense, succession issues, and the edifice complex.

From a paper by Manfred F.R. Kets de Vries. 

How doctors die

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

This is surprising:

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice. 

If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

And this paragraph made me wonder how much economics and medicine have in common:

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital. 

The system:

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Over-treatment?

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment. 

But not for doctors:

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common. 

And a very illustrative case:

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20. 

The article is short and fascinating. And doctors can be very good writers. You can read it all here.  

Death in Ghana - the property of the corpse

From a BBC article:

When a Ghanaian dies, the body belongs to the family - that is the legal position.

The definition of family, in this case, does not include a spouse or children.

What could be an efficient reason behind this social norm, at least historically? The extended family is very important, it is at the center of community in Ghana. If the family where one is born (which does not include spouse or children, to use the definition in the BBC article) makes the decision about the burial (when and where), the spouse and children will try to stay in good terms with the family during their lives, so that their opinion (spouse and children's) regarding the corpse is not rejected outright when death comes. If this interpretation is true, this social norm is a mechanism to keep families well connected. Well connected families can provide help in case that one of the members of the family is in need. In this regard, the social norm of the property of the corps might contribute to strengthening family links that perform as social insurance. [Of course this interpretation might be totally of target!]