Review of article "Eight reasons why doctors fear the elderly, chronic illness, and death" in The Journal for Transpersonal Psychology.

1. Literature review created for required writing sample
for application to academic admission, 2008
© 2008/2014 by Dawn Drake

2. © 2008/2014 by Dawn Drake
1
A Critical Review of Lieff, J. (1982). Eight reasons why doctors fear the
elderly, chronic illness, and death. The Journal of Transpersonal Psychology, 14(1),
47-60.
Literature Review
Jonathan Lieff, author of this article, holds a B.A. from Yale College and an
M.D. from Harvard Medical College, and is board certified by the American Board of
Psychiatry (Ages Health Services Inc., 1996). When the article was published in
1982, Lieff had developed services for elderly, handicapped, and terminally ill
patients in connection with the Boston Housing Authority, nursing homes, and
hospitals. He had also served as Director of Geriatric Fellowship at Boston
University and Chief of Geriatrics at Lemuel Shattuck Hospital, a Tufts University
Facility.
In this paper, I summarize the article and offer comments about selected
aspects, identify some relevant changes that have occurred since the article was
published, and suggest areas where additional research findings would assist in
understanding the current state of medical care in regard to the issues raised.
Article Summary
Lieff (1982) described recent (at the time of publication) research findings
that indicated “widespread and well-documented prejudice” (p. 47) against elderly
and terminally ill patients, and that suggested prejudice and avoidance behaviors
were fostered in American medical schools. He also documented benefits of
psychological support for dying patients and then identified and discussed eight

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reasons to explain the fear that he believed could explain doctors’ behaviors toward
these patients. Many of his explanations reflected spiritually related problems that
he believed were at the root of the issue. Lieff (1982) did note that some medical
professionals, mostly not physicians (i.e., nurses, social workers, therapists, and
some physicians who find personal reward in providing elder-care), countered the
norm by providing more effective services to the elderly. After discussing the
relevance of the spiritual needs of the dying, Lieff (1982) concluded by positing the
need for an increased professional emphasis on the “psychological and spiritual
considerations” (p. 59) of the final stage of life.
Critical Reflections
The dominant purpose of this article seems to be to convince the reader that
Western doctors (specifically, American doctors) were not prepared to support the
emotional and spiritual needs of the patients who were dying, and further, that
spiritual training should be included as a standard component of medical training
for doctors. All of the reasons for fear that Lieff (1982) discussed reflected
psychological or spiritual issues; consideration of other contributing factors was
noticeably lacking. Although Lieff (1982) offered persuasive ideas to explain why
doctors might fear chronically ill and terminal patients, many of his descriptions of
doctors’ attitudes and experiences included neither research references nor
acknowledgement that the statements were his opinions—presumably based on his
experiences in the profession, but opinions, nonetheless. Examples include
assertions (Lieff, 1982) that many doctors did not recognize the human potential to

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transcend physical limitations and find personal fulfillment, that doctors lacked
resources for finding “information about the purpose of the ending of life, and of
death” (p. 55), that most doctors were not prepared to deal with the impact that
religious beliefs or experiences had on the efficacy of medical treatment, and that
our society had given doctors “a kind of priestly status” (p. 58).
Acknowledging his comments as opinions or personal observations and then
explaining his reasoning could have provided an opportunity to persuade a skeptical
reader to agreement. By offering neither research findings nor personal reasoning,
Lieff potentially increased the reader's resistance to his arguments. Numerous
statements also seem to express Lieff's (1982) own frustration in coming to terms
with death and dying, especially within American society. For example,
Patients and their families generally turn to the physician for solutions to
these problems, . . . The typical doctor is perhaps no better prepared to take
care of his own elderly parents and grandparents . . . But they are expected
magically to provide solutions (p. 55).
Theorists, such as Erikson (1963) and Lidz (1976), attempt to include the
termination of life as a psychological developmental stage. But what
psychological development leads to death? (p. 56)
In a medical system that lacks a spiritual basis for making decisions, it is not
acceptable to die without a medical cause. This is just one of many ways in
which the doctor is rendered helpless in a system which is structured to help
him hide these feelings of helplessness (p. 58).
Upon recognizing this undertone of personal frustration, the reader might
question the objectivity, and therefore the validity, of the overall argument. This, in
conjunction with the lack of support for many of the assertions made, undermines
the potential benefit of Lieff's (1982) presentation of the issues.

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Further Research
Lieff (1982) supported Kastenbum’s recommendations for providing patient-
oriented standards, but expressed reservations about the whether those
recommendations could be successfully implemented in America. Lieff (1982)
suggested that hospices, which were rare in the U.S. in 1982—only about 1,500
programs existed by 1985 (National Hospice and Palliative Care Organization,
n.d.)—might provide a satisfactory model for end-of-life care. Changes have
occurred in American society that have dramatically altered the circumstances that
existed when Lieff (1982) wrote this article. Some pivotal ones that directly affected
medical care are
• in 1983, Medicare began paying for hospice care for eligible patients (von Guten
& Ferris, 2002),
• in 1997, Geriatric Psychiatry was approved as an official subspecialty (American
Board of Psychiatry and Neurology, Inc., n.d.),
• in 2006, the subspecialty of Hospice and Palliative Medicine (HPM) was
approved (American Board of Medical Specialties, 2006; palliative care provides
treatment to alleviate pain and symptoms without treating the underlying
cause), and
• according to the National Hospice and Palliative Care Organization (2007), in
2006 the number of hospice programs in the U.S. had grown to 4,500, serving an
estimated 1.3 million patients, and more than one third of all deaths in the
United States that year occurred in a hospice program.

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These changes suggest that a significant shift has occurred, or is occurring, in
the way the medical community views elderly and terminally ill patients, but they
don’t tell us the source or reason for the change. The research cited by Lieff (1982)
needs to be revalidated, especially in regard to whether prejudicial attitudes and
avoidance behaviors are still demonstrated in medical schools and among practicing
physicians, and what psychiatric treatment is provided to elderly and terminally ill
patients. It would also be appropriate to look for other factors besides the fear that
might contribute to those attitudes and behaviors.
Lieff’s (1982) comments also raised several other issues that suggest further
research opportunities. He noted that nurses, social workers, and therapists were
leading the way in providing better care for the elderly. How do their ways of
treating and interacting with patients differ from physicians? Do they have
different attitudes about patients or perspectives on life and death? What is the
source of any differences? If they learned the methods and attitudes in a formal
setting, how were those alternatives taught? Are those methods transferable to
physician training, and if so, has there been progress in incorporating those changes
into medical schools? How do patients and their families perceive the care that the
nurses and other care providers deliver in contrast to the care that is provided by
physicians? Do these patients and their families communicate their feelings to
others, and if so, has it effected any change in expectations in those others? How do
doctors respond to these methods—are they supportive, obstructive, or neutral?
What consequences do these practioners experience, and how does that affect their

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motivation to continue with their methods? And, of course, how many physicians
are entering the new subspecialties that are targeted to treating these patients?
Lieff (1982) suggested that physicians should receive more spiritual training,
based on his assessment of their fears. It would be appropriate to conduct current
research to determine whether his assessments are correct in regard to today’s
physicians; for example, whether doctors believe that they have a “priestly status”
(Lieff, 1982, p. 58) in our society and that they are ill prepared ethically and morally
“beyond obeisance to academic and guild organizations” (p. 58), whether death
certificate requirements make them feel helpless, and whether they refer patients
to specialists for assistance in coping with “problems of meaning and purpose” (p.
54). Research into doctors’ opinions about including spiritual orientation in medical
training would be important, and if they support the idea, what methods they would
consider acceptable for determining the content and delivery of that training. This
article raises issues and possibilities that are rife with questions worthy of
exploration. Additional examination should quickly raise research possibilities
beyond those suggested above.
Conclusion
Lieff (1982) presented convincing research that chronically ill and terminal
patients need psychological support, yet many American doctors exhibited
avoidance behaviors toward them in the early 1980s. It appears, though, that Lieff’s
primary goal was to persuade the reader that spiritual training should be included
in American medical training. Because he focused primarily on spiritual issues,

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positioned opinions as facts, and conveyed an undercurrent of frustration, the
article is subject to being discounted as fallacious rather than being accepted as an
objective, scholarly treatment of a legitimate professional concern.
More than a quarter of a century has passed since the article was published,
and in that time, significant changes have occurred in the medical field that affect
how terminally ill patients are treated in the U.S. Given the growing population of
the elderly and the seriousness of the concerns raised by Lieff (1982), current
research into medical training practices and the need and appropriate goals for
including spiritual training in medical education curricula seems both appropriate
and important to ensuring that a high quality of compassionate and effective care
will be available to individuals who are reaching the end of their life.

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References
Ages Health Services Inc. (1996). Form 10-KSB/A-1 Annual Report Pursuant to
Section 13 or 15(d) of the Securities Exchange Act of 1934. Retrieved from
http://www.secinfo.com—drP9x.81v.htm
American Board of Medical Specialties. (2006). News release: ABMS establishes
specialty certificate in hospice and palliative medicine. Retrieved April 30,
2008, from http://www.nhpco.org/i4a/pages/index.cfm?pageid=5072
American Board of Psychiatry and Neurology, Inc. (n.d.). Initial Certification in the
Subspecialty of Geriatric Psychiatry. Retrieved from
http://www.abpn.com/gp.htm
National Hospice and Palliative Care Organization (NHPCO). (n.d.). Growth in U.S.
hospice programs: 1974 to 2006. Retrieved from
http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-
figures_Nov2007.pdf
National Hospice and Palliative Care Organization (NHPCO). (2007). NHPCO facts
and figures: Hospice care in America. Retrieved from
http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-
figures_Nov2007.pdf
von Gunten, C. F., & Ferris, F. D. (2002). CAPC manual: Everything you wanted to
know about establishing a palliative care program but were afraid to ask.
Retrieved from
http://64.85.16.230/educate/content/rationale/ushospicegrowth.html