Article Review-Writing Sample

Literature review created for required writing sample for application to academic admission, 2008

© 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


2

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


3

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.


4

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.


5

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


6

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,


7

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.


8

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

Education

Article Review-Writing Sample