Respectful Insolence

Religion and end-of-life care

ResearchBlogging.orgGiven that I’m the proverbial lapsed Catholic cum agnostic, religion just doesn’t play that large a role in my life and hasn’t since around six years ago. I don’t know if I’ll ever discuss or explain on this blog what the last straw resulting in that transformation was (it’s too personal), but a couple of years ago I did go through a period where I became hostile to religion, perhaps spurred on by PZ and the whole anti-religion gestalt of the ScienceBlogs Collective here. That lasted maybe a year or two, during which time I did what every new disillusioned ex-religious person seems to do (reading books like Richard Dawkins’ The God Delusion, for instance) but eventually my hostility abated, as regular readers may have noticed by the topics and writing tone right here on this very blog. (Don’t worry, quackery and the antivaccine movement still get me as worked up as ever–perhaps even more so.) These days religion just doesn’t matter that much to me one way or the other, except for when it interferes with concrete things that matter, such as patient care, the teaching of science, or civil rights. Since then, for the most part it’s been live and let live.

That being said, I still maintain a healthy interest in the interface between science and religion or, more specifically, the interface between religion and medicine. That’s why a study released in the Journal of the American Medical Association yesterday caught my interest. A news story in the Los Angeles Times about this study describes it thusly:

After she was diagnosed with Stage IV breast cancer that had spread to her left lung, Gloria Bailey’s doctors recommended she have a mastectomy followed by hormone therapy to fight the tumors that remained. She followed their advice, but had a nagging feeling about the regimen.

“The Lord was just telling me, ‘They’re not being aggressive enough,’ ” Bailey recalled. So she sought out a new team of oncologists at the Cancer Treatment Centers of America’s Midwestern Regional Medical Center in Zion, Ill., more than 300 miles away from her home in Michigan. Those doctors suggested she undergo a bone marrow transplant, a harrowing ordeal that landed her in a coma.


Before I go on, I can’t help but comment on the Cancer Treatment Centers of America, which are well known for being very woo-friendly. Apparently they aren’t too keen on a firm scientific basis for how they use science-based therapies, either. Bone marrow transplantation for advanced breast cancer fell by the wayside a decade ago because clinical trials showed that it doesn’t work; it doesn’t prolong survival in breast cancer patients. Performing a bone marrow transplant for breast cancer is simply not indicated outside the context of a clinical trial. In this case, the Lord wasn’t up on science-based medicine and led Mrs. Bailey astray, I’m afraid.

But I digress. The real point of the study was this:

Faith in a higher power can often lead to more aggressive treatment than is medically warranted, research is beginning to show. As a result, the nation’s medical community is now grappling with the best way to bring God into the doctor-patient relationship without subjecting patients to needless suffering before they die.

In a study published today in the Journal of the American Medical Assn., researchers found that terminally ill cancer patients were nearly three times more likely to go on breathing machines or receive other invasive treatments if religion was an important part of their decision-making process. Such treatments didn’t improve a person’s long-term chances, however.

The finding that religiosity is correlated with the pursuit of more aggressive therapies in cancer is not new. There has been a body of evidence developing over the last few years suggesting that more highly religious people are more prone to pursue more aggressive treatments, to be less likely to understand the meaning of a “do not resuscitate” order, and an increased preference for what would be considered heroic end of life measures when compared to less religious people. Examples cited in the news story and the study itself include a studies showing that religious cancer patients who failed chemotherapy were twice as likely to want heroic end-of-life measures, that patients with advanced stage lung or colon cancer were more likely to want full codes, CPR and all, plus mechanical ventilation and ICU admission if they believed in divine intervention. In addition, they were less likely to have set up a living will. Knowing what I know and having seen what I’ve seen, I can’t understand it. I’ve seen patients with advanced cancer die; heroic measures only prolong the agony–if they even do that. Indeed, although I watched my mother-in-law waste away from metastatic breast cancer, I was happy that she had chosen hospice.

Previous studies aside, though, there had never been any evidence to show that these expressed preferences actually followed through with them. This study, performed by a group led by Holly Prigerson, director of the Center for Psycho-oncology and Palliative Care Research at the Dana-Farber Cancer Institute aimed to answer that question.

What Prigerson and her team did was at the same time straightforward but brilliant. Basically, these results were part of a larger study known as the Coping With Cancer Study, a multi-institutional investigation of patients with advanced cancer and their informal caregivers. The study was funded by the National Cancer Institute and the National Institute of Mental Health and was designed to examine the relationships between psychosocial factors, with a focus on religion and spirituality, and end-of-life outcomes such as use of aggressive medical care and quality of death. Participants with advanced cancer and their caregivers were surveyed using the Brief RCOPE, a validated 14-item questionnaire that assesses religious coping. the Brief RCOPE examines the extent to which patients engage in seven types of positive religious coping (“seeking God’s love and care,” for example) and 7 types of negative religious coping (“wondering whether God has abandoned me,” for example) using a 4-point Likert scale from 0 (not at all) to 3 (a great deal). The results of this survey were then correlated with how these patients actually coped with end of life care. Patients were also examined with another instrument and underwent the Structured Clinical Interview for the DSM-IV Axis I Modules to assess if patients met diagnostic criteria for panic disorder, major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.

Care preferences were then assessed with the following question: “If you could chose, would you prefer (1) a course of treatment that focused on extending life as much as possible, even if it meant more pain and discomfort, or (2) on a plan of care that focused on relieving pain and discomfort as much as possible, even if that meant not living as long?” They were also asked, “Would you want the doctors here to do everything possible to keep you alive even if you were going to die in a few days anyway?” Finally, patients were assessed for whether they had completed a do-not-resuscitate order, living will, or a health care proxy/durable power of attorney. The primary outcome variable to be assessed was intensive life-prolonging care, defined as receipt of ventilation or resuscitation during the last week of life. Secondary outcomes assessed included hospice enrollment and death in an intensive care unit.

The results were described as follows:

A high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared with patients with a low level (11.3% vs 3.6%; adjusted odds ratio [AOR], 2.81 [95% confidence interval {CI}, 1.03-7.69]; P = .04) and intensive life-prolonging care during the last week of life (13.6% vs 4.2%; AOR, 2.90 [95% CI, 1.14-7.35]; P = .03) after adjusting for age and race. In the model that further adjusted for other coping styles, terminal illness acknowledgment, support of spiritual needs, preference for heroics, and advance care planning (do-not-resuscitate order, living will, and health care proxy/durable power of attorney), positive religious coping remained a significant predictor of receiving intensive life-prolonging care near death (AOR, 2.90 [95% CI, 1.07-7.89]; P = .04).

Oddly enough, this is the opposite of what I would have expected. I would have expected that faith and “positive positive religious coping” would be more likely near the end of life to view the end as God’s will and therefore be less likely to insist on heroic measures. Alternatively, one might postulate that patients with a high degree of negative religious coping might be more likely to insist on heroic measures. It’s not hard to imagine the reason as being fear of hell or divine retribution. The authors explain the possible reason for this correlation thusly:

Intrinsic to positive religious coping is the idea of collaborating with God to overcome illness and positive transformation through suffering. Sensing a religious purpose to suffering may enable patients to endure more invasive and painful therapy at the end of life. Alternatively, religious copers might feel they are abandoning a spiritual calling as they transition from fighting cancer to accepting the limitations of medicine and preparing for death. Religious patients might thus equate palliative care to “giving up on God [before he has] given up on them.” Qualitative studies commonly report spiritual reasons for preferring life-sustaining treatments, including a belief that only God knows a patient’s time to die. Finally, high rates of intensive end-of-life care among religious copers may be attributable to religiously informed moral positions that place high value on prolonging life.

This may make sense. After all, there are Orthodox Jewish sects that value life above all else, sometimes to the point of insisting on keeping the bodies of brain dead children alive. Another potential explanation is that many faiths teach that suffering brings one closer to God:

Orthodox Jewish patients often express the belief that life is worth living no matter how debilitated the patient, and Christians sometimes welcome the opportunity to express their faith by enduring pain, said Betty Ferrell, a registered nurse who researches end-of-life care issues at City of Hope in Duarte.

“We’ve had patients who said, ‘Well, God suffered. Jesus suffered. So if I suffer, it’s going to make me more like God,’ ” she said.

Ferrell recalled the case of a terminally ill cancer patient who baffled her caregivers by embracing the prospect of an agonizing ending.

“She said, ‘I want my sons to remember that I fought until the end,’ ” Ferrell said. The patient wanted “her children to see she would not abandon her faith, even when things got tough.”

Some healthcare providers are now reconsidering what it means to have a “good death.”

The problem with this “good death,” however, is that it is not just about the patient demanding the heroic treatment measures. It’s also about a massive waste of resources for zero hope of prolonging life and every chance of causing more pain to both them and their family. Patient autonomy is important, but medical ethics do not demand that we as physicians acquiesce to every request patients make. On a strictly ethical basis, we are not obligated to administer care that has no hope of prolonging life and every hope of prolonging suffering of both the patient and the family. But it’s more complicated than that, because it’s not always easy to differentiate when care is futile or to persuade the patient and family that care is futile. As always, communication is key; the problem is that the communication of the patient needs to be helped coming to terms with his prognosis as soon as it is determined that he is no longer curable. All too often, such patients are permitted to continue to labor under the delusion that there is still a chance that they can be cured. Worse, all too often this misconception is allowed to persist even past the point where it’s even possible to prolong life anymore.

While it’s highly tempting to take the lazy and simplistic path of simply using a study like this as yet another convenient excuse to bash religion, but as much as certain atheists triumphantly gloat over this study as evidence that either religious people, when it comes right down to their time to check out, don’t really believe in heaven, the explanation for the results of this study probably comes down to a combination of factors, including valuing life over quality or form of life (think: abortion controversy); a belief that miraculous healing is possible; and the aforementioned belief that suffering brings one closer to God. These can be overcome, but it requires patience and respecting the patient’s belief system even if the physician does not share it. (And, believe me, most physicians, even highly religious ones, would not choose heroic measures in such circumstances.)

Patients have all sorts of unscientific, faith-based beliefs, not just religious ones, that we have to deal with all the time. While it’s true that certain religious beliefs can interfere with patient care to an extreme degree and that religion is elevated in society far beyond other irrational belief systems such that it is respected far beyond what it deserves, physicians have to deal with the patient, irrational beliefs and all, and try to work with him or her to provide the best care possible, to prolong life, and, when it is no longer possible to prolong life, to palliate symptoms as much as possible. We do not have the luxury of treating a patient’s religious beliefs with contempt.

REFERENCES:

Andrea C. Phelps, MD, Paul K. Maciejewski, PhD, Matthew Nilsson, BS, Tracy A. Balboni, MD, Alexi A. Wright, MD, M. Elizabeth Paulk, MD, Elizabeth Trice, MD, PhD, Deborah Schrag, MD, MPH, John R. Peteet, MD, Susan D. Block, MD, & Holly G. Prigerson, PhD (2009). Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer JAMA, 301 (11), 1140-1147

Comments

  1. #1 Greg
    March 19, 2009

    I’ve already seen this one with a ‘the religious are afraid of death’ spin. One could say that atheists are nihilistic and find no meaning in life, or that the religious find more joy in life. I don’t think any of the above are fair myself, but it’s fun to be an ass with stats.

  2. #2 DLC
    March 19, 2009

    Or, you could look at it as one friend of mine does, and note that life is a gift from god, and not to be thrown away, even though it comes with suffering and pain. So, they insist on living every moment of it, good and bad.
    Or, they’re just not ready to test their assumptions about the afterlife. . . Who knows.
    I really don’t think studies like this do anyone any good.
    It’s hard to take individual cases and extrapolate into generalities. Hard? maybe even impossible.

  3. #3 Bhetti
    March 19, 2009

    Yes, certainly not. Something that is hammered in my own medical education over and over; as well as in this extra course I took in culture.

    It’s not that simple what the actual goals of medical practice are about, is it? I wonder if you remember how your views have changed since your interview or your entrance essay for medical school?

  4. #4 PlanetaryGear
    March 19, 2009

    so under the new health care overlords orthodox godists and smokers will pay higher premiums…

  5. #5 Erp
    March 19, 2009

    I wonder if this varies between religions. There probably aren’t enough Buddhists or Hindus (or Muslims) in the study (and highly religious Buddhists aren’t likely to be identified by this survey anyway if the example questions are any indication). Many of the less religious (to non-religious) are probably humanists of some sort, perhaps it is humanism that makes people less likely to seek apparently futile means of prolonging life.

  6. #6 Sigmund
    March 19, 2009

    I wondered about the between religions comparisons also. In the US the largest faith group who say their religion is ver important to them are the evangelical Christians – a group that predominantly believes not only in heaven but also in a very judgemental God consigning people to an eterity of hellish torture for apparently minor transgressions (I’ve frequently hear evangelicals say that all sins are euqual to God).
    I wonder if its fear of hell rather than lack of faith in heaven that might underline these figures. Perhaps a comparison with other faith groups, such as the Jews or Buddhist who don’t have a belief in hell might be useful.

  7. #7 adina
    March 19, 2009

    These results are somewhat counterintuitive- I would figure that religious people might fear death less, because they believe that there is an eternal world that awaits
    (unless, of course, the person thinks they’re going to the “lower-tiered” afterlife…)
    Even for atheists who desire “death with dignity,” it must be difficult to opt for death, when you feel there’s nothing after that, and that you will no longer exist.
    Sorry to be so morbid.

  8. #8 S.K.Sutton
    March 19, 2009

    Uh, oh. You called PZ “lazy and simplistic.” I fear the hordes may be summoned to descend upon this site.

  9. #9 S.K.Sutton
    March 19, 2009

    Uh, oh. You called PZ “lazy and simplistic.” I fear the hordes may be summoned to descend upon this site.

  10. #10 Mu
    March 19, 2009

    There’s also the strong condemnation of suicide by some churches, and I’ve seen interpretations of refusing treatment as equivalent to suicide. Since we are still looking on a small fractions of both groups who demand the aggressive care (10% vs. 3%) it’s hard to judge which of the possible explanation gives rise to this choice.

  11. #11 rrt
    March 19, 2009

    I can’t agree that the study is useless, DLC…far from it. We need to understand religion much better. We need to be willing to approach it as a scientific question, as advocated by the recent book whose name and author I can’t recall. I think in the long run this will be healthier for atheist and theist alike. I could easily see this avenue of inquiry leading to better, theologically-comfortable health choices. Yeah, I know it’s fodder for arguments, but Orac nails it in pointing out there’s so much more to this. Yes, I do suspect that nonbelievers still come out ahead here, but so what? I still think studying this can help.

  12. #12 Mary
    March 19, 2009

    Orac says:
    “These days religion just doesn’t matter that much to me one way or the other, except for when it interferes with concrete things that matter, such as patient care, the teaching of science, or civil rights. Since then, for the most part it’s been live and let live.”
    Actually, you lost me right here since this is no small exception, rather it appears to be a frightening trend. It is nearly impossible to separate science from politics or religion, and I, for one, eagerly await your bold take on it. Sure it’s personal and painful, but tackle it anyway. That’s why I come here.

  13. #13 Calli Arcale
    March 19, 2009

    This is very interesting, and counterintuitive to me, given how often I’ve seen stories of people *refusing* medical care based on their faith. Antivaxxers, for instance, and Jehovah’s Witnesses refusing blood transfusions, and of course faith healers.

    I definitely do not think it’s because the religious either fear death or secretly doubt their own salvation. On the contrary, when I think about religious folks I know who’ve chosen to go for heroic measures, they’ve all bee rather self-assured people, confident in their salvation. Staying alive for them has nothing to do with fear of death *or* fear of not going to heaven. I’m sure the reasons vary from person to person, but this is probably a very complex subject.

    My grandfather recently passed away. He was a Christian (descended from Presbyterians, but nominally Unitarian himself), but also an adamantly non-religious person. Believed passionately in God, but generally considered organized religion a waste of time and resources. Politically, I’d describe him as a conservative libertarian. He was also a proponent of euthanasia, and had written a living will decades ago. When his time came, he was able to follow it to the letter. He died at home under hospice care, deliberately refusing food to hasten the end, and specifically refusing any resus at this point. While I don’t think I would have made the same decision (he could have made a strong recovery and had several more years with a decent quality of life; most people don’t consider themselves infirm merely because the doctor has told them to stop doing the five-mile daily constitutional), I greatly respect the dignity with which he exited this world.

    My grandparents on the other side are quite different. They are also ardent believers (Lutherans), and not especially religious, but they do attend church regularly and feel that organized religion has a place in daily life. Politically, I’d describe them as moderates, leaning somewhat to the left. They also have a living will, but theirs states that they want everything — CPR, intubation, even artificial feedings and hydration. What’s really interesting is that both despise actually being in the hospital, and my grandmother recently left the hospital after a knee replacement against medical advice (with adverse consequences). They both have a history of hiding symptoms and even outright lying to their doctors to avoid hospital admissions, to the point where they actually wind up in hospital *more* because their condition deteriorates to the point where it can no longer be denied. I do not fully understand this cognitive dissonance. They hate hospitals, but want mechanical ventilation?

    This thread has, however, given me another explanation that makes more sense than any I’ve thought of before. It’s not martyrdom, and it’s not fear of death. It’s hope. The same thing that drives people to buy lottery tickets and play slot machines, despite the odds. It’s also why very smart people get into hedge funds. As long as they believe that recovery isn’t actually impossible, they will not give up and do not want anyone else to give up either.

    Humans are notoriously bad at understanding risk factors. This is why our economy is in the state it’s in. Maybe that’s all it is. And maybe religious folks, on average, are just enough more prone to holding out hope that they’re less willing to turn off the machines. If they were to look at it analytically, they would see that a) the hope is too slim to justify the pain and suffering (or even nonexistent), and b) if they have faith in God, maybe they should really put their trust in Him and not hold things back artificially to absurd extremes. I think this is the case for my grandparents. It’s not that their religion makes them think that heroic measures are called for by God; it’s that they tend to be more optimistic about faint hopes. I’ve noticed this in them on other occasions, now that I think about it. It’s the “if we can just get through now, tomorrow will be better” philosophy. You might not have to endure the mechanical ventilation for long, and then you’ll be all better. Odds are against that, but they hope for it anyway, so ardently that they have difficulty seeing hte more.

    Speaking as a theist, it is very difficult to know when God is speaking to you and when you are just hearing what you want to hear (your own internal monologue). (Of course, I cannot know that I’m *ever* hearing God.) We believers need to be skeptical, and not immediately trust that the voice we’ve heard is actually God. We are more likely just hearing an echo of ourselves. (Or, for those who believe in Satan as an actual entity, we may be hearing him.) One *causal* factor for religion being related to heroic measures may be that the overtly religious are less likely to question their internal monologue, because they are afraid of doubting God. This is probably the case for the woman with breast cancer in the story, who opted for absurdly aggressive treatment and paid a heavy price.

  14. #14 The Perky Skeptic
    March 19, 2009

    My father just had a stroke and needs round-the-clock care that neither my family (I have to care for my autistic son) nor my brother’s family (with two-month-old baby) can provide. We cannot afford private care and he will have to go into a nursing home when he gets discharged from the hospital.

    The worst thing, the most horrifying part, is that his mental faculties are intact. He can still talk ballet and opera with me, but his body has given out. I’ve seen the way the hospital staff treats him (like a five-year-old), and it sends chills up my spine to think how much less respect and care he will receive in a Medicaid-paid-for nursing home.

    All this has made me change my mind on end-of-life issues. Medical science is too good at saving lives for my comfort. I would rather die from a stroke than have 911 called and end up surviving, like that, under those circumstances. Seriously– not only do I want the most aggressive DNR order possible, I also really don’t want emergency medical services if I’m over the age of 80. Is there a medalert bracelet for that?

  15. #15 ancientTechie
    March 19, 2009

    Although several have commented regarding fear of death or of eternal retribution, it seems to me that anxiety associated with change and simple fear of the unknown may play a very important role in this phenomena. Most people are at least a bit anxious regarding major changes in their live, even when those changes are positive in nature, (e.g. going off to college or entering a new job with higher pay and greater responsibility.) Christians are conditioned to believe that death entails a major transition from life in this world to life in another. Atheists see death as an end, not a transition, which should entail less fear and anxiety, though perhaps greater sadness born of one’s anticipated loss of opportunity to experience the world. Such differences could account for much of the effect of religion on medically related decisions among the groups under consideration in this study.

  16. #16 BB
    March 19, 2009

    Quote: This may make sense. After all, there are Orthodox Jewish sects that value life above all else, sometimes to the point of insisting on keeping the bodies of brain dead children alive.

    Orthodox Jew chiming in here. This is misleading in the context of the blog post. The mainstream rabbinic authorities (e.g. Rabbi Tendler) DO NOT subscribe to this at all. What they do say is to make a living will in accordance with rabbinic law (for DNR; when to put in feeding tubes or not, etc.).

  17. #17 Ryan Biggs
    March 19, 2009

    Religionists believe in miracles. Look at the Terry Schiavo case. All the CAT scans in the world couldn’t convince people that a miracle wasn’t possible. Many so-called Christians are not really firm believers, but maintain their status among the faithful just to “hedge their bets”. Why wouldn’t they similarly want to hedge their bets when a doctor tells you that a miraculous recovery is out of the question?

    I’m an atheist myself, but I applaud Orac’s handling of this study. In particular, the observations about Christianity’s notion that enduring pain and suffering with dignity can bring you closer to god.

  18. #18 Ryan Biggs
    March 19, 2009

    Religionists believe in miracles. Look at the Terry Schiavo case. All the CAT scans in the world couldn’t convince people that a miracle wasn’t possible. Many so-called Christians are not really firm believers, but maintain their status among the faithful just to “hedge their bets”. Why wouldn’t they similarly want to hedge their bets when a doctor tells you that a miraculous recovery is out of the question?

    I’m an atheist myself, but I applaud Orac’s handling of this study. In particular, the observations about Christianity’s notion that enduring pain and suffering with dignity can bring you closer to god.

  19. #19 Ryan Biggs
    March 19, 2009

    Religionists believe in miracles. Look at the Terry Schiavo case. All the CAT scans in the world couldn’t convince people that a miracle wasn’t possible. Many so-called Christians are not really firm believers, but maintain their status among the faithful just to “hedge their bets”. Why wouldn’t they similarly want to hedge their bets when a doctor tells you that a miraculous recovery is out of the question?

    I’m an atheist myself, but I applaud Orac’s handling of this study. In particular, the observations about Christianity’s notion that enduring pain and suffering with dignity can bring you closer to god.

  20. #20 mk
    March 19, 2009

    It is unsurprising to see someone, who was until fairly recently a practicing religionist, interpret this study as Orac has. Likewise unsurprising to see PZ, someone who–if memory serves–was never religious, interpret it his way. Also not surprising that Orac took offense. Religious folk tend to be super-sensitive that way.

    I wonder if PZ will apologize. ;^}

  21. #21 CyberLizard
    March 19, 2009

    The Perky Skeptic said:

    Seriously– not only do I want the most aggressive DNR order possible, I also really don’t want emergency medical services if I’m over the age of 80.

    I tend to agree, but one thing freaks me out: making a bad call or having a bad call made about me. Not so much about the over 80 target; by then I hope I’ve lived enough to be more accepting of death. But rather for while I’m still (relatively) young. I’ve thought that I’d want to order that I be allowed to die if the majority of, say, 5 specialists in whatever my condition is agree that I have almost no chance of recovery. Is that do-able? Too stringent? I just think it’s too excruciating and unfair to leave the decision up to my spouse, who will undoubtedly be under a tremendous amount of strain by the whole ordeal.

    Interesting story about a DNR: We were called to my Papa’s chair side (he hung out in a recliner rather than in bed) because they thought it was the end. The family decided to call for an ambulance to take him to the hospital just to make sure that it was truly the end. The paramedics who picked him up said that, even though he had a DNR, they were required to attempt resuscitation if he coded in the ambulance on the way. He survived the trip but ended up dying a week or so later. He had lapsed into a diabetic coma. To tie all this back to the original post, he was a Lutheran pastor and had absolutely no problem going “home” to be with his “heavenly father”.

  22. #22 RE
    March 19, 2009

    First, excellent, thoughtful posts, everybody.

    As a retired physician, I have seen a fair amount of death, as well. I know it’s anecdotal only, but I thought I did notice a trend that the religious were much more likely to choose aggressive measures that I would never choose for myself. Others, whether I knew they were religious or not, seemed to be of a similar mindset, though. I felt it was a personality issue…mainly a propensity for denial. A denial of problems, medical issues, death, you name it. If or when that stoic exterior ever broke, it was difficult for me and the families to deal with the almost infantalized person that remained at times. Often for the religious, it was a hard to watch questioning of faith, like their father had just beat them for the first time. It may be simply that whatever wiring allows one to come to the idea that atheism is a more realistic view of life, also allows one to take a more realistic view of medical outcomes. The real motivation for our choices still seems pretty vague. Why would one choose denial over rationalization as a coping mechanism for fear? As a matter of fact, I don’t know how you would decide the difference in one person’s “hope to never die” and another’s “fear of death” as a motivation.

    Somewhat off the subject, but I have another anecdotal experience, as well. I felt that minorities were more likely to choose aggressive measures. I put this off to their belief that a white doctor or the “system” was less likely to give them all the care that was needed if they didn’t demand it. Maybe religious motivations were there that I didn’t see?

  23. #23 Sastra
    March 19, 2009

    “While it’s highly tempting to take the lazy and simplistic path of simply using a study like this as yet another convenient excuse to bash religion, but as much as certain atheists triumphantly gloat over this study as evidence that either religious people, when it comes right down to their time to check out, don’t really believe in heaven, the explanation for the results of this study probably comes down to a combination of factors, including valuing life over quality or form of life (think: abortion controversy); a belief that miraculous healing is possible; and the aforementioned belief that suffering brings one closer to God.

    I don’t think PZ reacted to this story as evidence that “religious people don’t really believe in heaven.” What little he wrote was:

    Most religions are built on fear and ignorance, so we shouldn’t be at all surprised to find that these dying people respond to their situation with great fear, and with little planning or thought. I don’t even think it’s because religion tells people to ignore their wills or to seek the most excessive (and ultimately, futile) medical attention — this is a property of the kind of people who seek out religion.

    The “kind of people who seek out religion” — are very religious — will hold the sorts of views regarding valuing suffering, trusting in God, and expecting a miracle which could be uncharitably characterized as products of “fear and ignorance.” I’m not sure PZ would disagree with your assessment, then. It seems reasonable, and all those factors came up in comments.

    (I guess the hordes are descending.)

    It’s interesting to note, though, that had the results gone the other way, it’s likely that many religious people would have gleefully used it as demonstration that atheists have no comfort in the face of death, whereas those who know they go to meet God are calm and eager with expectation. It’s not unfair, then, to point out that they can’t use this.

  24. #24 Calli Arcale
    March 19, 2009

    Of course, Sastra. Whenever there is a study which involves the relationship between one’s religious or political views and various outcomes, one side or the other (sometimes both) will use it as some sort of gloating argument against the others’ point of view. Which is silly, because seldom do the studies really support that. At best, such studies reveal underlying traits in different groups, or reveal how different groups tend to respond to certain questions (since most such studies tend to be surveys dependent on self-report).

    One other thing that bears pointing out is that it is a false dichotomy between “religious” and “atheist” — and the study was cognizant of that, looking not only at whether or not someone called themselves a Christian/Jew/whatever but how heavily invested they were in the religious trappings of their faith — measures of religiousness. (Of course, that also points out a weakness — the study evaluated religiousness based on 14 measures of religious coping, and of course that is unlikely to encompass everything to do with a person’s religious opinions or practices. One would assume it got the biggies, though, and it sounds like they did a good job of finding a representative sample of religious measures.)

    What I’m trying to get at is that just because a person isn’t religious doesn’t mean they’re an atheist. My late grandfather is a good example. He was an ardent believer in God, but not even remotely religious. I think the last time he’d been to a church service was my brother’s wedding a few years ago, and that was mostly for the free food and drinks afterwards. ;-)

  25. #25 Jane Goth
    March 19, 2009

    I read a lot of fundamentalist Christian blogs, mostly out of fascinated horror. This is only anecdote so it doesn’t make a data set, but it does seem to me that hope of a miracle and the belief that life is to be fought for as long as possible forms a strong part of the seeking the most aggressive medical care that is available.

    It has been heart breaking to read some of the blogs especially where it has involved the eventual death of a child. The parents pleading for pray for a miracle from their readership whilst fighting for ongoing medical care, where to an impartial, non-fundamentalist (I’m an atheist) reader can see that the medical staff are right and there is no hope of recovery (in the case I’m thinking of the poor child was brain dead) every involuntary twitch was seen as a sign that the child was still capable of recognising them and that “God was good.” So so sad.

  26. #26 Joshua Zelinsky
    March 19, 2009

    Orac thanks for writing a well-thought piece about this study. I’ve seen a lot of junk about this. The problem of limited resources does raise serious ethical problems but we can’t just dismiss patients’ desires even if they strike us as irrational or poorly thought out. These are difficult issues that rarely have clear solutions.

  27. #27 Emp
    March 19, 2009

    I read about this study first on another blog, but I came away from it perplexed. Although I am an atheist with some degree of contempt for religion, it doesn’t seem plausible to me that religious people simply “don’t actually believe in heaven,” as someone put it. The fact that religious people seek more aggressive treatments makes a bit more sense now that I have factored in the martyr complex that is practically characteristic of many religions (notably Catholicism.) I’m sure some are holding out for an incredibly unlikely miracle as well.

  28. #28 AnnR
    March 19, 2009

    Maybe I wasn’t paying attention in Sunday school, but I thought Christ suffered and died for our sins and we are forgiven. All we have to do is acknowledge our sins and ask for it.

    Somehow the notion that suffering will bring us closer to him strikes me as lacking in faith.

    I’m more inclined to think that the hyper-relgious are hoping for a miracle.

  29. #29 Dick Alstein
    March 19, 2009

    I’m starting to think that my grandfather was the victim of the mirror image of this phenomenon. He was an atheist himself. When he got terminally ill the surgeon in charge started a treatment that, in retrospect, had no chance of success but made the end much more painful. I even recall the surgeon saying “we must always hope for a miracle”.

    On that note, I’d like to see this research repeated. But instead of measuring classical religiousness it should gauge the general belief in miracles like ESP, communication with the dead, tarot, etc.

  30. #30 Adrienne
    March 19, 2009

    As an ex-Catholic and former Opus Dei school student, let me add that I have noticed a belief among the fringiest of the religious right fringe that “palliative care” is basically a synonym for passive euthanasia. They believe “DNR” orders basically allow you to be put down or not given hydration/nutrition.

    Even worse, I have seen some wingnuts propagate the belief that doctors are eager to declare the seriously or terminally ill in a “vegetative state” so they can grab these people’s organs.

    Judie Brown of the American Life League, which is so “pro-life” as to oppose abortions even when the mother’s life is in danger, actively warns people not to be organ donors due to her belief that doctors routinely hasten along brain death in comatose people who have volunteered to be organ donors just so these doctors can take their organs while their heart still beats.

  31. #31 Adrienne
    March 19, 2009

    To see an example of the conservative Catholic mindset on this, see this link: http://www.nrlc.org/euthanasia/willtolive/Cockfield.html

    Here’s a highlight:

    While a hospital is a place of healing and care, it is also a potential place of danger for those of us who are disabled, elderly, or chronically ill. Whenever I have been admitted to a hospital, I experience a certain apprehension, knowing that medical caregivers may “opt out” of providing me life-saving medical treatment if they decide my quality of life is not sufficient to justify their effort and expense.

    Everyone is just an accident or illness away from joining me in the bulls-eye of the growing threat of euthanasia. Even now, many senior citizens are pressured to sign “Do Not Resuscitate” orders when admitted to the hospital. They are devalued because of age. As our Medicare and Medicaid systems lurch from one fiscal crisis to the next, the pressure increases to save money by denying medical care to those who are most expensive. That includes me along with others living with either physical or mental disabilities, or those with chronic illnesses whatever their ages.

    Also, I cut this from another Catholic “pro-life” site:

    “Do Not Resuscitate” (DNR) or “No Code” are examples of imprecise and ambiguous orders widely–and wrongly–accepted by physicians and courts. Do these orders mean no maintenance of an airway, or no ventilation, or no cardiac resuscitation, as well as no new or additional treatment? Furthermore, in light of the weakness of human nature, once the course has been plotted by a DNR or “No Code” order, there is a tendency to preclude, eliminate or reduce ordinary treatments, such as visits by physicians and care given by nurses and others. Therefore, broad orders of “Do Not Resuscitate,” “No Code,” and similar orders must be avoided. At no other time in medicine are treatment orders that are so broad and non-specific considered to be within the standard of care.

  32. #32 Joseph C.
    March 19, 2009

    While a hospital is a place of healing and care, it is also a potential place of danger for those of us who are disabled, elderly, or chronically ill. Whenever I have been admitted to a hospital, I experience a certain apprehension, knowing that medical caregivers may “opt out” of providing me life-saving medical treatment if they decide my quality of life is not sufficient to justify their effort and expense.

    What junk! Name me a country where heroic measures/futile care are give more frequently than the USA. You can’t. It’s well known that we venture into the domain of medical torture on a daily basis. It takes a far, far fringe religious type to spout this kind of nonsense. As a card-carrying atheist, I’m going to assume that this fellow is of the fringe of the fringe. Which I guess brings us to one of the issues with this whole theist-antitheist debate: people like to cite examples from the fringe as being representative. It’s just more complicated than that I’m afraid.

    Anyway, great post, Orac. Very thought provoking, even if it does seem that you are shying away from atheism more because you don’t want to be “guilty by association” with certain foaming mad dog atheist types than for any other reason.

  33. #33 Adrienne
    March 19, 2009

    As a card-carrying atheist, I’m going to assume that this fellow is of the fringe of the fringe.

    Judie Brown of American Life League (ALL), with her organ-donor scares, is indeed part of the fringe of the fringe. She left National Right to Life to found the American Life League because she disagreed with NRL’s position that abortion was justifiable only when the mother’s life was endangered.

    But that paragraph you quoted from my previous post is from an essay posted on the National Right to Life’s website, and National Right to Life (NRL) is definitely not “fringe”. It’s the largest and most visible “pro-life” organization in the United States.

    NRL doesn’t slam the idea of palliative care the way that ALL does, nor does it tell people not to be organ donors, but it clearly endorses the position that people should be wary of DNR orders.

  34. #34 Adriene
    March 19, 2009

    Oh,just to clarify, American Life League (ALL) opposes abortion under ANY circumstance, even when the mother’s life is in danger. And actually, Judie Brown encourages women facing danger from their pregnancy to embrace the nobility of pain and sacrifice as exemplified by Jesus on the Cross rather than take steps to protect their own lives.

  35. #35 notedscholar
    March 19, 2009

    Interestingly, there are prima facie reason to think religious people would be less likely to want heroic aggressive measures; namely, religious people allegedly want to go to Heaven. Some atheists mock religious people in this way, suggesting they should even kill themselves if they really believe this world is meaningless compared to Heaven.

    NS

  36. #36 Joseph C.
    March 19, 2009

    But that paragraph you quoted from my previous post is from an essay posted on the National Right to Life’s website, and National Right to Life (NRL) is definitely not “fringe”. It’s the largest and most visible “pro-life” organization in the United States.

    How about we say that NRL is fringe, but not fringe of the fringe?

    Exhibit A:

    http://www.nrlc.org/abortion/ASMF/asmf13.html

    There is strong evidence that abortion increases the risk of breast cancer. A study of more than 1,800 women appearing in the Journal of the National Cancer Institute in 1994 found that overall, women having abortions increased their risk of getting breast cancer before age 45 by 50%. For women under 18 with no previous pregnancies, having an abortion after the 8th week increased the risk of breast cancer 800%. Women with a family history of breast cancer fared even worse. All 12 women participating in the study who had abortions before 18 and had a family history of breast cancer themselves got cancer before age 45.

    Yep, they’re still pushing this nonsense.

  37. #37 Tom T.
    March 20, 2009

    ORAC, all I’ve read of the study are your excerpts, but are you saying that someone who is “wondering whether God has abandoned me” was classed as non-religious? Why would an atheist wonder whether God has abandoned her? This makes me a bit skeptical of this study’s criteria.

  38. #38 mj
    March 20, 2009

    I think that there may be the feeling that if you don’t prolong death as long as possible, you’re giving up on god performing a miracle. That you must wait as long as possible to give it time for a miracle to occur. And, additionally, that it’s hard to accept that no miracle is coming.

    Whereas, without faith, there’s no prospect of a magical recovery, and no belief that the rules of thermodynamics and medical science don’t also apply to you.

  39. #39 Mike
    March 20, 2009

    I wonder if this study has any relevance to antipathy to organ donation? Religion is often given as a reason to justify not supporting it, whether that person has any understanding of their particular religion’s support for donation, or not. All religions I know of, with the exception of a southwest native American sect, at least allow organ donation, yet the congregants who have never given the eventuality any serious thought before they’re asked often disagree. Most Jewish movements have concluded that organ donation is mandatory when possible, but that hasn’t translated to 100% support.

  40. #40 Gingerbaker
    March 20, 2009

    When you hear hoofbeats, expect horses, not zebras.

    I don’t understand the reluctance to attribute the results of the study to the most common human emotion – fear. Christianity is a death cult, after all. It is a game who’s scoring system is sin, and whose reward is heaven. It is ALL about living after death and how to ensure that that happens. Why, you can even purchase ‘indulgences’ now to lessen one’s time in purgatory while awaiting Heaven itself!

    The alternatives to simple doubt and fear listed by posters above simply prove the point – the basis for any of these alternatives is still fear.

    “…life is a gift from god, and not to be thrown away” …”fear of hell rather than lack of faith in heaven”…”more prone to holding out hope”…”enduring pain and suffering with dignity can bring you closer to god.” etc. All of these alternative motivations stem from the fear of death. They all stem from doubt about whether one has done enough to avoid ultimate and final death. They all assume that God, if he deems it, will deliver on the goods and death will be just the beginning.

    As others have pointed out, the highly religious are not the most introspective of people. They leave such questions to a ‘higher authority’. They have played the game of sin and heaven their entire lives in order to avoid thinking about their own mortality. They refuse to believe in their own mortality – it is the cornerstone of their faith. How many times have you seen a Believer hurl his most vile imprecation – “You (not me) are going to Hell!” As the doctor above related – these people are in denial.

    The study results are counterintuitive to us for a reason – those who truly believe in an afterlife should be least afraid to die. That they are not seems perfectly aligned with the simple explanation that after a lifetime of avoiding contemplation of their own mortality, they experience grave doubt when the rubber meets the road.

  41. #41 Dan
    March 20, 2009

    As a skeptical but practicing theist, my fondest hope is to go out in such a way that my organs can be given to as many people as possible.

    Greater love hath no man than this, that a man lay down his life for his friends.

  42. #42 Liesl
    March 20, 2009

    Oh god, Perky Skeptic, don’t give up on your dad that easily! People can and do get better after strokes with continued work. Just because your dad has lost function now does not mean he has lost it permanently. It could mean that, of course, but strokes are not the end result they once were, in many cases.

    By the way, I’m writing not as a medical professional (nowhere near such a thing), but as a multiple stroke survivor. Now, this stroke survivor is going to get her ass back outside to till some more soil. < ---see? science is indeed good. :->

  43. #43 Tina Kubala
    March 21, 2009

    I’m a Christian who is open minded enough to read Science Blogs. Heck, I don’t even think Genesis is a historical record.

    For me, faith makes me comfortable with the idea of my own death. Or, at least, as comfortable as a woman in her twenties can be. I know in my heart this life is only the tip of the iceberg, so why would I want to live without quality of life? Jesus wanted us to have “abundant” life. Being kept alive by machines isn’t my idea of abundance.

    As for organ donation, I know some Christians feel we will literally be risen when Christ returns, therefore they don’t cremate remains or donate organs. I’m hoping for a taller body with a faster metabolism in the after life, so I’m an organ donor ;-)

    In short, study or not, it’s not possible to judge religious folks as a group. We are not cut from the same cloth.

  44. #44 Abram
    March 22, 2009

    Scientism is so often a refuge for an injured soul.
    Orac, I have not read your previous stuff, so you will have to pardon my ignorance of it. But, those who rant against “quackery, anti-vaccine movements and religion” are, in my estimation, often people who are engaged in a religious search of their own. You want to stand on the firm ground of Truth (capital T). Other avenues which have promised you Truth have abused you, misled you, and discouraged your soul. Science is a form of rebellion for some.
    You see, Newton, Einstein and Darwin were all intensely religious people. For these great minds, there was no contradiction between their passion for nature (science) and a reverence for the God of nature. Religions are often empty vessels. But, science, pursued in place of religion (Scientism) is just as empty.
    One of the great Indian Chiefs once said (and I’ll have to paraphrase), “Once all the books have been written, and all of the preachers have finished preaching, and all of the teachers have finished teaching, one thing will still remain: the great mystery.” Unfortunately, the most important things can not be known, but the mystery itself may be the only firm ground.

  45. #45 Michael
    March 22, 2009

    An important aspect of the study that is being missed is that this is only about 10% of the patient population for those who were classified as positive religious copers. A significant problem with the way the statistical analysis was completed was that it created only two groups: high and low religious copers. When you look at the high religious copers, they are lumped into one group and this is where the problem lies. Most of those receiving aggressive care in the positive religious coping group were much closer to the middle of the overall scale. So if the scale was broken up into 4 groups: low, middle low, middle high, and high religious copers, the group receiving more aggressive care on a statistical level was the “middle high” group. The analysis hides this. It would appear that what is really going on is that those who have some religious identity and beliefs, but have not really had that identity solidified and integrated into their life, that they are the ones receiving more aggressive care.

  46. #46 Orac
    March 22, 2009

    Scientism is so often a refuge for an injured soul.
    Orac, I have not read your previous stuff, so you will have to pardon my ignorance of it. But, those who rant against “quackery, anti-vaccine movements and religion” are, in my estimation, often people who are engaged in a religious search of their own. You want to stand on the firm ground of Truth (capital T). Other avenues which have promised you Truth have abused you, misled you, and discouraged your soul. Science is a form of rebellion for some.

    Give me a break. What does “scientism” have to do with this post? If anything, i was defending the more religious viewpoint against what I considered to be unjustified attacks based on this study, even though I don’t subscribe to it.

    Methinks you have a set of boilerplate comment text that you plug in anywhere you sense anything that attacks your religion and then you use it, whether it fits or not.

  47. #47 Jud
    March 23, 2009

    Science is a form of rebellion for some.

    The only thing science “rebels against” is lack of knowledge. If that’s a problem, it’s yours, not one for those who love learning.

  48. #48 The Perky Skeptic
    March 23, 2009

    @ Liesl,

    Thank you for those words of encouragement! I’m really glad to hear about your experiences with regaining function after stroke.

    Sadly, my dad has tons of other health issues which might also necessitate round-the-clock care at this point, but we’re definitely not giving up on him. He’s working really hard on his physical therapy, so he might be able to do assisted living. Only time will tell.

  49. #49 Rsunder
    March 23, 2009

    I respect the fact that you became less “militant” against religion as your “deconversion” got further away, that tends to happen. What I absolutely resent is you in essentially contributing to the idea that only those who are militant against religion as simply reactionary.

    I am, in fact, a scholar of religion. Outside of my academic scholarship, I am also absolutely militantly anti-religious and have been for years. It is not reactionary due to my just losing faith as many, even other “uncle tom” atheists make it seem. There are completely valid logical reasons to actively fight against religion. Your post smells a bit like “I’m better than those reactionary atheists because I mellowed,” and that is very insulting to us who see the dangers of religion as something which needs to be fought tooth and nail.

  50. #50 Orac
    March 24, 2009

    My, my, my, my, you’re touchy. I assure you that nothing of the sort was intended. It was a simple statement of fact about how my views have evolved over the last three or four years.

    Feel insulted by it? Quite honestly, I don’t care. I think you’re being excessively sensitive.

  51. #51 Joseph C.
    March 24, 2009

    You see, Newton, Einstein and Darwin were all intensely religious people.

    Darwin was religious? What’s next? Richard Dawkins is religious?

  52. #52 Eamon
    March 24, 2009

    I agree with what Mu wrote earlier – the strong prohibition against suicide in certain churches is going to have a strong effect.

  53. #53 Tassie Devil
    March 26, 2009

    Late to the party, but I felt that the interpretation of this study was ass-backwards. People who don’t want to die, or at least want to believe that death is not the end, tend to stay religious. It’s the question/accusation most often thrown at atheists: ‘so, when your mother/partner/best friend dies, that’s it? Over? You heartless ****.’ The promise of life after death is the carrot held out by religion.

    Those who can deal with the fact that we all have only a short time in the sun have likely accepted the finality of death, and care instead about quality of life.

    I think people’s personalities dictate both whether they choose religion and their attitudes to death. 

     

  54. #54 Maureen Lycaon
    March 29, 2009

    Another study suggests that “religious people really are more optimistic that they aren’t going to die.” They demand that their lives be prolonged as long as possible, hoping for a miracle and believing it can happen.

    So Calli Arcale above seems to be right.

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