Article review by Dawn Drake – Writing sample 5/2008
Lieff, J. (1982). Eight reasons why doctors fear the elderly, chronic illness, and
death. The Journal of Transpersonal Psychology, 14(1), 47­60.
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 described recent (at the time of publication) research findings that

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indicated “widespread and well­documented prejudice” (p. 47) against elderly and
terminally ill patients, and that suggested prejudice and avoidance behaviors were
fostered in American medical schools. Lieff also documented benefits of
psychological support for dying patients and then identified and discussed eight
reasons to explain the “fear” (p. 47) 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 elder­care),
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

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for doctors. All of the reasons for fear that Lieff discussed reflected psychological or
spiritual issues; consideration of other contributing factors was noticeably lacking.
Although Lieff 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 that many
doctors did not recognize the human potential to transcend physical limitations and
find personal fulfillment, that doctors lacked resources for finding philosophical
insights into the purpose of death and the dying process, 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 own frustration in coming

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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…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).
Statements such as these contributed an emotional quality to the article that
might increase the persuasiveness of the argument for some readers, but that
others might find inappropriate in a scholarly article. Upon recognizing this
undertone of personal frustration, the reader has cause to 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 presentation of the issues.
Further Research
Lieff supported Kastenbum’s recommendations for providing patient­oriented
standards, but expressed reservations about the whether those recommendations
could be successfully implemented in America. Lieff (1982) suggested that hospices,

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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 end­of­life care.
Changes have occurred in American society that have dramatically altered
the circumstances that existed when Lieff wrote this article. Some pivotal ones that
directly affected medical care are,
1. In 1983, Medicare began paying for hospice care for eligible patients (von
Guten & Ferris, 2002).
2. In 1997, the American Board of Psychiatry and Neurology, Inc. approved
Geriatric Psychiatry as an official subspecialty (n.d.).
3. In 2006, the American Board of Medical Specialties (ABMS) approved the
subspecialty of Hospice and Palliative Medicine (HPM) (American Board
of Medical Specialties, 2006). (Palliative care provides treatment to
alleviate pain and symptoms without treating the underlying cause.)
4. 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 one­third
of all deaths in the United States that year occurred while the patient was

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receiving hospice care.
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 do not 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 Lieff identified, that might contribute to those attitudes and
behaviors.
Lieff’s 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

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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, etc., provide 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 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 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”
in our society and that they are ill prepared ethically and morally “beyond obeisance
to academic and guild organizations”, 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, 58).” Research into doctors’
opinions about including spiritual orientation in medical training would be

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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 worth
exploring; additional examination should quickly raise research possibilities beyond
those identified above.
Conclusion
Lieff 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,
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

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the elderly and the seriousness of the concerns raised by Lieff, 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 10­KSB/A­1 Annual Report Pursuant to
Section 13 or 15(d) of the Securities Exchange Act of 1934. Retrieved May 2,
2008, 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 April 30, 2008, from
http://www.abpn.com/gp.htm
Lieff, J. (1982). Eight reasons why doctors fear the elderly, chronic illness, and
death. The Journal of Transpersonal Psychology, 14(1), 47­60.
National Hospice and Palliative Care Organization (NHPCO). (n.d.). Growth in U.S.
hospice programs: 1974 to 2006. Retrieved May 5, 2008, from
http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts­and­
figures_Nov2007.pdf
National Hospice and Palliative Care Organization (NHPCO). (2007). NHPCO facts
and figures: Hospice care in America. Retrieved April 30, 2008, from
http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts­and­
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 May 4, 2008, from
http://64.85.16.230/educate/content/rationale/ushospicegrowth.html