Images and Symbols: Studies in Religious Symbolism
By Mircea Eliade, Philip Mairet; Sheed Andrews and McMeel

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I Symbolism of the "Centre"
THE PSYCHOLOGY AND HISTORY OF RELIGIONS

Many laymen envy the vocation of the historian of religions. What nobler or more rewarding occupation could there be than to frequent the great mystics of all the religions, to live among symbols and mysteries, to read and understand the myths of all the nations? The layman imagines that a historian of religions must be equally at home with the Greek or the Egyptian mythology, with the authentic teaching of the Buddha, the Taoist mysteries or the secret rites of initiation in archaic societies. Perhaps laymen are not altogether wrong in thinking that the historian of religions is immersed in vast and genuine problems, engaged in the decipherment of the most impressive symbols and the most complex and lofty myths from the immense mass of material that offers itself to him. Yet in fact the situation is quite different. A good many historians of religions are so absorbed in their special studies that they know little more about the Greek or Egyptian mythologies, or the Buddha's teaching, or the Taoist or shamanic techniques, than any amateur who has known how to direct his reading. Most of them are really familiar with only one poor little sector of the immense domain of religious history. And, unhappily, even this modest sector is, more often than not, but superficially exploited by the decipherment, editing and translation of texts, historical monographs or the cataloguing of monuments, etc. Confined to an inevitably limited subject, the historian of religions often has a feeling that he has sacrificed the fine spiritual career of his youthful dreams to the dull duty of scientific probity.

But the excessive scientific probity of his output has ended by alienating him from the cultured public. Except for quite rare exceptions, the historians of religions are not read outside the restricted circles of their colleagues and disciples. The public no longer reads their books, either because they are too technical or too dull; in short because they awaken no spiritual interest. By force of hearing it repeated--as it was, for instance, by Sir James Frazer throughout some twenty thousand pages--that everything thought, imagined or desired by man in archaic societies, all his myths and rites, all his gods and religious experiences, are nothing but a monstrous accumulation of madnesses, cruelties and superstitions now happily abolished by the progress of mankind--by dint of listening almost always to the same thing, the public has at last let itself be convinced, and has ceased to take any interest in the objective study of religions. A portion, at least, of this public tries to satisfy its legitimate curiosity by reading very bad books--on the mysteries of the Pyramids, the miracles of Yoga, on the "primordial revelations", or Atlantis--in short, interests itself in the frightful literature of the dilettanti, the neospiritualists or pseudo-occultists.

To some degree, it is we, the historians of religions, who are responsible for this. We wanted at all costs to present an objective history of religions, but we failed to bear in mind that what we were christening objectivity followed the fashion of thinking in our times. For nearly a century we have been striving to set up the history of religions as an autonomous discipline, without success: the history of religions is still, as we all know, confused with anthropology, ethnology, sociology, religious psychology and even with orientalism. Desirous to achieve by all means the prestige of a "science", the history of religions has passed through all the crises of the modern scientific mind, one after another. Historians of religions have been successively--and some of them have not ceased to be--positivists, empiricists, rationalists or historicists. And what is more, none of the fashions which in succession have dominated this study of ours, not one of the global systems put forward in explanation of the religious phenomenon, has been the work of a historian of religions; they have all derived from hypotheses advanced by eminent linguists, anthropologists, sociologists or ethnologists, and have been accepted in their turn by everyone, including the historians of religions!

The situation that one finds today is as follows: a considerable improvement in information, paid for by excessive specialisation and even by sacrificing our own vocation (for the majority of historians of religions have become orientalists, classicists, ethnologists, etc.), and a dependence upon the methods elaborated by modern historiography or sociology (as though the historical study of a ritual or a myth were exactly the same thing as that of a country or of some primitive people). In short, we have neglected this essential fact: that in the title of the "history of religions" the accent ought not to be upon the word history, but upon the word religions. For although there are numerous ways of practising history--from the history of technics to that of human thought--there is only one way of approaching religion--namely, to deal with the religious facts. Before making the history of anything, one must have a proper understanding of what it is, in and for itself. In that connection, I would draw attention to the work of Professor Van der Leeuw, who has done so much for the phenomenology of religion, and whose many and brilliant publications have aroused the educated public to a renewal of interest in the history of religions in general.

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In an indirect way, the same interest has been awakened by the discoveries of psychoanalysis and depth-psychology, in the first place by the work of Professor Jung. Indeed, it was soon recognised that the enormous domain of the history of religions provided an inexhaustible supply of terms of comparison with the behaviour of the individual or the collective psyche, as this was studied by psychologists or analysts. As we all know, the use that psychologists have made of such socio-religious documentation has not always obtained the approval of historians of religions. We shall be examining, in a moment, the objections raised against such comparisons, and indeed they have often been too daring. But it may be said at once that if the historians of religions had only approached the objects of their study from a more spiritual standpoint, if they had tried to gain a deeper insight into archaic religious symbolisms, many psychological or psychoanalytic interpretations, which look all too flimsy to a specialist's eye, would never have been suggested. The psychologists have found excellent materials in our books, but very few explanations of any depth--and they have been tempted to fill up these lacunae by taking over the work of the historians of religions by putting forward general--and too often rash--hypotheses.

In few words, the difficulties that have to be overcome today are these: (a) on the one hand, having decided to compete for the prestige of an objective "scientific" historiography, the history of religions is obliged to face the objections that can be raised against historicism as such; and (b) on the other hand, it is also obliged to take up the challenge lately presented to it by psychology in general--and particularly by depth-psychology, which, now that it is beginning to work directly upon the historicoreligious data, is putting forward working hypotheses more promising, more productive, or at any rate more sensational, than those that are current among historians of religion.

To understand these difficulties better, let us come now to the subject of the present study: the symbolism of the "Centre". A historian of religions has the right to ask us: What do you mean by these terms? What symbols are in question? Among which peoples and in what cultures? And he might add: You are not unaware that the epoch of Tylor, of Mannhardt and Frazer is over and done with; it is no longer allowable today to speak of myths and rites "in general", or of a uniformity in primitive man's reactions to Nature. Those generalisations are abstractions, like those of "primitive man" in general. What is concrete is the religious phenomenon manifested in history and through history. And, from the simple fact that it is manifested in history, it is limited, it is conditioned by history. What meaning, then, for the history of religions could there be in such a formula as, for instance, the ritual approach to immortality? We must first specify what kind of immortality is in question; for we cannot be sure, a priori, that humanity as a whole has had, spontaneously, the intuition of immortality or even the desire for it. You speak of the "symbolism of the Centre"--what right have you, as a historian of religions, to do so? Can one so lightly generalise? One ought rather to begin by asking oneself: in which culture, and following upon what historical events, did the religious notion of the "Centre", or that of immortality become crystallised? How are these notions integrated and justified, in the organic system of such and such a culture? How are they distributed, and among which peoples? Only after having answered all these preliminary questions will one have the right to generalise and systematise, to speak in general about the rites of immortality or symbols of the "Centre". If not, one may be contributing to psychology or philosophy, or even theology, but not to the history of religions.

I think all these objections are justified and, inasmuch as I am a historian of religions, I intend to take them into account. But I do not regard them as insurmountable. I know well enough that we are dealing here with religious phenomena and that, by the very fact that they are phenomena--that is, manifested or revealed to us--each one is struck, like a medal, by the historical moment in which it was born. There is no "purely" religious fact, outside history and outside time. The noblest religious message, the most universal of mystical experiences, the most universally human behaviour--such, for instance, as religious fear, or ritual, or prayer--is singularised and delimited as soon as it manifests itself. When the Son of God incarnated and became the Christ, he had to speak Aramaic; he could only conduct himself as a Hebrew of his times--and not as a yogi, a Taoist or a shaman. His religious message, however universal it might be, was conditioned by the past and present history of the Hebrew people. If the Son of God had been born in India, his spoken message would have had to conform itself to the structure of the Indian languages, and to the historic and prehistoric tradition of that mixture of peoples.

In the taking up of this position one can clearly recognise the speculative progress that has been made, from Kant--who may be regarded as a precursor of historicism--down to the latest historicist or existentialist philosophers. In so far as man is a historic, concrete, authentic being, he is "in situation". His authentic existence is realising itself in history, in time, in his time --which is not that of his father. Neither is it the time of his contemporaries in another continent, or even in another country. That being so, what business have we to be talking about the behaviour of man in general? This man in general is no more than an abstraction: he exists only on the strength of a misunderstanding due to the imperfection of language.

This is not the place to attempt a philosophical critique of historicism and historicist existentialism. That critique has been made, and by more competent authors. Let us remark, for the present, that the view of human spiritual life as historically conditioned resumes, upon another plane and using other dialectical methods, the now somewhat outmoded theories of environmental determinism, geographical, economic, social and even physiological. Everyone agrees that a spiritual fact, being a human fact, is necessarily conditioned by everything that works together to make a man, from his anatomy and physiology to language itself. In other words, a spiritual fact presupposes the whole human being --that is, the social man, the economic man, and so forth. But all these conditioning factors together do not, of themselves, add up to the life of the spirit.

What distinguishes the historian of religions from the historian as such is that he is dealing with facts which, although historical, reveal a behaviour that goes far beyond the historical involvements of the human being. Although it is true that man is always found "in situation", his situation is not, for all that, always a historical one in the sense of being conditioned solely by the contemporaneous historical moment. The man in his totality is aware of other situations over and above his historical condition; for example, he knows the state of dreaming, or of the waking dream, or of melancholy, or of detachment, or of œsthetic bliss, or of escape, etc.--and none of these states is historical, although they are as authentic and as important for human existence as man's historical existence is. Man is also aware of several temporal rhythms, and not only of historical time--his own time, his historical contemporancity. He has only to listen to good music, to fall in love, or to pray, and he is out of the historical present, he re-enters the eternal present of love and of religion. Even to open a novel, or attend a dramatic performance, may be enough to transport a man into another rhythm of time--what one might call "condensed time"--which is anyhow not historical time. It has been too lightly assumed that the authenticity of an existence depends solely upon the consciousness of its own historicity. Such historic awareness plays a relatively minor part in human consciousness, to say nothing of the zones of the unconscious which also belong to the make-up of the whole human being. The more a consciousness is awakened, the more it transcends its own historicity: we have only to remind ourselves of the mystics and sages of all times, and primarily those of the Orient.

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To Die Or Not to Die? Cross-Disciplinary, Cultural, and Legal Perspectives on the Right to Choose Death,
By Joyce Berger

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1 The Right to Die: Perspectives of the Patient, the Family, and the Health Care Provider
David V. Schapira

Possibly the most neglected aspect of patient care is the medical and psychological management of a patient's death. The existence of a deficiency may seem surprising. One would think that either patients would have reached a conclusion regarding their deaths and resuscitative measures prior to serious illness, or a discussion by the physician with the patient and family would result in a decision on how to handle resuscitation.

When addressing how aggressively to manage and treat serious illness, implications that lie outside the boundaries of human rights and a person's quality of life should be considered. Approximately two million Americans die each year and, because of an increase in the population and particularly an increase in the number of elderly citizens, the annual number of deaths is rising. Eighty percent of the health care dollar is spent on people who survive less than one year. The care of nonsurvivors is approximately double that of survivors ( Scotto and Chiazze, 1974). Only 10 percent of patients who require admission to an intensive care unit because of complications of their disease or treatment leave the hospital. In the past fifteen years the cost of health care has risen from 8 percent to over 13 percent of the gross national product--more than a 50 percent increase. These statistics should encourage health care providers to address the issue of resuscitation and aggressive management of life-threatening or terminal illnesses.

By addressing such issues at an appropriate time, the use of expensive medical care in the pursuit of prolonging a patient's life would be averted. It is particularly important that the decision of whether or not to implement heroic measures be resolved at a time when the patient is able to make a decision.

Despite our best intentions to grapple with and resolve the issues of a patient's right to die, there are obstacles that can render arriving at a solution difficult, if not impossible. I would like to describe these obstacles from the perspective of the patient, family, and health care provider.

THE PATIENT'S PERSPECTIVE
Patients may not wish to decide how aggressively their illness should be managed; they may wish to relinquish the decision to the physician. The severity of the illness can affect a patient's desire to participate in active decision making. Increasing severity of illness increases a patient's dependence on the physician. As the severity of illness increases, the fear of dying may alter a patient's decision whether or not to be resuscitated. The reality may be too overwhelming. Additionally, medications such as potent analgesics may alter a patient's mental state and reduce his or her capacity for judgment.

Although the physician may attempt to inform patients about the severity of their illnesses, patients may employ an appreciable amount of denial. In a study of 315 cancer patients ( Eidinger and Schapira, 1984) being treated with chemotherapy or radiation therapy for advanced cancer, only 50 percent of the patients correctly responded that their cancer had spread and was in an advanced stage. All the patients had been informed of their condition prior to the study. This lack of knowledge was not due to an unwillingness to seek information, as over 90 percent of the participants wished to learn all information regarding their disease, irrespective of whether the information was pleasant or unpleasant. We asked the participants what they felt their prognosis was. The majority of patients felt they would live at least three years or longer, and an appreciable percentage felt they would "beat the cancer." In fact, over 75 percent of the patients expired within a year of participating in the study. If patients have a very optimistic view of their prognosis, discussions regarding resuscitation may seem incongruous.

If patients deny the severity of their condition, they may not make a rational and realistic decision about how the process of dying should be medically managed. Patients may also feel that making a decision not to be resuscitated may result in abandonment by the health care team and enhance a feeling of hopelessness. It is of interest that only 14 percent of patients who had a "do not resuscitate" order on their chart left the hospital alive at the end of the admission.

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Factors other than denial may affect the patient's decision regarding resuscitation. A patient may make a decision not to be resuscitated based on erroneous information, emotion, or mood. A patient may become depressed with the side affects associated with the disease and feel that "life is not worth living." If, however, the symptoms can be alleviated, the patient's quality of life may be markedly improved and the desire to be aggressive with medical management may change.

Patients who feel they have not received a desired amount of attention and emotional support from spouse, family members, or friends may express a desire not to be resuscitated in an attempt to engender sympathy and emotional support from these individuals. Patients may even go so far as to attempt suicide to achieve the desired outcome.

Patients may have preconceived unpleasant illusions about the aspects of resuscitation. They may fear the trauma of intensive care units, tubes and intravenous lines inserted into the body, respirators, or the cardiac arrest procedure. Impressions of these traumatic measures may lead patients to decide to make a more passive decision.

These feelings of depression or fear that lead to a decision not to be resuscitated may be implemented by the health care team unless the reasons underlying the decision are examined. The situation can arise in which the patient's quality of life and desire for life is not dealt with appropriately. This is exemplified when an elderly patient with a terminal disease is admitted to an intensive care unit. The medical staff may view the admission and intensity of care to be inappropriate. They may be unaware that the patient wishes to remain alive for a few more weeks or months to see the birth of a grandchild or wedding of a child.

A somewhat similar philosophical decision was presented to a Massachusetts court ( Brophy vs. New England Mt. Sinai Hospital). The court authorized the withdrawal of nutrition from an adult in a chronic vegetative state. While healthy, he had stated that he would not want his life sustained if he were permanently unconscious. The court rejected the view that a decision to withdraw life-supporting measures could be made on the basis of a quality of life that was determined by individuals other than the patient. The decision should not be perceived as a step toward euthanasia for those patients who lack the capacity to satisfy someone else's vision of a satisfactory quality of life or are deemed to be a social burden.

THE FAMILY'S PERSPECTIVE
For reasons of grief or guilt, the family may press for disproportionately aggressive management. One can observe this phenomenon in patients undergoing treatment for advanced cancer. When all conventional treatments, usually chemotherapeutic drugs, have been exhausted and the patient and family have been told that nothing more can be done to prolong survival significantly, the family may persuade the patient to turn to unconventional therapies as a last resort. These therapies may not have demonstrated objective tumor shrinkage, but guilt or grief may drive the patient to try these treatments in desperation. Unfortunately, this decision can have disastrous economic results as the travel to the clinics and treatments are not covered by insurance. Thus the surviving family may expend an appreciable amount of its savings.

Families are placed in a similarly uncomfortable position when the patients are gravely ill and unable to make their wishes known due to decreased consciousness. Families may express a desire for inappropriately aggressive management because of guilt. A physician may attempt to educate a family with an objective presentation of the medical facts surrounding the case. Many families are uncomfortable with this amount of education and participation. They may not understand and assimilate the information at such an emotional time and may lack the objectivity to make such an important decision concerning a loved one. In order to avoid the responsibility and guilt associated with adopting a passive approach, they choose a safe course of action and request that "everything be done" for the patient. This situation can be rectified by the physician's explaining why a passive approach is in the patient's best interest; this can alleviate the family's guilt when they agree with the physician's decision.

Cultural or ethnic factors can make a decision regarding resuscitation almost impossible. Hispanic families prefer to shield the patient from unnecessary anxiety and depression and may ask the physician not to tell the patient anxiety-provoking information such as a diagnosis of cancer. Throughout the patient's course, the family protects the patient from any depressing information; therefore a discussion about dying and resuscitative measures between the physician and the patient is obstructed.

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Although the situation of not informing the patient may seem inconceivable, one must be careful not to impose one's belief system as regards health, disease, treatment, and death on patients from a different ethnic or cultural background. If one attempts to impose one's wishes and values on patients, the response is often denial, resistance, and decreased compliance. In fact, although we feel that we are open in telling patients their prognoses, physicians often collude with patients in not correcting optimistic misconceptions of prognoses.

Because of their cultural or religious beliefs, and indeed their personality, some patients may wish to take a passive role in the decision making regarding the circumstances of their deaths. To disregard the wishes and beliefs of the family and to confront the patient with the decision will probably not be fruitful, and indeed may lack understanding and not be in the patient's best interest. Such a confrontation may impair the patient's quality of life and future communication with the physician.

Although such an approach may still seem untenable, I would like to illustrate how the traditional approach of Western medicine can be unsuccessful. A Haitian man may present to an emergency room with palpitations. This is usually a benign condition called paraxysmal atrial tachycardia, and can be aborted by stimulating the vagus nerve, whether by manually massaging the carotid body in the neck or by having the patient swallow ice or attempt to blow air out of the mouth with the mouth closed. The condition can be precipitated by drinking excessive amounts of coffee, tea, or alcohol. Having corrected the abnormal rhythm, the physician could warn the patient not to consume the stimulants that precipitate the condition, teach the patient the cardiac-slowing maneuvers, and possibly prescribe a B-blocker, a medication that slows the heart. Such an approach would most likely be ineffective and the patient would not take the medication. The reason is that the Haitians call this condition battement de coeur, or beating of the heart, and believe it to be due to weak blood. They would expect to receive a liquid tonic to build up the blood. If a Haitian did not receive a tonic, it is unlikely that the patient would return to a practitioner of traditional Western medicine. Lest this example seem too primitive and far-fetched, one only has to remember that almost half of the population of the United States takes at least one vitamin pill per day for no justifiable reason--certainly not to avoid vitamin deficiency. A study I made (with others) revealed that over 90 percent of vitamin takers are unaware of the recommended daily allowance of any of the vitamins. Indeed, attempting to persuade the members of this sophisticated population to stop taking a vitamin has, in my experience, been extremely difficult.

Unfortunately, medical anthropology and thanatology are not part of the curriculum of most medical schools. Without a knowledge of these areas, physicians may lack awareness and sensitivity toward alternate belief systems relating to health, disease, and death. The physician can only be left to impose his or her belief system and values on the patient, the result being an unsatisfactory outcome.

THE PHYSICIAN'S PERSPECTIVE
Dealing with ill patients exacts a toll on physicians, particularly if they deal with chronic diseases in which dramatic improvement is not often seen. A physician may have a tendency to equate a patient's death with professional failure, or unrealistic expectations. Having to impart unfavorable information to patients on a continual basis tends to lead to a feeling of being "burned out." The physician finds that it is easier not to become engaged in a discussion with the patient over topics that will be emotionally draining and time consuming. Thus physicians may avoid discussing topics such as prognosis or resuscitation unless approached directly by the patient or the family.

Apart from their desire to avoid discussing emotionally laden issues, physicians vary in their communication skills. Some may lack directness or honesty or may use technical language that is beyond the understanding of the patient and family. In this situation a facilitator, such as a psychiatrist attached to the health care team, nurse, social worker, or chaplain, can act as an intermediary and resolve any difficulties in understanding the issues. I find this approach very effective as patients and families may not want to ask physicians questions for fear of interrupting their busy schedules or for fear that certain questions are too simple or inappropriate. Members of a psychological team may be able to discuss and allay a patient's or family's fears because of their training and the fact that patients may find them less intimidating than the physician. In a study by Bedell et al. ( 1983), 95 percent of physicians felt it was appropriate to discuss the patient's wishes regarding resuscitation, yet in only 19 percent of cases did the physician discuss the subject of resuscitation with the patient, and in only 33 percent of cases did the physician discuss resuscitation with the family.

Fear of legal liability may interfere with a physician's ability to make the best choice for the patient. A physician may have a primary objective of minimizing liability, real or imagined. This strategy may be at the expense of humane treatment and may be at odds with the family's wishes. There is only one case (as of 1984) in which two physicians were charged with murder for withholding life support from a comatose patient. The charges were dropped by the California Court of Appeals. The fear of litigation following the withholding of life support is grossly exaggerated by physicians. If the conversation with, and wishes of, the patient and family are documented in the hospital records, it is extremely unlikely that a physician will be sued. In spite of legal uncertainties, appropriate and compassionate care should have priority over undue fear of liability.

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WHAT CONSTITUTES RESUSCITATION?
It appears that most members of the public understand resuscitation to involve cardiopulmonary arrest maneuvers. They may be aware that these maneuvers involve the mechanical stimulation of the heart by manual compression of the chest, ventilation by a small ventilatory bag, and the insertion of intravenous fluids and cardiac stimulus. Although this is certainly a valid impression of the scenario that surrounds the final event of a cardiac arrest, there are other interventions in medical management that, if withheld, would lead to the death of the patient. These more subtle areas of medical management that the public is often not aware of lead to problems of interpretation when a patient has written a living will. These subtler areas of "resuscitation" are frequently not included in the conditions or scenarios of a living will; they include the withholding of antibiotics from a patient with a terminal disease who has a life-threatening infection; the withholding of steroids for patients with cerebral metastases; withholding of intravenous fluids or hyperalimentation; and not performing laboratory tests to correct electrolyte disorders. All of these instances obviously assume that patients are unable to transmit their wishes because of decreased consciousness. Although these situations do not directly involve the saving of life, they can, when implemented, appreciably prolong a patient's life. If patients are not conscious and cannot make their wishes known, implementing these interventions would seem to be uneconomical and contrary to the patients' interests.

The living will is a document, distributed nationally, that outlines patients' wishes regarding medical management should they subsequently become incompetent to decide ( Society for the Right to Die, Living Will, New York, 1985). This document is not binding in some states, but it does clearly outline a patient's desires and expectations. At the present, thirty-eight states have enacted living will or "natural death" legislation ( Jonsen, 1978).

CONCLUSION
There are no simple solutions when attempting to elicit a patient's request for withholding resuscitation and granting that request. The most important point to be made is that the patient has the ultimate right to control all aspects of medical care and resuscitation, and the family and health care team must abide by the patient's wishes. If patients are unable to make a decision, their spouse or close family may decide what course should be taken. It is hoped that their decisions would be based on prior discussion with patients regarding their opinions and wishes concerning resuscitation.

The medical team in a hospital is often faced with a situation in which a patient has a life-threatening episode such as cardiac arrhythmia or cardiac arrest, and there is no statement in the patient's chart regarding resuscitation. Under these circumstances the medical team has to make every effort to resuscitate the patient, even though resuscitation seems inappropriate and would have been against the patient's wishes. This not uncommon situation can be frequently averted if the attending physician discusses resuscitation measures with the patient either before admission or on the first day of admission to the hospital. This discussion should not be held with every patient, but only with those patients deemed to have limited survival or a serious life-threatening condition.

I doubt that this practice will become widespread, as it involves many emotionally draining and time-consuming discussions. I do not state this opinion with any degree of cynicism because I realize the very appreciable increased amount of time and emotion that physicians would have to give to engage in such discussions on almost a daily basis.

Another approach would be to educate patients regarding their rights to make a living will, and to make the drawing up of such a will a relatively simple and inexpensive exercise. Living wills drawn up by patients attempt to extend patients' authority to decline certain therapeutic measures that may be involved in their death. This attempt would be made at a time when the patient was capable of entering into decision making. A standardized document could be obtained from a doctor's office or hospital that would describe the various levels of resuscitative measures with explanations. Patients could then make informed decisions as to the level of resuscitative procedures that they would want to have invoked should they become critically ill.

A third approach would be to have certain criteria for the entry of patients with terminal illness into intensive care units. There is considerable evidence ( Cullen et al., 1974) that an appreciable portion of the cost of caring for terminally ill patients is associated with treatment in intensive care units. There are standards that cover the admission of patients to intensive care units. The bill for such an admission may not be totally covered by the insurance company and the surviving family may be left having to pay a considerable amount of money. A more stringent application of admission guidelines would reduce expenditures for the health care system and family, which is important when the admission of a patient to such a unit is inappropriate and unsuccessful.

A very reasonable alternative in caring for terminal patients who do not wish an aggressive approach to their management is the hospice movement. Hospices provide an alternative form of care for the dying. They allow terminally ill patients a choice of dying at home or in facilities other than the hospital. Hospices are often a more appropriate form of care, as they are designed for palliation and caring rather than curing. Patient autonomy and dignity are enhanced.

In 1982 Congress ensured that hospice care would be covered by Medicare. It is not clear that hospice care will reduce the cost of health care, but the system allows terminal illness to be more bearable for the patient and family if a decision has been made not to follow an aggressive course.

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