Dying, Economized. Palliative Care and the U.S. Moral Economy of Death

Dying, Economized is a sociological account of the intersection between morality and economics in U.S. end-of-life care. It is based on ethnographic and historical analyses of hospice and palliative care—a new medical subspecialty, which has transformed the U.S. way of dying and is today the main designated discipline treating dying and potentially dying patients. The dissertation analyzes the emergence of end-of-life care as a professional, moral, and economic field and the efforts of the clinicians active in this field to reconcile the tensions it engrains. The first part (chapters 1-3) explains how in the 1960s, 1970s, and 1980s clinicians, economists, and policymakers began thinking of dying as a social problem: they argued that the dying were treated with inappropriate and costly medical interventions, which posed serious ethical and economic challenges. The hospice and palliative care solution to these challenges, which has gained much influence since the 1960s, is to economize dying, both medically and financially: to restrain the medical ambition to prolong life at all costs, nurture a culture that accepts death, and by that control spending. The second part (chapters 4-5) draws upon an ethnographic study that I conducted in three California palliative care services and on in-depth interviews with clinicians of various professions and specialties, whose work pertains to the treatment of dying patients. This part analyzes how palliative care clinicians negotiate the tension between the effort to economize dying and the ethical inclination to respect patients’ wishes. Through this mixed-methods approach, the dissertation illuminates how expertise defines the relationship between moral and economic life in one of the most ethically challenging areas in modern medicine