Values at the End of Life: The Logic of Palliative Care.
In Values at the End of Life, Roi Livne conducts a multi-site ethnographic exploration of end-of-life care in three hospitals in California. Prior to conducting 80 days of observations and 80 in-depth interviews with clinicians, patients, and families, Livne carried out an extensive document review that positions the research and provides important historical and political context. The author states that the book "examines how clinicians apply the palliative way of care in different contexts" (p269), and while he fully delivers on this promise, this book provides much more than an account of how clinicians apply their practice. Livne does not take the patients and their families as people to be "acted upon" or as individuals that clinicians "apply" care to. Instead, through sophisticated theoretical sociological analysis, Livne respects the complexity by which actions and interactions can be interpreted in a complicated hospital environment. He moves beyond dated analyses of power differentials in medical institutions between patients and clinicians. These dated analyses often argued how power is exploited through clinician authority which flexes its proverbial muscles to obtain the outcome best suited to maintain that power. Instead, while still acknowledging the issue of power differentials between end-of-life care clinicians and the people they serve, he disentangles the relationship in a way that brings to light the importance of patient agency within a much larger cultural context.
Livne starts by outlining what he calls the "New Economy of Dying" in the introductory chapter giving context for the rest of the book. Chapter one delivers an account of how economized dying (embracing controlled and restrained conduct toward abundant medical interventions that modern medicine makes available (11)) came to be and what drove the field in this direction to economize. Chapter two explains how death and dying have become financially significant. In Chapter three, Livne argues that physicians were the primary drivers promoting economized dying. In the second part of the book, he draws from his ethnographic and interview data to outline practices such as how patients and families come to be "subjectified" by clinicians and health care teams when dealing with a patient at the end of life. He also articulates how clinician teams use the method of "taming" to help drive the economization process in those people who are not immediately favourable towards the idea of a more economized death.
Livne's work provides an in-depth descriptive analysis of end-of-life care, where he provides an intricate, neutral, and respectful account of all participants involved in the study. However, the work could arguably be seen as taking a normative stance about how palliative and end-of-life care systems should work. For example, Livne positions himself neutrally, but at times the choices of quotations depict a viewpoint that may be interpreted as hyper-critical of service providers. That said, this critique is warranted in the current climate of end-of-life care in North America which assumes the need for improved services in the climate of cost-control and efficiency in health care systems. It is also intimately relevant to ongoing debates around the autonomy of patients as they progress closer to the end of their lives (e.g. debates and controversy around medical assistance in dying (MAiD)). Further, it is worth noting that the author recognizes the potential for this critique of his work on the final page of the book when he states that being critical does not equate to denouncing the person or institution one is critiquing (Rabinow, 2007 in Livne, 2019).
Additionally, Livne explains in the book that he comes from an economic sociology background "at heart and by training" (261). Coming from this field of study, it is not surprising that the author comes to view the operation of palliative care in these hospitals to be inextricable from and heavily influenced by economic histories and contexts of the time. However, he takes this lens further by seeing the operations of palliative care as economically embedded in the decision-making of clinicians through the application of "economization" in end-of-life care delivery. He describes "economization" as a complex concept that involves the practice of providing less treatment as a means of providing better care to patients at the end of life.
Livne argues that clinicians attempt to apply this principle of economization to patients and families through "subjectification" and "taming" (in chapters 4 and 5 respectively). However, as previously mentioned, he does not overlook that patients come with their own agency and vary in their levels of internalizing and projecting the value of the economization of care. While it might seem all too obvious that an economic sociologist takes an economic lens to an analysis of the logic of palliative care, it would also be largely oblivious to study end-of-life care without this perspective. This is particularly true in the USA, which as he reports, has the costliest health system worldwide, making the provision of services undoubtedly influenced by cost-containment strategies.
Another refreshing addition that Livne brings to the literature in this book is that he avoids marching straight into the assumption that a socio-economic analysis of palliative care in health systems means that it should be interpreted exclusively through the lens of capitalism and neoliberalism. Livne provides a more inclusive conceptualization of "economization" and eschews what he refers to as a reductionist tendency by sociologists to ignore the diverse phenomena that the term "economy" describes. Instead, he argues that "the term economization should include a variety of possible economization projects and numerous different economies that emerge from them" (246).
Overall, Livne's book is worth reading. The reader may want to read it more than once to truly capture all of Livne's insights and analysis. He has uncovered practices that operate within the end-of-life care system that illustrate a power dynamic between actors in the end-of-life care process. This is a highly informative read for anyone wanting to learn more about the intricacies of systems from a economic sociological viewpoint.
Rabinow, Paul. "Anthropological Observation and Self-Formation." In Subjectivity: Ethnographic Investigations, edited by Joao Biehl, Byron Good, and Arthur Kleinman, Berkeley: University of California Press, 2007, 98-118.
Courtney R. Petruik
University of Calgary
Courtney R. Petruik is a PhD candidate in the Department of Sociology at the University of Calgary. Her interests are in the intersection of dying, death, and bereavement and marginalization. Courtney currently teaches a course on the sociology of dying, death, and bereavement in continuing education at the University of Calgary.