AFTER his stroke Maria’s father could no longer speak. But with his daughter reciting the words next to him, he could still pray. His final days brought a lot of pain but Maria believes that at the end, as he clasped her hand, he was at peace. When she thinks about her own priorities for her death, “being at peace spiritually” is top of the list.
It is a sentiment shared by fellow Brazilians, according to a survey conducted jointly by The Economist and the Kaiser Family Foundation, an American non-profit focused on health. Fully 88% thought that being at peace spiritually at the end was “extremely” or “very important” (see chart). In America and Japan not burdening families with the costs of care was the highest-ranked priority, cited as extremely important by 54% and 59% respectively. (The Japanese may be worrying about the cost of funerals, which can easily reach ¥3m, or $27,000.) A third of Italians emphasised having loved ones around them. Brazil was the only country where more people said they would put extending life ahead of reducing pain and stress than the other way around.
Religion accounts for some of these differences. There are more Catholics in Brazil than any other country. Many have presumably been influenced by their church’s long insistence that life should be extended whenever possible, even by heroic measures. In court battles in America and elsewhere, when families have sought to have feeding tubes removed from relatives who are in a persistent vegetative state, the church has often been opposed (though it now condemns only active measures to hasten death, rather than patients’ decisions to reject treatment, or death that is hastened by pain relief). Eighty-three per cent of Brazilians said that religion played a “major role” in their thinking about end-of-life care, against 50% of people in America and 46% in Italy.
In Japan, just 13% said that religion played a major role in their thinking. In other surveys most Japanese report that they are atheists or have no formal religious affiliation. But the idea of “spiritual peace” is nonetheless important in Japan—it is ranked second for what matters close to death.
The relative weights people place on extending life, and easing death, are also shaped by the quality of care available, and perceptions of what they will personally receive. Ninety per cent of Brazilians rated their health-care system as “fair/poor”, compared with 54-61% in the other three countries. Though their constitution guarantees comprehensive, free health care for all, it falls far short of that ideal. Even before a crippling recession that has already lasted three years, care was often precarious. More recently, cash-strapped hospitals in big cities, including Rio de Janeiro, have seen patients die in corridors.
In America, Italy and Japan people with degrees were most likely to say that too much emphasis is placed on extending life towards its end, as opposed to alleviating suffering. Better-educated people were also more likely to say patients and families should play a bigger role in decisions about end-of-life care.
Almost half of black Americans, and nearly as many Latinos, said that health care placed too little emphasis on preventing death, compared with just 28% of white Americans. Other research has found that minorities are more likely to die in hospital than white Americans. Richer Americans are more likely to die at home or in a hospice than those on lower incomes. All of which suggests a bitter irony: those who most need hospital care may receive it only when it is too late.