The problem, as Martensen sees it, is that ICUs dehumanize patients on their deathbed. The design of an ICU is modeled after Jeremy Bentham's panopticon (a prison in which all inmates could be observed at the same time from one central cylinder.) In the ICU, patient rooms are clustered around a central nursing station allowing nurses and doctors to monitor all patients simultaneously in order to maximize efficiency in treatment.

The panopticon design is not conducive to comfort, however, and patients in the ICU often lose their sense of time and reality. That is to say, ICUs are not pleasant places to die. Who would want to spend their final waking moments in the sterility of a hospital, white floors and ceilings, surrounded by an army of machines and unknown nurses? Why, then, is it that that is how so many people spend the last days of their lives?

The hospice is concerned with palliative care—relieving the pain while not treating the cause of the problem. A person nearing the end of a bout with terminal illness may seek out hospice. Though hospice wards exist, much of hospice care is home-based. With hospice, a person can die in the comfort and familiarity of their own home. Hospice has been around since the Middle Ages and is increasing in popularity, but it is still far from a majority practice. Martensen quotes a fellow physician who, after being diagnosed with terminal cancer in his forties, decided to move from the emergency room to hospice care:

"I'm working in hospice because I've seen all too many dying people come to it at the very end. Right now only about 15% of dying Americans ever get hospice care, and a third of those start in the last week of their lives. In the meantime, what do they think they are doing—getting cured?"

Hospice care, like many of the choices of coping with terminal illness, is not so much a matter of personal choice and autonomy as it is of geography. For instance, if you suffer from an illness and live in Boston, you are far more likely to be hospitalized than if you suffer from the same illness and live in New Haven, Connecticut—about sixty percent more likely. (This does not hold true for necessary surgeries.) The reason is not quality of care. Both cities are home to world-class treatment facilities. The difference is the number of hospital beds available. Boston has far more hospital beds available, and as the researcher Milton Roemer discovered in the 1960s, once built, hospital beds will be filled.

Patients do not have the individual choice in treatment that they might think they have. Medical culture varies from city to city and region to region. In part, this is a matter of what's available. South Florida is saturated with medical specialists to care for the wealthy population, abounding with retirement communities. Patients rarely see a primary care physician, instead opting for specialists. Compare this to a rural part of Alabama, which has far more primary care physicians. Interestingly, outcomes for areas with a large number of specialists are not better than those populations that are served mainly by primary care physicians.

Medicine has also succumbed to big business, and giant corporations often own hospitals that may have once been non-profit entities. As such, they are out to make money and are in competition with other area hospitals. Hospitals want people to occupy their beds—they make money off of it. Doctors are incentivized for pursuing aggressive care for patients, terminally ill or not. In the American culture of rampant lawsuits, doctors want to cover their backs. Should they deem treatment "futile"—a slippery concept in medicine—or refuse to perform a treatment due to associated risks, they open themselves up for lawsuits. Doctors are also positively incentivized: medical compensation is based on procedures. In private practice, the more procedures a doctor performs, the better he is compensated. In some cases, this can lead to abuse of the system.

Such is the case in McAllen, Texas, which Atul Gawande wrote about in a recent edition of the New Yorker. Gawande found that McAllen, apart from Miami, spends more than any other city on healthcare—$15,000 per person per year. The average person here makes $12,000 per year. The reason is that the medical culture in McAllen encourages often unnecessary tests. Regardless of your malady, if you live in McAllen chances are that you will receive a much more costly and aggressive treatment than if you lived in Rochester, Minnesota and were being treated at the Mayo Clinic (far below the average on costs). The results of your treatment would probably not be better in McAllen. Actually, the outcomes would probably be the same or worse. Ultimately, some of Martensen's concerns with treating terminal illness may become irrelevant because of issues of cost. Two weeks ago, I sat down for a beer with the doctor whom I called when my father was dying. Dr. John Koehler is an ER doctor by training who now owns a dozen or so immediate care clinics in the Chicago area. He's a fervent pragmatist whose rationality is only tempered by his strong evangelical religious convictions. I thought he might be able to answer some of the questions that Martensen leaves unanswered about the value of life in the face of terminal illness.

What would he do in his own situation, say thirty years from now, if he were diagnosed with terminal illness? Would he pursue aggressive treatment to extend his life, even if it meant a reduced quality of life? Would he allow himself to be put on life-support? He surprised me with his answer: "It won't matter what I want to do. The system is about to break. It's unsustainable. Care will eventually be rationed by the government or by insurance companies. We can't afford what we're doing now. In the future if you have a stage IV solid tumor, you won't be given the option of treatment.” I couldn't tell whether this bothered him or not.

In the United States, about one out of every six dollars earned goes towards health care. President Obama recently said that the "biggest threat to our nation's balance sheet is the skyrocketing cost of health care." The costs of medical care are staggering; approximately thirty percent of Medicare money is spent by patients in their final year of life. A terminally ill ICU patient has an average length of stay of almost thirteen days at a cost of $24,541, and non-ICU hospitalization of the terminally ill has an average stay of almost nine days at a cost of $8,548. The baby-boomers start to become eligible for Medicare in 2011; over the next ten to twenty years, the Medicare costs associated with the last year of life will increase dramatically. An over-extended system won't be able to handle the increased load. Health-care rationing for the terminally ill already exists in Europe. The poor of the United States already face some level of it. As Dr. Koehler sees it, it's not a question of if but when this rationing arrives for the rest of the population of the United States.

Martensen spends the first half of his book seriously questioning the aggressive treatment of terminal illness. If not read carefully, the book lends itself to the argument that if a person's quality of life is poor as the result of terminal illness, that life may not be worth living, or at least, that disease might not be worth treating. But Martensen takes more of an anthropological perspective, which becomes clear as the book progresses. Martensen's arguments are not based on a patient's quality of life, but on the patient's “unity of being”: "And should not recovery of the self, to the degree that the underlying disease permits, be the overall purpose for undergoing and delivering intense medical interventions?" Martensen is concerned with the question: "What does it mean to be human?"

This is a question that physicians have had to face in new ways in the last half century as new technologies have enabled physicians to keep patients alive when not possible. Physicians coined the phrase persistent vegetative state (PSV) to describe an extended state of being in which a patient is still alive though not responsive to stimuli. (Perhaps the most famous case of PSV was Terri Schiavo.) The patient may breathe, grow, and excrete waste, but their cerebral cortex, the part of the brain that defines one’s identity, is unresponsive. The longer a person remains in such a state, the less likely his or her brain will regain the ability to fully function. Though current law states that someone is not legally dead until all electrical impulses in the brain cease, there is a current push among physicians (and hospitals eager to profit off of the harvesting of patients' organs) to change the law to accommodate the cessation of life support in cases where the cerebral cortex is inactive. A functional cerebral cortex then, at least according to some doctors, is what makes someone human. Someone breathing but not thinking is only a shell of a human.

Martensen resists answering the question that his book hinges upon: "We—doctors and patients alike—confuse ourselves if we assume that biomedicine (and the corporate interests that increasingly shape its imagination) can and should tell us the purpose and meaning of our lives." In fact, the tendency to locate one's physiological being within the cerebral cortex is peculiar to the modern west. Other cultures and traditions tend to locate life with the soul and therefore the beating heart. Medicine and biology can speak to aspects of what it means to be human but certainly cannot claim a monopoly on the truth. As Martensen aptly states, the "existential terrain" of the meaning of life, "belongs to notions of wholeness, integrity, and being, ancient concepts that encompass both a sense of surrender to the fact of our own existence and unsentimental embrace of that existence."

Ultimately, Martensen wants to encourage a surrender to the fact of our own existence, our humanity—part of which includes death. Sadly when we do face death, be it our own or the death of a loved one, most of us will be ill-prepared, forced to confront not only the grief but also a difficult decision making process. Trying to navigate the medical-industrial system and the many choices it presents is the nightmarish version of the old Choose-Your-Own Adventure stories, though almost every choice leads to the same tragic end. Martensen's book is useful in providing an overview of the terrain so that one can know what to expect in facing terminal illness. We cannot always control when we die, but to some extent, we can control how we die. But this much is clear: as hard as it is to retain one's humanity in life, it may be much harder when facing death.

David Michael is the executive editor of Wunderkammer.

Image courtesy of Jeremy Harper.