A decade ago, Hadley Vlahos was lost. She was a young single mother, searching for meaning and struggling to make […]

Modern medicine has been a miracle for healthy aging. But what if we’re still thinking about the subject of living better for longer all wrong? That’s the premise of Dr. Peter Attia’s book, “Outlive: The Science & Art of Longevity,” which he wrote with Bill Gifford and has been a runaway best seller since it was published this spring. In the book, Attia distinguishes between standard medical thinking, what he calls Medicine 2.0, and his approach, Medicine 3.0. In his telling, Medicine 2.0 is oriented toward addressing the four chronic diseases of aging that will probably be the cause of most of our deaths, but only after they become problems. (Those chronic diseases are heart disease, cancer, Alzheimer’s and related neurodegenerative diseases and Type 2 diabetes and related metabolic dysfunction.) Medicine 3.0, though, aims to proactively prevent those things for as long as possible and allow us to maintain better health deeper into old age. How exactly? Not through any techno-fantasies of biohacking or wonder-drug supplements but largely with highly rigorous, detailed and personalized monitoring and treatment of our nutrition, sleep, exercise and mental health. “When you’re at the end of your life, if your health has failed you, no amount of money is going to buy that back,” says Attia, who is 50. “Health is everything to us. As such, we have to accept the fact that it might take work to get it right.”

Let’s say someone reads your book and decides that they want to pursue a Medicine 3.0 approach to health. Then they go to their general practitioner, and their G.P. says, contrary to you, “Nah, we don’t need to get into the weeds of your glucose levels and lipids.” Then what? How do people operationalize Medicine 3.0 in a world of Medicine 2.0 doctors? Some of the work you can do on your own. The exercise — you don’t need a doctor for that. Nutrition, sleep, the emotional-health stuff — you don’t need an M.D. to help with that. But there is a big chunk of this that does require a physician. You need someone to order and check those labs, and you may need prescriptions as a result. But imagine you’re trying to sue a company that has wronged you. You’re going to talk to a bunch of attorneys until you find the person whose strategy makes sense to you. It’s the same with finding the right doctor. When you’re talking about who’s your attorney, who’s going to be your doctor, these are important decisions, and the exception is finding that person on the first chance, not the rule.

In my experience, and I think this applies to a lot of people, the doctor-patient dynamic is basically a parent-child one. The doctor gives information and guidance, and the patient obeys. But you’re implicitly calling for people to be much more hands-on in directing their medical care. Do you have a sense of what physicians might think about having that traditional doctor-patient dynamic upended? I can certainly tell you every time it annoyed a physician, because I hear about it! You’ve probably heard me harp on the importance of knowing your ApoE genome type. I get a lot of pushback on that from physicians saying, “Why would you want to burden a patient with that knowledge?” I welcome that debate because it opens a discussion: Do you or do you not believe that this a deterministic gene? If it’s not deterministic, the next most important question is: Is there a manner in which you can alter the outcome? I believe the answer is emphatically yes: It’s not deterministic, but it’s risk-associated, and you can alter your trajectory. Therefore, how would you not want to know this? Another area where I hear about a lot of pushback is on lipid stuff. I’m adamant about everybody knowing their Lp(a) and their ApoB. Cardiovascular disease — you’ve got to prevent early, and you have to know those metrics. You’d be amazed at how many doctors are like, “LDL cholesterol is fine, and this Lp(a) thing — I don’t even know what it is.” I say to patients: “Let your doctor’s response be a litmus test to the caliber of their thinking. You don’t have to agree with me on everything, but you have to disagree with evidence.”

When I read your book, I was thinking, this guy is advising me to pursue a fair bit of medical testing, which I doubt my insurance covers. There’s equipment he thinks I should probably buy. He’s suggesting psychotherapy. This stuff all costs money. So to put it crassly, is your method just for the rich? The biggest asset class a person needs is not financial; it’s time. It would be delusional of me to say that a single working mom with five kids in the inner city has the same amount of time that the wealthy mom in Beverly Hills has. Of course not. Unfortunately, the truth of it is that health is not fully democratized. There’s a certain income level and disposable time requirement that’s probably necessary. You don’t have to be wealthy, but you have to be above a certain threshold in terms of disposable time and income to spend on good food, gym memberships or exercise equipment at home and those things. I don’t know that dollar amount. I don’t think it’s that high. But it’s certainly higher than where many people are, unfortunately.

What would it run me to be one of your patients? I mean, it’s not cheap.

All right, we can leave it at that. If you were to say to someone, “If you don’t do anything else to increase your health span, at least start doing X,” what would X be? For most people, the answer is exercise more. Then within that, you can get into the weeds. Many people, I think, are underemphasizing strength training. There’s the sense that, Yep, I’m out there, I’m hiking, I’m walking. Those things are great, but the sine qua non of aging is the shrinkage or atrophy of Type 2 muscle fiber. That’s the thing we probably have to guard most against, and you can’t do that without resistance training. Count the number of times in human history when someone in the last decade of their lives said: “I wish I had less muscle mass. I wish I was less strong.” The answer is zero.

You’re asking people to pay a significant amount of attention to the specifics of their nutrition, physical activity and sleep. All of which are subjects that you say doctors typically don’t learn enough about nor pay enough attention to when it comes to patients’ long-term health. I’m sure that’s true, but don’t you think there’s a real danger of pathologizing these totally normal things by micromanaging them and linking them to potential risks? That’s possible. We also probably see extreme examples of excessive exercise. I’m aware of patients who, in the era of rampant sleep tracking, are overwhelmed by sleep data. The question is: What is the balance of benefit versus harm? We’re probably still in a world where a majority of people are not paying enough attention to those things, as opposed to too many people paying too much attention.

Dr. Peter Attia during a 20-plus-mile swim for cancer research in 2005.
Allen J. Schaben/Los Angeles Times, via Getty Images

Sorry, I remain curious: What does it cost to get into your practice? I’m not looking to get any patients into the practice. I would like it if maybe there wasn’t much of a focus on my practice. It’s small, it’s bespoke, and the intention is to keep it that way.

Fair enough. I can’t help wondering if your methods have an element of robbing Peter to pay Paul. If I decide to exercise two hours a day, become hyperfocused on well-being, get very particular about what I eat, in the hope that I’ll be healthier and have more quality time to spend when I’m older — but I could be using that time now! Why give away all this time and energy when I’m still relatively young and healthy? Do you not see any tension or contradiction there? I see it as an optimization problem. I’ll give you a personal example that happened today: My son in kindergarten had a thing at school. Parents come in, and from 9 to 9:30 the kids are going to read you the story that they wrote. This poses a challenge for my schedule, because from 6 until 7:15, when my kids go to school, I’m with my wife and kids. Then the second my kids leave until about 8, I’m getting as much work done as I can before I jump in the gym — I usually work out until 10:30. Then my day runs scheduled, 11 to 5. Well, today, not only do I have my son’s thing at 9, but then I have my skin exam at 10:30. Once a year, you’ve got to get the dermatologist to look you over for moles. So I had a choice to make, which was I could have punted on going to my son’s thing and got my full workout in, or I could have squeaked in a 45-minute workout, then gone to the dermatologist. I thought about this for two nanoseconds, and it was clear what the right thing was: I’m not going to miss this school thing, because that’s not the dad I want to be. That’s costing me a little in terms of fitness. Today was supposed to be a killer day: squats and dead lifts. It didn’t happen. I didn’t do my blood-flow restrictions. I missed stuff that I wanted to do, but that’s the trade-off I wanted to make. We have to think about those things constantly. I could say, “I am going to spend this summer in Ibiza, partying with my friends, never lifting a finger, and boy, will I have fun.” But the price I will pay with my health is too great.

One summer would be that bad? I’m not 25 anymore. I don’t want to suggest that I’m an old man, but when I was 40 I had a superhuman ability to exercise and recover. I don’t have that anymore. When I do a crushing workout today, I feel it for the rest of the day. Let’s give you another example. Do you want to eat like a monk every minute of every day? No. I love food. My days of being a freak around food are over. Now, I don’t think I’m as healthy as I was from 2011 to 2014, when I had the most restrictive diet in the history of diets. I was a physical specimen. Seven percent body fat. My biomarkers were out of this world. But if my kids made cookies, I couldn’t eat them. I couldn’t go to Italy and eat a thing. Whereas now, I could go to Italy and eat anything. I pay a little price for a week, but I can get back in the zone. Same with alcohol. There is zero reason to consume one gram of ethanol. I still probably have five or six drinks a week, because I really, really like tequila and mezcal.

So more specifically, how would you suggest people think about balancing adherence to what strikes me as your pretty demanding health strategy and not letting that plan get in the way of the pleasures that make life worth living in the first place? You have to think about it the way you think about retirement. Let’s pretend you’re making $100,000 a year, and you’re 40 years old. At some point, you’re going to find yourself at an age where maybe you don’t want to work as hard. You’re going to have to put money away for that time. You can do the math that says: This is how old I am, this is how much I make, this is the standard of living I want, this is how long I want to work, this is my risk appetite for how I invest, and therefore this is approximately what I need to do. What I’m saying is no different from that type of analysis. For me, I’m tethered to the marginal decade. I think about that all the time because I’ve seen too many examples of what a bad marginal decade looks like, and that’s not what I want. The beauty of the marginal decade is: I’m not going to be working, I’m not going to have any nonsense that’s going to bug me anymore. The only thing that matters is spending time with people you care about and the state of your health to enjoy those relationships — not being in pain, being able to travel, to play in a park. If you can’t do that, I don’t care how much you partied in Ibiza; it’s not worth it.

But saving for retirement has metrics that we can apply to help us achieve our goals. What are the analogous metrics when it comes to healthful aging? That’s what we do with patients. I’ll use my example: I have a paper where I draw my lifeline. So I’m at 50. Then I go out by decade: at 60, 70, 80, 90. So what is the game between 80 and 90? I have a specific list of things — probably more than 25 — that I want to be able to do in that decade. It’s not just like I want to be able to walk. It’s like I want to be able to walk at this speed for this duration; I want to be able to pull myself out of a pool if there are no steps; I want to be able to pull back on a compound bow with a 50-pound draw weight. Then we deconstruct each of those from objective measurements. What VO2 max is required to do that? What amount of leg strength? What amount of lower-leg variability? What grip strength? Then we ask, given the inevitable decline of all those features, if you want to have those parameters at 90, what do they need to look like at age 50? What do they need to look like at age 70? At 80? Just as we use a discount rate on future cash flows to figure out retirement, we’re doing the same thing on physiologic parameters. All of my training is geared toward performance 40 years from now.

Attia in the 2022 National Geographic series “Limitless With Chris Hemsworth.”
Craig Parry/National Geographic for Disney+

Does your wife have the same health regimen as you? I mean, my wife is a very healthy woman. She’s an amazingly fit human being, eats sensibly, sleeps well. Nobody meets her and thinks she’s a psycho.

Unlike you. [Laughs.] Yeah. People meet me and think I’m intense, and I keep telling them, I’m not actually that intense.

Do you think about your kids in terms of Medicine 3.0? I think about it. I’ll give you silly examples. My kids wear minimalist shoes and have standing desks at home. I know the damages of oversize running shoes, where basically they lose the proprioception of their feet. I know the damages of sitting. They have to sit at school. I can’t change that, but they’re not going to sit that much at home. If they’re watching TV, they’re going to do it standing. They’re going to wear minimalist shoes when they run around and play sports. We’re not crazy, but those are subtle things. They also come in the gym with me. They don’t really work out, but they see that Mom and Dad work out a lot. I bring them when I go for rucks. I think it’s mostly creating a mind-set around being healthy.

This is a somewhat random question, but in the book there’s an aside where you’re talking about trying to be more empathetic. And the scenario you give is being understanding about your wife being sharp with you because you realize, among other things, that maybe earlier in the day she was waiting in line at the deli counter to get your meat sliced a certain way. How exactly do you like your deli meat sliced? Oh, I am fanatical about it being microtomed. If you go up to the counter, you can get it really, really, really thin, but if you buy the prepackaged —

It’s too thick. And if the deli slices earlier in the day — you know how they’ll sometimes slice it earlier in the day? They do it too thick for my taste.

What does Esther Perel make of the work you do? I have never asked her that question. I understand why I initially got into this space. I got into this because I didn’t want to die. I wasn’t afraid of death; I was afraid of dying. I was afraid of not finishing what I knew I needed to do. I was afraid of being incomplete, not being a great fill-in-the-blank: father, husband, son, brother. Just thinking, I need more time to fix it. But I was never fixing it. I was just running. I don’t feel that way today. I don’t feel like I’m in this frenetic race to not die.

Can I share my theory about you? Of course.

I think as a young child, you had a deeply scarring, formative loss of control as a result of being abused, and you’ve since been compelled to carve out a life of total control, especially over your own body. It’s certainly possible. There’s no question that I was drawn at such a young age to boxing and training and exercising. It was like, there was nobody that was ever going to be able to harm me again. That to me is unmistakable. I’ve never really thought about the connection you’ve made, but I’m open to nonlinearity and orthogonal logic when it comes to that.

You do rationally understand that you probably won’t get to decide the terms of your decline and when and how you die, right? It’s all about controlling what I can control, which improves the odds that I will get the desired outcome. Look, there could be a cancer brewing inside me today that I’m unaware of that ends my life next year. I understand that. And if that’s the case and I’m on my death bed in a year, I won’t regret how hard I’ve worked to try to live a longer, better life. I’ll have given it my all.

This interview has been edited and condensed from two conversations.

David Marchese is a staff writer for the magazine and writes the Talk column. He recently interviewed Emma Chamberlain about leaving YouTube, Walter Mosley about a dumber America and Cal Newport about a new way to work.

As the founding director of the Johns Hopkins Center for Psychedelic and Consciousness Research, Dr. Roland Griffiths has been a pioneer in investigating the ways in which psychedelics can help treat depression, addiction and, in patients with a life-threatening cancer diagnosis, psychological distress. He has also looked at how the use of psychedelics can produce transformative and long-lasting feelings of human interconnectedness and unity. One could surely classify his achievements using various medical and scientific terms, but I’ll just put it like this: Griffiths has expanded the knowledge of how we might better learn to live.

Now he is learning to die. Griffiths, who is 76, has been diagnosed with Stage 4 metastatic colon cancer. It’s a diagnosis, in all likelihood terminal, that for him has brought forth transcendently positive feelings about existence and what he calls the great mystery of consciousness. “We all know that we’re terminal,” says Griffiths, who since being diagnosed has established an endowment at Johns Hopkins to study psychedelics and their potential for increasing human flourishing. “So I believe that in principle we shouldn’t need this Stage 4 cancer diagnosis to awaken. I’m excited to communicate, to shake the bars and tell people, ‘Come on, let’s wake up!’ ”

Can we start with your current prognosis? [Laughs.] Prognosis is a 50 percent chance that I’ll make it to Halloween.

And how are you feeling about that? In spite of that, life has been more beautiful, more wonderful than ever. When I first got that diagnosis, because I work out regularly, I watch my diet, I sleep well, this came out of left field. There was this period in which it felt like I was going to wake up and say, “Boy, that was” — to put it in psychedelic language — “a bummer, a bad dream.” But soon after that I started to contemplate the different psychological states that would be naturally forthcoming with a diagnosis like mine: depression, anxiety, denial, anger, or adopting some belief system of religious outcomes, which as a scientist I was not cut out to do. I went through those, exploring what life would be like if I inhabited those reactions, and I quickly concluded that that was not a wise way to live. I have a long-term meditation practice, and the focus there is on the nature of mind, of consciousness, and one comes to see that thoughts, emotions, are transient. They’re appearances of mind that you needn’t identify with. That practice — and some experience with psychedelics — was incredibly useful because what I recognized is that the best way to be with this diagnosis was to practice gratitude for the preciousness of our lives. Grasping for the cure wasn’t useful. [Laughs.] Actually we just got back another blood result that was an indication as to whether the cancer is progressing. My wife, Marla, and I say to each other, “No matter what this shows, it’s perfect.” Indeed, it showed a big jump in this blood marker, which wouldn’t be something to celebrate. It is what it is. It’s real. And what’s more fun than reality?

Roland Griffiths at a TEDMED conference in 2015.
TEDMED

You’re 76. You’ve had a long, full life. Is your perspective maybe one that a 40-year-old, say, with a terminal cancer diagnosis would be able to inhabit so profoundly? I’ve always lived under this illusion that I’m about 30 years younger than I am. I was feeling completely healthy at the time of this diagnosis. I was not about to wind down anything. As a scientist, it’s like a kid in the candy store with respect to what research, what questions need to be answered about psychedelics and the theme of the endowment and human flourishing. We were continuing to build out the center. I was more deeply engaged than ever and feeling that I was about 35. This was not in my game plan.

You talk about your cancer almost as if it’s a gift. Does that mean you don’t have regrets about what’s happening? My life has never been better! If I had a regret, it’s that I didn’t wake up as much as I have without a cancer diagnosis. It’s been incredible. There have been so many positive things: my relationship with my children, my grandchildren, my siblings, my wife. Marla and I have lived together for 11 years and felt that it was unimportant to get married. Then at dinner one evening, I asked Marla, “Would it be emotionally important to you, now, to be married?” She thought about it. The next day she said, “You know, it would be.” Immediately it became important to me. We were just married in our living room with my three children and two of our best friends. It was beyond beautiful. So do I have any regrets? No, but my concern is principally for Marla and how she’s going to deal with this. We’ve talked about my passing as being an opportunity, like my diagnosis, to wake up. Because these are opportunities to use events that could be labeled and experienced as miserable but don’t need to be.

Have you taken psychedelics since getting your diagnosis? Yes. After getting the diagnosis, I had no immediate interest in psychedelics. I felt in many respects that I was having a very psychedelic-like experience. There was this awakening, this aliveness, and I hesitated to take a psychedelic because I wondered whether it was going to disrupt that. Then a question arose: Is there something I’m avoiding by not taking a psychedelic? Am I defending against some dark, fearful thing I’m in denial about? Am I papering it over with this story of how great I’m doing and actually I’m scared to death? I thought, Well, this would be an interesting stress test. So I did a session with a psychedelic and went into that explicitly asking a couple of questions. First, asking myself, “Is there something I am not dealing with?” The answer came back: “No, the joy you’re experiencing is great. This is how it should be.” Then I asked a question directly of the cancer. I’m hesitant to talk about it because it’s reifying the cancer as “other,” and I don’t hold that the cancer is some “other” with which I can have a dialogue. But as a metaphor, it’s an interesting way to probe that question. So I asked the cancer: “What are you doing here? What can you tell me about what’s going on?” I got nothing back. Then I wanted to humanize it, and I said: “I really respect you. I talk about you as a blessing. I have had this astonishing sense of well-being and gratitude, despite everything that’s happening, and so I want to thank you. This process, is it going to kill me?” The answer was, “Yes, you will die, but everything is absolutely perfect; there’s meaning and purpose to this that goes beyond your understanding, but how you’re managing that is exactly how you should manage it.” So then I said: “OK, there’s purpose and meaning. I’m not ungrateful for the opportunity, but how about giving me more time?” [Laughs.] I got no response to that. But that’s OK.

How else have psychedelics, both studying them and using them, helped prepare you for death? Our first study was in cancer patients. Ironically enough, these were cancer patients who were depressed and anxious because of a life-threatening diagnosis. The findings of that study were profound: A single treatment of psilocybin produced large and enduring decreases in depression and anxiety. I’ve had some limited experience with psychedelics since then. But what did that teach me about my diagnosis? We’ve now treated hundreds of participants with psychedelics and before sessions, one of the key things that we teach them is that upon taking a psychedelic, there’s going to be an explosion of interior experiences. What we ask them to do is be with those experiences — be interested and curious. You don’t have to figure anything out. You’re going to have guides, and we’re going to create this safety container around you. But here’s the trick: These are not necessarily feel-good experiences. People can have experiences in which they feel like they come to this beautiful understanding of who they are and what the world is, but people can also have frightening experiences. The preparation we give for these experiences is to stay with them, be curious and recognize the ephemeral nature of them. If you do that, you’re going to find that they change. The metaphor we use is, imagine that you’re confronted with the most frightening demon you can imagine. It’s made by you, for you, to scare you. I’ll say: “There’s nothing in consciousness that can hurt you. So what you want to do is be deeply curious and, if anything, approach it.” If your natural tendency is to run, it can chase you for the entire session. But if you can see it as an appearance of mind, then you go, “Oh, that’s scary, but yeah, I’m going to investigate that.”

Griffiths in one of the psilocybin treatment rooms at Johns Hopkins University.
Will Kirk/Johns Hopkins University

Ah, OK. You can choose to investigate the experience rather than identify with it. But let me ask you this: The approach that you’re describing is pretty far from the typical mind-set of many doctors, who are working within a framework of curing, fixing, prevention. So if the ultimate goal is to help more otherwise healthy people get safe access to the potential benefits of using psychedelics, wouldn’t that require a radical rethinking by medical practitioners about what helping people even means? Yes, it will. One of the inspirations for the endowment is that it’s not aimed at patient populations. It’s not aimed at reducing clinically recognized suffering. Right now, there’s money pouring into this area, but that’s all going to be patient-related — there’s a pathway to medical approval. I do have concerns that we don’t replicate the mistakes that occurred in the 1960s, which over-promoted psychedelics’ use culturewide. They’re so powerful that if misaligned with cultural institutions, they can result in cultural kickback. In the 1960s they became aligned with the antiwar movement and radicalized-youth movement that was terrifying to existing political structures and institutions, and as a consequence, legislation was put up against them, funding dried up, they were considered a third rail in academic research. We need to proceed cautiously. It’s going to be critically important not to threaten existing cultural institutions. So I’ve been a proponent of medicalization, because with medicalization, we already have regulatory structures in place. It goes through F.D.A. approval; they’re going to set standards to maximize safety by specifying who should be eligible to receive, who is authorized to prescribe, and under what conditions treatment should occur. So I’m cautious, but that’s why I’ll have the endowment in perpetuity. If we look at the long range, this could be critical to the survival of our species. Because there’s something about the nature of these experiences under these certain conditions that produce remarkable experiences of interconnectedness of all things. At the deepest level, if we recognize we’re all in this together, then we have the kernel of what I suspect is most religious traditions and impulses and that is realizing that the Golden Rule makes a lot of sense.

I’ve noticed that often when you discuss human consciousness and our awareness of the preciousness of life, you talk about those things as an awe-inspiring “mystery.” What do you get out of putting it in those terms? Because consciousness may be a mystery now, but I’ve read theories that are convincing, to a layperson like me, that thoughts come from emotions and our emotions are one of the body’s mechanisms of maintaining homeostasis. Or as far as the awareness that life is precious, I could easily imagine that biophilia has evolutionary advantages. So I don’t see why these states of being have to be understood as mysteries. Does it diminish them to see them as explainable? No, I can easily inhabit an evolutionary account that explains how we have come to be who we are — with the exception of the question of interiority! Why would evolution waste its precious energy on our having interior experiences at all? I don’t get that. To me, it’s a very precious mystery, and that mystery, if you want to put it in religious terms, is God. It’s the unknowable. It’s unfathomable. I don’t believe in God as conceptualized within different religious traditions, but the mystery thing is something that strikes me as undeniable.

What do you struggle with? There must be something. Marla and I had just adopted a dog and that’s brought us incredible joy. Then we got some test results back suggesting the possibility of kidney failure. That’s been more difficult than dealing with my own diagnosis. We might both be on a parallel course of expiry. That’s difficult for me and doubly difficult for Marla. I can say, acutely, that this gives me something new to work with. It’s just accepting what is real and then appreciating that in the context of celebration of life. In some ways, if I knew that this precious dog is also facing a terminal condition, there may be beautiful synergy there. I’m not going to rule that out as a possibility.

So you have this sense, near the end of your life, of waking up to life’s real meaning. What’s the most important thing for everyone else who’s still asleep to know? I want everyone to appreciate the joy and wonder of every single moment of their lives. We should be astonished that we are here when we look around at the exquisite wonder and beauty of everything. I think everyone has a sense of that already. It’s leaning into that more fully. There is a reason every day to celebrate that we’re alive, that we have another day to explore whatever this gift is of being conscious, of being aware, of being aware that we are aware. That’s the deep mystery that I keep talking about. That’s to be celebrated!

This interview has been edited and condensed for clarity from two conversations.

David Marchese is a staff writer for the magazine and writes the Talk column. He recently interviewed Emma Chamberlain about leaving YouTube, Walter Mosley about a dumber America and Cal Newport about a new way to work.

Serious illness and suffering. Fear and fresh awareness of death. The uncertainty they all bring and what, for each, would constitute humane and effective medical treatment. Those physical and emotional concerns, central to palliative care, have forced their way into so many of our lives during the pandemic, even as we edge toward some skewed version of normalcy. They’re also the concerns that Dr. Diane E. Meier has been working on and thinking deeply about for decades. Meier, 68, is the longtime director of the Center to Advance Palliative Care, which is part of New York City’s Mount Sinai Hospital, and a 2008 recipient of a MacArthur Foundation “genius” fellowship. She has been a uniquely qualified observer of the Covid-induced cataclysms — often existential — experienced by patients and physicians. “If ever we needed to be reminded of how important human connection and support is for people with serious illness,” Meier says, “this pandemic has made the point very, very clearly.”

In September, you were quoted in The Washington Post saying that during the pandemic, other physicians have been looking to palliative-care doctors “to be the human side of medicine.” What does that imply about the medical system’s deficiencies? That the public’s experience with the medical profession has been subsumed by the marketplace, where there is enormous pressure on everyone working in the system to see multiple patients in a very short period of time and ensure that the services we offer are well reimbursed. Which is why the pandemic was such a blow to the economy of many health care systems: The major sources of income, which had to do with elective surgical and other procedures, were shut down because of the need to repurpose health systems for masses of people with Covid. The pandemic is the exemplar of why that is such a fragile foundation for a major first-world country’s health care system. The drivers are about doing what is necessary to get paid as opposed to what we thought our profession was all about, which was serving human beings who are suffering. It’s not that my colleagues are uncaring or don’t realize that their relationship with patients is a powerful instrument of healing; my point is not that my colleagues don’t want to be bothered. They can’t bother. So they’re relieved to have palliative-care colleagues who will take the time that they know their patients and patients’ families need. That enables our colleagues to overcome the moral distress and ethical inner conflict that the business side of medicine creates.

Do patients feel differently about palliative care when the need for it is caused by something unfamiliar like Covid-19 as opposed to, say, a cancer diagnosis? The fear and anxiety is completely different. It’s not that getting a diagnosis of dementia or cancer or kidney failure is not frightening. It is, but it’s somewhat normalized. You know people it’s happened to. Whereas the Covid pandemic — there was so much interesting coverage marking the 500,000th death about how invisible all the grieving is and how the whole country is in a state of numbness and denial because it is all too much to take in. It is too much to process. Let’s say that’s been your mind-set: It’s not going to happen to me. Then it does. All that denial falls apart. All that numbness won’t protect you. It is frightening, and compounded by the fact that family members can’t be with patients. One of the largest sources of suffering is the isolation of the patient and that the people who love them best can’t be with them. I will tell you, iPads and iPhones do not substitute.

Dr. Diane E. Meier in her office at Mount Sinai in 1997.
Linda Rosier

Has the pandemic affected our collective attitude toward grief? There are many shadow pandemics. One is the trauma to the entire health profession during this last year. The other trauma is the roughly 10 people for every person who has died from Covid who are grieving. That’s over five million people. That is a shadow pandemic that will be with us long after we get the virus under control. Our current president has worked hard to begin to address that through the ritual ceremonies to remember the dead and honor them, and he has talked a lot about his own losses, to normalize talking about losses and how they’re with you every day. That’s important. We need other people to do it too.

This is a bit of a sidetrack: In December, you published a piece in JAMA Internal Medicine about the “slippery slope” of increased access to physician-assisted death. But I’m still not quite clear why there would be a major concern about people unduly requesting medical assistance with ending their life when, by and large, people don’t want to die. Countries that have enabled euthanasia or assisted suicide have claimed that it has to be totally voluntary, cannot be due to financial or family pressures, cannot be due to untreated or unrecognized depression and cannot be due to untreated, poorly managed pain. They state that, and yet there is no evidence that those are not the major factors driving this. What it takes to adhere to those guidelines is incredibly expensive and time-consuming and doesn’t happen. That’s the situation in the Netherlands and Belgium and Canada: All the heartfelt adherence to restrictions that are announced when you first get the public to vote in favor of this go up in smoke once the practice is validated. And it’s always with the talking points that it’s about relief of suffering, that the person, even though he cannot say this, would agree that he would be better off dead. Ethically, do I think people should have the right to control the timing of their death? I do. I think it’s dangerous public policy. It’s a dangerous path to go down with the claim that it is all about respect for autonomy, when the real drivers are getting rid of a painful and expensive burden on society.

But couldn’t we always say that if people had access to better care then they wouldn’t consider this other option? What if the reality is that access to better care isn’t there? Are we saying to suffering people, “There are ways to still find meaning in life; we just can’t necessarily guarantee you’ll be able to take advantage of them”? There is a real tension there. Our system is so broken. But do we solve that problem by offering them physician-assisted death? I wouldn’t want to be part of that society. There was a recent case in Canada: a guy with neurodegenerative disorder who was cognitively intact. In order to go home from the hospital, he needed 24-hour care, and the government would not pay for 24-hour care. He recorded hospital staff offering him medical aid in dying as an alternative. You think that doesn’t create pressure on people who already feel like burdens? They need to be met with a resounding commitment to continued relationship. Not: “You’re right. I agree you’d be better off dead. Here’s a prescription.” That pushes someone who is struggling right over the cliff.

Might there be a lack of understanding on the part of some advocates of physician-assisted death that while palliative care maybe can’t relieve the entirety of one’s pain, it can still help patients find quality of life? It’s important to disabuse you of the notion that pain is the reason people request medical aid in dying. Pain is not the reason. It is existential and spiritual. The only treatment for that is relationship, attention, sitting with. Not trying to fix. That willingness to be with and engage the person in giving voice to that suffering is such a powerful intervention. It requires training. It’s a procedure. It isn’t about, “We can fix everything.” But we can enable giving voice to profound suffering, and that makes a huge difference.

Meier and a Mount Sinai colleague, Dr. R. Sean Morrison (right), discussing palliative care with Senator Sheldon Whitehouse of Rhode Island in Washington in 2011.
Kevin Wolf/Associated Press, for Center to Advance Palliative Care

Should we think of suffering as inevitable? That’s a great question, and the answer to any great question is “It depends.” It depends on the type of suffering. Dame Cicely Saunders used to talk about “total pain.” It was not just pain or constipation or fatigue or depression or difficulty sleeping. It was issues of purpose, meaning, identity, relationships. So while the practice of medicine is pretty good at the mechanics of treating things that cause tremendous suffering, the existential, spiritual and relationship fundamentals are addressed very often in the purview of palliative care teams. We see that as part of our job. In the rest of medicine, clinicians don’t, and people are left to find their way. If they’re not strongly embedded in a faith community or extended family, it causes tremendous suffering, because meaning comes through relationship. The fear of death is about the loss of relationship with the world and the people in it.

At this stage of your career, are there aspects of the human experience of chronic illness or pain that used to be mysterious to you that you now understand? It has to do with trauma. Trauma is widespread. In wealthy families and poor families; individual and family trauma; community trauma and societal trauma. We have so much of that here — just start with racism and go on. It is repressed and treated with denial. That doesn’t make it go away. It’s controlling how people respond to new trauma, whether it’s a diagnosis or a pandemic or a January 6th. So my perspective on trauma has a bigger scale than it used to — a species-level and tribal-level scale. And as I read the news, I don’t know whether we’re going to evolve our way out of this. The need to hate and kill the other is a determinative human characteristic and it informs so many aspects of our society. I also don’t see a disconnect between what has happened to the practice of medicine and that reality, because what’s happened to medicine is being driven by a societal commitment to profit above all else. And what is that? It’s trauma.

You could imagine somebody rolling their eyes at you, saying “You’re saying capitalism is trauma?” What has happened to the practice of medicine is that the public perception is that it has become totally transactional. That we do things either to make money or to avoid spending money. So, for example, many people of color fear that a conversation about whether or not they want cardiopulmonary resuscitation is not about what’s best for that patient; it’s about saving money for the hospital. Those perceptions are not wrong. That’s the problem. And there’s more than a kernel of truth in the perceptions of people feeling as if they or their loved one is being put through a marketplace of M.R.I.s and P.E.T. scans and specialists and subspecialists, and everybody is billing. The visibility of the extraction mind-set of the practice of medicine — it’s not subtle, and the public knows it. I’m worried about blowing the hard-earned trust that our profession worked toward over hundreds of years through, essentially, the commercialization of health care delivery.

Can you tease out the link you suggested earlier between trauma and killing the other? The analogy is post-traumatic stress disorder: an overreaction to new traumas because the prior traumas were never addressed, never expressed, never worked through. So everything that happens re-triggers it. There’s a book called “The Body Keeps the Score,” and that’s what it’s about: Things that happened to you years ago don’t ever go away. They are embedded in your mind and body and inform how you react to things that happen today. In my typical mechanistic doctor manner, I will tell you that there are things to do about it: It’s called trauma-informed care. It’s literally as simple as asking people what happened to them. What happened during your childhood? Because people know. They’ve just never been asked. And until it is unearthed and respected for the power that it had in that person’s life, it is controlling. The only way to take back control is to bring it to consciousness and name it.

Have you found that there are common positive meanings people find in life when they’re seriously ill that are applicable to those who aren’t? Yes. You may have read people talking about how while they would not wish their diagnosis on anyone, they are grateful for it. Because it made them stop worrying about things that aren’t important and focus on the things that are. That might be putting the garden in or spending time with grandchildren. Or my colleague — she’s 60 — said she’s going to become a bat mitzvah. She’s not sick, but the pandemic focused her on things she had put off. And she realized, What am I waiting for? That process of reflection requires pausing the racing in circles that our normal life tends to be: Get up at 6, go to the gym, go to work, etc. Whether we’re pausing because it has been forced on us by the pandemic or because we have a new diagnosis that requires us to reorganize our days — the busy-ness that has characterized everyday life for most people gets in the way of reflection. But it is a very common phenomenon for people to take the time and reflect about what’s important. People are trying desperately to make room for one’s inner life.

This interview has been edited and condensed for clarity from two conversations.