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On purpose: New directions in life and health
On Purpose: New Directions in Life and Health Victor J. Strecher PII: DOI: Reference:
S1058-9813(16)00031-X doi: 10.1016/j.ppedcard.2016.02.002 PPC 901
To appear in:
Progress in Pediatric cardiology
Please cite this article as: Strecher Victor J., On Purpose: New Directions in Life and Health, Progress in Pediatric cardiology (2016), doi: 10.1016/j.ppedcard.2016.02.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT On Purpose: New Directions in Life and Health Victor J. Strecher, PhD, MPH Professor, University of Michigan School of Public Health
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I felt that what I was standing on had given way, that I had no foundation to stand on, that that which I lived by no longer existed, and that I had nothing to live by.__
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Leo Tolstoy
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No Foundation to Stand On
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Born healthy, my daughter Julia contracted a chicken pox virus when she was an infant. Rather than causing a few days of illness, however, this virus attacked and destroyed her heart. Her only hope, and it was a long shot, was a new heart; without it she’d last only a few months.
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In 1990 a scant number of children had received heart transplants, and there was very little data on what would happen to the ones who had. Given this uncertainty, one of the biggest decisions that my wife, Jeri, and I needed to make was whether to even put Julia on a transplant waiting list. The alternative was letting her die in peace. It was an alternative worth considering – we had no idea what would happen if she were to receive a new heart. No idea what the quality of her life would be. We were on the front edge of this wave, and would be for Julia's entire life. We decided to list her for a transplant – in part, frankly, because we couldn’t bear to watch her die. But we were well aware that if she did get a new heart, we’d need to work incredibly hard to keep her well – to give her a big life. We’d also need to approach our life with her in a whole new way – in a way that assumed she might die at any moment. Julia received a new heart on Valentine’s Day, 1991, and our lives were changed forever. She lived through many challenges, including a second transplant when she was nine. Her life wasn’t easy by any stretch, but it was a big life. Friends, camp, softball, girl scouts, travel – experiences that many kids have, but that Julia never took for granted. This expression “took for granted” suggests that life and its experiences should be granted to you. But the unexpected thing that happened to the rest of our family is that we stopped taking our own lives for granted. We stopped expecting a certain life to happen to us, and instead started creating our own. This new outlook turned our lives turned from black and white into Technicolor. Personally, I started caring less about what people thought of me and more about what I thought of myself. As an assistant professor at a university, I started caring
ACCEPTED MANUSCRIPT less about getting tenure and more about making a difference in the world. Most importantly, I stopped thinking that I’d live forever and realized that I’m on this earth for an extraordinarily brief period of time – so I should make the most of it.
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Julia wanted to emulate the people who helped her so much through the years, so she enrolled as a student in the University of Michigan’s School of Nursing. Away from home for the first time in her life, Julia worked hard to balance her schoolwork with the management of her medications and their side effects. By winter, she needed a break. So on Spring Break, 2010, we took both of our daughters and their boyfriends to an island in the Caribbean. On the third night of our stay, after having a dinner by the ocean, my 19-year-old daughter turned to her boyfriend and said “I’m so happy right now that I could die.” And that night she did . . . in her sleep, of a sudden, unexpected, heart attack. A Search for Meaning
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After our daughter’s memorial service, a student from her old high school sent me an email she’d received from Julia after sending her a message of admiration for the strength with which she led her life. Julia had responded to her (without informing us): “The only reason I keep my head above water is because I have a goal in life that I am determined to reach.” She had a purpose.
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Those who lose their “foundation to stand on,” as Tolstoy put it, sometimes turn to Viktor Frankl, the Austrian psychiatrist. Frankl was one of the first, and certainly the foremost, to scientifically analyze the existential philosophy of purpose and meaning that can emerge from tragedy. In doing so he created a new approach to psychotherapy. Through his personal experiences in four Nazi concentration camps, Frankl observed that his fellow prisoners who were able to maintain a purpose in their lives were more likely to survive: “Woe to him who saw no sense in his life, no aim, no purpose, and therefore, no point in carrying on. He was soon lost.” His famous work, Man’s Search for Meaning (Frankl, 1946), became my clarion call to repurpose my life. Among my own family, friends, and colleagues, and even total strangers, I began to noticing people who lived purposeful lives. I found them in all walks of life. “Do you have a purpose in your life?” I once asked a New York cab driver. Without hesitation he replied, “I’m helping my daughter become the first person in our family to go to college. That’s why I work twelve hours a day.” A colleague of mine told me of a custodian at the University of Michigan’s Medical Center who, when asked, if he had a purpose in your life, replied, “I’m a part of the medical team. Every morning I put a fresh flower next to a woman who’s been a coma for months. If she wakes up, the first thing she’ll see is something beautiful.” In 2003 an epidemic of the SARS virus started sweeping through major cities in China. Population sizes and densities in modern Chinese cities are immense
ACCEPTED MANUSCRIPT compared with most other countries, and controlling the spread of an illness that kills roughly a third of those who catch it verges on the impossible.
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While visiting Tianjin’s Center for Disease Control a few years ago, I met with a senior public health professional who had worked in the city during the epidemic. China implemented a complete quarantine of Tianjin. Only public health workers were allowed in – but not out. The death rate among these workers approached one in three. I asked him whether his family (who lived outside of the quarantined area) was concerned while he was in Tianjin. He smiled and said, “Of course!”
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What a stupid question. Did he fear for his own life? He looked me in the eye and calmly replied, “This is what I do.”
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This was his purpose. Mark Twain said that a “man who lives fully is prepared to die at any time.” The Tianjin health professional seemed prepared to die at any time . . . for his purpose. The Research of Purposeful Living
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Surprisingly, having a purpose that transcends one’s life seems to be beneficial to one’s life. Studies have demonstrated that people with a strong purpose, on average, live much longer lives than those without one. Traditional risk factors including tobacco use, poor diet, inactivity, stress, and so on contribute to at least half of disease and early death. The media are filled with messages about these issues, but far less is written about purpose. People with heart disease but with a high purpose in life are significantly less likely, two years later, to have a heart attack (Kim et al, 2012). In a separate study, those with strong purpose were found less likely, four years later, to have a stroke (Kim et al, 2013). A study of over 900 seniors with no cognitive impairment found that the ones with low purpose in life were 2.4 times more likely to develop Alzheimer’s Disease than those with high purpose. (Boyle et al, 2010) People with a strong purpose in life also, on average, do better psychologically and socially than those without. They sleep better (Kim et al, 2015), are less likely to become depressed (Wood & Joseph, 2010), and have better sex (Prairie et al, 2011). People who have received drug and alcohol rehab are half as likely to relapse six months later if they had a strong purpose when they started (Martin et al., 2011). Physiologically, purpose in life is associated with an increase in natural killer cells that attack viruses and cancerous cells. It's also associated with a reduction in inflammatory cell production, an increase in HDL cholesterol, and an increase in telomerase, the enzyme that fuels the repair of our DNA (Jacobs et al., 2011). Do these outcomes translate into reductions in health care costs? My colleagues Eric Kim, now at Harvard University, Carol Ryff of the University of Wisconsin, and I studied the impact of purpose in life on health care use six years later among over
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7,000 adults over the age of 50. (Kim et al, 2015b) We used a six-point index that ranged from very low to very high purpose in life. After statistically controlling for initial demographics, health behaviors, and health status, we found an 8% average reduction in nights spent in the hospital each year for every one-point increase on the scale.
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So let’s imagine a drug which, in clinical trials, added an average of seven years to your life, reduced risk of heart attack and stroke; cut your risk of Alzheimer’s Disease by more than half; helped you relax during the day and sleep better at night; doubled your chances of staying drug- and alcohol-free after treatment; activated your natural killer cells while diminishing your inflammatory cells; increased your good cholesterol; and repaired your chromosomes. What if this imaginary drug reduced hospital stays so much that it put a sizable dent in the national health care crisis? Oh, and as a bonus, gave you better sex? This "miracle drug" would be in our drinking water.
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The Daimon Inside
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Over 2,300 years ago, Aristotle wrote that with some exceptions (being a slave, for one), we choose for ourselves the type of person we become. Whether born rich or poor, we choose our character and our virtues. We can live a life of self-enhancing, hedonic pleasure (a life Aristotle likened to grazing cattle) or listen to our inner voice that he termed the “daimon.” A "eudaimonic" life, Aristotle posited, is one of excellence, chosen with reason and guided by virtues such as courage, generosity, and justice. In psychology, the capacity for human beings to make the choices that guide their lives is called “agency.” Though it seems obvious that most individuals have at least some agency in today's world, it was quite different in Aristotle’s time, when it was the norm to make sacrifices to the gods to influence one’s fate. If we do have agency, Aristotle considered, we should use our gift of reason in choosing what to be in our lives. Socrates, the Athenian street philosopher, famously said that, “the unexamined life is not worth living.” As he was teaching others to examine their lives, Socrates would often stop in the middle of a conversation for a brief tete-a-tete with his inner daimon. Sculptors of his era would often hide a golden figurine inside terracotta busts they made of the Greek gods. One of the Socrates’ students likened him to one of these statues -- on the outside he was a bald, pot-bellied man, but his inner daimon gave him his true direction. The lack of connection with one’s daimon may be a chronic condition of modern life, leaving us unfulfilled despite our material successes. The philosopher David Norton described this feeling of emptiness eloquently: “...most of us today have no sense of an oracle within.... Turning our backs to the
ACCEPTED MANUSCRIPT void, we become infinitely distractible by outward things, prizing those that ‘demand’ our attention. We secretly treasure the atmosphere of world crises, for the mental ambulance-chasing it affords.” (Norton, 1976)
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Research of Eudaimonia and Hedonia
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Over the past decade there’s been a significant amount of research studying these Aristotelian concepts. In 2013 psychologist Barbara Fredrickson (Fredrickson et al, 2013) led a team of researchers “to map the potentially distinct biological effects of hedonic and eudaimonic well-being.” First they found that both hedonic and eudaimonic well-being were strongly linked; if you were hedonically well you were more likely to also be eudaimonically well, and vice versa. Participants scoring high on a hedonic index, however, were far more likely to have inflammatory gene expression and decreased expression of genes involved in antibody and antiviral response, whereas participants scoring high on a eudaimonic index had the opposite pattern of expression. Both hedonic and eudaimonic activities make us feel good, but our bodies respond to them in very different ways. As the researchers wrote:
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“Hedonic and eudaimonic well-being were originally distinguished to resolve basic and ancient philosophical questions regarding the best way for humans to live. The present data offer little grounds to prefer one mode of happiness over the other based on affective experience, but they identify a stark contrast at the level of molecular physiology.” In another recent study (Telzer et al, 2014) researchers examined activation in the ventral striatum of adolescents when engaged in eudaimonic versus hedonic decision making. The adolescents’ brains were scanned using functional magnetic resonance imaging (fMRI) while making eudaimonic decisions (to donate money to their family) or hedonic decisions to keep it. This allowed the researchers to identify adolescents who had more blood flow to the ventral striatum during eudaimonic versus hedonic choices. A year after the imaging was done, adolescents with greater activation of their brain’s reward system while giving money were found to have, on average, a decline in depressive symptoms, whereas those with greater activation in this system when keeping the money had an increase. Purpose in Practice Many financial advisors assume that their clients just want to get rich – that they value money for its own sake. The most effective financial advisors, however, ask their clients what they care most about in life – Their children? Their community? Their aging parents? Independence? Security? – and then invest in accordance with their clients' purposes and values.
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In health care we often assume that patients’ and families’ interests are focused almost solely on avoiding death. Yet many people care more about, and are motivated by, living than not dying. This is more than a semantic distinction; understanding an individual's purpose and values could very well determine a course of treatment. Allowing choice in these decisions could also motivate behavior change.
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Psychologists use terms such as self-determination, autonomy, and intrinsic motivation to refer to decisions one makes for oneself, based on one’s own values and purpose. An exemplar of self-determination is Aimee Mullins. Born without fibulae in both legs, Mullins was told she would never walk, and would likely spend the rest of her life using a wheelchair. To give her an outside chance at independent mobility, doctors amputated both her legs below the knee – on her first birthday. Through her childhood, Aimee used heavy, painful prosthetic legs made of wood with metal hinges.
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“When I was fourteen it was Easter Sunday,” she told me in 2010, “and I was going to be wearing a dress that I’d bought with my own money. The first thing I ever bought that wasn’t on sale. A momentous event – you never forget it. I had a paper route since I was twelve, and I went to the Limited and I bought this dress that I thought was the height of sophistication. Sleeveless, Safari dress, belted, hits the knee.
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“As I'm coming downstairs, my father’s in the living room waiting to take us to church. He takes one look and says, ‘That doesn’t look right. Go upstairs and change.’ I was like, ‘My super-classy dress? What are you talking about? It’s the best thing I own!’ He said, ‘You can see the knee joint when you walk. It doesn’t look right. It’s inappropriate. Go change.’ And something snapped in me. I refused to change. And it was the first time I defied my father. I refused to hide something about myself that was true.” Later, while attending Georgetown University's prestigious School of Foreign Service, Mullins competed in NCAA track and field events against able-bodied athletes and was named by Sports Illustrated "One Of The Coolest Girls in Sports.” She is now an acclaimed fashion model and actress. As the owner of twelve pairs of prosthetic legs, including a pair of hand-carved wooden ones, she can now reign at any "height of sophistication," by making Cyborg-like transformations from five to over six feet tall by choosing different legs. Mullins told me, “I decide, I will decide, and decide again and I get to create and recreate the Aimee Mullins I want to be.” Alignment with Purpose In 2015 I asked a group of clinicians at the University of Michigan to state their life purposes, and received, among others, the following responses:
ACCEPTED MANUSCRIPT “To make even a tiny contribution each day to alleviating or preventing suffering in the world.” “To be an inspiring and engaged physician, mentor, and leader who helps others to improve health care and health.”
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“To reduce racial/ethnic disparities in health and health care.” “To show my kids that women can be successful fulfilling important roles at work and at home.”
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“To improve the quality of cancer care in big (population) and not-so-small (patientby-patient) ways.”
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These purposes read as self-determined personal challenges: goals that are deeply valued by the individual. Goals determine the amount of effort, concentration, and persistence that we're willing to devote. They also motivate self-examination and change. Psychologists Edward Deco and Richard Ryan state, “...the eudaimonic approach ascribes content to human nature and works to uncover that content and to understand the conditions that facilitate versus diminish it.” (Deci and Ryan, 2008). Just what, then, are the conditions that facilitate rather than diminish alignment with one’s purpose?
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Two thousand years ago the ancient Stoic philosopher Seneca wrote, “When a man does not know what harbor he is making for, no wind is the right wind.” But what if you have a harbor and no wind in your sails? A harbor, in Seneca’s statement, represents purpose in life. Energy (or vitality) is the “wind in the sails,” and is necessary for purposeful living. To extend Seneca's metaphor, one needs a rudder to steer toward the harbor. Using one of the clinician’s purposes as an example, in order to “be an inspiring and engaged physician, mentor and leader who helps others to improve health care and health,” one needs to maintain daily energy and willpower. What factors influence energy and willpower? Studies have demonstrated that energy and willpower are both are boosted by sleep, mindfulness, physical activity, and a good diet. The physician quoted above may find more energy and willpower toward his or her purpose by learning to sleep better, taking up Yoga, walking to work, or adopting a Mediterranean Diet. And beyond those benefits, such healthrelated behaviors can also reduce substance abuse and improve self-care and resilience to stressors. There may be other influences of energy and willpower, including family issues, the economy, news events, and even the weather. Researchers of Ourselves By combining Socrates's admonition that an unexamined life is not worth living with Aristotle’s suggestion that a purposeless life is not worth examining, I've concluded that health professionals can greatly benefit both their patients and themselves by learning how to live purposefully – and then doing it. In his book Megatrends, John Naisbitt said that, “The most exciting breakthroughs of the 21st century will not occur because of technology but because of an expanding
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concept of what it means to be human.” Naisbitt is, in my opinion, correct in thinking that we have an opportunity to live better, not just longer, lives. He may also be implying that the enemy of being more human is technology. (People who constantly interrupt face-to-face conversations to check their Instagram feed is a depressing sign that Naisbitt may be onto something!) But we may also be able to use technology to become more human.
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With ever more integration of biometric devices, mobile phones, the Web, big data, and advanced forecasting science, we are now able to create a new generation of health products that help people become better researchers of themselves – in particular, of the factors that contribute to (or detract from) their own energy, willpower, and alignment with their purpose.
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Here's how it could work. Location and time-based data collection from smartphones allows us to model causal influences of (among countless other factors) time of day, day of the week, day of the month, temperature, barometric pressure, pollen count, local gas prices – even a favorite sports teams’ wins and losses, a. Subsequently integrating these data with biometric devices such as accelerometers, as well as with larger databases of location and time-based information, could create an individual’s “personal causal model” of energy, willpower, and alignment with purpose.
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This development could provide useful, non-obvious information to the user. We don’t typically notice the influence of multiple days of behavior, delayed effects of a behavior (such as sleep), or interactions with other behaviors or the environment (e.g., lack of physical activity yesterday combined with three nights of poor sleep brought on by a loss by their favorite sports team). (Cornil and Chandon, 2014) But a machine – a very smart machine – can. Once equipped with a better understanding of interior and exterior influences on energy and willpower, an individual may become more interested in modifying these influences. A person may seek help from experts; or, as we often do, look to others like themselves who have successfully changed their own behavior. In software design, this is called ‘collaborative filtering"; in societies it's called "emulation." Recommender systems, such as those used by Amazon or Netflix, employ collaborative filtering algorithms to identify solutions from others similar to the user. These systems can, for example, identify similar others who have started to sleep better. The tips that work best receive high ratings, and rise to the top of the list. Becoming a Force of Nature George Bernard Shaw once said that “the true joy in life” is “being used for a purpose recognized by yourself as a mighty one. Being a force of nature instead of a feverish, selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy.” The fact that you’re reading this particular journal
ACCEPTED MANUSCRIPT suggests that your purpose, indeed, is “a mighty one.” Rising above the condition of a “little clod of ailments and grievances” is not easy in the beleaguering world of the modern health care industry.
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It’s also not easy given the sad fact that many children you treat fail to survive and fulfill their own purposes. But as a parent of one of those losses, I understand personally the importance and meaning to be gained from the struggle itself, even if it ultimately proves to be futile. As the French philosopher and resistance fighter Albert Camus wrote (as the Nazis were marching into his home city of Paris), “The struggle itself toward the heights is enough to fill a man’s heart.” (Camus, 1944)
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It is my fervent hope that health care professionals remember the reasons they became health care professionals in the first place, and can learn to better maintain their energy and willpower. I also hope that the health care industry itself contributes to these efforts, by creating a nurturing environment that allows health care professionals to live purposefully. Without them, my daughter would never have had a purpose, or a meaningful life. And neither would I.
ACCEPTED MANUSCRIPT References Aristotle. Nichomachean Ethics
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Boyle PA, Buchman AS, Barnes LL, and Bennett DA. (2010). Effect of a purpose in life on incident Alzheimer Disease and mild cognitive impairment in communitydwelling older persons. Archives of General Psychiatry. 67(3):304-310.s
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Camus A. The Myth of Sisyphus. 1944.
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Cornil Y and Chandon P. (2013). From fan to fat? Vicarious losing increases unhealthy eating, but self-affirmation is an effective remedy. Psychological Science 24(10):1936-46.
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Crocker J, Niiya Y, Michkowski D. (2008). Why does writing about important values reduce defensiveness? Self-affirmation and the role of positive other-directed feelings. Psychological Science 19(7):740-7. Deci EL and Ryan RM. (2008). Hedonia, eudaimonia, and well-being: An introduction. Journal of Happiness Studies. 9:1-11.
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Falk EB, O’Donnell MB, Cascio CN, Tinney F, Kang Y, Lieberman MD, Taylor SE, An L, Resnicow K, Strecher VJ. (2015). Self-affirmation alters the brain’s response to health messages and subsequent behavior change. Proceedings of the National Academy of Science 112(7):1977-82. Frankl V. Man’s Search for Meaning. 1946. Fredrickson BL, Grewen KM, Coffey KA, Algoe SB, Firestine AM, Arevalo JM, Ma J, Cole SW. (2013). A functional genomic perspective on human well-being. Proceedings of the National Academy of Science 110(33):13684-9. Jacobs TL, Epel ES, et al. (2011). Intensive meditation training, immune cell telomerase activity, and psychological mediators. Psychoneuroendocrinology. 36:664-681. Kim ES, Sun JK, Park N, and Peterson C. (2013). Purpose in life and reduced incidence of stroke in older adults: The health and retirement study. Journal of Psychosomatic Research. 74:427-432. Kim ES, Sun JK, Park JK, Kubzansky LD, and Peterson C. (2012). Purpose in life and reduced risk of myocardial infarction among older U.S. adults with coronary heart disease: A two-year follow-up. Journal of Behavioral Medicine. Martin RA, MacKinnon S, Johnson J, and Rohsenow DJ. (2011). Purpose in life predicts treatment outcome among adult cocaine abusers in treatment. Journal of Substance Abuse Treatment. 40:183-188.
ACCEPTED MANUSCRIPT Norton DL. Personal Destinies: A Philosophy of Ethical Individualism. 1976. Princeton University Press. Plato. Symposium
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Prairie BA, Sheier MF, Matthews KA, Chang CCH, and Hess R. (2011) A higher sense of purpose in life is associated with sexual enjoyment in midlife women. Menopause. 18(8):839-844.
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Telzer EH, Fuligni AJ, Lieberman MD, and Galvan A. (2014). Neural sensitivity to eudaimonic and hedonic rewards diffentially predict adolescent depressive symptoms over time. Proceedings of the National Academy of Science.
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Wood AM and Joseph S. (2010). The absence of positive psychological (eudemonic) well-being as a risk factor for depression: A ten year cohort study. Journal of Affective Disorders. 122:213-217.
S1058-9813(16)00031-X doi: 10.1016/j.ppedcard.2016.02.002 PPC 901
To appear in:
Progress in Pediatric cardiology
Please cite this article as: Strecher Victor J., On Purpose: New Directions in Life and Health, Progress in Pediatric cardiology (2016), doi: 10.1016/j.ppedcard.2016.02.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT On Purpose: New Directions in Life and Health Victor J. Strecher, PhD, MPH Professor, University of Michigan School of Public Health
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I felt that what I was standing on had given way, that I had no foundation to stand on, that that which I lived by no longer existed, and that I had nothing to live by.__
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Leo Tolstoy
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No Foundation to Stand On
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Born healthy, my daughter Julia contracted a chicken pox virus when she was an infant. Rather than causing a few days of illness, however, this virus attacked and destroyed her heart. Her only hope, and it was a long shot, was a new heart; without it she’d last only a few months.
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In 1990 a scant number of children had received heart transplants, and there was very little data on what would happen to the ones who had. Given this uncertainty, one of the biggest decisions that my wife, Jeri, and I needed to make was whether to even put Julia on a transplant waiting list. The alternative was letting her die in peace. It was an alternative worth considering – we had no idea what would happen if she were to receive a new heart. No idea what the quality of her life would be. We were on the front edge of this wave, and would be for Julia's entire life. We decided to list her for a transplant – in part, frankly, because we couldn’t bear to watch her die. But we were well aware that if she did get a new heart, we’d need to work incredibly hard to keep her well – to give her a big life. We’d also need to approach our life with her in a whole new way – in a way that assumed she might die at any moment. Julia received a new heart on Valentine’s Day, 1991, and our lives were changed forever. She lived through many challenges, including a second transplant when she was nine. Her life wasn’t easy by any stretch, but it was a big life. Friends, camp, softball, girl scouts, travel – experiences that many kids have, but that Julia never took for granted. This expression “took for granted” suggests that life and its experiences should be granted to you. But the unexpected thing that happened to the rest of our family is that we stopped taking our own lives for granted. We stopped expecting a certain life to happen to us, and instead started creating our own. This new outlook turned our lives turned from black and white into Technicolor. Personally, I started caring less about what people thought of me and more about what I thought of myself. As an assistant professor at a university, I started caring
ACCEPTED MANUSCRIPT less about getting tenure and more about making a difference in the world. Most importantly, I stopped thinking that I’d live forever and realized that I’m on this earth for an extraordinarily brief period of time – so I should make the most of it.
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Julia wanted to emulate the people who helped her so much through the years, so she enrolled as a student in the University of Michigan’s School of Nursing. Away from home for the first time in her life, Julia worked hard to balance her schoolwork with the management of her medications and their side effects. By winter, she needed a break. So on Spring Break, 2010, we took both of our daughters and their boyfriends to an island in the Caribbean. On the third night of our stay, after having a dinner by the ocean, my 19-year-old daughter turned to her boyfriend and said “I’m so happy right now that I could die.” And that night she did . . . in her sleep, of a sudden, unexpected, heart attack. A Search for Meaning
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After our daughter’s memorial service, a student from her old high school sent me an email she’d received from Julia after sending her a message of admiration for the strength with which she led her life. Julia had responded to her (without informing us): “The only reason I keep my head above water is because I have a goal in life that I am determined to reach.” She had a purpose.
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Those who lose their “foundation to stand on,” as Tolstoy put it, sometimes turn to Viktor Frankl, the Austrian psychiatrist. Frankl was one of the first, and certainly the foremost, to scientifically analyze the existential philosophy of purpose and meaning that can emerge from tragedy. In doing so he created a new approach to psychotherapy. Through his personal experiences in four Nazi concentration camps, Frankl observed that his fellow prisoners who were able to maintain a purpose in their lives were more likely to survive: “Woe to him who saw no sense in his life, no aim, no purpose, and therefore, no point in carrying on. He was soon lost.” His famous work, Man’s Search for Meaning (Frankl, 1946), became my clarion call to repurpose my life. Among my own family, friends, and colleagues, and even total strangers, I began to noticing people who lived purposeful lives. I found them in all walks of life. “Do you have a purpose in your life?” I once asked a New York cab driver. Without hesitation he replied, “I’m helping my daughter become the first person in our family to go to college. That’s why I work twelve hours a day.” A colleague of mine told me of a custodian at the University of Michigan’s Medical Center who, when asked, if he had a purpose in your life, replied, “I’m a part of the medical team. Every morning I put a fresh flower next to a woman who’s been a coma for months. If she wakes up, the first thing she’ll see is something beautiful.” In 2003 an epidemic of the SARS virus started sweeping through major cities in China. Population sizes and densities in modern Chinese cities are immense
ACCEPTED MANUSCRIPT compared with most other countries, and controlling the spread of an illness that kills roughly a third of those who catch it verges on the impossible.
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While visiting Tianjin’s Center for Disease Control a few years ago, I met with a senior public health professional who had worked in the city during the epidemic. China implemented a complete quarantine of Tianjin. Only public health workers were allowed in – but not out. The death rate among these workers approached one in three. I asked him whether his family (who lived outside of the quarantined area) was concerned while he was in Tianjin. He smiled and said, “Of course!”
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What a stupid question. Did he fear for his own life? He looked me in the eye and calmly replied, “This is what I do.”
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This was his purpose. Mark Twain said that a “man who lives fully is prepared to die at any time.” The Tianjin health professional seemed prepared to die at any time . . . for his purpose. The Research of Purposeful Living
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Surprisingly, having a purpose that transcends one’s life seems to be beneficial to one’s life. Studies have demonstrated that people with a strong purpose, on average, live much longer lives than those without one. Traditional risk factors including tobacco use, poor diet, inactivity, stress, and so on contribute to at least half of disease and early death. The media are filled with messages about these issues, but far less is written about purpose. People with heart disease but with a high purpose in life are significantly less likely, two years later, to have a heart attack (Kim et al, 2012). In a separate study, those with strong purpose were found less likely, four years later, to have a stroke (Kim et al, 2013). A study of over 900 seniors with no cognitive impairment found that the ones with low purpose in life were 2.4 times more likely to develop Alzheimer’s Disease than those with high purpose. (Boyle et al, 2010) People with a strong purpose in life also, on average, do better psychologically and socially than those without. They sleep better (Kim et al, 2015), are less likely to become depressed (Wood & Joseph, 2010), and have better sex (Prairie et al, 2011). People who have received drug and alcohol rehab are half as likely to relapse six months later if they had a strong purpose when they started (Martin et al., 2011). Physiologically, purpose in life is associated with an increase in natural killer cells that attack viruses and cancerous cells. It's also associated with a reduction in inflammatory cell production, an increase in HDL cholesterol, and an increase in telomerase, the enzyme that fuels the repair of our DNA (Jacobs et al., 2011). Do these outcomes translate into reductions in health care costs? My colleagues Eric Kim, now at Harvard University, Carol Ryff of the University of Wisconsin, and I studied the impact of purpose in life on health care use six years later among over
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7,000 adults over the age of 50. (Kim et al, 2015b) We used a six-point index that ranged from very low to very high purpose in life. After statistically controlling for initial demographics, health behaviors, and health status, we found an 8% average reduction in nights spent in the hospital each year for every one-point increase on the scale.
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So let’s imagine a drug which, in clinical trials, added an average of seven years to your life, reduced risk of heart attack and stroke; cut your risk of Alzheimer’s Disease by more than half; helped you relax during the day and sleep better at night; doubled your chances of staying drug- and alcohol-free after treatment; activated your natural killer cells while diminishing your inflammatory cells; increased your good cholesterol; and repaired your chromosomes. What if this imaginary drug reduced hospital stays so much that it put a sizable dent in the national health care crisis? Oh, and as a bonus, gave you better sex? This "miracle drug" would be in our drinking water.
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The Daimon Inside
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Over 2,300 years ago, Aristotle wrote that with some exceptions (being a slave, for one), we choose for ourselves the type of person we become. Whether born rich or poor, we choose our character and our virtues. We can live a life of self-enhancing, hedonic pleasure (a life Aristotle likened to grazing cattle) or listen to our inner voice that he termed the “daimon.” A "eudaimonic" life, Aristotle posited, is one of excellence, chosen with reason and guided by virtues such as courage, generosity, and justice. In psychology, the capacity for human beings to make the choices that guide their lives is called “agency.” Though it seems obvious that most individuals have at least some agency in today's world, it was quite different in Aristotle’s time, when it was the norm to make sacrifices to the gods to influence one’s fate. If we do have agency, Aristotle considered, we should use our gift of reason in choosing what to be in our lives. Socrates, the Athenian street philosopher, famously said that, “the unexamined life is not worth living.” As he was teaching others to examine their lives, Socrates would often stop in the middle of a conversation for a brief tete-a-tete with his inner daimon. Sculptors of his era would often hide a golden figurine inside terracotta busts they made of the Greek gods. One of the Socrates’ students likened him to one of these statues -- on the outside he was a bald, pot-bellied man, but his inner daimon gave him his true direction. The lack of connection with one’s daimon may be a chronic condition of modern life, leaving us unfulfilled despite our material successes. The philosopher David Norton described this feeling of emptiness eloquently: “...most of us today have no sense of an oracle within.... Turning our backs to the
ACCEPTED MANUSCRIPT void, we become infinitely distractible by outward things, prizing those that ‘demand’ our attention. We secretly treasure the atmosphere of world crises, for the mental ambulance-chasing it affords.” (Norton, 1976)
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Research of Eudaimonia and Hedonia
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Over the past decade there’s been a significant amount of research studying these Aristotelian concepts. In 2013 psychologist Barbara Fredrickson (Fredrickson et al, 2013) led a team of researchers “to map the potentially distinct biological effects of hedonic and eudaimonic well-being.” First they found that both hedonic and eudaimonic well-being were strongly linked; if you were hedonically well you were more likely to also be eudaimonically well, and vice versa. Participants scoring high on a hedonic index, however, were far more likely to have inflammatory gene expression and decreased expression of genes involved in antibody and antiviral response, whereas participants scoring high on a eudaimonic index had the opposite pattern of expression. Both hedonic and eudaimonic activities make us feel good, but our bodies respond to them in very different ways. As the researchers wrote:
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“Hedonic and eudaimonic well-being were originally distinguished to resolve basic and ancient philosophical questions regarding the best way for humans to live. The present data offer little grounds to prefer one mode of happiness over the other based on affective experience, but they identify a stark contrast at the level of molecular physiology.” In another recent study (Telzer et al, 2014) researchers examined activation in the ventral striatum of adolescents when engaged in eudaimonic versus hedonic decision making. The adolescents’ brains were scanned using functional magnetic resonance imaging (fMRI) while making eudaimonic decisions (to donate money to their family) or hedonic decisions to keep it. This allowed the researchers to identify adolescents who had more blood flow to the ventral striatum during eudaimonic versus hedonic choices. A year after the imaging was done, adolescents with greater activation of their brain’s reward system while giving money were found to have, on average, a decline in depressive symptoms, whereas those with greater activation in this system when keeping the money had an increase. Purpose in Practice Many financial advisors assume that their clients just want to get rich – that they value money for its own sake. The most effective financial advisors, however, ask their clients what they care most about in life – Their children? Their community? Their aging parents? Independence? Security? – and then invest in accordance with their clients' purposes and values.
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In health care we often assume that patients’ and families’ interests are focused almost solely on avoiding death. Yet many people care more about, and are motivated by, living than not dying. This is more than a semantic distinction; understanding an individual's purpose and values could very well determine a course of treatment. Allowing choice in these decisions could also motivate behavior change.
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Psychologists use terms such as self-determination, autonomy, and intrinsic motivation to refer to decisions one makes for oneself, based on one’s own values and purpose. An exemplar of self-determination is Aimee Mullins. Born without fibulae in both legs, Mullins was told she would never walk, and would likely spend the rest of her life using a wheelchair. To give her an outside chance at independent mobility, doctors amputated both her legs below the knee – on her first birthday. Through her childhood, Aimee used heavy, painful prosthetic legs made of wood with metal hinges.
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“When I was fourteen it was Easter Sunday,” she told me in 2010, “and I was going to be wearing a dress that I’d bought with my own money. The first thing I ever bought that wasn’t on sale. A momentous event – you never forget it. I had a paper route since I was twelve, and I went to the Limited and I bought this dress that I thought was the height of sophistication. Sleeveless, Safari dress, belted, hits the knee.
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“As I'm coming downstairs, my father’s in the living room waiting to take us to church. He takes one look and says, ‘That doesn’t look right. Go upstairs and change.’ I was like, ‘My super-classy dress? What are you talking about? It’s the best thing I own!’ He said, ‘You can see the knee joint when you walk. It doesn’t look right. It’s inappropriate. Go change.’ And something snapped in me. I refused to change. And it was the first time I defied my father. I refused to hide something about myself that was true.” Later, while attending Georgetown University's prestigious School of Foreign Service, Mullins competed in NCAA track and field events against able-bodied athletes and was named by Sports Illustrated "One Of The Coolest Girls in Sports.” She is now an acclaimed fashion model and actress. As the owner of twelve pairs of prosthetic legs, including a pair of hand-carved wooden ones, she can now reign at any "height of sophistication," by making Cyborg-like transformations from five to over six feet tall by choosing different legs. Mullins told me, “I decide, I will decide, and decide again and I get to create and recreate the Aimee Mullins I want to be.” Alignment with Purpose In 2015 I asked a group of clinicians at the University of Michigan to state their life purposes, and received, among others, the following responses:
ACCEPTED MANUSCRIPT “To make even a tiny contribution each day to alleviating or preventing suffering in the world.” “To be an inspiring and engaged physician, mentor, and leader who helps others to improve health care and health.”
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“To reduce racial/ethnic disparities in health and health care.” “To show my kids that women can be successful fulfilling important roles at work and at home.”
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“To improve the quality of cancer care in big (population) and not-so-small (patientby-patient) ways.”
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These purposes read as self-determined personal challenges: goals that are deeply valued by the individual. Goals determine the amount of effort, concentration, and persistence that we're willing to devote. They also motivate self-examination and change. Psychologists Edward Deco and Richard Ryan state, “...the eudaimonic approach ascribes content to human nature and works to uncover that content and to understand the conditions that facilitate versus diminish it.” (Deci and Ryan, 2008). Just what, then, are the conditions that facilitate rather than diminish alignment with one’s purpose?
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Two thousand years ago the ancient Stoic philosopher Seneca wrote, “When a man does not know what harbor he is making for, no wind is the right wind.” But what if you have a harbor and no wind in your sails? A harbor, in Seneca’s statement, represents purpose in life. Energy (or vitality) is the “wind in the sails,” and is necessary for purposeful living. To extend Seneca's metaphor, one needs a rudder to steer toward the harbor. Using one of the clinician’s purposes as an example, in order to “be an inspiring and engaged physician, mentor and leader who helps others to improve health care and health,” one needs to maintain daily energy and willpower. What factors influence energy and willpower? Studies have demonstrated that energy and willpower are both are boosted by sleep, mindfulness, physical activity, and a good diet. The physician quoted above may find more energy and willpower toward his or her purpose by learning to sleep better, taking up Yoga, walking to work, or adopting a Mediterranean Diet. And beyond those benefits, such healthrelated behaviors can also reduce substance abuse and improve self-care and resilience to stressors. There may be other influences of energy and willpower, including family issues, the economy, news events, and even the weather. Researchers of Ourselves By combining Socrates's admonition that an unexamined life is not worth living with Aristotle’s suggestion that a purposeless life is not worth examining, I've concluded that health professionals can greatly benefit both their patients and themselves by learning how to live purposefully – and then doing it. In his book Megatrends, John Naisbitt said that, “The most exciting breakthroughs of the 21st century will not occur because of technology but because of an expanding
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concept of what it means to be human.” Naisbitt is, in my opinion, correct in thinking that we have an opportunity to live better, not just longer, lives. He may also be implying that the enemy of being more human is technology. (People who constantly interrupt face-to-face conversations to check their Instagram feed is a depressing sign that Naisbitt may be onto something!) But we may also be able to use technology to become more human.
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With ever more integration of biometric devices, mobile phones, the Web, big data, and advanced forecasting science, we are now able to create a new generation of health products that help people become better researchers of themselves – in particular, of the factors that contribute to (or detract from) their own energy, willpower, and alignment with their purpose.
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Here's how it could work. Location and time-based data collection from smartphones allows us to model causal influences of (among countless other factors) time of day, day of the week, day of the month, temperature, barometric pressure, pollen count, local gas prices – even a favorite sports teams’ wins and losses, a. Subsequently integrating these data with biometric devices such as accelerometers, as well as with larger databases of location and time-based information, could create an individual’s “personal causal model” of energy, willpower, and alignment with purpose.
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This development could provide useful, non-obvious information to the user. We don’t typically notice the influence of multiple days of behavior, delayed effects of a behavior (such as sleep), or interactions with other behaviors or the environment (e.g., lack of physical activity yesterday combined with three nights of poor sleep brought on by a loss by their favorite sports team). (Cornil and Chandon, 2014) But a machine – a very smart machine – can. Once equipped with a better understanding of interior and exterior influences on energy and willpower, an individual may become more interested in modifying these influences. A person may seek help from experts; or, as we often do, look to others like themselves who have successfully changed their own behavior. In software design, this is called ‘collaborative filtering"; in societies it's called "emulation." Recommender systems, such as those used by Amazon or Netflix, employ collaborative filtering algorithms to identify solutions from others similar to the user. These systems can, for example, identify similar others who have started to sleep better. The tips that work best receive high ratings, and rise to the top of the list. Becoming a Force of Nature George Bernard Shaw once said that “the true joy in life” is “being used for a purpose recognized by yourself as a mighty one. Being a force of nature instead of a feverish, selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy.” The fact that you’re reading this particular journal
ACCEPTED MANUSCRIPT suggests that your purpose, indeed, is “a mighty one.” Rising above the condition of a “little clod of ailments and grievances” is not easy in the beleaguering world of the modern health care industry.
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It’s also not easy given the sad fact that many children you treat fail to survive and fulfill their own purposes. But as a parent of one of those losses, I understand personally the importance and meaning to be gained from the struggle itself, even if it ultimately proves to be futile. As the French philosopher and resistance fighter Albert Camus wrote (as the Nazis were marching into his home city of Paris), “The struggle itself toward the heights is enough to fill a man’s heart.” (Camus, 1944)
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It is my fervent hope that health care professionals remember the reasons they became health care professionals in the first place, and can learn to better maintain their energy and willpower. I also hope that the health care industry itself contributes to these efforts, by creating a nurturing environment that allows health care professionals to live purposefully. Without them, my daughter would never have had a purpose, or a meaningful life. And neither would I.
ACCEPTED MANUSCRIPT References Aristotle. Nichomachean Ethics
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Boyle PA, Buchman AS, Barnes LL, and Bennett DA. (2010). Effect of a purpose in life on incident Alzheimer Disease and mild cognitive impairment in communitydwelling older persons. Archives of General Psychiatry. 67(3):304-310.s
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Camus A. The Myth of Sisyphus. 1944.
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Cornil Y and Chandon P. (2013). From fan to fat? Vicarious losing increases unhealthy eating, but self-affirmation is an effective remedy. Psychological Science 24(10):1936-46.
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Crocker J, Niiya Y, Michkowski D. (2008). Why does writing about important values reduce defensiveness? Self-affirmation and the role of positive other-directed feelings. Psychological Science 19(7):740-7. Deci EL and Ryan RM. (2008). Hedonia, eudaimonia, and well-being: An introduction. Journal of Happiness Studies. 9:1-11.
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Falk EB, O’Donnell MB, Cascio CN, Tinney F, Kang Y, Lieberman MD, Taylor SE, An L, Resnicow K, Strecher VJ. (2015). Self-affirmation alters the brain’s response to health messages and subsequent behavior change. Proceedings of the National Academy of Science 112(7):1977-82. Frankl V. Man’s Search for Meaning. 1946. Fredrickson BL, Grewen KM, Coffey KA, Algoe SB, Firestine AM, Arevalo JM, Ma J, Cole SW. (2013). A functional genomic perspective on human well-being. Proceedings of the National Academy of Science 110(33):13684-9. Jacobs TL, Epel ES, et al. (2011). Intensive meditation training, immune cell telomerase activity, and psychological mediators. Psychoneuroendocrinology. 36:664-681. Kim ES, Sun JK, Park N, and Peterson C. (2013). Purpose in life and reduced incidence of stroke in older adults: The health and retirement study. Journal of Psychosomatic Research. 74:427-432. Kim ES, Sun JK, Park JK, Kubzansky LD, and Peterson C. (2012). Purpose in life and reduced risk of myocardial infarction among older U.S. adults with coronary heart disease: A two-year follow-up. Journal of Behavioral Medicine. Martin RA, MacKinnon S, Johnson J, and Rohsenow DJ. (2011). Purpose in life predicts treatment outcome among adult cocaine abusers in treatment. Journal of Substance Abuse Treatment. 40:183-188.
ACCEPTED MANUSCRIPT Norton DL. Personal Destinies: A Philosophy of Ethical Individualism. 1976. Princeton University Press. Plato. Symposium
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Prairie BA, Sheier MF, Matthews KA, Chang CCH, and Hess R. (2011) A higher sense of purpose in life is associated with sexual enjoyment in midlife women. Menopause. 18(8):839-844.
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Telzer EH, Fuligni AJ, Lieberman MD, and Galvan A. (2014). Neural sensitivity to eudaimonic and hedonic rewards diffentially predict adolescent depressive symptoms over time. Proceedings of the National Academy of Science.
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Wood AM and Joseph S. (2010). The absence of positive psychological (eudemonic) well-being as a risk factor for depression: A ten year cohort study. Journal of Affective Disorders. 122:213-217.