FRED DE SAM LAZARO: Saturdays are set aside for funerals in Accra. In the numerous congregations that line the streets and alleys, the air is filled at times with prayer, most times with song blaring at its electronic limits. And nowhere, it seems, is there any outward sign of sorrow or grief.  With few exceptions, like the death of a young person, my host here said that’s the way it is.

NII ADEI KLU: When somebody dies in Christ, or dies a Christian, it’s a good thing because, I mean, he’s going to God, he has died on a good path.  But when somebody dies a pagan or somebody who does not know God, then people cry because his soul is lost.

DE SAM LAZARO: We saw little evidence of any crying on this Saturday. And it would be hard to discern a lost soul. The vast majority of people in this city strongly profess some form of Christianity. About 16% of Ghanaians are Muslim. Most live in the country’s north.

Funerals are major social events that bring together far-flung extended families. Obituary flyers and posters cover neighborhood walls. Often they are anticipated years in advance, and say much about a person’s status. Nowhere is that more evident than in the coffins favored by the Ga ethnic group in southeastern Ghana.

ABLADE (Art Dealer): People who have achieved in their lifetime.

DE SAM LAZARO: The well to do.

ABLADE: Well to do. And usually it has to show your area of achievement. If one were a fisherman, they would show some canoe or fish or things like that. If you are a driver and own transport, they would show some transportation.

DE SAM LAZARO: We saw coffins waiting for the next crab fisherman, hunter — or could this one be for an animal lover? There’s one for the beer lover, farmer, and athlete. Fantasy coffins have gained a reputation for their high art. Many are sold to foreigners and collectors.

At the root of all this is a strong tradition — of honoring, even worshipping ancestors, says Ablade. Grand funerals are a way for the living to please the newly departed elder, to continue the communion with those who went before and to ask for blessings.

ABLADE: The belief is simply that the ancestors are there and if you’re going to meet them, you must meet them properly. I mean, his being there becomes a blessing to the family. They will start calling upon him, “Hey, send us something, this week, things are not so good…”

DE SAM LAZARO: In fact, funerals, even without the expensive fantasy coffins, are a huge financial drain on families: Providing meals and libation for dozens, sometimes hundreds of guests, the musicians, and of course the morticians.

KLU: The family will be paying this money with interest, maybe the person has left children behind, or he has left some properties, sometimes it has to be auctioned or sold to defray the debts which has been incurred.

DE SAM LAZARO: There are calls from time to time from religious leaders to cut out the excess. But funerals are an investment in harmony with one’s ancestors, a true measure of one’s esteem for the departed. How, many families ask, do you put a limit on that?

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Accra, Ghana.

BETTY ROLLIN, correspondent: For years, Natalie Albin endured aggressive treatment for leukemia. She wound up in Memorial Sloan Kettering Hospital in New York. Death was near.

FRAN CRONIN: She’d had years of chemo. She was done with it. There was nothing left for her body to tolerate.

ROLLIN: Her daughter, Fran Cronin, says that what the family wanted at this point was a quiet time to be together and say goodbye.

CRONIN: But the doctors kept on coming back to us and asking us if we’d like to do tests, what else we could do, and we’d have to say, well, what kind of difference will this make? Is this going to change the prognosis? No. This might extend her life for a couple of months. What quality of life is she going to have? Nothing really better, can’t guarantee. In our effort to say goodbye to my mother we were always being interrupted by the hospital’s own need to be service-driven. They weren’t about hospice care. It wasn’t about saying goodbye. Their role and their interaction with us was to provide treatment.

DR. LACHLAN FORROW (Beth Israel Deaconess Hospital): We are wired as human beings, thankfully, to when in doubt you fight for life no matter what. Doctors and nurses are trained, first we want to try to save a life.

ROLLIN: While the person whose life is being saved wants to be kept as comfortable as possible, he or she doesn’t necessarily want to be saved, and often this hasn’t been made clear to either the doctor or the patient’s family. Dr. Lachlan Forrow is director of ethics and palliative care at Beth Israel Deaconess Hospital in Boston.

DR. FORROW: The tragedy is our health care system does not provide any context to help doctors and nurses have the time to talk with people about these hard things, and the whole system is greased to pay hospitals and others for expensive things people might not even want. One of the fundamental problems is what gets called our fee-for-service system. Doctors and hospitals get paid for the things that they do that tend to be expensive. The more expensive it is, the more you get paid.

ROLLIN: Our medical system can’t keep everyone healthy, but it excels at keeping people alive, which is expensive. Twenty-five percent of all Medicare spending is for the 10 percent of patients who are in their final year of life. For the year 2012 alone, that’s expected to be $137 billion. Most of the money is spent in the last 6 months of life, which is often of little benefit, if any, to the patient. And the conversations between patients and doctors and family members which might make a difference, Dr. Forrow says, aren’t happening, partly because people are afraid to talk about death and because the part of the Obama health care reform plan, which would have reimbursed doctors for these conversations, was shot down.

DR. FORROW: Cheap, political, inflammatory comments like “death panels” and “pulling the plug on grandma” for cheap political points have terrified the American people in a way that I think—I think that’s immoral.

ROLLIN: Dr. Susan Mitchell, who has studied advance dementia in nursing home patients, has found that even though these patients can be treated and kept more comfortable in a nursing home, they are often hospitalized where they receive aggressive and sometimes painful treatment that is covered by Medicare.

DR. SUSAN MITCHELL (Senior Scientist, Hebrew SeniorLife): The nursing home does not get reimbursed for taking care of a patient who’s acutely ill with advanced dementia, which can take a lot of staff time and resources. So it’s at no cost to them to send them to the hospital where they will get that care.

ROLLIN: The Alzheimer’s Association estimates that the cost for dementia care in 2011 will be approximately $183 billion, mostly paid by the government, and that cost will go up to $1.1 trillion in 2050.

DR. MITCHELL: I think there’s a lot of unnecessary and costly medical care being provided for patients with advanced dementia that is not what the families and patients want.

ROLLIN: But even if patients and their families have expressed their wishes, that doesn’t solve the entire cost problem.

PROFESSOR DAN BROCK (Harvard Medical School): At the end of life, people often have greater difficulty in giving up, in no longer using resources, and so you hear this notion, particularly from families, “I want everything done,” and implicitly there, or sometimes explicitly, “Don’t worry about the cost,” right?

ROLLIN: Professor Dan Brock, who teaches ethics at Harvard Medical School, is one of the few who believes America must ration covered health care based on efficacy and cost.

PROFESSOR BROCK: I was once at a meeting in Britain many years ago with British physicians, and we were talking about end-of-life care decisions, and the Americans asked, “Well, what do you do when patients demand or when families demand?” And the British docs sort of looked bemused and said, “Well, they don’t do that here. They don’t demand here.” We have insurance, so we say we’re entitled to it, and we have this view that rationing is a bad thing to do, and so we think we ought to get it.

ROLLIN: The problem is more acute when the patient is dying.

PROFESSOR BROCK: Should we cover this new cancer drug which extends life on average for three months and costs $200,000 or $300,000 to do so? And when you look at it that way, then people can begin understand that, well, it doesn’t seem to make sense.

ROLLIN: And the other difficulty, Professor Brock adds, is that once a drug is considered safe, Medicare does not consider cost in their approval of coverage. They ask only whether the treatment is “reasonable and necessary.”

PROFESSOR BROCK: Medicare is not able to deny coverage on grounds that—what’s usually called cost effectiveness. That is, the cost isn’t merited by the benefits.

ROLLIN: Many experts say if the question of cost is not dealt with it will surely get worse because of new treatments, which will be more expensive. Also, a growing population of the aged and their physicians will want these treatments, no matter the cost to Medicare.

For Religion & Ethics NewsWeekly I’m Betty Rollin in Boston.

BOB FAW, correspondent: On that terrible day ten years ago, when New York City firefighters began responding to the attacks, firefighter Scott Kopytko found that his spot taken by a new recruit.

RUSSELL MERCER: And he was in his position….

JOYCE MERCER: All right. So Scott bumped him off the truck. He told him to get off the truck, you’re in my spot.

FAW: As Scott climbed the stairs of the South Tower to rescue people, it collapsed. Kopytko, 32, was killed. His remains have never been found. In his Forest Hills, New York, hometown, Kopytko is now honored at a small plot lovingly tended by his stepfather. It is the only memorial the family has, and they say it is not enough.

JOYCE MERCER: We’ve never been able to fully go through the normal process of death where you bury your loved one, you grieve, you remember all the good times. This we’ve been stunted in the middle. We know our son is dead, but we’ve never been able to lay him to rest.

RUSSELL MERCER: It’s like being deprived of something, like a meal or a loved one that you had. You don’t have that final solution. I mean, it’s insane. You don’t have no idea what we have to go through.

DIANE HORNING: I think we live in a country where we assume we will be given proper burials. That’s not—but they weren’t. The 9/11 dead were scooped out of the site very quickly with bulldozers and backhoes and dumped into trucks and barges.

FAW: On 9/11, Diane Horning lost her 26-year-old son, Matthew, who was working on the 95th floor of the North Tower. She and some other families have fought hard to get the remains moved to a common burial site.

HORNING: We just want what every person in this country gets, which is a decent, respectful burial, which is what we gave Osama Bin Laden. I’m not angry that he had a burial with rites and rituals. I think that shows a common decency, and we want the same.

FAW: Despite intense efforts to find all the remains, the fact is of the 2753 people killed at the World Trade Center, the remains of more than 40 percent have not been identified. When the 9/11 memorial opens September 11, there will be no common burial site for the remains. Thousands of unidentified bone and body fragments will be placed near the museum behind a wall with an inscription from Virgil reading, “No day shall erase you from the memory of time.” There, scientists will continue trying to identify the remains. James Young is an expert on memorials.

PROFESSOR JAMES E. YOUNG (University of Massachusetts at Amherst): Once the families know that the remains are right nearby, for them the memorial experience then maybe is just a little bit too close to the forensic work going on in the medical examiner’s office. They look at that big wall, and that’s all they can think of, not just what’s behind it but that my loved one’s remains have not been identified yet. I have nothing to show.

FAW: Disaster ministries expert Peter Gudaitis counseled scores of relatives on proper arrangements.

PETER B. GUDAITIS (Executive Director, National Disaster Interfaiths Network): It’s been a very difficult path to follow, because there are religious accommodations that families expect and deserve and by law actually have a right to. At the same time, there are all sorts of complicated impracticalities to what remains that is identified, who are the custodians of those remains, and what are remains?

FAW: In a public letter, family members involved in the memorial planning process defend what is being done here, insist it is what most families want, and argue that since the remains will not be part of the museum’s space proper, nor will they be seen by the public, that those remains are being treated “with the utmost care, respect, and reverence.” But the plan to shelter remains underground near the museum where officials are considering charging an admission fee has troubled many. Diane Horning says she won’t go to the memorial.

HORNING: I don’t think there’s much dignity in that memorial at all. I will never go to it, and I would recommend that no one go to it. I think that it is a commercial enterprise. The most important thing is the building, not the people. I find that unethical, to take my son’s remains, the remains of the people with whom he died, and have it be a draw in a museum, in a pay-to-view museum.

FAW: The Mercers say they won’t visit the site of the remains.

RUSSELL MERCER: They’re just pushing us aside. Move out of the way, we want to get this done now. These men were heroes. After 9/11, the first responders, the New York City had them and the world had them walking on water. Now they’re going to put them seven stories below ground level. It’s a disgrace to these men, a total disgrace.

FAW: At the site of mass murder, whether at the memorial for victims of the Oklahoma City bombing, Ground Zero, or the Pentagon, victims are honored, memorialized—sites where great evil has been committed, but also consecrated, made into sacred ground, given the blood shed.

YOUNG: I for one don’t believe that there is an intrinsic sacredness in any site. We make them sacred in our visits. These sites become part of a national civic religion, in a way.

FAW: The 9/11 victims will be honored at the new 9/11 memorial with their names placed alongside two pools built in the footprint of the twin towers. Hundreds of memorials to the victims of 9/11 have been built in the last ten years. In Hazlet, New Jersey, in the shadow of the goalposts where he played high school football, victim Steve Paterson is remembered. In Guatemala, four houses have been constructed in Matthew Horning’s name, and along the boardwalk at the New Jersey shore he so loved, there is a bronze memorial plaque. What is needed now, says his mother, is a final resting place, like the Tomb of the Unknown Soldier.

HORNING: I think that this Tomb of the Unknown should have been accessible to everyone, because it is something that happened to everyone. We have all changed, and I would like this ability to pay respect, to contemplate.

RUSSELL MERCER: That was the way I was brought up. Have some place where you can honor the remains of your loved ones. There’s no honor there, no place I can go in private, on the holidays.

JOYCE MERCER: Well, we know what happened to our Scott, but I don’t feel he’s at rest, and we can’t be at rest.

FAW: Ten years later then, despite painstaking labor here and all the effort to respect the wishes of surviving relatives, what seems clear is that no memorial can bring complete comfort, much less serve as a final resting place.

GUDAITIS: There is that sense of yearning, that loss, that reopened wound, this scabbed, you know, wound. It’s this kind of wound in the city that’s never been healed. It is a constant reminder that there’s still a chance that they could find some part of their loved one but that it’s not complete. Nothing’s complete. The journey isn’t complete.

FAW: And until it is, no matter how successful this memorial, some will continue waiting quietly with their memories and pain or tenderly maintain their own tributes for loved ones who disappeared on 9/11, and who they fear are disappearing again.

For Religion & Ethics NewsWeekly this is Bob Faw in New York.

BOB ABERNETHY, host: Faith-based and international aid groups rushed to help victims of the catastrophes in Japan. It’s estimated that more than 10,000 people were killed by the massive earthquake and tsunami. Japanese officials say more than 450,000 are homeless and in need of supplies. Humanitarian efforts, however, have been severely complicated by radiation from four of the country’s nuclear reactors.

We get more from Dave Toycen, the president and chief executive officer of the Christian aid group World Vision Canada. We spoke to him by phone from Tokyo on Friday night (March 18). Dave, thanks so much for staying up so late to talk with us. Are you and the others doing relief work there, are you able to get to all the people who need help, and do you have the supplies you need to help them?

DAVE TOYCEN (President and CEO, World Vision Canada): Well, basically we do. We’re anticipating we’ll be raising somewhere between $10 and $20 million, so our team here has already spent, you know, a chunk of that because they know it’s coming. But of course we believe we’re going to be able to raise that amount of money, and of course that turns into supplies and things that we can provide here. So, yes, I am positive about that.

ABERNETHY: But you are able to, or the people who are in need are able to get help from you or from the government or from somebody else, right?

TOYCEN: Yes, generally so. My perception is, in the conversations we’ve had, what I’ve seen first hand, people are getting at least the basics of life. That means water, food on a daily basis, and most people now are in schools, gymnasiums, community centers, so that they are at least not out in the elements. It was minus four this morning with about ten, well, eight inches of snow.

ABERNETHY: What have you seen that moved you the most?

TOYCEN: Well, I think one of the things that moves me so much is in every one of these centers they have sheets of paper with people either saying yes, I’m alive and I’m at this location. The other ones that are even more poignant are the ones where you read where people are saying I am looking for my son, my daughter, do you know about them? And that always touches your heart. That just really, really touches your heart. And today I had a mother say to me, you know, this has been awful, but it’s my kids. The fact that my kids are alive, and children are precious because they remind us that life is about hope, and even our children in the midst of these difficult circumstances they still find the time to be happy and joyful. That’s humbling.

ABERNETHY: Dave, very quickly, we are almost out of time, but a lot of people are saying, well, we don’t need to give anything because Japan is a first-world country. It’s well organized. They don’t need as much help as perhaps people at other places and other disasters. How would you respond to them?

TOYCEN: Well, my first comment is yes, you’re right to a certain extent. They don’t need as much help. This is a first-world country. But, on the other hand, my experience is that most of us, or many of us at least, when somebody’s in trouble we have a sense we want to help out in some ways. And then when you think about, even I think of. say. Hurricane Katrina in the United States, how much Americans appreciated, at least that’s the feedback I got, when people from Canada and other places in the world came in and pitched in and gave, either volunteered or gave some money. So I think everybody has to make their choice, and we’re so pleased at World Vision. We’ve had so many people who want to step up and say we’re willing to help in Japan and send a message of hope.

ABERNETHY: Dave Toycen of World Vision Canada. Many thanks.

Faith groups around the world held prayer services this week for victims of the disasters. Meanwhile, some observers have spoken about the strong cultural and spiritual resources the Japanese have displayed as they deal with the catastrophe. Reverend Maggie Izutsu is an Episcopal priest who is also an expert on Asian bereavement rituals. She lived in Japan for many years and joins us now from Austin, Texas, where she leads the organization the Rite Source. Maggie, welcome.

REV. MAGGIE IZUTSU: Thank you. It’s an honor to be here.

ABNERNETHY: As you see the way the Japanese people are responding to these tragedies, what stands out for you?

IZUTSU: I guess one of the things that my mind keeps going to is how they don’t ask the question “why me?” They’re not consumed with wondering what put them in harm’s way. They know they’re in harm’s way. They are very attentive to their surroundings, and they have a great reverence and fear of nature.

ABERNETHY: And so a disaster is just part of life? Multiple disasters are just part of life? You accept it and get on with things—pick up and continue you life?

IZUTSU: Yes, I believe so. I think that partly comes from their Shinto tradition of this reverence for nature and their understanding of the vicissitudes of nature and capriciousness of nature. It’s also part of their Buddhist tradition that understands that all things are impermanent and things are subject to change, and they don’t see themselves as entitled to good fortune all the time or even good fortune ever. Of course, they seek that and they strive for that, but that’s not their focus.

ABERNETHY: We’ve seen a little disruption—frustrations of trying to get supplies and things. But, in general, the images have been of people who are very orderly and very respectful of each other. Talk about that a little bit.

IZUTSU: Yes, well, I think that may come from very early training that is part and parcel of the Confucian tradition, which was imported from China, that seeks to make every opportunity in life—in daily life, secular life, as well as spiritual life or, more pointedly, religious life—an opportunity for moral self-cultivation, and it starts at a very early age. For instance, my son in a three-year-old’s class at nursery school’s teacher would talk about how she went home every night to try to understand how she could better inculcate a sense of little Johnny’s effect on little Tommy in terms of how he was behaving. So that sensibility of commiseration or empathy or understanding how our behavior affects other people starts there at a very early age.

ABERNETHY: And now there is the grieving and the rituals that are available, too, for helping people through that. What are the most important of those?

IZUTSU: The Buddhist tradition, as well as the new religions, have these very elaborate, very elongated memorial services—a sequence of memorial rites that go on literally ad infinitem, and they’re a wonderful occasion for families and friends of the deceased to come together at sporadic intervals to remember the deceased and share in the support that they can offer each other in that process. It also serves, I think, as a context for remembering the relative nature of our own egos, and the place that we have in this vast line of our ancestors and hopefully the progeny that will yet be coming, and to remember our place in society, and that also becomes a context for remembering that behaving well is a very important attribute of living.

ABERNETHY: Reverend Maggie Izutsu of the Rite Source in Austin, Texas. Many thanks.

IZUTSU: Thank you.

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