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　　Death is a difficult subject for anyone, but Americans want to talk about it less than most. They have a cultural expectation that whatever may be wrong with them, it can be fixed with the right treatment, and if the first doctor does not offer it they may seek a second, third or fourth opinion. Legal action is a constant threat, so even if a patient is very ill and likely to die, doctors and hospitals will still persist with aggressive treatment, paid for by the insurer or, for the elderly, by Medicare. That is one reason why America spends 18% of its GDP on health care, the highest proportion in the world.

　　That does not mean that Americans are getting the world's best health care. For the past 20 years doctors at the Dartmouth Institute for Health Policy and Clinical Practice have been compiling the “Dartmouth Atlas of Health Care”, using Medicare data to compare health-spending patterns in different regions and institutions. They find that average costs per patient during the last two years of life in some regions can be almost twice as high as in others, yet patients in the high-spending areas do not survive any longer or enjoy better health as a result.

　　Ira Byock is the director of palliative medicine at Dartmouth-Hitchcock Medical Center. His book is a plea for those near the end of their life to be treated more like individuals and less like medical cases on which all available technology must be let loose. With two decades' experience in the field, he makes a good case for sometimes leaving well alone and helping people to die gently if that is what they want.

　　That does not include assisted suicide, which he opposes. But it does include providing enough pain relief to make patients comfortable, co-coordinating their treatment among the different specialists, keeping them informed, having enough staff on hand to see to their needs, making arrangements for them to be cared for at home where possible—and not officiously keeping them alive when there is no hope.

　　But it is not easy to decide when to stop making every effort to save someone's life and allow them to die gently. The book quotes the case of one HIV-positive young man who was acutely ill with multiple infections. He spent over four months in hospital, much of the time on a ventilator, and had countless tests, scans and other interventions. The total bill came to over $1m. He came close to death many times, but eventually pulled through and has now returned to a normal life. It is an uplifting story, but such an outcome is very rare.

　　Dr Byock's writing style is not everybody's cup of tea, but he is surely right to suggest better management of a problem that can only get worse. As life expectancy keeps on rising, so will the proportion of old people in the population. And with 75m American baby-boomers now on the threshold of retirement, there is a limit to what the country can afford to spend to keep them going on and on.

　　36. According to Paragraph 1, the disproportional large spending in health care stems from

　　[A] Americans' failure to admit death as part of their life

　　[B] doctors' inclination to overtreat the patient

　　[C] a culture that is obsessed with youth and health

　　[D] a legal system which has a bias in favor of patients

　　37. The author cited the findings of Dartmouth Institute for Health Policy and Clinical practice to illustrate that

　　[A] the medical care quality differs widely from region to region

　　[B] there is little that hospitals can do in saving people's lives

　　[C] a lot of medical resources are wasted

　　[D] the American medical system is notorious for its low cost-effectiveness

　　38. The central idea of Ira Byock's book is to appeal to the hospital to

　　[A] save every life with every possible means

　　[B] help people to die if that is his/her will

　　[C] make people feel comfortable in their remaining hours

　　[D] consider whether the cure is worthwhile before conducting it

　　39. In the author's opinion the example of the HIV-positive young man in Paragraph 5

　　[A] eliminates the possibility of applying gentle dying process in medicare

　　[B] is merely an extreme case that should not be taken as a standard

　　[C] emphasizes the importance of aggressive treatment even with slim hope

　　[D] is used as an irony of the current state of American medical system

　　40. According to the author, the American government will the proposal of gentle dying

　　[A] disapprove of [B] divide at

　　[C] hesitate at [D] side with