Death and Dying in the media

Article

Approaches to Death and Dying: A Cultural Comparison of Turkey and the United States

Darla D. Beaty 1

Abstract

Three principles that guide the bioethics movement in the United States and

other Western societies apply to the approaches of death and dying in both

the United States and Turkey. These three principles, Autonomy, Beneficence,

and Justice, are reflected in the practices of people in both countries. The

issue of autonomy is of greater concern to those in the United States, while

decisions are made entirely with family and physician involvement in Turkey.

Beneficence and Justice can be identified as ethical issues in both countries.

Similarities with end-of-life experiences are linked by faith-based beliefs of Islam

and Christianity. Differences in sociocultural influences, such as policies about

advance directives in the United States, account for differences in end-of-life

decision making. This article examines the spiritual, cultural, legal, and political

factors that inform the experience of people in Turkey and in the United States

when death is at hand.

Keywords

end-of-life, Turkish customs, United States customs, autonomy, beneficence,

justice, death, Islam, Christianity, hospice, advance directives, self-determination,

bioethics

OMEGA—Journal of Death and

Dying

2015, Vol. 70(3) 301–316

! The Author(s) 2015

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DOI: 10.1177/0030222815568962

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1 Social Work Program, Tarleton State University – Waco, TX, USA

Corresponding Author:

Darla D. Beaty, Social Work Program, Tarleton State University – Waco, 1400 College Drive, Waco,

TX 76708, USA.

Email: [email protected]

Introduction

The three principles that guide the bioethics movement in Western societies apply to the approaches of death and dying in both the United States and Turkey. The Belmont Report was designed to inform the protection of human subjects in research, but the guidelines are based on ethics in medical practice. The same principles are reflected in the values prescribed by the spiritual, cul- tural, and medical beliefs and practices of people in the United States and Turkey. These three principles include Respect for Persons (Autonomy), Beneficence, and Justice (Levine, 2005).

Respect for persons includes two ethical convictions: first, that individuals should be treated as autonomous agents and second, that persons with dimin- ished autonomy are entitled to protection. This issue of autonomy is treated differently in the United States than in Turkey. However, the other two prin- ciples can be identified as similar ethical issues in both countries.

Beneficence includes the idea that community members and medical staff are obliged to make efforts to secure the well-being of individuals in addition to protecting them from harm. This is an extension of the Hippocratic maxim “do no harm.”

The sense of justice relates to fairness in distribution or what is deserved. An injustice occurs when some benefit to which a person is entitled is denied without good reason. Another way of conceiving the principle of justice is that equals ought to be treated equally (Amdur & Bankert, 2007). This principle of justice is seen time and again in Turkey.

Background

Ninety-eight percent of people in Turkey are Muslim, and most of those are Sunni Muslim. Freedom of religion is ordered by the secular government of Turkey. Turkish people rely on their religious beliefs as well as family support networks to study and interpret the meanings of life and death. There is limited literature on the treatment of the aged, death and dying issues in the Turkish culture translated in English, but there is considerable discussion in the literature about Islamic beliefs, particularly about death and dying. Many of the state- ments in this article will be a comparison of Islamic customs and attitudes and those in the United States, with clarification about when Turkey residents may differ from Islamic traditions.

America is an immigrant society with many groups migrating to the United States for religious freedom. The majority of Americans practice one of a variety of Judeo-Christian religions: Baptist, Catholic, Church of Latter-Day Saints, Church of Christ, Episcopal, Jewish, Lutheran, Methodist, Presbyterian, Seventh-Day Adventist, and so forth (Noll, 1992). There is a mandated separ- ation of church and state, and the U.S. government cannot prevent any religious activity or support a particular religion. Minority religions include Amish,

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Buddhism, Hindu, Muslim, and others. As the majority of Americans are Christian and their cultural responses to aging, illness, death and dying are derived in large part on their spiritual beliefs, the comparison in this article is primarily of Christian Americans.

The U.S. history of informed consent and decision making for medical treat- ment at end of life demonstrates a process of intellectual development with a foundation in the moral and legal principles which guide Western medical and legal practice (Faden & Beauchamp, 1986). The principles of autonomy, benefi- cence, and justice serve as theories by which to judge the consent and decision- making process in treatment and research (Levine, 2005). The theories of autonomy are particularly relevant to this discussion of differences in attitudes, as practitioners in both countries consider the autonomous person and autono- mous actions. Faden and Beauchamp (1986) describe an autonomous person as one who has capacities for insight and understanding, and resistance to manipu- lations and social conformity.

This article addresses the contrast between the value of autonomy related to end-of-life decisions in the United States and in Turkey. Whereas individual freedom is highly valued in the United States, collective consciousness is valued in Turkey. Due to the emphasis in American society on individual rights and a series of legal cases in the 1970s, 1980s, and 1990s regarding end of life, autonomy is a central issue about decisions of the dying. Turkey has a more paternalistic approach in allowing physicians and the collective family group to make decisions at end of life (Fisek, 1989). In the United States, there is an assumption that the physician has provided adequate information for the individual or surrogate to make an educated judgment, then it must be determined if the patient/or proxy can understand enough to make the decision, with consultation by physician and family.

Turkey and the United States are more in line with each other about Beneficence and Justice, with the belief that we must do no harm and treat others fairly, reflective of the spiritual foundations of Islam and Christianity. There are similar beliefs about rewards and punishment in the afterlife based on the judgment about how a person conducted their interactions with others. Similarities in the beliefs related to aging and death are demonstrated by the belief in both faiths that the way a person lives will be judged and consequences will be eternal. Respect for elders and parents are similar in both faiths. Death ceremonies differ based on the Muslim preparation of the body, such as pos- itioning toward Mecca, but ceremonies of those with both belief systems include reading from the holy book.

Justice

Islamic and Christian religions, like Judaism, are considered Abrahamic reli- gions. The most important principle in Islam is the belief in only one God,

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or Allah. Muslims professing this religion generally abide by guiding principles. Among those principles is to believe that there is a day of judgment and a life after death and duty to give generously to poor people (Gilanshah, 1993). Muslims believe that Muhammed was the final in a series of prophets, including Jesus. They believe in Heaven and Hell and that, aside from belief in Allah, judgment about one’s destination lies in the actions on earth. According to Gilanshah (1993), in Muslim beliefs, the dead will be judged by good and bad actions on earth, with good actions weighing more than bad ones, with the most critical criterion being justice. This emphasis on the principle of Justice guides Muslims in their lives and in their end-of-life experiences.

Christians are expected to live by certain values. Most Christians believe that upon bodily death, the soul experiences particular judgment and is rewarded with either eternal heaven or condemned to hell. There are some variations within denominations, such as the belief with Catholics that those who die with unforgiven sins or incomplete penance undergo purification in purgatory to achieve the holiness necessary for entrance to heaven. Some believe that at the second coming of Christ at the end of time, all who have died will be resurrected bodily, and for some Christians, this causes concern about cremation and the burial process, encouraging preservation of the body.

Issues of justice in extended life, with sometimes impaired functioning, become a reality that older people deal with in the United States. Instead of dying of infectious disease, chronic diseases such as high blood pressure, dia- betes, and stroke are the challenges at the end of life. The losses of ability to walk and drive are primary concerns for many aging Americans as is the loss of memory. This challenge of being dependent changes the end of life. Many people have chronic problems which require that they have home health services, if they are able to stay in a home environment. Many live for decades with chronic problems. Skilled care can be paid for by Medicare in the home, but chronic maintenance is not paid for by Medicare. If the older person has low enough income, and lives long enough to have their name get to the top of the waiting list, they can get provider services paid for at home by Medicaid. Hospice services are available to those who have a diagnosis of a terminal illness and who choose not to pursue aggressive curative care. A terminal illness, in this article, is defined as a diagnosis of advance stage illness with a prognosis of 6 months or less if the disease runs its expected course (Centers for Medicare & Medicaid Services, 2005). Multidisciplines visit the person in the home to meet their needs at the end of life.

Justice is a central theme in many of the traditions at the time and after death. Death is discussed frequently in Islamic cultures, due to the beliefs of Muslims about their life after death. Death is considered a natural process of life and is treated thus differently than in the United States. Muslims believe that death is a passage to life in heaven with God. There is no emphasis on material goods as Muslims believe that one leaves this world alone, leaving material goods behind.

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When death is close, family members stay close at hand and pray for God’s blessing and read from the Koran. There is often a religious leader, an Imam, present. As soon as the relatives see that the person is dead, they often take the following actions (Gilanshah, 1993):

Turn the body toward Mecca

Have someone sitting near the body read the Koran

Close the body’s mouth and eyes, and cover the eyes and face

Straighten both legs and stretch both hands by the sides

Announce the death immediately to all friends and relatives

Hasten to bathe the body and cover it with white cotton.

The body is not left alone. Two people wash the body, males bathe males and females bathe females. A Turkish tradition, rather than Islamic, includes the use of three kinds of water if available; water with leaves of the plum tree, camphor- ized water, and pure water.

Muslims, as many Christians, do not practice cremation because of their belief that the body must remain whole. The body in Turkey is washed and wrapped in a white cloth. There are exceptions which allow for organ donation. Often the body is displayed in the home for a day or two, as was traditional in the United States a century ago. In Turkey, the body is removed from the coffin for burial and placed in the grave by key male members of the family. Prayers are said at that time and 7 days after death, more prayers are said. The trad- itional mourning period is 40 days at which time, women following traditional customs may wear black clothes or a black scarf (Towle & Arslandoglu, 2003).

The belief in the afterlife does not diminish the expression of great sadness and grief in the Turkish people and Americans. There is a good deal of crying and sadness expressed at the funeral and later in the home of the family of the deceased. Usually, a meal is prepared for guests of the family, who stay for the day or the night. Close family members stay for an entire week. On the third day after a Muslim burial, a ceremony of several hours is held in the Mosque where friends and relatives gather to pray (Gilanshah, 1993). An Imam prays and reads from the Koran. Prayer for the first 7 days after death is crucial, and after those 7 days, a stone and fresh flowers are placed on the grave. One year after the person’s death, there is another ceremony to pray for and remember the deceased. Muslims believe that throughout the years that family members should pray for the deceased and honor them by giving money to the poor and asking for God’s blessing.

The variation in the United States in customs and beliefs is greater because of the many cultures from which Americans originate. Regardless of cultural back- ground, family members come to the dying person as death nears. The Christian beliefs overlie many of the customs. The belief in life after death and in the teachings of the Bible lead many people to have a religious leader of their

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faith come to the bedside of the dying person to read the Bible and to pray. Once the person has died, close family members spend moments in grief with the body and announce to the rest of the family that the loved one has died. There is no prescribed ceremony about preparation of the body, and usually this task is done by nursing professionals in hospitals or home nurses. Cremation is more common than in Turkey, but there are many Christians who believe that the body must stay intact. Funeral ceremonies vary by religious denomination and family. Usually, a religious leader speaks about the person’s life. Often during the ceremony, individual family members and friends will share their memories of the person who has died. Flowers and contributions to charities are seen as a sign of respect for the deceased and their family. There is often an open casket, and those who wish to can file by one by one to view the deceased. Many Americans see this as an important part of accepting the death (Rosenblatt, 1993). The body remains in the casket, which sometimes is placed in a vault and a separate ceremony takes place at the sight of the burial. Friends and extended family gather for a meal at the home of immediate family members, in most cultures. Expression of grief varies greatly among cultures, but most of them spend time reflecting on the life of the deceased. Extended mourning is often not a recognized need in the United States and many people are faced with grief which is not understood or accepted by individuals in their circle of influ- ence. According to Harding, Flannelly, Weaver, and Costa (2005), a study of death anxiety and acceptance identified correlations between belief in God and the afterlife to higher level of acceptance of death and lower levels of anxiety.

Beneficence

The principle of Beneficence is noted in apparent in the Muslim belief that they must assist the sick and provide for the needy, according to Kulwicki (2003).

Turkey has sought for 50 years to be a member of the European Union (EU). According to Morelli and Migdalovitz (2010), a number of obstacles have pre- vented Turkey joining, among them human rights issues. Turkey signed the 13th Protocol to the European Convention on Human Rights concerning the aboli- tion of the death penalty in all circumstances. In addition, Turkey ratified three international instruments with foundations in principles that could be inter- preted as addressing justice and benevolence: the Convenant on Civil and Political Rights; the International Covenant on Economic, Social, and Cultural Rights; and the 6th Protocol on the European Convention (EU) on Human Rights (Ugur, 2006). The adoption of these humane protocols was explicitly linked to the EU conditions.

The current health system in Turkey was restructured in the 1940s in the Turkish Republic. The country struggled with tuberculosis, smallpox, and other infectious diseases as well as malnutrition and pneumonia. Restructuring established three levels of care, which still exist today.

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Health awareness is promoted primarily by the first levels of care at health centers, staffed by general practitioners, midwives, and nurses giving basic ser- vices and preventive care. State hospitals provide the second level of care (where mental health care is provided as well as general medical hospitalization needs). The third level of care is at university and specialist hospitals. The principles of justice and beneficence can be seen at work in the Turkish health system cur- rently, as individuals are eligible for all levels of basic and specialized care.

Turkey still has problems in providing basic health services and preventive care, but many services have become quite developed in recent years. According to Aksoy (2005), these improvements are reflected largely in care for elderly patients and palliative care. The intrinsic aim in health care in Turkey is to bring about a medical good. A medical good is used as a blanket term to cover medical treatments leading to the reduction of symptoms or possible cure of disease processes, the relief of suffering, and the prolongation of life.

There are five kinds of health insurance services in Turkey and 83% of the population is covered by one of these insurance services (Aksoy, 2005). (a) The Retirement Fund covers civil servants and their families. (b) The Social Insurance Institution is for laborers and their families. (c) The Social Insurance Institution is for craftsman and tradesman and other self-employed. (d) Green Card is for poor people with no social security and their families and (5) private health insurance. Turkish people are inclined toward Western, technologically sophisticated medical care but attitudes tend to be holistic as well. Emotional well-being as it affects physical well-being is considered instru- mental to the healing process (Towle & Arslandoglu, 2003). Physicians are adopted as members of the family of their patients and are given gifts of grati- tude. Families often have a bed in the room with the patient and are integral to decision making. Traditional healers may be sought out if Western medicine is not working or not accessible.

Pain management at end of life is approached differently in the two countries. The Hospice movement which has become prevalent in the United States in the last 20 years has not become a factor in Turkey. Turkish culture allows freedom to express pain, but professionals are not likely to administer medication. Beduk (1991) described a concern about narcotic analgesic addiction that affected atti- tudes of nurses toward pain management. Pain management is not included in all nursing school curricula in Turkey, and if a physician orders pain medica- tions, nurses are likely to minimize the advantages of pain relief. Only in the very late stages of life is pain medicine administered. There has been much discussion in the United States about the high cost of dying. Much of national health-care expense is incurred during the last year, when patients go to intensive care units, with high-cost equipments such as ventilators, MRIs, and tests in often futile attempts to prolong the inevitable. Expenditures for Medicare patients during their last year of life account for approximately one quarter of Medicare’s total outlay (Merrick, 2005). The Hospice Association of America reports that in

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1997 the costs of home hospice care were approximately $108 per day, compared with hospitalization at $2,121 per day and skilled care in a nursing home of $454 per day (Merrick, 2005).

Respect for Persons

The treatment of aging members of society differs in Turkey in other significant ways from much of the United States. Until recently, life expectancy in Turkey was less than in the United States. Those in Turkey who did survive the threats of childhood and infectious diseases were honored with respect. Older adults in Turkish culture are given respect, yet their authority diminishes as they become weak or when they retire. Caring for elderly parents is considered normal and individuals are socialized to expect that aspect of life. Grandparents remain active in family life and in caring for their grandchildren. Extended families often live together or nearby and interact often.

The cultural value of respecting one’s parents is evident in their views about where one should die. Many Turkish people do not favor end of life for their parents in a nursing home or hospice. Aksoy (2005) noted that 47% of the Turkish public would not be interested in having families die in a hospital. Much like in the United States, the majority of people in Turkey say that they would prefer to die in a hospital rather than at home, in order to spare their family members and in hope that they could get more help in a hospital, with the numbers preferring home death increasing in the United States due to hospice care increasing. Turkey is considered to be a paternalistic society and decisions are made by the physician and the family. Yet Turkish physicians are given very little training in end-of-life care. According to Aksoy (2005), a survey of health- care professionals sought to find out if they had any courses on how to deal with a dying patient or a patient who is terminally. Virtually all of the nurses had a course on the subject and almost none of the doctors (5%) had a single course or lecture on how to deal with a dying patient.

Legal and institutional reforms have affected Turkey. Kagitcibast (1990) reported that Turkey ranked below European, Asian, and American countries at that time in valuing women’s decision-making powers. He notes that, due to the effect of Westernization and urbanization, it is best to take care when gen- eralizing the attitudes of Turkish peoples towards women as they age. Older women are granted more respect, not just regarding issues at end of life, but in general (Aksit, 1993). Understanding the treatment of individuals at end of life is important to social workers and other health-care professionals, as we pay par- ticular attention to the needs and empowerment of people who are vulnerable (National Association of Social Workers, 1997). Those at end of life can be viewed as vulnerable and therefore in need of particular protections within treatment settings. Their autonomy is jeopardized and society is thus obligated to treat them with justice and beneficence. As we consider the ethical obligations

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of health-care providers in dealing with those at end of life, we must also balance vulnerability with client self-determination and the dignity and worth of persons.

In a study of 988 American terminally ill patients and their 893 caregivers, researchers found that “terminally ill patients and caregivers can discuss death, dying and bereavement in a structured interview with minimal stress and report that the interview was helpful” (Emanuel, Fairclough, Wolfe, & Emanuel, 2004, p. 1999). Other studies demonstrate the need for assessing the patient’s perspec- tive rather than building treatment models based only on the opinions of clin- icians. In a qualitative study of 10 terminally ill patients, researchers explored what people living with terminal illness considered were the areas of priority in their lives (Carter, MacLeod, Brander, & McPherson, 2004). They concluded that current palliative care outcome measures may be limited in assessing patients’ end-of-life experiences because these measures are based on models derived by clinicians and experts rather than the patient’s perspective. Supporting this finding, researchers found responses by participants did not follow current end-of-life models regarding differences in definitions of good and bad deaths and end-of-life scenarios in a qualitative study of one-on-one interviews of 26 men with terminal heart disease or cancer (Vig & Pearlman, 2004).

Autonomy

Autonomy is a key concept of the principle of Respect for Persons. The right of individuals to health choices has impacted the causes of death in the United States and Turkey. Despite the advances on human rights fronts, there are still high-risk behaviors that affect the life expectancy and causes of death in Turkish people. Cigarette smoking is the primary high-risk behavior that affects the health and early death of many men in Turkey. It is widespread and citizens start at a young age. One study indicated that 57% of men smoke. Women smoke at a rate of 9% (O’Nat, Senoak, Surdum, & Arci, 1993). This compares to 22% of men and 17% of women in the United States, according to the Centers for Disease Control (CDC). Health consequences can be seen in the rates of cardiovascular and cerebral vascular diseases, which account for the highest mortality in Turkey (Fisek, 1989). Cancer is the third most frequent cause of death, and lung cancer is the most frequently seen of the cancers in Turkey, due primarily to the prevalence of cigarette smoking. The causes of death are similar in the United States; this is particularly of interest when discussion about decisions of end of life is an issue related to ventilator support.

The causes of death are similar in the United States, with the exception of the health consequences of alcohol and drug abuse. Due to the Muslim prohibition about alcohol use, alcoholism is not a societal problem and neither is drug abuse on the scale that it is seen in the United States. According to the 2003 World

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Health Organization study, 81% of adults in Turkey are lifetime abstainers (65% of men and 92% of women). This compares to CDC’s report that 52% of adults in the United States were frequent drinkers and another 11% were infrequent drinkers. Despite the fact that the life span is one of the longest in the United States, access to health care is not universal. The health care system in the U.S. prior to the Affordable Care Act was entrenched in a private insurance system with managed care focusing on cost containment, limiting the eligibility and use of benefits (Merrick, 2005). Medicare for older adults and adults with disabilities is available, as is Medicaid to cover basic health care for the impoverished. Corporations and government employees are covered by group insurance at times and some individuals carry private insurance. States vary widely about coverage for children. There are increasingly many families who have no health insurance. Life spans in the United States in 2001 were 74.3 years for males and 79.5 years for females. Child mortality rates were low at 9 deaths per 1,000 live births for males and 7 per 1,000 for females. How health and mortality outcomes will be affected by the new health-care laws is yet to be determined.

Preventive care and medical treatment in the United States has improved to the point that infectious diseases are not as much of an issue as death by chronic illness in the aged. Where and how Americans die has changed over the past few decades, much more so than is the case in Turkey. The emphasis on independ- ence and autonomy in Americans relates to aging and where a person dies. Peter Laslett (1979) notes that the origins of this pattern harkens back to English customs. The Western, specifically the English, the Anglo-American, the Anglo-Saxon-familial policy with respect to the aged may indeed have been based on the premise of providing the greatest possible independence for them. Americans value family relationships as do the Turkish, but societal changes have resulted in families being unable to care for their elderly in America. Many couples have one or two children and it is a mobile society. Many offspring do not live in the towns with their parents. Offspring often are working until their own retirement. Family members usually will try to care for parents until they can no longer care adequately for them, because of incontin- ence, dementia, or physical needs. There is a great reluctance to give up and accept that one’s loved one will have to live in a nursing home. It is seen by many as a waiting room—a place where people wait to die. It is noted that 60% of those who live past 65 go to a nursing home and those who stay past 6 months never leave alive (Merrick, 2005). Few families want their loved ones to stay in an institution. The increase in nursing home residents has economic repercus- sions for the country. Nursing home care costs an average of $5,000 per month and the savings of many of the residents are depleted in a few months. Medicare will only pay for skilled care in temporary rehabilitation situations, for a max- imum of 90 days, for physical therapy and skilled care after health crises such as a hip fracture with replacement or cerebral vascular accident (stroke).

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Medicaid will pay for custodial care, if savings have been depleted and income is low enough.

The ethics of aging and quality of life have come to the forefront in the American consciousness during the past 30 years. Autonomy and self-determi- nation have altered end-of-life issues in the United States. Two issues have converged to make this in the forefront of American minds—the rise of bioethics related to treatment and research as well as legal cases which have come before the courts. The premise in the United States that patients should have decision- making abilities, autonomy, is the root of one of the difference in United States and Turkey experiences at end of life. One definition of informed consent used which clarifies criteria (Faden & Beauchamp, 1986) includes three general requirements: (a) a patient or subject must agree to an intervention based on an understanding of (usually disclosed) relevant information, (b) consent must not be controlled by influences that would engineer the outcome, and (c) the consent must involve the intentional giving of permission for an intervention.

Legal doctrine is intertwined with the moral and ethical considerations of informed consent for treatment. It was not until the early 20th century, that the notion of consent as it relates to autonomy was addressed by the courts. Thus, the dawning of modern day consent considerations occurred. There were several notable court cases in the 1950s, 1960s, and 1970s which transformed the consent laws into truly informed consent. In the 1957 court case, Salgo v. Leland Stanford J. University Board of Trustees, a patient suffered paralysis because of a procedure his physician performed. Saldo sued based on his physician’s failure to warm him of the risks. The courts found that the physician was required to give information necessary to make an informed consent (Faden & Beauchamp, 1986).

These treatment issues coincided with the advances in the ethical consider- ations related to research. The Nuremberg Code and the Declaration of Helsinki outlined the principles of autonomy, justice, and beneficence by which research- ers should model their consent processes (Amdur & Bankert, 2007). These eth- ical guidelines were the result of a series of violations of human rights by researchers, including the Nazi WWII experiments, the Tuskegee Syphilis stu- dies, the Milgram obedience studies, and the Wichita Jury deception studies (Brody, 1998). Each of these landmark incidences in research resulted in regu- latory guidelines. The NIH established Clinical Center policies in the 1960s, and the FDA developed regulations about informed consent related to medications. Henry Beecher, a well-respected physician researcher, reported in 1966 about his study of ethics violations in over 100 studies he examined (Beecher, 1966). The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was established in 1974 (Levine, 2005) and established the Common Rule for treatment of issues such as consent to research.

The underlying tenet of consent to treatment is that the practitioner is making a clinical assessment and judgment that the proposed treatment or options are

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the best suited for the patient’s condition. If the patient is determined to be incompetent or not to have capacity, it represents a moral imperative for the physician to seek consent from a qualified surrogate decision maker (Annas, 2007). Medical settings have developed clear guidelines for determining capacity. Critical cases about young women who were being kept alive on life support changed the laws and behaviors around consent and surrogate decision making.

Fins (2006) reports the case of Karen Ann Quinlan in 1976. She was a high school student when she lapsed into a permanent coma. Her family petitioned the court to remove her life-supporting ventilator. The New Jersey Supreme Court honored the request of her family based on the futility of any further interventions. She had been diagnosed as being in a persistent vegetative state. Fin observed highly personal choices about end-of-life care, regardless of brain injury, came to the forefront in societal values.

The next keystone case in bioethics about end-of-life decisions came with the case of Nancy Cruzan in 1990. Like the Quinlan case, Nancy was a young woman in a vegetative state. The issue with her was the removal of artificial nutrition, not a ventilator. The Cruzan case went to the U.S. Supreme court and they decided that an individual had the right to refuse life-sustaining treatment. The court gave states, however, the obligation to define guidelines for surrogate decision making.

The United States was faced with a well-publicized case about end of life in 2003 with Terri Schiavo, a 39-year-old woman in a vegetative state following brain injury. This case had similar issues with the Quinlan and Cruzan cases, but there was conflict within the family about whether to remove a feeding tube or not. According to Werth (2006), the case had a long and complicated course in the court system. The final ruling by a district court judge upheld previous rulings. This reinforced the right of the husband of Terri Schiavo to remove the feeding tube, against her parent’s wishes. The tube was removed and she died within 13 days of the removal of the tube. This brought to the forefront of the conflict about surrogate decision making.

These legal decisions have had an impact on daily decisions made in hospitals, homes, and nursing homes throughout the United States. Most of these cases are with people who have lived much longer lives than the three women in the court cases. Berneice Neugarten (1982), a pioneer in Gerontology, noted that although age was not a useful predictor of health status, age could predict the morbidity and mortality rates of groups. Older people most often die of heart disease, malignancies, and cerebrovascular disease, and the lifespan in the United States has expanded well into the 70’s. Thus, in U.S. societies, death and dying is associated more with aging than causes of death in youth. Advances in medical science, which allow for prolonged lives, improved nutrition, and other preventive health habits, have led in the United States to death being more an issue of chronic decline than from childhood diseases.

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Advance directives such as have evolved in the United States are essentially nonexistent in Turkey. It is considered appropriate to respect patient’s wishes, but advance statements do not bind caregivers to a treatment they feel is wrong. The majority of people wanted to know their diagnosis but would not let their families know, in order to protect them. Yet there is not much autonomy in decision making and physicians do not have the ability to decide that it is futile to resuscitate, as they do in the United States. According to Aksoy (2005), physicians do not have the legal right to give Do Not Resuscitate orders. Both passive and active euthanasia remain unlawful under Turkish criminal law. Aksoy noted that, as in all divinely revealed religions, euthanasia is abso- lutely forbidden in Islamic doctrine. The notions of justice in fair treatment of all in medical settings and pain management of those suffering at end of life are apparent in Turkish treatment of death and dying, but autonomy as understood in U.S. history is not a value they embrace.

Conclusion

There are many similarities and differences in the way that the Turkish people and those in the United States approach death and dying. The similarities relate to their common faith systems that believe in life after death. Both cultures value justice in the care of the aged, ill, and vulnerable. The belief in beneficence in promoting health and the medical good guides the medical practices as well in both cultures. One of the primary differences in the experiences in the two countries at end of life relates to the belief in individualism and autonomy that has been a part of the American heritage. This has emerged in the United States as a focal issue with decision making for the dying. Death policy in the United States is well established. Patients with decision-making capacity can refuse life-sustaining treatment. Those who are incompetent can have surrogate decision makers appointed and states can require clear and convincing evidence of what would be the patient’s preferences. Despite the wide-spread discussion and publicity about patient self-determination in the United States, there are relatively few Americans who have executed an advance directive. The reasons for this relate primarily to the fact that death and dying is not treated as a normal part of the life cycle. People in the United States do not typically have aging family members in their homes and are uncomfortable with coping with end-of-life issues. The issues of how and where to die are often not discussed until the dying individual has a catastrophic illness which prevents rational dis- cussion. Social workers and other health-care providers are in a key position to encourage discussion of individuals and their families about what their thoughts and preferences are and about how and where they want to be at life’s end.

Collective consciousness and preferences are more valued in Turkey and needs of the family are more highly valued. Turkey is at a crossroads, blending their traditional Muslim beliefs with Western values. As they become more

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technologically sophisticated and have the means to prolong life by artificial means, they will be facing some of the difficult decisions that Americans have dealt with in the court systems. As Americans age with the surge of Baby Boomers moving into the last stages of their lives, they will be faced with coping with death in large numbers as a final step in the process of life. Dialogue and consideration of mutual experiences can inform the challenges faced by these two countries in coping with the meanings of life and death.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, author- ship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

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Author Biography

Darla D. Beaty, PhD, LCSW, is an Assistant Professor of Social Work at Tarleton State University. She practiced social work for 25 years, with many clients at end of life. She has been involved in bioethics through service on Institutional Review Boards for 15 years. She has led study abroad trips to Turkey and studied the similarities and differences in traditions with those of the U.S.

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