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The Last Dance

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The Last Dance tenth edition

Encountering Death and Dying

L Y N N E A N N D e S P E L D E R Cabrillo College

A L B E R T L E E S T R I C K L A N D

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THE LAST DANCE: ENCOUNTERING DEATH AND DYING, TENTH EDITION

Published by McGraw-Hill Education, 2 Penn Plaza, New York, N Y 10121. Copyright © 2015 , 2011,

and 2009 by Lynne Ann DeSpelder and Albert Lee Strickland. All rights reserved. No part of this

publication may be reproduced or distributed in any form or by any means, or stored in a database

or retrieval system, without the prior written consent of McGraw-Hill Education, including, but not

limited to, in any network or other electronic storage or transmission, or broadcast for distance

learning.

Some ancillaries, including electronic and print components, may not be available to customers

outside the United States.

This book is printed on acid-free paper.

1 2 3 4 5 6 7 8 9 0 DOC/DOC 1 0 9 8 7 6 5 4

ISBN: 978-0-07-803546 -3

MHID: 0-07-803546 -5

Senior Vice President, Products & Markets: Kurt L. Strand Vice President, General Manager, Products & Markets: Michael Ryan Vice President, Content Production & Technology Services: Kimberly Meriwether David Senior Brand Manager: Maureen E. Prado Roberts Managing Development Editor: Penina Braffman Marketing Specialist: Alexandra Schultz Director, Content Production: Terri Schiesl Lead Content Project Manager: Jane Mohr Buyer: Nichole Birkenholz Cover Designer: Studio Montage, St. Louis, MO. Cover Images: Edvard Munch, The Dance of Life, 1889–1900. Oil on canvas. 49¼” 3 74¾”. National

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All credits appearing on page or at the end of the book are considered to be an extension of the

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Library of Congress Cataloging-in-Publication Data DeSpelder, Lynne Ann, 1944-

The last dance : encountering death and dying / Lynne Ann DeSpelder, Cabrillo College, Albert

Lee Strickland.—Tenth edition.

pages cm

ISBN 978-0-07-803546 -3 (alk. paper)

1. Death—Psychological aspects—Textbooks. 2. Death--Social aspects—Textbooks. I. Strickland,

Albert Lee. II. Title.

BF789.D4D53 2014

155.9’37—dc23 2013041273

The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a

website does not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-

Hill Education does not guarantee the accuracy of the information presented at these sites.

www.mhhe.com

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In memory of

Coleen DeSpelder

who lived with lightness

through the shadows of terminal illness

April 2, 1954—May 17, 2001

and to our parents

Bruce Erwin DeSpelder

and

Dorothy Roediger DeSpelder

Luther Leander Strickland

and

Bertha Wittenburg Strickland

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Brief Contents

Preface xxi Prologue, by David Gordon 1

CHAPTER 1: Attitudes Toward Death: A Climate of Change 5

CHAPTER 2: Learning About Death: Socialization 49

CHAPTER 3: Perspectives on Death: Historical and Cultural 89

CHAPTER 4: Death Systems: Mortality and Society 139

CHAPTER 5: Health Care: Patients, Staff, and Institutions 175

CHAPTER 6: End-of-Life Issues and Decisions 213

CHAPTER 7: Facing Death: Living with Life-Threatening Illness 259

CHAPTER 8: Last Rites: Funerals and Body Disposition 295

CHAPTER 9: Survivors: Understanding the Experience of Loss 341

CHAPTER 10: Death in the Lives of Children and Adolescents 385

CHAPTER 11: Death in the Lives of Adults 417

CHAPTER 12: Suicide 447

CHAPTER 13: Risks, Perils, and Traumatic Death 489

CHAPTER 14: Beyond Death / After Life 531

CHAPTER 15: The Path Ahead: Personal and Social Choices 569

Epilogue, by David Gordon 599 Notes 601 Credits and Sources 671 Name Index 677 Subject Index 693

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Contents

Preface xxi Prologue, by David Gordon 1

C H A P T E R 1

Attitudes Toward Death: A Climate of Change 5

Expressions of Attitudes Toward Death 6 Mass Media 6

In the News 6

Entertaining Death 8

Language 10

Music 12

Literature 15

Visual Arts 18

Humor 23

Living with Awareness of Death 25 Contemplating Mortality 26

Dimensions of Thanatology 26

Death Anxiety and Fear of Death 27

Terror Management 29

Studying Death and Dying 31 The Rise of Death Education 31

Pioneers in Death Studies 32

Factors Affecting Familiarity with Death 34 Life Expectancy and Mortality Rates 35

Causes of Death 37

Geographic Mobility and Intergenerational Contact 38

Life-Extending Technologies 40

The Internet and the Digital Age 42

Examining Assumptions 43 Death in a Cosmopolitan Society 44

Exploring Your Own Losses and Attitudes 46

Further Readings 47

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C H A P T E R 2

Learning About Death: Socialization 49

A Child’s Reasoning 50

A Mature Concept of Death 51

Understanding Death Through the Life Course 53 Infancy and Toddlerhood 57

Early Childhood 58

Middle Childhood or School-Age Period 60

Adolescence 62

Emerging Adulthood 64

Early Adulthood 64

Middle Adulthood 65

Later Adulthood 66

The Evolution of a Mature Concept of Death 66

Agents of Socialization 67 Family 68

School and Peers 69

Mass Media and Children’s Literature 72

Religion 76

Teachable Moments 76

The Death of a Companion Animal 78

The Mature Concept of Death Revisited 81

Further Readings 87

C H A P T E R 3

Perspectives on Death: Historical and Cultural 89

Traditional Cultures 92 Origin of Death 92

Names of the Dead 94

Causes of Death 95

Power of the Dead 97

Western Culture 98 The Deathbed Scene 100

Burial Customs 102

Charnel Houses 102

Memorializing the Dead 104

The Dance of Death 104

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Death Masks 106

Invisible Death? 107

Cultural Viewpoints 108 People of Native American Heritage 108

People of African Heritage 112

The LoDagaa of Northern Ghana 114

Traditions Among African Americans 116

People of Hispanic Heritage 117

Attitudes Toward Death in Mexico 118

Día de los Muertos 118

People of Asian Heritage 122

Paper Offerings 127

Ch’ing ming and O-bon Festivals 128 People of Jewish Heritage 129

People of Celtic Heritage 129

People of Arab Heritage 132

People of Oceanian Heritage 132

Mixed Plate: Cultural Diversity in Hawaii 133 Characteristics of Hawaii’s Peoples 133

Death and Local Identity 134

Death in Contemporary Multicultural Societies 136

Further Readings 137

C H A P T E R 4

Death Systems: Mortality and Society 139

Certifi cation of Death 140

The Coroner and the Medical Examiner 141

Autopsies 144

Assessing Homicide 147

Capital Punishment 150

Defi ning Death 151 Conventional Signs of Death and New Technology 153

Conceptual and Empirical Criteria 155

Four Approaches to the Defi nition and Determination of

Death 157

Irreversible Loss of Flow of Vital Fluids 157

Irreversible Loss of the Soul from the Body 157

Irreversible Loss of the Capacity for Bodily Integration 159

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Irreversible Loss of the Capacity for Consciousness or Social

Interaction 160

The Uniform Determination of Death Act 162

Organ Transplantation and Organ Donation 165

Medical Ethics: A Cross-Cultural Example 170

The Impact of the Death System 172

Further Readings 173

C H A P T E R 5

Health Care: Patients, Staff, and Institutions 175

Modern Health Care 176 Health Care Financing 178

Rationing Scarce Resources 180

The Caregiver-Patient Relationship 181 Disclosing a Life-Threatening Diagnosis 182

Achieving Clear Communication 183

Providing Total Care 185

Care of the Dying 185 Hospice and Palliative Care 187

The Origins of Hospice and Palliative Care 191

Challenges for Hospice and Palliative Care 192

The Future of Hospice and Palliative Care 195

Home Care 196

Social Support 198

Elder Care 199

Trauma and Emergency Care 201

Death Notifi cation 204

Caregiver Stress and Compassion Fatigue 207

A Changing Health Care System 209

Further Readings 210

C H A P T E R 6

End-of-Life Issues and Decisions 213

Principles of Medical Ethics 214

Informed Consent to Treatment 215

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Principles of Informed Consent 215

Preferences Regarding Informed Consent 217

Choosing Death 221 Withholding or Withdrawing Treatment 225

Physician-Assisted Death 226

The Rule of Double Effect 229

Euthanasia 229

Palliative Care and the Right to Die 230

Nutrition and Hydration 231

Seriously Ill Newborns 232

Advance Directives 233 Using Advance Directives 238

Advance Directives and Emergency Care 240

Inheritance: Wills, Probate, and Living Trusts 241 Wills 242

The Formally Executed Will 245

Amending or Revoking a Will 246

Probate 248

The Duties of the Executor or Administrator 248

Laws of Intestate Succession 250

Living Trusts 251

Insurance and Death Benefi ts 253

Considering End-of-Life Issues and Decisions 255

Further Readings 256

C H A P T E R 7

Facing Death: Living with Life-Threatening Illness 259

Personal and Social Meanings of Life-Threatening Illness 261

Coping with Life-Threatening Illness 263 Awareness of Dying 263

Adapting to “Living-Dying” 264

Patterns of Coping 266

Maintaining Coping Potency 269

Treatment Options and Issues 272 Surgery 275

Radiation Therapy 276

Chemotherapy 277

Alternative Therapies 277

The Placebo Effect 280

Unorthodox Treatment 281

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Pain Management 282

The Language of Pain 283

Treating Pain 283

The Dying Trajectory 286

The Social Role of the Dying Patient 289

Being with Someone Who is Dying 292

Further Readings 293

C H A P T E R 8

Last Rites: Funerals and Body Disposition 295

Psychosocial Aspects of Last Rites 298 Announcement of Death 298

Mutual Support 301

Impetus for Coping with Loss 302

Funerals in the United States 303 The Rise of Professional Funeral Services 304

Criticisms of Funeral Practices 306

New and Rediscovered Memorial Choices 309

Selecting Funeral Services 311 Funeral Service Charges 313

Comparing the Costs 314

Professional Services 314

Embalming 315

Caskets 317

Outer Burial Containers 318

Facilities and Vehicles 319

Miscellaneous Charges 319

Direct Cremations and Immediate Burials 319

Funeral and Memorial Societies 321

Body Disposition 321 Burial 324

Cremation 326

Memorialization 328

Laws Regulating Body Disposition 329

New Directions in Funerals and Body Disposition 330

Remembrance Rituals and Linking Objects 333

Making Meaningful Choices 334

Further Readings 339

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C H A P T E R 9

Survivors: Understanding the Experience of Loss 341

Bereavement, Grief, and Mourning 343

Tasks of Mourning 346

Models of Grief 347 Working Through Grief 347

Continuing Bonds with the Deceased 348

Telling the “Story”: Narrative Reconstruction 350

The Dual Process Model of Coping 351

The Two-Track Model of Bereavement 352

Toward an Integrated Model of Grief 353

The Experience of Grief 355 Mental Versus Emotional Responses 355

The Course of Grief 355

The Duration of Grief 358

Complications of Grief 359

The Mortality of Bereavement 362

Variables Infl uencing Grief 364 Survivor’s Model of the World 364

Personality 364

Cultural Context and Social Roles 365

Perceived Relationship with the Deceased 365

Values and Beliefs 367

Coping Patterns and Gender 367

Mode of Death 369

Anticipated Death 370

Sudden Death 371

Suicide 371

Homicide 372

Disaster 372

Multiple Losses and Bereavement Burnout 373

Social Support and Disenfranchised Grief 373

Unfi nished Business 375

Grief Counseling and Grief Therapy 376

Support for the Bereaved 379

Bereavement as an Opportunity for Growth 380

Further Readings 382

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C H A P T E R 1 0

Death in the Lives of Children and Adolescents 385

Experiences with Death 388

Children as Survivors of a Close Death 391 The Bereaved Child’s Experience of Grief 392

The Death of a Parent 393

The Death of a Sibling 395

Children with Life-Threatening Illnesses 399 The Child’s Perception of Serious Illness 400

The Child’s Coping Mechanisms 401

Providing and Organizing Care 402

Pediatric Hospice and Palliative Care 403

Decisions About Medical Treatment 405

Caring for a Seriously Ill Child 406

Support Groups for Children 407

Helping Children Cope with Change and Loss 409 Discussing Death Before a Crisis Occurs 409

Discussions When a Family Member Is Seriously Ill 411

Discussions in the Aftermath of Loss 412

Further Readings 415

C H A P T E R 1 1

Death in the Lives of Adults 417

Death and the College Student 418

The Death of a Friend 420

The Death of a Parent 420

Parental Bereavement 423 Childbearing Losses 424

Miscarriage 426

Induced Abortion 426

Stillbirth 428

Neonatal Death 429

Sudden Infant Death Syndrome 430

Grief for “Unlived” Lives 431

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The Death of an Older Child 432

The Death of an Adult Child 433

Coping with Bereavement as a Couple 434

Social Support in Parental Bereavement 435

Spousal Bereavement 436 Factors Infl uencing Spousal Bereavement 436

Social Support for Bereaved Spouses 439

Aging and the Aged 440

Further Readings 445

C H A P T E R 1 2

Suicide 447

Comprehending Suicide 448 Statistical Issues 449

The Psychological Autopsy 451

Explanatory Theories of Suicide 453 The Social Context of Suicide 453

Degree of Social Integration 453

Degree of Social Regulation 455

Psychological Insights About Suicide 456

Toward an Integrated Understanding of Suicide 457

Some Types of Suicide 459 Suicide as Escape 459

Cry for Help 461

Subintentioned and Chronic Suicide 464

Risk Factors Infl uencing Suicide 464 Culture 466

Personality 467

The Individual Situation 468

Life-Span Perspectives on Suicide 471 Childhood 471

Adolescence and Early Adulthood 472

Middle Adulthood 475

Late Adulthood 476

Contemplating Suicide 476

Suicide Notes 479

Suicide Prevention, Intervention, and Postvention 481

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Prevention 482

Intervention 483

Postvention 484

Helping a Person Who Is in Suicidal Crisis 485

Further Readings 487

C H A P T E R 1 3

Risks, Perils, and Traumatic Death 489

Accidents and Injuries 490

Risk Taking 491

Disasters 494 Reducing the Impact of Disasters 498

Coping with the Aftermath of Disaster 499

Violence 501 Random Violence 503

Serial Killers and Mass Murderers 503

Familicide 505

Steps Toward Reducing Violence 506

War 507 Technological Alienation 508

The Conversion of the Warrior 509

Coping with the Aftermath of War 511

Making War, Making Peace 513

Genocide 516

Terrorism 517 September 11, 2001 519

Rescue, Recovery, and Mourning 521

The Mind of the Terrorist 521

Horrendous Death 523

Emerging Infectious Diseases 524 The Response to AIDS 525

Living with AIDS 527

The Threat of Emerging Diseases 527

Traumatic Death 529

Further Readings 529

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C H A P T E R 1 4

Beyond Death / After Life 531

Traditional Concepts About Life After Death 532

Jewish Beliefs About Death and Resurrection 534

Classical Greek Concepts of Immortality 536

Christian Beliefs About the Afterlife 538

The Afterlife in Islamic Tradition 542

Death and Immortality in Asian Religions 543 Hindu Teachings About Death and Rebirth 544

The Buddhist Understanding of Death 547

After-Death States in Tibetan Buddhism 550

The Consolations of Religion 551

Secular Concepts of Immortality 552

Near-Death Experiences: At the Threshold of Death 554 NDEs: A Composite Picture 555

Dimensions of Near-Death Experiences 556

Interpreting Near-Death Experiences 558

Death Themes in Dreams and Psychedelic Experiences 562

Beliefs About Death: A Wall or a Door? 565

Further Readings 566

C H A P T E R 1 5

The Path Ahead: Personal and Social Choices 569

Exploring Death and Dying 570

Cultural Competence 572

New Directions in Thanatology 574 Gaining a Global Perspective 576

Bridging Research and Practice 580

Creating Compassionate Cities 581

Living with Death and Dying 584 Humanizing Death and Dying 585

Defi ning the Good Death 587

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Death in the Future 591

Postscript and Farewell 596

Further Readings 597

Epilogue, by David Gordon 599

Notes 601

Credits and Sources 671

Name Index 677

Subject Index 693

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Preface

In The Last Dance: Encountering Death and Dying, we offer a comprehensive and readable introduction to the study of death and dying, one that highlights

the main issues and questions. The study of death—or thanatology, from the

Greek thanatos, meaning “death”—is concerned with questions rooted at the core of our experience. Thus, the person who sets out to increase his or her

knowledge of death and dying is embarking on an exploration that is partly

a journey of personal discovery. This is a journey that has both cognitive

(intellectual) and affective (emotional) components. Thus, The Last Dance embodies an approach to the study of death and dying that combines the

intellectual and the emotional, the social and the psychological, the experi-

ential and the scholarly.

The title The Last Dance relates to a book written by Carlos Castaneda about the warriors of the Yaqui Indian tribe in Central America. Because a

warrior can die on any day, the warrior makes a dance of power in the face

of death. Castaneda says that, to truly live, we must keep death over our left

shoulder. In other words, death is part of life and, because we can die at any

time, we should be dancing through life.

The painting on the cover, The Dance of Life, by Norwegian artist Edvard Munch, evokes thoughts of the inexorable, compelling cycle of life. It depicts

a festival dance on the Asgaardstrand beach on a midsummer night. An

indifferent moon sheds light on the water while the dancers dance a roundel,

a ring dance. One woman is entering the dance, another is leaving. There is

youth, innocent new life, and age.

We are sometimes asked how we came to write a college textbook on

death and dying. Lynne says, “It’s as simple as the realization that students

hated buying the many books needed for studying all of the topics important

to learning about death and dying. And I hated having to assign all those

books. One day at the start of a new semester, after getting the usual com-

plaints from students, I whined to Al, ‘Why isn’t there just one book that a student could pick up and put under his or her arm that would cover all of

these topics?’ Al’s response was, ‘Well, why don’t we write one?’”

So, some years ago, after fi ve years dedicated to research and writing, The Last Dance: Encountering Death and Dying was born. Each subsequent edition refl ects the changes and transformations that have occurred in the fi eld of

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death studies. This book provides a solid grounding in theory and research

as well as in methods for applying what is learned to readers’ own circum-

stances, both personal and professional. It encourages a constructive process

of self-discovery. The Last Dance is not an indoctrination to any particular point of view but, rather, an introduction to diverse points of view. The values

of compassion, listening, and tolerance for the views of others are empha-

sized. Readers may form their own opinions, but when they do we hope it

is only after considering other possibilities in a spirit of open-mindedness.

Unbiased investigation leads to choices that might otherwise be neglected or

overlooked.

While retaining the popular features of earlier editions, this new edition

of The Last Dance refl ects the ongoing evolution of death studies. Although people sometimes think, “What changes about death?” the truth revealed

in these pages is that much has changed in recent decades and continues to

change in the present. Because of this fact, every chapter has been revised to

integrate the latest research, practices, and ideas and to enhance clarity of

presentation.

Throughout the text, we give attention to the ways cultural and ethnic

viewpoints shape our relationship with death, and there is specifi c discus-

sion of the viewpoints and traditions associated with people of African heri-

tage, Hispanic heritage, Native American heritage, Jewish heritage, Celtic

heritage, Arab heritage, Oceanian heritage, and Asian heritage, including

the diverse cultures of Southeast Asia as well as the cultures of India, China,

Taiwan, Japan, Korea, and the Philippines. In the pages of The Last Dance, you will also fi nd coverage of

• Ongoing developments in care of the seriously ill and dying, especially as

they pertain to hospice and palliative care

• Death through the life course, from infancy through later adulthood,

including a new section on death and the college student

• New directions in mortuary services, including personalized funerals, “green

burials,” and innovative options for body disposition and memorialization

• A changing health care system and its impact on dying and death

• How the Internet is infl uencing our relationship to death, dying, and

bereavement in the digital age

• Insights about grief gained through an appreciation of the dual process

and two-track models of coping with bereavement, as well as other models

that can aid in understanding bereavement, grief, and mourning, includ-

ing discussion of working through grief, maintaining continuing bonds

with the deceased, and “telling the story” or narrative approaches to

coping with grief

• How achieving the “Care-Full Society” and striving toward the creation of

“compassionate cities” could improve and enhance our encounters with death

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xxiii

In addition, this edition contains new and updated material on physician-

assisted suicide, remembrance rituals and linking objects, grief counseling

and grief therapy, horrendous death, the placebo effect, familicide, and the

death of a companion animal.

The study of death is unavoidably multidisciplinary. Accordingly, con-

tributions from medicine, the humanities, and the social sciences are all

found here in their relevant contexts. Throughout the book, principles and

concepts are made meaningful by use of examples and anecdotes. Boxed

material, photographs, and other illustrative materials expand upon and

provide counterpoint to the textual presentation. Specialized terms, when

needed, are clearly defi ned. Accompanying this edition is a companion

Online Learning Center, www.mhhe.com/despelder10e , designed to pro-

mote mastery of the material covered in the text itself. We urge readers to

make use of these features.

Chapter-by-Chapter Tour Before you begin using The Last Dance, please join us for a quick tour through the text.

• In Chapter 1, we look at expressions of attitudes toward death in mass

media, language, music, literature, and the visual arts. We ask what it

means to live with an awareness of death, and we explore death anxiety,

or fear of death. We conclude by examining the reasons people tend to be

unfamiliar with death in modern, cosmopolitan societies.

• In Chapter 2, we investigate how we learn about death throughout the life

course.

• In Chapter 3, we explore historical and cultural factors that shape atti-

tudes and practices relative to dying and death.

• Chapter 4 shows how public policy affects our dealings with dying and

death by means of a society’s “death systems.” Certifi cation of death, the

role of coroners and medical examiners, the functions of autopsies,

procedures for legally defi ning and making a determination of death,

medicolegal views of homicide and capital punishment, and rules regard-

ing organ donation and transplantation are important aspects of the

death system. An instructive cross-cultural example describing how Japan

has dealt with ethical, moral, and legal questions involving brain death

and organ transplantation wraps up this discussion.

• Care of dying persons is the primary focus of Chapter 5. Topics include

health care fi nancing; rationing of health resources; the relationship

between caregivers and the patient; hospice, palliative care, and home

care; elder care; trauma and emergency care; death notifi cation proce-

dures; and caregiver stress and compassion fatigue.

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• Chapter 6 deals with a variety of issues and decisions that pertain to the

end of life. Some of these issues and decisions become important in

the context of diagnosis and treatment—for example, informed con-

sent. Others come to the fore when individuals face a more immediate

prospect of dying. These include choices about withholding or with-

drawing life-sustaining medical treatment, physician-assisted death, and

euthanasia, as well as issues involving artifi cial nutrition and hydration.

Also discussed is the rule of double effect, which may be invoked when a

medical intervention that is intended to relieve suffering leads to death.

Some issues regarding the end of life can be dealt with before the crisis

of a life-limiting illness—for example, making a will, setting up a living

trust, obtaining life insurance, and completing advance directives to

express wishes about medical treatment in the event one becomes inca-

pacitated.

• Chapter 7, with its focus on how people live with a life-threatening illness,

gives attention to the psychological and social meanings associated with

such illnesses and offers insight about the ways individuals and families

cope with “living-dying,” from the time of initial diagnosis to the fi nal

stages of the dying trajectory. Discussion includes treatment options and

issues, as well as pain management and complementary therapies. The

chapter concludes with sections on the social role of the dying patient and

advice about being with someone who is dying.

• The ceremonies and rituals enacted by individuals and social groups after

a death form the content of Chapter 8. Death rites and customs create

opportunities for expressing grief and integrating loss. This chapter exam-

ines the nature and function of last rites, with particular attention to the

history of mortuary services in the United States. Information about the

options for funeral services and body disposition, as well as a discussion

about making meaningful choices, completes the chapter.

• Chapter 9 is devoted to helping readers gain a comprehensive under-

standing of bereavement, grief, and mourning. A number of important

models of grief are discussed, with the recognition that any notion that

“one size fi ts all” is likely to be inadequate. An understanding of the ways

people experience and express grief, and of the variables that infl uence

grief, demonstrates that there are many ways to cope with grief and to

provide support to the bereaved. The concluding section shows that,

despite loss, bereavement can present opportunities for growth.

• Employing a life-span perspective, Chapters 10 and 11 deal with death-

related issues associated with different stages of life, from early childhood

through old age.

• Chapter 10 includes discussion of children with life-threatening illness

and discussion of children as survivors of a close death. It provides guide-

lines for helping children cope with change and loss.

• Chapter 11 examines losses occurring in adulthood, such as miscarriage,

stillbirth, and neonatal death, and the death of a child, a parent, a spouse,

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xxv

or a close friend, as well as losses associated with aging. A new section on

death in the lives of college students has been added for the tenth edition.

• Chapter 12 offers insights into suicide and its risk factors, including the

social and psychological context of suicide and suicidal behavior; life-span

perspectives on suicide; psychological autopsies; suicide notes; and suicide

prevention, intervention, and postvention. The chapter concludes with

advice about helping someone who is in a suicidal crisis.

• Chapter 13 broadens the scope of death-related risks and threats. These

include accidents and injuries, disasters, violence, war, genocide, terror-

ism, emerging diseases, and other examples of horrendous and traumatic

death.

• Questions about human mortality and its meaning are at the forefront in

the fi nal two chapters of the book. Chapter 14 describes a variety of both

religious and secular viewpoints, as well as accounts of near-death experi-

ences, to present a survey of concepts and beliefs concerning immortality

and the afterlife. Whether death is viewed as a “wall” or as a “door” can

have important consequences for how we live our lives.

• Chapter 15 emphasizes personal and social values that are enhanced by

learning about death. Examples of new directions in thanatology include

efforts to bridge research and practice, clarify the goals of death educa-

tion, gain an international perspective, and create compassionate cities,

as well as to improve cultural competence. What does it mean to live with

death and dying? Bringing together a host of topics covered in earlier

chapters, this fi nal chapter presents food for thought that can stimulate

consideration of how a “good death” might be defi ned.

For those who wish to pursue further study of particular topics, a list

of recommended readings is provided at the end of each chapter, and cita-

tions given in the chapter notes provide guidance to additional sources and

references. Thus, while the text serves as an introduction to a broad range of

topics in death studies, readers are pointed to resources for investigating top-

ics that evoke special interest.

Supplements In addition to the textbook itself, there are a number of instructor and stu-

dent resources available.

• The Online Learning Center at www.mhhe.com/despelder10e provides

instructors with a Test Bank, Instructor’s Guide, PowerPoint presentations,

quizzes, and other premium instructor’s content. This premium content

contains numerous fi les ranging from instructor’s resources on the Web

to activities an instructor might use such as a questionnaire to examine

attitudes and experiences.

• For students, the Online Learning Center, www.mhhe.com/despelder10e ,

offers a glossary, and each chapter has quizzes, Web activities, chapter

objectives, key terms, and fl ashcards.

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xxvi

Acknowledgments The Last Dance has been reviewed by professors in a broad range of academic disciplines. Their suggestions have helped to make this text an outstand-

ing teaching tool. Formal reviews have been provided by Jennifer T. Aberle,

Colorado State University; Susan Adams, University of Central Arkansas;

Joel R. Ambelang, Concordia University, Wisconsin; Lisa Angermeier, Indi-

ana University at Bloomington; Patrick Ashwood, Hawkeye Community

College; Thomas Attig, Bowling Green State University; Ronald K. Barrett,

Loyola Marymount University, Los Angeles; Michael Beechem, University of

West Florida, Pensacola; Laura Billings, Southwestern Illinois College; John

B. Bond, University of Manitoba; Tashel Bordere, University of Central Mis-

souri; Sandor B. Brent, Wayne State University; Tom Bruce, Sacramento City

College; John P. Colatch, Lafayette College, Easton, Pennsylvania; Elizabeth

M. Collier, The College of New Jersey; Richard Cording, Sam Houston State

University; Charles A. Corr, Southern Illinois University; Gerry R. Cox, Fort

Hays State University; Illene N. Cupit, University of Wisconsin, Green Bay;

Steven A. Dennis, Utah State University; Kenneth J. Doka, College of New

Rochelle; Donald J. Ebel, Minnesota State University; Alishia Ferguson, Uni-

versity of Arkansas; Stephen J. Fleming, York University, Toronto; Audrey K.

Gordon, Oakton Community College; Judy Green, Walsh University, Ohio;

Debra Bence Grow, Pennsylvania State University; John Harvey, Western

Illinois University; Russell G. Henke, Towson State University; Lorie Hen-

ley, Finger Lakes Community College; David D. Karnos, Eastern Montana

College; Linda C. Kinrade, California State University, Hayward; Dennis

Klass, Webster University; Anthony Lenzer, University of Hawaii at Manoa;

Daniel Leviton, University of Maryland; Paul C. Luken, Arizona State Uni-

versity West, Phoenix; J. Davis Mannino, Santa Rosa Junior College; Coleman

C. Markham, Barton College, North Carolina; Wendy Martyna, University

of California, Santa Cruz; Samuel J. Marwit, University of Missouri; Debbie

Mattison, University of Michigan School of Social Work; Marsha McGee,

Northeast Louisiana University; Walter L. Moore, Florida State University,

Tallahassee; Lachelle Norris, Tennessee Tech University; Tina Olson, Ari-

zona State University; Leah Rogne, Minnesota State University; Vincent M.

Rolletta, Erie Community College; Cheri Barton Ross, Santa Rosa Junior

College; Lee Ross, Frostburg State University, Maryland; Rita S. Santanello,

Belleville Area Community College, Illinois; Thomas W. Satre, Sam Houston

State University; Edwin S. Shneidman, University of California, Los Angeles;

Virginia Slaughter, The University of Queensland; Judith M. Stillion, Western

Carolina University; Gordon Thornton, Indiana University of Pennsylvania;

Jeffrey S. Turner, Mitchell College; Mary Warner, Northern State University,

South Dakota; Hannelore Wass, University of Florida, Gainesville; Jack Bor-

den Watson, Stephen F. Austin State University, Nacogdoches, Texas; John

B. Williamson, Boston College; C. Ray Wingrove, University of Richmond;

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xxvii

Robert Wrenn, University of Arizona, Tucson; Joseph M. Yonder, Villa Maria

College of Buffalo; Margaret H. Young, Washington State University; and

Andrew Scott Ziner, University of North Dakota. In addition to those named,

other colleagues and students have generously shared ideas for enhancing

and improving the text. We thank all who have offered helpful suggestions

about the book through its successive incarnations.

We also thank our collaborators who have helped prepare ancillary

instructional materials over the course of various editions of The Last Dance. These include Barbara Jade Sironen, Patrick Vernon Dean, Robert James

Baugher, Matt and Kelley Strickland, and Carol Berns, who deserves spe-

cial thanks for her work on this edition’s test bank and other resources for

instructors , as well as on the Online Learning Center at www.mhhe.com/ despelder10e . In addition, we are grateful to staff members at many muse-

ums, libraries, and governmental institutions who have assisted us in our

research and in gathering both text and art resources over the years.

Over the course of ten editions of The Last Dance, we have had the plea- sure of working with many talented people who exemplify excellence in

publishing. At McGraw-Hill, among the many individuals who helped bring

this book to press, we want to particularly thank Mike Sugarman, publisher

par excellence; Terri Schiesl, production maven, who at the outset got the ball rolling down the right track; and Erin Guendelsberger, developmental edi-

tor, who guided the typescript into production with attention to detail, good

cheer, and thorough professionalism. To all whose help was instrumental in

bringing this edition of The Last Dance to readers, our heartfelt thanks.

L. A. D.

A. L. S.

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xxviii

Additional McGraw-Hill Resources • Craft your teaching resources to match the way you teach! With McGraw-

Hill Create™, www.create.mcgraw-hill.com , instructors can easily re arrange

chapters, combine material from other content sources, and quickly

upload personal content such as a course syllabus or teaching notes. Find

the content you need in Create by searching through thousands of lead-

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Create even allows you to personalize your book’s appearance by selecting

the cover and adding your name, school, and course information. Order a

Create book and you’ll receive a complimentary print review copy in three

to fi ve business days or a complimentary electronic review copy (eComp)

via e-mail in minutes. Go to www.create.mcgraw-hill.com today and regis-

ter to experience how McGraw-Hill Create™ empowers you to teach your

students your way.

• With the CourseSmart eTextbook version of this title, students can save

up to 50 percent off the cost of a print book, reduce their impact on the

environment, and access powerful Web tools for learning. Faculty can also

review and compare the full text online without having to wait for a print

desk copy. CourseSmart is an online eTextbook, which means users need

to be connected to the Internet in order to access it. Students can also

print sections of the book for maximum portability. For further details,

contact your sales representative or go to www.coursesmart.com .

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1

I don’t know how much time I have left. I’ve spent my life dispensing salves and purga- tives, potions and incantations—miracles of nature (though I admit that some were pure medicine-show snake oil). Actually, half the time all I offered was just plain com- mon sense. Over the years, every kind of suffering person has made his or her way here. Some had broken limbs or broken bodies . . . or hearts. Often their sorrow was an ailing son or daughter. It was always so hard when they’d lose a child. I never did get used to that. And then there were the young lovers. Obtaining their heart’s desire was so important to them. I had to smile. I always made them sweat and beg for their handful of bark, and for those willful tortures I’ll probably go to hell . . . if there is one. My God, how long has it been since I had those feelings myself? The fever, the lump in the throat, the yearning. I can’t remember. A long time . . . maybe never. Well, there have been other passions for me. There’s my dusty legion of jars. Each one holds its little secret. Barks, roots, soils, leaves, fl owers, mushrooms, bugs—magic dust, every bit of it. There’s my book—my “rudder,” a ship’s pilot would call it. That’s a good name for it. Every salve, every purgative . . . they’re all in there. (Everything, that is, except my stained beard, scraggly hair, and fl owing robes—they’ll have to fi gure those out on their own.) And then there’s my walking stick (always faithful) . . . and the ballerina. And ten thousand mornings, ten thousand afternoons, ten thousand nights. And the stars. Oh, I have had my loves.

It hurts to move. My shelf and jars seem so far away, though I know that, if I tried, I could reach them. But no. It’s enough, and it’s time . . . almost. I hope he makes it back in time. He burst through my door only two days ago. A young man, well spoken. Tears were streaming down his face. He looked so bent and beaten that I could not

P R O L O G U E

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2 p r o l o g u e

refuse him. He told me that his wife had died over a month ago and that he had been inconsolable since.

“Please help me,” he pleaded, “or kill me.” He covered his face with his hands. “Per- haps they’re the same thing. I don’t know anymore.”

I let him cry a while so I could watch him, gauge him. When at last he looked up, with my good hand I motioned him to take a seat. Then, between coughing fi ts, I went to work. “Do you see that toy there?” I said. “The little ballerina . . . yes, that’s it. Pick it up.”

“Pick it up?” “It won’t bite. Pick it up.” (He probably thought it was a trick—that’s what they

expect.) He grasped it carefully with one hand, then wiped his eyes with the other. “That’s better,” I continued. “That’s just a toy to you. You don’t know what meaning to put to it yet. So, I want you to look at that ballerina.”

He was hesitant, but I waited stubbornly until he looked down and fi xed his atten- tion on the little toy dancer. I went on: “I knew a young man once who was very hand- some—always had been. He not only turned every head, he was strong and smart, and his family was wealthy. His main concern each day was which girl he should court that evening. He had planned that, after several seasons of playing at love, he would marry a beautiful girl, have beautiful children, and settle down to spend the money his father had promised him. And he had plans for that money. He had already purchased the land he wanted to live on and was having built there the biggest house in the area. He was going to raise and race horses, I think. One morning, he got on his favorite horse and went for a ride. He whipped that horse into a gallop; it stepped in a hole and threw him. The young man broke his neck and died.” I stared at my guest and waited.

“That’s a tragedy,” he fi nally croaked. “For whom? For those he left behind, perhaps. But was it for him? When he opened

his eyes that morning, he didn’t know he would die that day. He had no intention of dying for another sixty years, if then. None of us does.” The young man looked con- fused. “His mistake was that he forgot that he could die that day.”

“That’s a morbid thought,” he replied, and he looked as though he had just smelled something putrid.

“Is it? A moment ago, you asked me to end your grieving by ending your own life. Suppose I oblige?” I stared at him for a few moments with my most practiced penetrating glare. “Suppose I did agree to kill you. How would you spend your last few minutes?”

He was still a little wary of me but relieved that I seemed to be suggesting a hypo- thetical situation rather than a serious course of action. He considered the possibilities for a while, then straightened in his chair. “Well, I guess I would step outside and take a last, best look at the sky, the clouds, the trees.”

“Suppose you lived that way all the time?” He stared at me, then looked down at his hands, searching them. “That young man I told you about . . . perhaps the tragedy for him was not that he died, but that he failed to use the eventual certainty of his death to make himself live ! Did he woo each of those ladies as though it might be his last romance? Did he build that house as though it might be his last creation? Did he ride that horse as though it would be his last ride? I don’t know; I hope so.” My young guest nodded, but he was still sad. I pointed to the toy ballerina he was holding. “That was given to me by a young lady who understood these things.”

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p r o l o g u e 3

He looked at the fi gure closely. “Is she a dancer?” “Yes, she is, and she is dead.” The young man looked up, once again off balance.

“She has been dead for, oh, a very long time.” After all these years, a tear fell onto my cheek. I let it go. “She was many things. A child, a woman, a cook and a gardener, a friend, lover, daughter.  .  .  . But what she really was—who she was—was a dancer. When she was dying, she gave that doll to me, smiled, and whispered, ‘At the moment of my death, I will take all of my dancing and put it in there, so my dancing can live on.’”

Tears welled in my guest’s eyes. “I can help you,” I said, “but fi rst there is something that you must do.” He became

very attentive. “Go to town, and knock on the door of the fi rst house you come to. Ask the people inside if their family has ever been touched by death. If so, go to the next house. When you fi nd a family that has not been touched by death, bring them to me. Do you understand?” He nodded, and I sighed. “I’m tired now.”

He got up, set the ballerina back on the table, and started for the door. I stopped him. “Young man!” He faced me from the doorway. “Come back as soon as you can.”

David Gordon

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In a Spanish village, neighbors and relatives peer through the doorway upon the deathbed scene of a villager.

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5

C H A P T E R 1

Attitudes Toward Death:

A Climate of Change

D ead end. Dead on. Dead center. Dead heat. Deadwood. Deadbeat. Dead tired. Dead stop. Deadline. Dead reckoning. Deadlock. Dead ahead.

Look at some of the connotations of the word dead in the English language. Are they

positive or negative? There is no place to go when you get to a dead end, and there are usu-

ally unpleasant consequences when you miss a deadline. In contrast, however, dead reckon-

ing gives us direction to a place where we are going.

This bit of linguistic exploration points up a paradox involved in the study of death and

dying. How is our social world, our culture, set up to deal with death and the dead? Do we,

consciously or unconsciously, relate to death as something to avoid? Or does death capture

our attention as a defi ning moment, worthy of refl ection and deliberate thought?

Of all human experiences, none is more overwhelming in its implications than death.

Yet, we tend to relegate death to the periphery of our lives, as if it can be kept “out of sight,

out of mind.” 1 A fi rst step toward gaining new choices about death is to recognize that avoid-

ing thinking about it estranges us from an integral aspect of human life. As one writer says,

“The moment we begin to be we are old enough to die.” 2

The study of death can “lead us to take seriously our fi nitude, our mortality, as some-

thing that provides signifi cance to our lives.” 3 Formally, thanatology is defi ned as the study of

the facts or events of death and the social and psychological mechanisms for dealing with

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6 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

them. The word is a linguistic heir of Thantatos from Greek mythology, where it is generally understood as a reference to “the personifi cation of death.” A

practical defi nition of thanatology includes ethical and moral questions, as

well as cultural considerations. It is concerned not only with medicine and

philosophy, but also with many other disciplines: history, psychology, sociol-

ogy, and comparative religion, to name a few. In a commencement address at

Stanford University, Apple founder Steve Jobs said, “Death is very likely the

single best invention of life.” He called it “life’s change agent.” 4

Expressions of Attitudes Toward Death Direct, fi rsthand experience with death is rare. Nevertheless, death has a sig-

nifi cant place in our social and cultural worlds. This is revealed through the

manner in which death is portrayed by the mass media and in the language

people use when talking about death, as well as in music, literature, and the

visual arts. Notice how these varied expressions reveal thoughts and feelings

about death, both individually and culturally.

Mass Media Modern communication technology makes us all survivors of death as

news of disasters, accidents, violence, and war is fl ashed around the world.

When situations involve a perceived threat, people turn to the mass media

for information. On September 11, 2001, for example, more than two billion

people worldwide watched the attacks in real time or watched news reports

about the attacks. 5 The Internet not only increases the speed at which news

is reported, it also allows us to follow along with updates from international

news agencies and comments from blogs giving further details and opinion. 6

What do these secondhand sources tell us about death and dying?

In the News When you read the newspaper or an online news source, what kinds of

encounters with death vie for your attention? You are likely to fi nd an assort-

ment of accidents, murders, suicides, and disasters involving sudden, violent

deaths. A jetliner crashes, and the news is announced with banner head-

lines. You see a story describing how a family perished when trapped inside

their burning home, or a story describing how a family’s vacation came to an

untimely end due to a fatal collision on the interstate.

Then there are the deaths of the famous, which are likely to be announced

on the front pages, followed soon by feature-length obituaries. Prefaced by head- lines, obituaries send a message about the newsworthiness editors attribute to

the deaths of famous people. News organizations maintain fi les of pending

obituaries for individuals whose deaths are considered newsworthy, and these

obituaries are kept updated so they are ready when the occasion demands.

In contrast, the death of the average Joe or Jill is usually made known

by a death notice —a brief, standardized statement printed in small type and listed alphabetically in a column of vital statistics “as uniform as a row of tiny

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Expressions of Attitudes Toward Death 7

grave plots.” 7 In some newspapers, obituaries for “ordinary Joes” are given

more attention with “egalitarian obits,” which aim to “nail down quickly what

it is we’re losing when a particular person dies.” 8 Still, ordinary deaths—the

kind most of us will experience—are usually mentioned only in routine fash-

ion. The spectacular obscures the ordinary.

Whether routine or extraordinary, our encounters with death in the

news media infl uence the way we think about and respond to death. Reports

may have less to do with the event than with how that event is perceived. This point is illustrated by Jack Lule in his description of how black activist Huey

Newton’s death was reported in newspapers across the country. 9 Newton had

a public career spanning two decades, yet most reports focused on the violent

nature of Newton’s death while ignoring other aspects of his life.

People look to the media not only for information about events but also

for clues about their meaning. This can present problems in determining

what is appropriate to report in stories that involve death and survivors’ grief.

Media coverage of horrifi c deaths sometimes leads to “revictimization” or

“second trauma” after the initial trauma of the event itself. Reporters may

seek to capture the experience of a tragedy at the expense of victims or their

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8 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

survivors. The journalistic stance “If it bleeds, it leads” often sets priorities.

Do the media help us explore the meaning of death or merely seek to grab

our attention with sensational news fl ashes? Robert Fulton and Greg Owen

point out that the media may “submerge the human meaning of death while

depersonalizing the event further by sandwiching actual reports of loss of life

between commercials or other mundane items.” 10 The distinction between

public event and private loss sometimes blurs, and the grief experienced by survivors or the disruption of their lives is generally given little attention.

Deaths from cancer and heart disease don’t seem to interest us as much as

deaths from plane crashes, roller coaster mishaps, or mountain lion attacks.

Bizarre or dramatic exits grab our attention. Although the odds of dying

from a heart attack are about 1 in 5, we seem more fascinated by death from

bee stings (1 in 62,950), lightning (1 in 81,701), or fi reworks (1 in 479,992). 11

Media experts say that the “reality violence” on TV news really began

with coverage of the Vietnam War. 12 As a “living-room” war, replete with

daily doses of violent images for more than a decade, it would exert a last-

ing infl uence on how news is presented. Viewers were given a succession of

violent images: wartime casualties both friend and foe, the execution of a

Viet Cong lieutenant by gunshot to the head on a Saigon street, pictures of

napalmed children, and images of a burning monk. This is “action news,”

and it is a marketable format that fl ourishes with such events as school shoot-

ings and the public death of a man on a Los Angeles overpass who, retrieving

a shotgun, “blasted half his head away as police and news choppers hovered

above.” 13 Allan Kellehear says, “There is no shortage of death reportage in the

media . . . however, what passes for death is frequently merely violence.” 14 He

adds: “As long as death and loss appear in newspapers and TV programmes

in the context of ‘problems’ and ‘tragedies,’ our understanding of these will

be coloured by these terms and concepts.” 15

Media analyst George Gerbner observes that depictions of death in the

mass media are often embedded in a structure of violence that conveys “a

heightened sense of danger, insecurity, and mistrust.” 16 Such depictions

refl ect what Gerbner and his colleagues call a “mean world syndrome,” in

which the symbolic use of death contributes to an “irrational dread of dying

and thus to diminished vitality and self-direction in life.”

According to Gerbner, the effect of violent images in the media is not to

cause viewers to become more violent themselves; rather, viewers are likely

to perceive the world as a frightening and scary place, a place of murder and

mayhem, disease and plague, threats of war, a world populated by psychotic

killers, child abductors, terrorists, and threatening animals. This perception

of a mean world in which predators of every stripe—and every species—

appear forever on the loose and in attack mode creates a sense of anxiety and

fear that is out of proportion with reality. 17

Entertaining Death Television’s infl uence on our lives is well established. Programs such as Six

Feet Under, Bones, and CSI may challenge certain taboos surrounding death,

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Expressions of Attitudes Toward Death 9

but this interest in death and dying mainly serves to make the corpse what

some commentators call the new “porn star” of popular culture. 18 Seldom do

images portrayed in the mass media enhance our understanding of death by

dealing with such real-life topics as how people cope with a loved one’s death

or confront their own dying.

Besides its appearance in movies of the week and on crime and adven-

ture series, death is a staple of newscasts (typically, several stories involving

death are featured in each broadcast), nature programs (death in the animal

kingdom), children’s cartoons (caricatures of death), soap operas (which

seem always to have some character dying), sports (with descriptions such

as “the ball is dead” and “the other team is killing them”), and religious

programs (with theological and anecdotal mention of death). Despite this,

the lack of stories depicting realistic themes portraying death, dying, and

bereavement has been characterized as “an impoverishment of death sym-

bolism” in the media. 19

Turning to programming directed toward children, recall cartoon depic-

tions of death. Daffy Duck is pressed to a thin sheet by a steamroller, only to

pop up again a moment later. Elmer Fudd aims his shotgun at Bugs Bunny,

pulls the trigger, bang! Bugs, unmarked by the rifl e blast, clutches his throat,

spins around several times, and mutters, “It’s all getting dark now, Elmer. . . .

I’m going. . . .” Bugs falls to the ground, both feet still in the air. As his eyes

close, his feet fi nally hit the dirt. But wait! Now Bugs pops up, good as new.

Reversible death!

Consider the western, which mutes the reality of death by describing the

bad guy as “kicking the bucket”—relegated, no doubt, to Boot Hill at the

edge of town, where the deceased “pushes up daisies.” The camera pans from

the dying person’s face to a close-up of hands twitching—then all movement

ceases as the person’s breathing fades away in perfect harmony with the musi-

cal score. Or, more likely, the death is violent: the cowboy gunfi ght at the OK

Corral, high noon. The gent with the slower draw is hit, reels, falls, his body

convulsing into cold silence.

People who have been present as a person dies describe a very different

picture. Many recall the gurgling, gasping sounds as the last breath rattles

through the throat; the changes in body color as fl esh tones tinge blue; the

feeling of a once warm and fl exible body growing cold and fl accid. Surprised

by the reality, they say, “Death is not at all what I thought it would be like; it

doesn’t look or sound or feel like anything I see on television or in movies!”

Unrealistic portrayals of violent death fail to show real harm to victims,

their pain, or appropriate punishment for perpetrators.

Thrillers featuring extreme violence and what has been called death

porn have become a profi table genre for moviemakers. The road to more

“blood and gore” in popular fi lms was paved in part by the success of classic

“slasher” or “dead teenager” movies, like Nightmare on Elm Street (1984), which included point-of-view shots from the killer’s perspective. In traditional hor-

ror fi lms, the audience viewed the action through the eyes of the victim and

thus identifi ed with his or her fate. In slasher fi lms, however, viewers are asked

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10 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

to identify with the attacker. (A similar form of identifi cation can be found in

violent video games.) The depictions of violence in such movies suggest that

residual tendencies from our evolutionary background may attract human

beings to “exhibitions of brutality and terror.” 20

When told of his grandfather’s death, one contemporary seven-year-old

asked, “Who did it to him?” Death is generally portrayed on television or in

movies as coming from outside, often violently, reinforcing the notion that

dying is something that happens to us, rather than something we do. Death is an accidental rather than a natural process. As our fi rsthand experiences of death and violence have diminished, representations of death and violence in the media have increased in sensationalism.

Movies engage our psychological faculties in profound and unique

ways. 21 In thinking about the fi lms, DVDs, and television programs you’ve

watched recently, what are your observations about the ratio of positive and

negative images of dying and death?

Language Listen to the language people use when talking about dying or death,

and you are likely to discover that it is often indirect. The words dead and dying tend to be avoided; instead, loved ones “pass away,” embalming is “preparation,” the deceased is “laid to rest,” burial becomes “interment,” the

corpse is “remains,” the tombstone is a “monument,” and the undertaker is

transformed into a “funeral director.” Such euphemisms—substitutions of

indirect or vague words and phrases for ones considered harsh or blunt—

tend to suggest a well-choreographed production surrounding the dead.

Hannelore Wass, a pioneering death educator, notes that euphemisms substi-

tuting for plain-spoken “ D words” turn up even in the language of death and dying experts as terminal care becomes “palliative care,” and dying patients

are described as “life threatened.” 22 Death may be described as “a negative

patient-care outcome” and an airline crash as an “involuntary conversion of

a 727.” 23

When plain talk about death is subverted by substitutions, reality is

devalued and depersonalized. For example, description of the horror of

death in war is often cloaked by euphemisms—individuals killed in battle

One of the fi rst things we teach to journalism students in the USA is to use “died”

instead of “passed away” or “departed this life,” which is how most people can tell

the difference between an obituary written by the funeral director and one writ-

ten by a newspaper staff member. Even in American English, it seems nearly disre-

spectful to go to such lengths to avoid saying the obvious; when my time comes, I

hope to have pre-written my own obit, which will say something to the effect that

“Old Man Wilcox is dead. He has ceased to be. He has expired and gone to meet

his maker. He is a stiff. Bereft of life, he rests in peace. Services will be held on

Wednesday; cocktails will be served.”

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Expressions of Attitudes Toward Death 11

are described in terms of “body counts” and civilian deaths are termed “col-

lateral damage.” The language people use when talking about death often

refl ects a desire to avoid blunt reality. Euphemisms, metaphors, and slang

make up a large part of death talk (see Table 1-1 ).

However, the use of euphemism and metaphor does not always imply an

impulse to deny the reality of death or avoid talking about it. These linguistic

devices are also used to communicate subtler or deeper meanings than those

associated with plainer speech. For example, terms like passing or passing on may convey an understanding of death as a spiritual transition, especially

among members of some religious and ethnic traditions.

Similarly, sympathy cards provide a way for people to express condo-

lences to the bereaved without directly mentioning death. 24 Some cards

refer to death metaphorically, as in sentiments like “What is death but a

long sleep?” while others apparently deny it in verses like “He is not dead,

he is just away.” Images of sunsets and fl owers create an impression of peace,

quiet, and perhaps a return to nature. The fact of bereavement, losing a

loved one by death, is generally mentioned within the context of memories

or the healing process of time. It is interesting to check the greeting-card

rack to see if you can fi nd a card that plainly uses the word dead or death. By acknowledging loss in a gentle fashion, sympathy cards are intended to

comfort the bereaved.

Croaked No longer with us

Kicked the bucket Taking the dirt nap

Gone In the great beyond

Expired On the other side

Succumbed Asleep in Christ

Left us Departed

Lost Transcended

Wasted Bought the farm

Checked out With the angels

Laid to rest Cashed in

Pushing up daisies Crossed over Jordan

Called home Perished

Was a goner Ate it

Bit the dust It was curtains

Annihilated Out of his/her misery

Liquidated Ended it all

Terminated Resting in peace

Gave up the ghost Dropped the body

Rubbed out That was all she wrote

Snuffed Joined the ancestors

Bit the grass Subject just fataled

Took the last journey Gone west

t a b l e 1-1 Death Talk: Metaphors, Euphemisms, and Slang

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12 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

After someone dies, our conversations about that person usually move

from present tense to past tense: “He was fond of music,” “She was a leader in her fi eld.” Using this form of speech, which grammarians term the indicative voice, is a way of acknowledging the reality of death while distancing us from the dead. One way to continue to include the “voice” of the deceased in pres-

ent circumstances lies in the use of the subjunctive, which has been described as the mode of “as if,” of what “might be” or “could have been.” It is a “zone

of possibility,” rather than certainty. 25 We hear examples of this when people

say things like “He would have been proud of you” or “She would have enjoyed

this gathering tonight.”

Language usage also tells us something about the intensity and imme-

diacy of a person’s encounter with death, as in the form of “danger of death”

narratives—stories about close calls with death. In such stories, a shift in

tense typically occurs when the narrator reaches the crucial point in his or

her story, the point when death seems imminent and unavoidable. Consider

the following example: A man who had experienced a frightening incident

while driving in a snowstorm began telling his story in the past tense as he

described the circumstances. As he came to the point when his car went out

of control on an icy curve and began to slide into the opposing lane of traffi c,

however, he abruptly switched to the present tense, as if he were reliving the experience of watching an oncoming car heading straight for him and believ-

ing in that moment that he was about to die. 26

Word choices can also refl ect changes in how a death event is experi-

enced at different times. For example, after a disaster occurs, as the focus

of rescue efforts changes, so does the language used to describe the work

of emergency personnel and search-and-rescue teams. As hours stretch into

days, rescue work becomes recovery work. Scholars point out that language appears to infl uence many aspects of

human thought. In fact, what we normally call “thinking” is a complex set

of collaborations between linguistic and nonlinguistic representations and

processes. 27 Look again at the words and phrases used in death talk (see

Table 1-1 ). Notice how language offers clues about the manner of death and

the speaker’s attitude toward the death. Subtle distinctions may refl ect dif-

ferent attitudes, sometimes involving cultural frameworks. Consider, for

instance, the difference between passed away and passed on. Paying attention to the euphemisms, metaphors, slang, and other linguistic devices people use

when talking about death is a way to appreciate the variety and range of atti-

tudes toward dying and death.

Music In Music of the Soul, Joy Berger writes, “Nearly every civilization, culture,

and religion exemplifi es the use of music at times of loss and grief.” 28 Pipes

and fl utes were referred to by Euripedes in his play Helen as an aid to mourn- ing. Leonard Bernstein’s Symphony no. 3 ( Kaddish ) is based on the Jewish prayer for the dead. Richard Strauss’s Death and Transfi guration depicts the death of an artist. Signifi cant compositions written to commemorate the

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Expressions of Attitudes Toward Death 13

events of September 11, 2001 include John Adam’s On the Transmigration of Souls and Steve Reich’s WTC 9/11. Music scholar Ted Gioia reminds us that the potency and transformational power of music is enhanced by its ability

to create a unity of purpose. He notes that the “deep faith in the transfor-

mational power of sound is so widespread in traditional cultures that we are

perhaps justifi ed in calling it a universal belief.” 29

The dirge (a hymn of grief) is a musical form associated with funeral processions and burials. The jazz funeral of New Orleans is a well-known

example of a popular interpretation of the dirge. Beethoven, Schubert,

Schumann, Strauss, Brahms, Mahler, and Stravinsky all wrote dirges.

Related to dirges are elegies —musical settings for poems commemorat- ing a person’s death—and laments. Elegies are emotional acknowledg- ments that “all things are impermanent, which is itself a profound spiritual

understanding.” 30

Laments are an expression of stylized or ritualized leave-taking found

in many cultural settings, one example being Scottish clan funerals, where

bagpipes are played. Vocally, the typical lament is an expression of mourn-

ing called keening, an emotional expression of loss and longing that is remi- niscent of crying. For the ancient Greeks, lamentation was intended to both

“praise the deceased and provide emotional release for the bereaved.” 31 An

audience, hearing the lament, were “enabled to use the expressions of loss

and sorrow as their own, thereby diminishing the opportunity for explosive

and spontaneous eruptions of anguish.” 32

Laments may help the bereaved identify their altered social status and

seek sympathetic understanding from the community. 33 Italian philosopher

Ernesto De Martino traced how the practice of lamentation—in word, ges-

ture, and music—moderates the tendency toward collapse or breakdown that

threatens persons in moments of extreme crisis, such as the aftermath of the

death of a close relative. 34 In this way, laments promote the cultural reinte-

gration of the mourner while simultaneously reestablishing bonds of alliance

between the living and the dead. In a well-known Greek lament, a mother

says that she will take her pain to the goldsmith and have it made into an

amulet so that she can wear it forever. 35

The requiem, a musical composition played at a mass for the dead, is related to the elegy. This musical form has attracted composers like Mozart,

Berlioz, and Verdi, among others. One section of the Requiem Mass, the Dies Irae (“Day of Wrath”), is a musical symbol for death in works by many compos- ers. In Berlioz’s Symphonie Fantastique (1830), this theme is heard, fi rst follow- ing an ominous tolling of bells and then, as the music reaches its climax, in

counterpoint to the frenzied dancing of witches at a sabbat. Berlioz’s Symphonie tells the story of a young musician who, spurned by his beloved, attempts sui-

cide with an overdose of opium. In a narcotic coma, he experiences fantastic

dreams that include a nightmarish march to the gallows. The Dies Irae is also heard in Camille Saint-Saëns’s Danse Macabre (1874) and Franz Liszt’s Toten- tanz (1849), two of the best-known musical renditions of the Dance of Death (discussed in its historical context in Chapter 3).

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14 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

Tragedy and death are common in opera. This art form, which combines

drama with music, has been characterized as obsessed with death, or at least

a romanticized view of death prevalent in Western culture during the time

frame of such classic compositions as Aida, Carmen, La Bohème, Madame But- terfl y, Tosca, and La Traviata. 36

As these examples attest, death themes are heard in both religious and

secular compositions. Pink Floyd’s “Time” is a musical reminder of the limits

of a life span and how each day’s passing brings us “closer to death.” Eric

Clapton’s “Tears in Heaven” was written for his four-year-old son who died

from a fall from a high-rise in Manhattan. Tim McGraw’s “Live Like You

Were Dying” celebrates life renewed after the death of his father.

The lyrics of Elvis Presley’s early hit “Heartbreak Hotel” reportedly were

inspired by a suicide note that contained the phrase “I walk the lonely street.”

The branch of heavy metal music known as death metal is partly defi ned by

its lyrics, which convey images of homicide, catastrophic destruction, and sui-

cide, performed by bands with names like Morbid Angel, Napalm Death, Car-

cass, and Entombed. Indeed, death imagery in rock music may have helped

break the taboo against public mention of death. Support for this thesis is

found in surveys of Top 40 songs. 37 Some authorities have traced the begin-

nings of the civil rights movement to a musical event that occurred sixteen

years before Rosa Parks refused to yield her seat on a Montgomery, Alabama,

bus: Billie Holiday’s singing of “Strange Fruit,” the lyrics of which describe

horrifi c imagery of the lynching of African Americans. 38

Music has been recruited to enlist patriotic support for war efforts, as in

George M. Cohan’s “Over There” during the First World War. 39 It has also

been used to cast doubt on the legitimacy of war. During the Vietnam con-

fl ict, listeners heard Country Joe McDonald’s “Fixin’ to Die Rag,” with its

well-known refrain, “What are we fi ghting for?”

Mayhem and misery have long been staples of music. Folk ballads describe

premonitions of death, deathbed scenes, last wishes of the dying, the sorrow

and grief of mourners, and the afterlife. Consider such songs as “Where Have

All the Flowers Gone?” (war), “Long Black Veil” (mourning), “Casey Jones”

(accidental death), and “John Henry” (occupational hazards).

Themes of suicide are also common, especially in tales of love and death.

Some songs, such as “The Ballad of Jesse James,” glorify outlaws and other

bad guys. Graeme Thomson observes that “Stagger Lee” is a close relative of

“Jesse James,” except “Stag has no great quest for justice to pursue; he is just

plain bad. ” 40 This musical genre is also found in Mexican popular culture in the form of narcocorridos, narrative songs or corridos that describe the careers of smugglers and drug lords. 41

In American blues music, themes of loss, separation, tribulation, and

death are commonly heard. Disasters have inspired blues lyrics, as with the

sinking of the Titanic and the 1927 Mississippi River fl ood. The desire to be remembered after death is voiced in Blind Lemon Jefferson’s “See That My

Grave Is Kept Clean.” In “I Feel Like Going Home,” Muddy Waters tells us

that death sometimes brings relief. Other examples of blues themes include

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Expressions of Attitudes Toward Death 15

Bessie Smith’s “Nobody Knows You When You’re Down and Out” (economic

reversal), T-Bone Walker’s “Call It Stormy Monday” (lost love), John Mayall’s

“The Death of J. B. Lenoir” (death of friend in a car accident), and Otis

Spann’s “The Blues Never Die” (consolation in loss). In all, the blues express

“a deep stoic grief and despair, a dark mood of lamentation, but also a wry

and ribald humor.” 42

Sometimes characterized as the fl ip side of the blues, gospel music

expresses a wealth of images of loss and grief. Examples include “Oh, Mary

Don’t You Weep” (mourning), “Known Only to Him” (facing one’s own

death), “When the Saints Go Marching In” (the afterlife), “If I Could Hear

My Mother Pray Again” (a parent’s death), and “Precious Memories” (adjust-

ment to loss and sustaining bonds with the deceased).

Charles Reagan Wilson identifi es six categories of death in country

music: (1) the pervasiveness of death, (2) violent and tragic death, (3) songs

of love and death, (4) death and the family, (5) celebrity death, and (6) reli-

gious infl uences on death. 43 “Will the Circle Be Unbroken,” a song that can

be classifi ed as both gospel and country, describes a mother’s death and a

child’s grief in precise imagery. The Appalachian dirge “O, Death” refl ects

the memento mori tradition, a reminder of the reality of death. Country songs, as Wilson says, “continue to embody the idea that death should not be segre-

gated from the rest of life, but should be dealt with openly as a natural and

profound human concern.” 44

In traditional Hawaiian culture, chants known as mele kanikau were used as laments for commemorating a person’s death. 45 Some kanikau were care- fully composed; others were chanted spontaneously during the funeral pro-

cession. Imagery of the natural world is called upon to portray the writer’s

experience of loss. 46 Memories of shared experiences amid natural surround-

ings are mentioned: “My companion in the chill of Manoa” or “My compan-

ion in the forest of Makiki.” Such chants fondly recall the things that bind

together the deceased and his or her survivors. The message was not “I am

bereft without you” but, rather, “These are the things I cherish about you.”

Think about how music provides solace in experiences of loss. As we cope

with losses that beset us throughout life, certain songs and musical works

bring to mind poignant memories that refresh our grief. 47 Whether Mozart’s

Requiem or a Top 40 tune, music can cue the recall of happy moments shared with loved ones whose death has left us bereft. At other times, a lyric or mel-

ody sets us refl ecting on our own mortality.

Themes of loss and death are heard in all musical styles (see Table 1-2 ). 48

As you listen to various styles of music, notice the references to dying and

death and ask yourself, What messages are being conveyed? What attitudes

are being expressed? Whatever your musical taste, you will fi nd a wealth of

information about individual and cultural attitudes toward death.

Literature From the epic poetry of Homer’s Iliad and the classic drama of Sophocles’

Oedipus the King and Shakespeare’s King Lear, through modern classics like

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16 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

Leo Tolstoy’s The Death of Ivan Ilych, James Agee’s A Death in the Family, William Faulkner’s As I Lay Dying, and Ernest J. Gaines’s A Lesson Before Dying, death is treated as signifi cant in human experience. 49 Ted Bowman observes that

the language of bereavement and grief is enhanced by literary resources that

help people give voice to their own stories of loss. 50

Uncertainty about death is often found in poetry of mourning for the

dead, which, Jahan Ramazani says, “assumes in the modern period an extra-

ordinary diversity and range, incorporating more anger and skepticism, more

confl ict and anxiety than ever before.” 51 Earlier in this chapter, we discussed

elegies in the context of musical expressions of attitudes toward death. Elegies

are also expressed in literature. Note that the elegy is not to be confused with

a eulogy (oratory or praise in honor of the deceased) or epitaph (a brief state-

ment commemorating the deceased, often inscribed as a memorial on a tomb).

The term elegy refers to a poem or song memorializing the dead. 52 It is usually pensive, refl ective, or plaintive, an expression of suffering or woe. Ele-

gies typically describe feelings of sorrow, sadness, mournfulness, melancholy,

Performer Song Theme

Beatles “Eleanor Rigby” Aging and loss

Boyz II Men “Say Goodbye to Yesterday” Grief

Jackson Browne “For a Dancer” Eulogy

Mariah Carey “One Sweet Day” Missing a loved one

Johnny Cash “The Man Comes Around” Judgment Day

Eric Clapton “Tears in Heaven” Death of young son

Joe Diffi e “Almost Home” Father’s death

Dion “Abraham, Martin, and John” Assassination

Doors “The End” Homicide

Bob Dylan “Knockin’ on Heaven’s Door” Last words

Grateful Dead “Black Peter” Social support

Jimi Hendrix “Mother Earth” Inevitability of death

Elton John “Candle in the Wind” Deaths of Marilyn Monroe

and Princess Diana

Patty Loveless “How Can I Help You Say

Goodbye”

Mother’s death

Dave Matthews “Gravedigger” Anticipation of dying

Sinead O’Connor “I Am Stretched on Your

Grave”

Mourning

Pink Floyd “Dogs of War” Combat death

The Police “Murder by Numbers” Political deaths

Elvis Presley “In the Ghetto” Violent death

Snoop Dogg “Murder Was the Case” Urban homicide

Bruce Springstein “Streets of Philadelphia” AIDS

James Taylor “Fire and Rain” Friend’s death

Stevie Wonder “My Love Is With You” Death of a child

Warren Zevon “My Ride’s Here” Arrival of hearse and death

t a b l e 1-2 Death Themes in Popular Music

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Expressions of Attitudes Toward Death 17

nostalgia, lamentation, or some blending of these qualities. Elegies have been

characterized as “a way to say goodbye while celebrating who or what is gone.” 53

Early examples of the genre of elegy in English literature include John

Milton’s “Lycidas” (1637) and Thomas Gray’s “Elegy Written in a Country

Churchyard” (1750). Examples from American literature include “O Captain,

My Captain” (1865), Walt Whitman’s elegy on the death of President Abraham

Lincoln, and “For the Union Dead” (1965), Robert Lowell’s elegy based on

the story of Colonel Robert Shaw, who led the fi rst all-black brigade during

the American Civil War.

Elegies have been written to express a personal sense of grief as well as out

of a generalized feeling of loss and metaphysical sadness. Examples include

the series of ten poems in Duino Elegies by the German poet Rainer Maria Rilke and poems by Czeslaw Milosz, which lament the cruelties of totalitarian

government. Other examples are Wilfred Owen’s poems of moral objection

to the pain wrought by industrialized warfare; Allen Ginsberg’s Kaddish after the death of his mother; Seamus Heaney’s memorials to the suffering caused

by political violence in Ireland; and the “parental elegies” in the poetry of

Sylvia Plath, Anne Sexton, and Adrienne Rich. Poems give us insight into the

universality of loss in ways that can be consoling and therapeutic. 54 Edward

Hirsch tells us, “Implicit in poetry is the notion that we are deepened by

heartbreaks, that we are not so much diminished as enlarged by grief, by our

refusal to vanish—to let others vanish—without leaving a verbal record.” 55

In literature, the meaning of death is often explored as it relates to soci-

ety as well as the individual. Novels about war depict how individuals and soci-

eties search for meaning in shattering experiences of trauma and loss. In All Quiet on the Western Front, a novel set in the time of World War I, Erich Maria Remarque described the pointlessness of modern warfare by telling the story

of a youthful combatant who quickly moves from innocence to disillusion-

ment. The technological horror of World War II, particularly devastation

John O’Hara’s Appointment in Samarra reminds us that we cannot escape our mor- tality nor the pervasive angst that it arouses. In that story, a servant returns, pro-

foundly shaken, from a trip to the market. His master asks what has caused the

servant’s terror. The servant replies that when someone in the crowd jostled him,

he turned and noticed the Angel of Death beckoning him. The horror-stricken

servant then asks his master for a horse so that he might ride to Samarra, some

distance away, where the Angel of Death won’t be able to fi nd him. The master

agrees, and the servant leaves for Samarra. Later that day, the master goes to the

market. He, too, encounters the Angel of Death and asks why the Angel had made

that threatening gesture to his servant. Death allegedly replies, “That was not a

threatening gesture, simply one of surprise. I didn’t expect to see him here today

since I had an appointment to meet him tonight in Samarra.”

Jean Lipman-Blumen, “Our Existential Vulnerability to Toxic Leaders”

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18 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

caused by the atomic bomb, is the focus of John Hersey’s Hiroshima. The surreal aspects of the Vietnam War received attention in books like Michael

Herr’s Dispatches and Tim O’Brien’s Going After Cacciato, and similar accounts are being published about the recent wars in Iraq and Afghanistan.

In Holocaust literature, devastating experiences of horror and mass

death are dealt with in victims’ diaries, as well as in novels and psychologi-

cal studies. 56 Examples include Chaim Kaplan’s Warsaw Diary, Charlotte Delbo’s None of Us Will Return, Elie Wiesel’s Night, and Anne Frank’s Diary of a Young Girl.

Modern literature often explores the meaning of death in situations

that are seemingly incomprehensible. The hero tries to come to terms with

sudden and violent death in situations that allow no time or place for sur-

vivors to express their grief or mourn their dead. 57 Themes may focus on a

“landscape of violence.” 58 In “vigilante” stories, for example, such as detec-

tive novels and some westerns, the hero sets out to avenge evil but is often

corrupted by a self-justifying morality that only perpetuates violence. 59

Finding meaning in death is problematic, as violence reduces persons to the

status of things. Cadets at the United States Military Academy (West Point) learn about

the historical role of poetry in shaping culture, attitudes, and values, with the

aim of “dispelling the illusion that prepackaged answers are always there for

the taking in a world fl ush with ambiguities.” 60

Visual Arts In the visual arts, death themes are revealed through symbols, signs, and

images. 61 Edvard Munch’s The Dance of Life, which appears on the cover of this text, represents the artist’s summing up of human fate: “Love and death,

beginnings and endings, are fused in a roundel that joins private lives and

lusts to the larger, inexorable cycle of ongoing generations.” 62

Art is often a vehicle for expressing the impact of personal loss. When

Pan Am Flight 103 was brought down by a terrorist bomb, Suse Lowenstein’s

son was among those killed. As a sculptor, she found a way to express her

own grief and that of other women bereft by the crash by making a series of

female nude fi gures that compose an exhibit titled Dark Elegy. In earth tones, the larger-than-life fi gures are shown in the throes of grief (see Figure 1-1 ).

Some fi gures look mute. Others are obviously screaming. Some look as

though they were eviscerated. Lowenstein expressed the hope that Dark Elegy will be “a reminder that life is fragile and that we can lose that which is most

precious to us so easily and have to live with that loss for the remainder of

our lives.” 63

Art gives us a window into the customs and beliefs of other ages and

places. For example, Charles Willson Peale’s Rachel Weeping (1772 and 1776) depicts a deathbed scene from the American colonial period in which the

artist’s wife is shown mourning their dead child. The child’s jaw is wrapped

with a fabric strap to keep it closed. Her arms are bound with cord to keep

them at her sides. Medicines, all of which have proved ineffective, sit on a

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Expressions of Attitudes Toward Death 19

Figure 1-1 Dark Elegy About the women portrayed in her work Dark Elegy, the artist says, “One by one, they come into my studio, step onto a posing platform, close their eyes, and go back to December 21, 1988, to that horrible moment when they learned that their loved one had died. . . . This is the moment I freeze in time. This is the pose that I shape into sculpture.”

© S

u se

L o

w e n

st e in

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20 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

bedside table. As the mother gazes heavenward, she holds a handkerchief to

wipe away the tears streaming down her face, her grief in marked contrast to

the dead child’s peaceful countenance.

Francisco José de Goya’s Self-Portrait with Dr. Arrieta exemplifi es an artistic genre that depicts deathbed scenes and persons in extremis. Completed for the doctor who aided in Goya’s recovery from a life-threatening illness, this

painting shows the doctor holding medicine to Goya’s lips while the fi gure

of Death is depicted next to people who are thought to be Goya’s priest and

his housekeeper. Suicide is another theme dealt with by artists of virtually all

eras and cultures. A well-known example is Rembrandt van Rijn’s The Suicide of Lucretia, which portrays Lucretia with a tear in her eye, moments after she has stabbed herself with a dagger.

One of the most arresting expressions of dying and death ever to emerge

in the graphic arts occurred in Western Europe during the Middle Ages.

Growing out of widespread fears about the spread of plague, the images asso-

ciated with the Danse Macabre (Dance of Death) display a concern with the stark features of mortality and fears of sudden, unexpected death. An exam-

ple is found in the Bargello National Museum in Florence, where a series

of three wax sculptures by Italian artist Gaetano Giulio Zumbo depicts the

process of body dissolution from the fresh cadaver to one the worms have

completely devoured. The morbid aspects of mortality have also evoked atten-

tion by more recent artists, as in Fritz Eichenberg’s woodcuts depicting the

fears of our era: annihilation caused by war, environmental catastrophe, and

diseases such as AIDS. 64

In some art, we fi nd a whimsical attitude toward death, as in the engrav-

ings of Mexican artist José Guadalupe Posada, which contain skeletal fi gures

from all walks of life engaged in daily routines, or in American sculptor Rich-

ard Shaw’s Walking Skeleton, with the skeleton composed of twigs, bottles, play- ing cards, and similar found objects.

During the nineteenth century, people throughout the United States

incorporated both classical and Christian symbols of death to memorial-

ize public fi gures as well as family members. 65 Embroidered memorials to

the dead were hung in the parlor, the most important room of the house,

and elaborate quilts were sewn into designs that celebrated the life of the

deceased. Such mourning art provided not only a way to perpetuate memo-

ries of a loved one but also a focus for physically coping with grief, an oppor-

tunity to actively grieve by doing something.

Similar motives led to the making of a massive quilt to commemorate per-

sons who had died from AIDS: The Names Project AIDS Memorial Quilt. 66 In

folk art, quilts represent family and community. As the largest ongoing com-

munity arts project in America, the AIDS Quilt affi rms the value of creative

expression as a means of coping with loss.

The quilt symbolized individuals sharing their grief by sharing their continuing

bonds with friends and lovers, and in doing so the survivors became a

community of mourners. 67

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Expressions of Attitudes Toward Death 21

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The making of a memorial quilt was among the elaborate personal and social mechanisms for dealing with grief widely practiced during the nineteenth century, as in this example memorializing a granddaughter who died in infancy. This tra- ditional mourning custom was revived recently to commemorate and remember per- sons who died from AIDS; in the example shown here, words and symbols express beloved qualities of Joe’s life. For survivors, the creation of such memorials provides not only a focus for physically working through grief but also a means of perpetual- izing the memory of the loved one.

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22 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

Maxine Junge points out,

Creativity in the face of death offers a spectrum of life-enhancing possibilities.

These possibilities can ward off a meaningless conclusion to a life, give meaning

and hope to a life lived and to a future in which the dead, through memory, still

exist. 68

The urge to memorialize the dead and offer comfort to the bereaved

through artistic means is also demonstrated by a variety of homemade con-

dolences sent to relatives of military men and women killed in Iraq and

Afghanistan. 69 Operation Gold Star Flag, formed by a group of military

wives, revived a tradition of fl ag-making that began during World War I,

when families with relatives in the military displayed in their windows small

fl ags—white fi elds with red borders and in the middle a blue star, which was

changed to gold if the serviceman was killed. Other groups, such as Marine

Comfort Quilts and Operation Homemade Quilts, fashion quilts with center

squares personalized in memory of each casualty.

A woman who had been given one of the Marine Comfort Quilts

described how, when she fi nds herself missing her brother, she wraps her-

self in the quilt and cries until the wee hours of the morning: “It’s called a

‘comfort quilt,’” she said, “and that’s exactly what it is; it has so much love

from so many different people who never even met my brother.” Another

woman, a mother whose son was killed by friendly fi re (that is, by his own

comrades), said: “Your friends and family are there, but when you receive

good deeds from people you don’t even know, it makes you feel like you’re

not alone.” 70

Like the AIDS Memorial Quilt, the Vietnam Veterans Memorial Wall in

Washington, D.C., designed by architect Maya Lin, is an example of contem-

porary mourning art that works to counter the anonymity of lives lost. It has

been described as the “iconographic reversal of the Tomb of the Unknowns,”

with its “vast polished surface” serving as “the tombstone of the known.” 71

On the wall, names of the dead are listed chronologically by the date of their

death, rather than alphabetically, presenting a chronicle that vividly depicts

the scale of losses. Mementos left by visitors are collected by the National

Park Service, and items have been displayed at the Smithsonian’s National

Museum of American History.

Similarly, at Arlington National Cemetery, the graves of veterans killed

in Iraq and Afghanistan are decorated with handwritten notes and items that

poignantly celebrate personal connection. Before those wars, the expression

of grief at Arlington was confi ned to wreaths and fl owers. Now, personnel

from the U.S. Army Center for Military History come each week to add to a

collection that may one day become an exhibit in a museum devoted to tell-

ing the story of war and its cost. About the commemorative function of war

museums, Andrew Whitmarsh says:

Memory and commemoration are constructed according to the social, cultural,

and political nature, as well as the needs and experiences, of the society and

individuals producing them. War museums have often been accused of sanitizing

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Expressions of Attitudes Toward Death 23

or glamorizing war through their depiction of “heroes” and their portrayal of

death, The commemorative aspect of war museums directly affects their style of

interpretation. 72

In Japan, a shrine honoring the “spirits” of war dead has stirred diplomatic

and domestic controversy because of differing interpretations of its signifi -

cance and purpose. 73

As Carla Sofka points out, when handled with care and sensitivity, such

museums can be healing spaces, honoring the memories and legacies of both

victims and survivors. 74

The importance of the arts in a comprehensive understanding of how

people cope with loss is expressed in this statement by the International Work

Group on Death, Dying, and Bereavement:

The arts and humanities with their images, symbols, and sounds express

themes of life, death, and transcendence. They are the language of the soul

and can enable people to express and appreciate the universality as well as the

particularity of each person’s experience. 75

In the visual arts, these themes and this language are evident in a broad

range of works, from those formed out of the particulars of an individual’s

unique loss—as in the sculptures of Suse Lowenstein, which depict the grief

of a parent following the death of a child—to those that function on a larger

scale as sites of memory for losses that are both personal and communal—such as those commemorated by the AIDS Memorial Quilt and the Vietnam Veter-

ans Memorial Wall. Whatever the scale, as Sandra Bertman points out, one of

the main functions of art is to engage our awareness and “bring us closer to

what language cannot reach.” 76

Humor Humor defuses our anxiety about death. It puts fearful possibilities into

manageable perspective. James Thorson says, “We make fun of that which

threatens us.” 77 Death-related humor comes in many different forms, from

funny epitaphs to so-called black or gallows humor. Incongruity is one of the

components of humor. 78 One joke, for example, describes a project manager

who leaves a suicide note in the form of a PowerPoint presentation; the joke

tells how his colleagues ignore the tragic content of the note while critiqu-

ing its presentation. Similarly, on a highway, motorists are taken aback by a

gleaming white hearse with the cryptic license plates “Not Yett.” Serious and

somber matters can be easier to deal with when there is comedic relief.

There are “intimate connections between death and laughter.” 79 Mary

Hall observes that “what is humorous to each of us depends on our particu-

lar cultural set, our own experience, and our personal inclination.” 80 Humor

often functions as a kind of comment on incongruity or inconsistency rela-

tive to social norms or perspectives, as when a young girl wrote a letter to

God asking, “Instead of letting people die and having to make new ones, why

don’t you just keep the ones You have now?” 81 As Thorson points out, “Taking

potshots at the spectre that will destroy us may not in fact do away with the

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24 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

Ultimate Problem, but satire at least makes us feel better in some small way

about our common fate. This is the essence of coping.” 82

A joke that is shared gleefully by one group of people may be shocking to

others; there are constraints on the kinds of humor that a particular person

or group fi nds acceptable. Nevertheless, humor helps us cope with painful

situations. Individuals held as prisoners of war during the Vietnam War con-

sidered humor so important to coping that they would “risk torture to tell a

joke through the walls to another prisoner who needed to be cheered up.” 83

Humor is an important aid in confronting our fears and gaining a sense of

mastery over the unknown.

Humor functions in several ways relative to death: First, it raises our

consciousness about a taboo subject and gives us a way to talk about it. Sec-

ond, it presents an opportunity to rise above sadness, providing a release

from pain and promoting a sense of control over a traumatic situation, even

if we cannot change it. Third, humor is a great leveler; it treats everyone

alike and sends the message that there are no exemptions from the human

predicament. Thus, it binds us together and encourages a sense of intimacy,

which helps us face what is unknown or distressing. Humor can be a “social

glue” that helps us empathize with others. After a death has occurred,

humor can comfort survivors as they recall the funny as well as the painful

events of a loved one’s life. A sense of humor can moderate the intensity of

negative life events.

In place of the conventional sentiment usually engraved on tombstones, a touch of whimsy adorns this memorial to B. P. Roberts at a cemetery in Key West, Florida.

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Living with Awareness of Death 25

In situations involving interactions between patients and health care

providers, humor is “one of the great tools of reassurance on the hospital

ward.” 84 For people who are seriously ill, humor offers a way to cope with the

effects of a shattering diagnosis. It provides another perspective on a pain-

ful situation, as in the jest “Halitosis is better than no breath at all.” When

things are bad, humor can serve a protective psychological function and help

people maintain their equilibrium.

Emergency services personnel and other individuals who encounter

death on their jobs use humor to distance themselves from horrifi c death,

as well as to rebond as a team rather than feeling isolated in their individ-

ual grief after traumatic incidents. A group of doctors at a medical center

avoided using the word death when a patient died because of concern that it might alarm other patients. One day, as a medical team was examining a

patient, an intern came to the door with information about the death of a

patient. Knowing that the word death was taboo and fi nding no ready substi- tute, she announced, “Guess who’s not going to shop at Walmart any more?”

This phrase quickly became the standard way for staff members to convey the

news of a patient’s death among themselves when in a public setting. For care-

givers, humor serves to communicate important messages, promote social

relations, diminish discomfort, and manage delicate situations; it has been

called the “oil of society.” 85

Living with Awareness of Death It is said that “one of the most important and unique aspects of human expe-

rience is the awareness of our own mortality.” 86 Ultimately, one cannot ignore

or deny death. “Societies have traditionally taken tremendous care with the

shared transformation of life into death because of their responsibility to

preserve everyday life’s continuity and stability in the face of death’s many

disruptions.” 87 In our time, globalization exposes us to information about

deaths far distant from the comfort of our own homes. We are confronted

with death seemingly at every turn.

Threats of environmental destruction, nuclear catastrophe, violence,

war, and terrorism have been joined by the specter of emerging pandem-

ics. Today’s global population has been described as hibakusha, a Japanese word meaning “explosion affected.” Initially used to describe survivors of the

Clearly, nobody was exempt from the life of life, which dictated that old age, dis-

ease, and death were our common lot. Krishnamurti himself had often talked

about it, jokingly quoting an Italian saying, “Tutti gli uomini debbeno morire, forse anch’io.” When I asked him what it meant, he translated it, “All men must die, per- haps I, too.”

Michael Krohnen, The Kitchen Chronicles: 1001 Lunches with J. Krishnamurti

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26 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

atomic bombings of Hiroshima and Nagasaki, the term now connotes perva-

sive anxiety about the threat of annihilation in our “cosmopolitan era.”

Contemplating Mortality Why is there death? Looking at the big picture, we see that death pro-

motes variety through the evolution of species. The normal human life span

is long enough for us to reproduce ourselves and ensure that the lineage of

our species continues. Yet it is brief enough to allow for new genetic combi-

nations that provide a means of adaptation to changing conditions in the

environment. From the perspective of species survival, death makes sense.

But this explanation offers little comfort when death touches our own lives.

Norman Wirzba observes:

Life as we know it depends on death, needs death, which means that death is not simply the cessation of life but its precondition. . . . Eating involves us in

a daily life and death drama in which, beyond all comprehension, some life is

sacrifi ced so that other life can thrive. 88

In an article titled “Human Existence as a Waltz of Eros and Thanatos,”

the authors suggest that

the proper antidote for death is love, but until the ubiquitous and powerful role

of death is accepted, until we learn to “dance with death,” love will continue to

be treated as something appropriate only for romance and Sunday School. 89

To remedy this misapprehension and expand our understanding of the rela-

tionship between love and death, we need to step out of our fast-paced lives

and take time to learn how to “waltz with death” by contemplating the basic

questions of human existence.

Dimensions of Thanatology As pioneering Italian thanatologist Francesco Campione points out,

death is not only a topic for refl ection, study, and research; it is also an “exis-

tential problem,” which touches every aspect of human existence and every

fi eld of knowledge. 90 Existential questions—such as, Who am I? What am I

doing here? Where do I fi t in the world?—focus on the meaning of life. Such

questions are “concerned with the nature of authenticity and the responsibil-

ity of choice,” and they are “discovered via a person’s perception of reality

and meaning.” 91

Robert Kastenbaum says that, although the term thanatology is usually defi ned as “the study of death,” it is perhaps better defi ned as “the study of

life with death left in.” 92 Thus, as a fi eld of study, thanatology encompasses a

variety of disciplines and areas of concern (see Table 1-3 ). Other dimensions

and examples can be added to this listing. For instance, religious thanatology has concerns similar to those of philosophical thanatology, but specifi cally as

they occur in the context of devotion to a set of beliefs about the nature of

ultimate reality (usually involving a deity); issues such as what happens to a

person’s soul or spirit after death and the nature of the afterlife are impor-

tant within this domain of thanatology.

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Living with Awareness of Death 27

Focus Major Areas of Concern Example Issues

Philosophical

and ethical

The meaning of death in human

life; questions of values and

ethics

“Good” vs. “bad” death;

concept of death; suicide

and euthanasia

Psychological Mental and emotional effects of

death on individuals

Grief; coping with terminal

illness; death anxiety

Sociological How groups organize themselves

to deal with social needs and

problems related to dying and

death

Response to disaster;

disposal of the dead;

socialization of children

Anthropological Role of culture and environment

across time and space regarding

how individuals and societies

relate to death and dying

Funeral rites;

memorialization;

ancestor worship

Clinical Management of dying and death

in medical settings; diagnosis

and prognosis; relationships

among patients, doctors, nurses,

other caregivers

Treatment options; hospice

and palliative care; pain

and symptom control

Political Governmental actions and

policies related to dying and

death

Capital punishment; organ

transfer rules; conduct of

war

Educational Death education; public

awareness of death-related issues

and concerns

Curricula for instruction

in schools; community

programs

t a b l e 1-3 Dimensions of Thanatology

Acquiring a core knowledge of thanatology involves becoming familiar

with all of these dimensions and their aspects. Together, they constitute what

might be called “Thanatology” with a capital T. Professionals who work with the dying or the bereaved need to establish a fi rm foundation in thanatology

alongside their expertise in health care or counseling.

Reviewing the scope and mission of death studies, Kastenbaum notes

that mainstream thanatology has devoted its efforts to improving the care of

people faced with life-threatening illness or bereavement, and it may be time

to broaden the focus to include “large-scale death” and “death that occurs

through complex and multi-domain processes.” 93 This perspective would

include not only the “horrendous deaths” that human beings infl ict on each

other in war and other forms of violence but also human-caused activities

that threaten or result in the extinction of other species.

Death Anxiety and Fear of Death Our relationship with death has, as Herman Feifel observed, “a shaping

power on thinking and behavior at all points in the life span.” 94 The way in

which we anticipate death, Feifel says, governs our “now” in an infl uential

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28 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

manner. This applies not only to people who are terminally ill, combatants in

war, or people who fi t other categories we tend to associate with an increased

risk of death, such as those who are very old or suicidal. On the contrary, it is

true for everyone and “for all seasons.” Death challenges the idea that human

life has meaning and purpose. 95

The manner in which individuals respond to this challenge is “inter-

twined with the death ethos of the cultures in which they are embedded.” 96

The distinctive stance toward death in a particular culture affects the behav-

ior of its members as they go about their daily lives, infl uencing, for example,

their willingness to engage in risky behaviors or their likelihood of taking

out an insurance policy, as well as their attitudes toward such issues as organ

donation, the death penalty, euthanasia, or the possibility of an afterlife. In

a variety of ways, our culture helps us “deny, manipulate, distort, or camou-

fl age death so that it is a less diffi cult threat with which to cope.” 97 Consider,

for example, the effect of a public health discourse that suggests death and

misfortune can be avoided if people behave properly—eat the right things,

exercise, stop smoking, and so on. 98 The paradox of our attitude toward death

is highlighted by the writer Thomas McGuane in his remark that “everyone

knows that they are going to die; yet nobody believes it.” 99

Avery Weisman pointed out that realization is critical in our efforts to understand death: “Most people concede that death is inevitable, a fact of

nature. But they are not prepared to realize. We postpone, put aside, disavow,

and deny its relevance to us.” 100 Individuals and societies must, in fact, both

accept and deny death. We must accept death if we wish to maintain a grasp

on reality. Yet we must deny it if we are to go about our daily lives with a sense

of commitment to a future that is inevitably limited by our mortality. Accord-

ing to Talcott Parsons, the characteristic attitude toward death in modern

societies is less a matter of outright denial than it is “bringing to bear every

possible resource to prolong active and healthful life” and accepting death

only when “it is felt to be inevitable.” 101

The largest area of empirical research in thanatology is concerned with

the measurement of attitudes toward death, and, more particularly, death anxiety. 102 In posing the question, What do we fear when we fear death? Robert Neimeyer and his colleagues suggest that the term death anxiety may be understood as “a shorthand designation for a cluster of death attitudes

characterized by fear, threat, unease, discomfort, and similar negative emo-

tional reactions, as well as anxiety in the psychodynamic sense as a kind of

diffuse fear that has no clear object.” 103

Generally speaking, the fi ndings from this research indicate that death

anxiety tends to be higher among females than among males, higher among

blacks than among whites, and higher among youth and middle-aged adults

than among older people. People who describe themselves as religious tend

to report less death anxiety than those who do not characterize themselves

this way. Individuals who report a greater degree of self-actualization and

sense of internal control also report less death anxiety than their counter-

parts. This summary gives a very broad-brush understanding of the overall

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Living with Awareness of Death 29

picture of death anxiety research. It is important to understand, however,

that the responses elicited by such research are “by no means a full represen-

tation of one’s awareness of the advancing resoluteness of death or conscious-

ness of being-in-the-world.” 104

Despite the accumulated data from numerous studies, there are signifi -

cant questions, which Neimeyer summarizes as follows: 105 First, what defi ni-

tion of death is implied by the various testing instruments? Second, what are

the strengths and limitations of the various instruments that have been used

in death anxiety research? Third, based on answers to the fi rst two questions,

what are the implications for future research? And, fi nally, reviewing the data

gathered up to now, what do we really know?

One conclusion reached by Neimeyer and his colleagues is that “persons

who accept both the dying process and the prospect of being dead one day as

a natural part of their lives express less intense fear of dying and death.” In

short, they are “probably more able than others to see meaning in death by

putting it into an overarching context.” 106

Research into death anxiety has been characterized by Kastenbaum as

“thanatology’s own assembly line.” 107 Part of the appeal of death anxiety

research, he says, lies in the fact that it “allows the researcher (and the read-

ers, if they so choose) to enjoy the illusion that death has really been studied.”

How data from such research can be applied to practical issues is uncertain.

If, for example, it were possible to reliably state that doctors with high death

anxiety relate poorly to dying patients, then that fi nding might be applied

constructively in health care settings. However, we are mostly unable to ade-

quately gauge the effect of death anxiety on real-world issues.

What shall we make of studies showing that women have higher death

anxiety scores than men? Does this gender difference mean that women are

too anxious about death or that men are not anxious enough? Reviewing the research in this area, Herman Feifel said:

Fear of death is not a unitary or monolithic variable. . . . In the face of personal

death, the human mind ostensibly operates simultaneously on various levels

of reality, or fi nite provinces of meaning, each of which can be somewhat

autonomous. We, therefore, need to be circumspect in accepting at face value

the degree of fear of death affi rmed at the conscious level. 108

Terror Management Terror management theory (TMT) states that human behavior is mostly

motivated by an unconscious fear of mortality. In other words, awareness

of one’s own death affects the decision making of individuals and groups,

a concept known as mortality salience. 109 Because death is always a possibil- ity for us, fear of death is built into human life. 110 To cope with this fear, we

erect defenses against death awareness, defenses that are based in denial and

include an irrational belief in being “personally special” as well as an irratio-

nal belief in “an ultimate rescuer.” 111

Terror management theory suggests that people learn to assuage their

fears of death by fi nding meaning in life and value in themselves, this meaning

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30 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

and value being provided by the culture into which people are socialized. 112

“The resulting perception that one is a valuable member of a meaningful uni- verse constitutes self-esteem; and self-esteem is the primary psychological

mechanism by which culture serves its death-denying function.” 113 Although

cultures differ in their specifi c beliefs, they “share claims that the universe

is meaningful and orderly, and that immortality is attainable, be it literally,

through concepts of soul and afterlife, or symbolically, through enduring

accomplishments and identifi cations.” 114

In an interview days before his death, Ernest Becker, the initiator of ter-

ror management studies, addressed “four strands of emphasis” relevant to

terror management theory: 115

1. The world is a terrifying place.

2. The basic motivation for human behavior is the need to control our basic

anxiety, to deny the terror of death.

3. Because the terror of death is so overwhelming, we conspire to keep it

unconscious.

4. Our heroic projects aimed at destroying evil have the paradoxical effect

of bringing more evil into the world. . . . We are able to focus on almost

any perceived threat, whether of people, political or economic ideology,

race, religion, and blow it up psychologically into a life and death strug-

gle against ultimate evil. . . . This is the dynamic of spiralizing violence

that characterizes so much of human history.

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Studying Death and Dying 31

One of the common reactions to terror management theory is that it

couldn’t possibly be correct because people just don’t think about death all

that often. 116 However, studies show that “fear of death functions as a moti-

vating force whether people are currently focused on this particular issue or

not; it is the implicit knowledge of death rather than current focal awareness

that is the motivating factor.” 117 In a commentary on the TMT perspective,

Robert Kastenbaum points out that we live with sorrow as well as anxiety, and

that there are connections between anxiety and sorrow. 118 He says, “Much

remains to be learned about the interweaving of sorrow and anxiety through-

out human experience.” 119 Summarizing the insights of TMT, Robert Solo-

mon says, “Put in the least fl attering way, we might say that my death is a bad

thing because it deprives the universe of me.” 120

Studying Death and Dying Take a death and dying course or read a book like this, and someone will

probably ask, “Why would you want to take a class about death?” or “Why

are you reading about death?” Despite public interest in death-related issues,

individuals exhibit varying degrees of avoidance and acceptance when it

comes to discussing death openly. A philosophy teacher tells how he was

asked to lecture on a subject of his choosing, so he submitted the title “Fac-

ing Death.” He reports that his hosts were shocked, forcing him to change to

“Immortality: Pros and Cons.” 121 Our relationship with death seems to be in

a period of transition.

Ambivalent attitudes toward death are evident when one educator

applauds the study of death as the “last of the old taboos to fall,” while

another contends that death is “not a fi t subject for the curriculum.” In

response to this state of affairs, Patrick Dean observes that, if death educa-

tion is criticized by some as a “bastard child of the curriculum, hidden in the

closet,” then those who value death education can be grateful to such critics

because they are creating opportunities for highlighting the importance of

death education as preparation for living. 122 In fact, Dean says, death educa-

tion could appropriately be renamed “life and loss education,” because “only

through awareness of our lifelong losses and appreciation of our mortality

are we free to be in the present, to live fully.”

The Rise of Death Education Informal death education occurs in the context of “teachable moments”

that arise out of events in daily life. Such an event may be the death of a gerbil

in an elementary school classroom, or it may be an event experienced widely,

such as a school shooting, a terrorist attack, a devastating tsunami or hurri-

cane, or the sudden death of a celebrity.

The fi rst formal course in death education at an American university was

initiated by Robert Fulton at the University of Minnesota in the spring of

1963. 123 The fi rst conference on death education was held at Hamline Uni-

versity in Minnesota in 1970. From these beginnings, death education has

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32 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

embraced a wide range of issues and topics, from nuts-and-bolts issues such

as selecting mortuary services or probating an estate to philosophical and

ethical matters such as the defi nition of death and speculation about what

happens after death.

Because death education addresses both objective facts and subjec-

tive concerns, it receives broad academic support, with courses offered in

a variety of disciplines. 124 In most courses, mastery of facts is enhanced by

personal narratives that describe the myriad ways human beings encounter

and cope with death. 125 The arts and humanities serve to balance scientifi c

and technical perspectives. Images, symbols, and sounds express themes

of life, death, and transcendence that allow for many ways of knowing and

learning.

In the broad picture, death education includes training for physicians,

nurses, allied health personnel, funeral directors, and other profession-

als whose duties involve contact with dying and bereaved individuals. This

includes police offi cers, fi refi ghters, and emergency medical technicians

(EMTs). As witnesses to human tragedy in the line of duty, they are called

upon to comfort victims and survivors. The stoic image of the police offi cer,

EMT, or fi refi ghter who “keeps it all in” instead of expressing natural emo-

tions is challenged by the recognition that such a strategy may be physically

and psychologically harmful.

Pioneers in Death Studies The establishment of death studies in modern times can be traced to

explorations of death by Freud and others of the psychoanalytic school and

to anthropological accounts of death customs in far-fl ung societies. Dis-

course about death and dying during the 1940s and 1950s is highlighted by,

for example, Sylvia Anthony’s studies of children (1940), Erich Lindemann’s

analysis of acute grief among survivors of a nightclub fi re (1944), and Geoffrey

Gorer’s essay “The Pornography of Death” (1955; reprinted 1963). 126 Edgar

Jackson wrote about grief for both lay and scholarly readerships in publica-

tions such as Understanding Grief: Its Roots, Dynamics, and Treatment (1957) and You and Your Grief (1961). The 1950s may have been the threshhold of a new era in which death and dying were “rediscovered.” The question became

“What does death mean to you?” 127

The modern scientifi c approach to the study of death, or thanatology, is

usually traced to a symposium organized by Herman Feifel at a 1956 meeting

in Chicago of the American Psychological Association. 128 This symposium

resulted in a book, edited by Feifel: The Meaning of Death (1959). This land- mark book brought together experts from different disciplines whose essays

encompassed theoretical approaches, cultural studies, and clinical insights.

Death was shown to be an important topic for public and scholarly consid-

eration. Given the prevailing resistance at that time to discussing death, this

was no easy feat. About his early efforts in death studies, Feifel recalled that

he was emphatically told that “the one thing you never do is to discuss death

with a patient.” 129

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Studying Death and Dying 33

The same message was communicated to Elisabeth Kübler-Ross, whose

book On Death and Dying (1969) “caught the public’s imagination” by “offer- ing a vision of a natural death unburdened by technology.” 130 Hospice pio-

neer Cicely Saunders had addressed similar issues in her earlier work, Care of the Dying (1959). Barney G. Glaser and Anselm L. Strauss applied the tools of sociological analysis to conduct studies focusing on the way awareness of

dying affected patients, hospital staff, and family members and on how the

“timing” of death occurred in hospital settings. These studies, published as

Awareness of Dying (1965) and Time for Dying (1968), showed that caregivers were reluctant to discuss death and avoided telling patients they were dying.

Jeanne Quint Benoliel, who collaborated with Glaser and Strauss, published

The Nurse and the Dying Patient (1967), which called for systematic death edu- cation for nurses.

The 1960s were a fruitful period for death studies. John Hinton’s Dying (1967) shed light on contemporary practices and suggested how care of the

dying could be improved. In “Death in American Society” (1963), sociologist

Talcott Parsons looked at the impact of technological advances in health

and medicine on dying. Philosopher Jacques Choron traced the history of

ideas and attitudes about death and investigated the fear of death and its

meaning for human beings in Death and Western Thought (1963) and Death and Modern Man (1964). Robert Fulton gathered a group of scholars and practitioners to address both theoretical and practical issues in his compila-

tion, Death and Identity (1965). During the same era, literary works such as C. S. Lewis’s A Grief Observed (1961) brought attention to issues involving bereavement and mourning.

The progress of death studies during the 1960s continued into the 1970s

with works like Avery D. Weisman’s On Dying and Denying: A Psychiatric Study of Terminality (1972), which astutely combined research skills and clinical expe- rience with dying patients, and Ernest Becker’s The Denial of Death (1973), which drew upon a broad range of psychological and theological insights

in order to better understand the “terror” of death in human life. Richard

Kalish and David K. Reynolds initiated multicultural studies in Death and Ethnicity: A Psychocultural Study (1976). The early 1970s also witnessed the blossoming of the fi rst peer-reviewed journal in the fi eld of death studies,

Omega: Journal of Death and Dying, which had begun its life as a newsletter in 1966 with an article in the fi rst issue by Weisman titled “Birth of the Death-

People.” 131 This was a decade of collaboration and connection, as individuals

recognized a mutual interest manifested in organizations like The Founda-

tion of Thanatology, Ars Moriendi (a forerunner of the International Work

Group on Death, Dying, and Bereavement, or IWG) and the Forum for Death

Education and Counseling (now known as the Association for Death Educa-

tion and Counseling, or ADEC). 132

In the decades since these pioneering contributions, Omega has been joined by other scholarly journals, including Death Studies; Journal of Personal and Interpersonal Loss; Illness, Crisis, and Loss; and Mortality (an international journal published in the United Kingdom), and textbooks in thanatology

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34 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

have come on the scene. 133 Meanwhile, books written for a general read-

ership, such as Mitch Albom’s Tuesdays with Morrie and Joan Didion’s The Year of Magical Thinking, have become bestsellers, and information about death and dying is now widely available on the Internet. In 1971, the Psychol- ogy Today questionnaire “You and Death” garnered a response from read- ers that exceeded the response to a previous sex questionnaire. A recent

study of responses to the questionnaire concluded that “interest in death as

a topic was not a passing fad but continues to be a topic of interest across the

United States.” 134

The publication of several encyclopedic works covering death studies

(including at least one on the Internet) is another sign of the maturing of the

fi eld. 135 Clearly, the seeds planted a few decades ago by pioneers have ripened

into a thriving interest in dying, death, and bereavement that is evident in

both the academic setting and the larger public arena. 136

Tracing the emergence of thanatology, Luciana Fonseca and Ines Testoni

write: “Thanatology theory took shape as death studies and research, whereas thanatology practice manifests primarily as formal death education, end-of- life care, and bereavement counseling.” 137 Hannelore Wass observes that

thanatology can help individuals and societies transcend self-interest in

favor of concern for others. 138 Death studies “is about love, care, and compas-

sion . . . about helping and healing.”

Factors Affecting Familiarity with Death The past hundred years have seen dramatic change in the size, shape, and

distribution of the American population—that is, its demographics. These changes—the most notable of which involve increased life expectancy and

lower mortality rates—signifi cantly affect our expectations about death. In

the past, a typical household would include parents, uncles, aunts, and aged

grandparents, as well as children of varying ages. Such extended families,

with several generations living together under the same roof, are rare today.

One consequence is that most of us have fewer opportunities to experience

our relatives’ deaths fi rsthand.

Consider how experiences with dying and death have changed. 139 During

the late 1800s and early 1900s, individuals typically died at home, often sur-

rounded by an extended family that spanned several generations. As death

drew near, relatives and friends gathered to maintain a vigil at the bedside.

Afterward, they washed the body and prepared it for burial. A home-built

coffi n was placed in the parlor of the house, where friends and relatives

participated in a wake and shared in mourning the deceased. Death was a

domestic experience.

In close-knit communities, a death bell tolled the age of the deceased,

giving notifi cation of the death so that others in the community could join

in the rites and ceremonies marking the deceased’s passing (see Figure 1-2 ).

Children were included in activities surrounding the dead, staying with

adults and sometimes sleeping in the same room as the corpse. Later, in a

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Factors Affecting Familiarity with Death 35

family plot at the homeplace or a nearby churchyard cemetery, the coffi n was

lowered into the grave, and those closest to the deceased shoveled dirt over

the coffi n to fi ll in the grave. Throughout this process, from caring for the

dying person through burial, death remained within the realm of the family.

If you were a person living in those times who was suddenly transported

to the present, you would likely experience culture shock as you walked into

the “slumber room” of a typical mortuary. There, in place of a simple wooden

coffi n, you view an elaborate casket. The corpse shows the mortician’s skill

in cosmetic restoration. At the funeral, you watch as relatives and friends

eulogize the deceased. Ah, that’s familiar, you say—but where is the dear

departed? Off to the side a bit, the casket remains closed, death tastefully

concealed. At the graveside, as the service concludes, you are amazed to see

mourners leaving while the casket lies yet unburied; the cemetery crew will

complete the actual burial. You may be most impressed by the fact that the

deceased’s family and friends are spectators rather than participants. The

tasks of preparing the dead for burial and managing the rites of passage are

carried out by hired professionals.

Our familiarity with death has also been powerfully infl uenced by sophis-

ticated medical technologies, which have affected both the place where death most often occurs and the manner in which most people die. In contrast to earlier generations, who typically had major roles in the care of their dying

and dead, we usually rely on professionals—from the cardiologist to the coro-

ner to the cremator—to act as our go-betweens. The net result is that, for

most of us, death is unfamiliar.

Life Expectancy and Mortality Rates Since 1900, average life expectancy in the United States has increased

from forty-seven to nearly seventy-nine years (see Figure  1-3 ). 140 Japan, at

eighty-three years, has the longest life expectancy of countries worldwide. 141

These fi gures refl ect what demographers call “cohort life expectancy,” mean-

ing the average number of years a specifi ed group of infants would live if they were to experience throughout their lives the age-specifi c death rates pre-

vailing in their birth year. Thus, for 2011, life expectancy at birth for the

U.S. population as a whole was 78.7 years. When this overall U.S. cohort is

You can feel the silence pass over the community as all activity is stopped and

the number of rings is counted. One, two, three—it must be the Myer’s baby that has

the fever. No, it’s still tolling—four, fi ve, six. There is another pause at twenty—could

that be Molly Shields? Her baby is due at any time now—no, it’s still tolling. Will it

never stop? Thirty-eight, thirty-nine, another pause—who? It couldn’t be Ben; he was

here just yesterday; said he was feeling fi t as a fi ddle—no, it’s starting again. Seventy,

seventy-one, seventy-two. Silence. You listen, but there is no sound—only silence.

Isaac Tipton. He has been ailing for two weeks now. It must be Isaac.

Figure 1-2 Tolling the Bell

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36 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

broken out into population groups, however, we fi nd that Hispanic females

have the longest life expectancy (83.7 years), followed by non-Hispanic white

females (81.1 years), Hispanic males (78.9 years), non-Hispanic black females

(77.8 years), non-Hispanic white males (76.4 years), and non-Hispanic black

males (71.6 years). 142 In addition to differences between birth cohorts, it

should be recognized that such fi gures represent statistical life expectancies.

The actual life span lived out by any particular individual may well be signifi -

cantly shorter or longer than the average for his or her cohort.

Although there are certainly localized and regional variations, wide-

spread human longevity is quite recent, occurring in the last century or so.

As one writer said, “Despite what the fashion magazines tell you, 40 isn’t the

new 30. Seventy is.” 143 Today, we tend to assume that a newborn child will live

into his or her seventh or eighth decade, perhaps longer. This was not the

case in 1900. Over half of the deaths in 1900 occurred among children age

fourteen and younger; now, fewer than 2 percent of deaths occur among this

age group. 144 This fact infl uences how we think (or don’t think) about death.

Another way to appreciate the changing impact of death is to examine

death rates (which are typically stated as the number of individuals dying per

1000 population in a given year). In 1900, the death rate in America was about

17 per 1000; today, it is about 7.4 per 1000, a record low (see Figure 1-4 ). 145

Figure 1-3 Expectation of Life at Birth, 1900–2010

Male

Female

Year 20

10 20

00 19

90 19

80 19

70 19

60 19

50 19

40 19

30 19

20 19

10 19

00

85

75

65

55

45

35

0

A ge

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Factors Affecting Familiarity with Death 37

Imagine yourself in an environment where death at an early age is

common. Consider how different experiences of dying and death were at a

time when the comparatively high percentage of infant deaths tended to be

thought of as a matter of “fate” that could not be changed. Both young and

old were familiar with death as a natural part of the human condition. In the

1870s, nine out of ten Americans over fi fteen had lost a parent or sibling. 146

Mothers died in childbirth; babies were stillborn; one or both parents might

die before their children had grown to adolescence. Surviving siblings often

had a postmortem photograph of a dead brother or sister displayed, a memo-

rial to the deceased and testament to the integrity of the family. 147 Living

with a commonplace awareness of mortality, our ancestors could not avoid

the fact of death. Ultimately, of course, none of us is exempt. Despite the

increases in life expectancy and lowered death rates, the statistical odds of

dying still fi nally add up to 100 percent.

Causes of Death Changes in life expectancy and mortality rates are due largely to changes

in the most common causes of death. In the early 1900s, the leading causes of

death were related to acute infectious diseases such as tuberculosis, typhoid

fever, diphtheria, streptococcal septicemia, syphilis, or pneumonia. Most

such diseases came on suddenly, and death soon followed. Today, most deaths

result from a chronic illness, such as heart disease, cancer, or stroke, and tend

Figure 1-4 Death Rates, 1900–2011

Year 20

00 20

11 19

90 19

80 19

70 19

60 19

50 19

40 19

30 19

20 19

10 19

00

18

16

14

12

10

8

6

4

2

0

D ea

th s

p er

1 00

0 p

o p

u la

ti o

n

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38 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

to follow a slow, progressive course that lasts weeks, months, or even years

(see Table 1-4 ). The ten leading causes of death account for about 75 percent

of all deaths in the United States, with the top two causes, heart disease and

cancer, accounting for nearly half of all deaths. 148 (It is worth noting that,

although heart disease and cancer are the two leading causes of death, acci-

dental deaths result in slightly more lost years of potential life; that is, the

number of dead is smaller, but the number of years of life lost is greater.) 149

This historical shift in patterns of disease and causes of death—a shift

that demographers call an epidemiologic transition —is characterized by a redis- tribution of deaths from the young to the old. 150 (Epidemiology is the study

of the patterns of health and disease.) With a reduced risk of dying at a young

age from infectious diseases, more people survive into older ages, where they

tend to die from degenerative diseases. This results in a growing proportion

of aged people in the population.

In 1900, people sixty-fi ve and older made up 4 percent of the popula-

tion in the United States; now they constitute just over 13 percent. 151 In other

words, the proportion of aged people in the population has more than tri-

pled since 1900, and adults aged sixty-fi ve and over are expected to consti-

tute one-fi fth of the total U.S. population by the year 2030. 152 In 1900, people

sixty-fi ve and older accounted for about 17 percent of deaths; today, about

73 percent of the 2.5 million deaths each year in the United States occur among

people in this age group. 153 In short, people are living longer and dying at

older ages. One result is that we tend to associate death with the elderly when,

in fact, it is not confi ned to any particular segment of the life span.

Geographic Mobility and Intergenerational Contact Historically, relationships with friends, neighbors, and relatives were

closely tied to place; today, they depend more on one’s present role or func-

tion than on a lifetime of shared experiences. Children, once they are grown,

rarely live in the same house with parents or, even more rarely, with their

Cause of Death Deaths % of Total Deaths

All causes 2,512,873 100.0

Heart disease 596,339 23.7

Cancer 575,313 22.9

Respiratory disease 143,382 5.7 Stroke 129,931 5.2

Accidents 122,777 4.9

Alzheimer’s disease 84,691 3.4

Diabetes 73,282 2.9

Infl uenza and pneumonia 53,667 2.1

Kidney disease 45,731 1.8

Suicide 38,285 1.5

t a b l e 1-4 Leading Causes of Death: United States

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Factors Affecting Familiarity with Death 39

brothers and sisters in an extended family setting. Few high school or col-

lege friendships continue through marriage and the childrearing years into

retirement. Because of social and geographic mobility, people are less likely

to be present at the deaths of relatives or friends. The result is a loss of shared

death rituals.

Of course, some families maintain close relations, even when they

don’t share the same dwelling or live in the same town. Patterns of mobility

also vary among individuals and groups. Some ethnic and cultural groups

Five generations of the Machado family form an extended family network rarely seen today. Firsthand experiences of death in such a family come through the closeness of multigenera- tional living.

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40 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

continue to place a high value on maintaining strong family ties despite gen-

eral trends in society. Reduced contact with kin may be partly compensated

for by increased contact with friends and neighbors.

Generally speaking, in modern societies there is less intermingling of the

generations, a normal part of daily life in earlier times. Consider the experi-

ence of two small children on a Halloween trek, going door to door. After

knocking on several well-lighted doors in a seniors-only mobile-home park

and receiving no response, their cries of “Trick or treat!” were answered by a

woman who said, “You’ll not get any Halloween treats in this place. Only old

people live here, and they leave their lights on for security and safety, not to

welcome children on Halloween!”

Life-Extending Technologies Seriously ill or injured individuals are likely to fi nd themselves sur-

rounded by an astonishing array of machinery. Sophisticated machines

monitor such biological functions as brain wave activity, heart rate, body

temperature, respiration, blood pressure, pulse, and blood chemistry. Signal-

ing changes in body function by light, sound, and computer printout, such

devices can make a crucial difference in situations of life or death. In place

of a sense of the inevitability of death, we are now prone to “an exaggerated

faith in the ability of scientifi c medicine to prolong life.” 154 This faith has

been called “exaggerated optimism” and “irrational exuberance.” 155

Advanced medical technology that seems to one person a godsend,

extending life, may seem to another a curse that only prolongs dying. Dignity

can be devalued amid technology focused solely on the biological organism.

What are the trade-offs in applying medical technologies to the end stage of

life? The conventional defi nition of death as “the cessation of life, the total

and permanent cessation of all vital functions” may be superseded by a medi-

colegal defi nition, which acknowledges the fact that life can be sustained arti-

fi cially. In short, the defi nition of death is not always as straightforward as the

simple statement “When you’re dead, you’re dead.”

Thus, medical technology is yet another factor lessening our familiarity

with dying and death. Modern medicine tends to distance family and friends

from the patient who is dying. The attitude that “what can be done, should

I often wonder what it would be like to be born and raised and live one’s whole

life in the same zip code. I wonder what it would be like to be able to dial all of

one’s family and friends without an area code. What it would be like not to always

be missing one person or the other, one place or the other. What it would be like

to return to a family home in which one grew up and still had things stored in

the attic.

My family is in area code 405 and my best friend’s in 415 and I’m living in 212.

The in-laws are in 203. And there are other friends in 213 and 202, in 412 and 214.

Beverly Stephen, “A Mobile Generation in Search of Roots”

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Factors Affecting Familiarity with Death 41

be done” increases the odds that technological fi xes will be tried, even when

success or cure is unlikely. When death does come, it may seem unexpected.

Technological medicine promotes a view of death as an event that can be

deferred indefi nitely rather than as a normal, natural part of life. In short,

death has become “a radically unnatural occurrence.” 156

The “medicalization of death” is a signifi cant manifestation of the dis-

appearance of death from the public domain. Although discussion of death

occurs to some extent in the public space, death is hidden from public gaze. At

the same time, as Chris Shilling notes, “there is a growing demand for repre-

sentations of death: from war documentaries and news, to violent movies and

television series based around hospital casualty departments.” 157 All of these

demographic and social variables can be understood as sociocultural forces

that infl uence the way we learn about death through childhood and beyond.

Lifelines—tubes and wires monitoring heartbeat, breathing, and blood pressure—increase this premature baby’s chances of survival in the intensive care unit of Philadelphia’s Children’s Hospital. The special-care nursery often becomes an arena for many of the most diffi cult ethical decisions in medicine.

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42 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

The Internet and the Digital Age Another force currently shaping our attitudes and understanding toward

death is information and communication technology (ICT). This refers to

the integration of telecommunications (telephone lines and wireless signals)

and computers, as well as necessary software, middleware, storage, and audio-

visual systems, which enable users to access, store, transmit, and manipulate

information. These technologies, which have spread rapidly worldwide, are

affecting global consciousness regarding death, dying, and bereavement.

Scholars note that “the use of the Internet for death-related information and

education has expanded to include loss-specifi c multifaceted websites, social

networking for support, interactive counseling, artistic expression, blogging,

cyber memorials, and postmortem continuing bonds.” 158 Gadgets like smart

phones and tablets expand opportunities for connection to the Internet. Tony

Walter and colleagues say the evidence indicates that “the internet has signifi -

cant implications for many current concepts in death studies.” 159 It is accurate

to say that the Internet and World Wide Web have become part of the modern

death system (discussed in Chapter 4). Indeed, ICT infl uences thanatology in

many ways, not only in terms of access to information but also in terms of sup-

port for people with life-threatening illness and for those who are bereaved.

The editors of a book about death in the “online universe” report the

following story:

A young man was able to participate in his grandmother’s funeral despite

being unable to book a fl ight in time to attend the actual event. Instead, as a

musician, he composed a piece in honor of his grandmother, digitally recorded

it, and attached it to an email sent to his aunt, who burned it onto a CD and

played it less than twelve hours later at the memorial service. 160

Social networking sites allow for connection to family, friends, and commu-

nity and are important sources of support for the bereaved. 161 The bereaved

may maintain relational continuity with the deceased by posting messages

on sites such as Facebook. Indeed, grieving individuals often post messages

to the deceased as if the deceased could read the messages. 162 Although it

is usual to think of teens and young adults as the “wired” generation, social

networking sites like Facebook also receive heavy use by the elderly and the

disabled, who are empowered to manage social contacts without leaving

home. As Robert Neimeyer says, “We are wired for attachment in a world of

impermanence.” 163

Crisis text lines are becoming a new form of hotline to which teens and

other individuals who are in crisis can “text” their concerns rather than call-

ing a telephone hotline or using other forms of computer-based chat. One

teen, who used a hotline to seek assistance in averting suicidal thoughts, said,

“I think teens would defi nitely use a hotline if they could text to it; most teens

keep their feelings to themselves.” 164

Social media are also being integrated into emergency- preparedness

efforts. Web-based platforms use information gathered from online com-

munities (“crowd-sourced”) to support crisis management, link health care

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Examining Assumptions 43

providers, get supplies to those needing them, and aid trapped victims. 165 The

Internet can be an avenue providing immediate response to crisis and loss.

Internet activities can reduce social isolation and disenfranchisement by

allowing individuals to form online communities devoted to particular losses,

such as pet loss. The virtual world offers opportunities to mourn that are not

available in the “real” world. However, there can also be negative aspects to

social media as grievers experience a lack of privacy. Exposure online may

leave some users feeling distressed and violated.

Finally, what about the “digital afterlife”? Observers remark, “In the vir-

tual world, if you have an online presence, you have the issue of your ‘digital

legacy’ to consider as you prepare for your eventual death.” 166 What hap-

pens to online accounts after a person’s death? Families and online compa-

nies may fi nd themselves on opposite sides in a battle for access to digital

assets: social media accounts, online photos and other records, e-mails, posts,

and blogs. Consider a death by suicide. In earlier times, diaries and letters

could be examined for clues to the individual’s state of mind or the circum-

stances leading to his or her death. Now, such paper-based artifacts are being

replaced by digital fi les. Whereas a safe deposit box at the bank becomes part

of the deceased’s estate and whoever controls the estate can open the box,

the situation with online assets is less clear. Privacy tends to be a big issue

in the online world, and the deceased may not have wanted his or her fam-

ily or other persons granted access to Internet fi les. Survivors may have no

idea about what their loved one would want to have happen to their online

accounts.

With some social media providers, a dead user’s account can be memori-

alized, which leaves it active so friends and family can leave posts in remem-

brance. Other providers say that accounts are not transferable and simply

deactivate an account upon receipt of a death certifi cate. Companies such as

Legacy Locker and Entrustet provide avenues for determining the disposi-

tion of Internet accounts after death.

Examining Assumptions Death is unavoidably part of our lives. Not thinking or not talking about

death doesn’t remove us from its power. Such ostrichlike behavior only lim-

its our choices for coping with dying and death. As death educator Robert

Kavanaugh said, “The unexamined death is not worth dying.” 167 Historian

David Stannard tells us that in societies in which each person is unique, impor-

tant, and irreplaceable, death is not ignored but is marked by a “community-

wide outpouring of grief for what is a genuine social loss.” 168 Conversely, in

societies where people feel that “little damage is done to the social fabric by

the loss of an individual,” death tends not to be acknowledged outside of that

person’s immediate circle.

Among communities where traditional beliefs, values, and practices are

maintained, death is part of the natural rhythm of life. The act of dying, the

most private act any person can experience, is a community event. A death

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44 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

initiates an outpouring of social support for the bereaved family and for the

wider community. Our values and preferences play an unavoidable part in

the quest to examine assumptions and think clearly about death.

Death in a Cosmopolitan Society At the California Science Center in Los Angeles, a public exhibition of

more than 200 cadavers attracted more than 650,000 visitors (doubling the

previous record set by an exhibit of Titanic artifacts). 169 Titled “Body Worlds: The Anatomical Exhibition of Real Human Bodies,” previous exhibitions

in Europe and Asia had spawned protests over displaying bodies that had

been plastinated (a process that involves replacing body fl uids with clear, pli- able plastic, making it possible to position in dynamic poses not only a whole

cadaver but also skeletal bones and internal systems such as blood vessels),

thereby offering viewers an “insider’s view of the effects of disease and ail-

ments, such as lung disease, hardened arteries, tumors, and ulcers.” German

physician Gunther von Hagens, inventor of the plastination process, calls the

result “anatomic artwork.”

Some said the exhibit’s popularity was due to the fact that “morbid-

ity has always been a spectator sport,” alluding to the exhibit’s macabre

aspects. Others praised it as an educational opportunity for both children

and adults to appreciate fi rsthand the wonder of the human body, as well

as its deterioration from the ravages of disease. What do these contrasting

reactions tell us about attitudes toward death? Is the specter of death, posi-

tive or negative, in the eyes of the beholder? What do you imagine your own

response might be?

The quest for meaningful answers to questions involving human mortal-

ity requires us to contemplate what it means to live in a society that scholars

describe as “postmodern” and “cosmopolitan.” 170 This perspective encour-

ages us to value diversity and pluralism by examining “taken-for-granted”

beliefs and considering ideas and practices from other historical periods and

cultures. In the contemporary era, individuals are exposed to diverse cul-

tures and a “plurality of life worlds.” 171

Postmodern thought is concerned with the contingency, fragility, and

arbitrariness of human life. 172 As one scholar remarked, “Postmodernism can

be regarded as a rejection of many, if not most, of the cultural certainties on

which life in the West has been structured.” 173 It refl ects a skepticism about

culture and its aims, including a belief in progress in all areas of human

endeavor.

In a cosmopolitan world, people are being forced to deal with three

related social processes: globalization, accelerated individualization, and

consumer societies. As one writer said, “Accelerated individualization has

largely emancipated individuals from many ascribed social bonds,” resulting

in “an unprecedented degree of freedom, but at the same time [creating] an

unprecedented task of coping with its consequences.” 174

According to Ulrich Beck, a German scholar and keen observer of the

“cosmopolitan society,” the human condition in the present century cannot

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Examining Assumptions 45

be understood nationally or locally but only globally. 175 British sociologist

Anthony Giddens says,

In a globalizing world, where information and images are routinely transmitted

across the globe, we are all regularly in contact with others who think

differently, and live differently, from ourselves. 176

Global concerns are becoming part of local experiences for an increasing

number of people. 177

Your classmates may arrive at different conclusions as they seek appro-

priate responses to death. Some may prefer an option for swift and low-cost

body disposal instead of the traditional funeral. Others might choose a

conventional funeral because they feel it provides a necessary framework

for meeting the social and psychological needs of survivors (see Figure 1-5 ).

Or consider the likelihood of differing values and attitudes concerning

such issues as medical care at the end of life and decisions about whether

to withhold or withdraw life-sustaining treatment. Is it feasible to allow

space for only one point of view? Or do we need room for diversity of opin-

ion and practice?

Medical technology, demographic changes, shifting disease patterns,

urbanization, and professionalization, among other factors, all infl uence how

we die, grieve, and care for our dead. Marina Sozzi, an Italian thanatologist,

observes that the wish to die a “natural” death, seen as an event that concludes

Figure 1-5 Embossed Linen Death Notifi cation, 1875 This card exemplifi es the formality of nineteenth-century mourning customs. The etiquette books of the period often devoted considerable space to the pro- cedural details associated with the wearing of mourning clothes, the issuance of funeral invitations, and other behaviors appropriate to the survivors of a death.

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46 c h a p t e r 1 Attitudes Toward Death: A Climate of Change

a genetically determined life cycle, has become a modern myth. By delegat-

ing our relationship with death to professionals—doctors, nurses, undertak-

ers, and so on—we try to avoid thinking about mortality and “dream about

someone who, equipped with the necessary skills,” will guarantee us a “sweet”

death with no real loss of self. “Our culture,” she says, “has lost the capacity of

making the experience of death fecund; thus, death becomes an impersonal

deadline of the body, a fatality inscribed inside it, pure biology.” 178

The latest chapter of the modern story of dying is perhaps best termed

managed death. Even when a prognosis of death has been accepted by medical staff and families, and when further treatments intended to cure have been

put aside, there may nevertheless be a strong desire to manage the situation

so that it comes out “right.” However, as Robert Kastenbaum says, “guidelines

for an existentially correct management of death have yet to forthcome.” 179

One expression of movement toward managed death involves the aim of end-

ing treatment just at the proper moment so that the person is enabled to die a

quiet or peaceful death. Another involves the attempt to control the timing of

death even more completely through physician-assisted suicide or euthana-

sia. In light of such efforts, Daniel Callahan says it seems that death is becom-

ing “ just one more choice-and-effi ciency issue, to be domesticated along with

traffi c jams and other excesses of modern life.” 180

Exploring Your Own Losses and Attitudes Social scientists use the term cultural lag to describe the phenomenon

of societies’ “falling behind” in dealing with new challenges resulting from

rapid technological and social change. It may be that we are in a period of

cultural lag with respect to dying and death. Recently, a novel forum for dis-

cussing death and end-of-life matters has proliferated in venues worldwide,

primarily in Europe and the United States: the death café. This is an event at which coffee and cake are served in a relaxed setting while people gather to

initiate conversation about death-related topics. Organizers aim to create an

environment where talking about death is natural and comfortable. The goal

is “to increase awareness of death with a view to helping people make the

most of their (fi nite) lives.” 181 Glennys Howarth observes, “We appear to be

living in a period where the study of death and the recognition of mortality

have gained in popularity.” 182

Andrew Ziner says,

Like nearly every other aspect of our lives, our understandings and feelings

about dying and death are derived from our involvement in the myriad of

groups, organizations, and institutions that represent our communities and,

ultimately, constitute our society. As these religious, economic, legal, and

familial structures change over time, we also change. This is because, as social

beings, all of the meanings we attach to personal and cultural concerns—

including dying and death—are inexorably tied to our social worlds. For

example, how do you feel when you hear the word death? If you were born a century earlier, would you feel the same way? Is the difference due to individual

or social factors? 183

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Further Readings 47

A perspective informed by values of connectedness and community,

which acknowledges and celebrates difference and diversity, can help us dis-

cover personally meaningful and socially appropriate choices for the times

in which we live and die, giving us a “pluralistic way of understanding and

being in the world.” 184 After reviewing dozens of studies, researchers found

that contemplating mortality brings positive results, such as better health

decisions, increased altruism and helpfulness, and decreased militaristic

attitudes. 185

Our attitudes toward death develop out of a lifetime of experiences

with signifi cant losses, beginning in childhood and continuing into old age.

Exploring the meaning of these losses and their infl uence on our attitudes

and practices is part of a comprehensive study of death and dying. It can be

helpful to construct a “lossography,” an account of the losses we have experi-

enced, allowing time for investigation and refl ection about the circumstances

in which they occurred and the ways in which we and signifi cant others in our

environment responded to those losses.

It’s been said, “The most precious thing in life is its uncertainty.” 186

Further Readings Christopher A. Dustin and Joanna E. Ziegler. Practicing Mortality: Art, Philosophy, and

Contemplative Seeing. New York: Palgrave Macmillan, 2005. Marilyn Johnson. The Dead Beat: Lost Souls, Lucky Stiffs, and the Perverse Pleasures of Obit-

uaries. New York: HarperCollins, 2006. Allan Kellehear, ed. The Study of Dying: From Autonomy to Transformation. New York:

Cambridge University Press, 2009.

Daniel Liechty, ed. Death and Denial: Interdisciplinary Perspectives on the Legacy of Ernest Becker. Westport, Conn.: Praeger, 2002.

Carla J. Sofka, Illene Noppe Cupit, and Kathleen R. Gilbert, eds. Dying, Death, and Grief in an Online Universe. New York: Springer, 2012.

Graeme Thomson. I Shot a Man in Reno: A History of Death by Murder, Suicide, Fire, Flood, Drugs, Disease and Misadventure as Related in Popular Song. New York: Continuum, 2008.

Adrian Tomer, Grafton T. Eliason, and Paul T. P. Wong, eds. Existential and Spiritual Issues in Death Attitudes. New York: Lawrence Erlbaum, 2007.

Irvin D. Yalom. Staring at the Sun: Overcoming the Terror of Death. San Francisco: Jossey- Bass, 2008.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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© R

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A father and son make an offering at the grave of their Chinese ancestors during village cremation ceremonies held in Peliatan, Bali. In this way, religious and cultural traditions are passed along to successive generations through socializing processes that are important to the ongoing life of the community.

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49

C H A P T E R 2

Learning About Death:

Socialization

I magine yourself as a child. Someone says, “Everybody’s going to ziss one of these days. It happens to all of us. You, too, will ziss.” Or, one day as you’re playing, you are told,

“Don’t touch that, it’s zissed!” Being an observant child, you notice that, when a person

zisses, other people cry and appear to be sad. Over time, as you put together all your expe-

riences of “zissing,” you begin to develop some personal feelings and thoughts about what

it means to ziss.

The understanding of death evolves like this. As a child grows older, incorporating

various experiences of death, his or her concepts and responses to death begin to resem-

ble those of the adults in the culture. Just as a child’s understanding of “money” changes

over time—at fi rst, it is a matter of little or no concern; later, it seems to come into the

child’s experience almost magically; and fi nally, it engages the child’s attention and partic-

ipation in many different ways—so, too, does the child develop new understandings about

the meaning of death. As with other aspects of human development, the understanding of

death evolves as experiences stimulate reevaluation of previously held knowledge, beliefs,

and attitudes.

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50 c h a p t e r 2 Learning About Death: Socialization

A Child’s Reasoning A twenty-seven-month-old child had been waking several times each night

and screaming hysterically for a bottle of sugar water. 1 This had been going

on for two months. His father describes getting up one night for the second

or third time and deciding with his wife to use fi rmness in refusing to meet

the child’s demand. He went into his son’s room and told him that he was too

old to have a bottle and would have to go back to sleep without it. The father,

his mind made up that enough was enough, started to leave the room.

But then he heard a frightened cry, one of desperation that sounded like

the fear of death. Wondering what could be causing the child such alarm,

the father turned back into the room, took his son out of the crib, and asked,

“What will happen if you don’t get your bottle?” The child, no longer hys-

terical, but very tearful and sniffl ing, said, “I can’t make contact!” The father

asked, “What does that mean, ‘you can’t make contact’?” His son replied, “If I

run out of gas, I can’t make contact—my engine won’t go. You know!”

The father then remembered several family excursions during the pre-

vious summer, when vehicles had run out of gas. “What are you afraid will

happen if you run out of gas?” Still crying, the child replied, “My motor won’t

run, and then I’ll die.” At that point, the father recalled another incident his

son had witnessed. Some time earlier, when they were selling an old car, the

prospective buyer had tried to start the engine, but the battery was dead, and

the engine wouldn’t turn over. The child had heard remarks like “It’s prob-

ably not making contact, ” “the motor died, ” and “I guess the battery’s dead. ” With this in mind, the father asked, “Are you afraid that your bottle is

like gasoline and, just like when the car runs out of gas, the car dies; so, if

you run out of food, you’ll die?” The child nodded his head yes. The father

explained, “Well, that’s not the same thing at all. You see, when you eat food,

your body stores up energy so that you have enough to last you all night. You

eat three times a day; we only fi ll up the car with gas once a week. When the

car runs out of gas, it doesn’t have any saved up for an emergency. But with

people, it isn’t anything like that at all. You can go maybe two or three days

without eating. And, even if you got hungry, you still wouldn’t die. People

aren’t anything like cars.”

This explanation seemed to do little to alleviate the child’s anxiety, so

the father tried a different tack. “You’re worried that you have a motor, just

like a car, right?” The child nodded yes. “So,” continued the father, “you’re

worried that, if you run out of gas or run out of food you’ll die, just like the

motor of a car, right?” Again, the child nodded yes. “Ah, but the car has a key,

right? We can turn it on and off anytime we want, right?”

Now the child’s body began to relax. “But where is your key?” The father

poked around the boy’s belly button: “Is this your key?” The child laughed.

“Can I turn your motor off and on? See, you’re really nothing like a car at all.

Nobody can turn you on and off. Once your motor is on, you don’t have to

worry about it dying. You can sleep through the whole night, and your motor

will keep running without you ever having to fi ll it up with gas. Do you know

what I mean?” The child said, “Yes.”

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A Mature Concept of Death 51

“Okay. Now you can sleep without worrying. When you wake in the morn-

ing, your motor will still be running. Okay?” Never again did the child wake

up in the middle of the night asking for a bottle of warm sugar water.

The father later speculated that two experiences had contributed to his

child’s concerns: First, the child had decided that sugar water would give him

gas because he had overheard his parents saying that a younger sibling had

“gas” from drinking sugar water; second, when the child’s parakeet died, his

question, “What happened to it?” was answered by his father: “Every animal

has a motor inside that keeps it going. When a thing dies, it is like when a

motor stops running. Its motor just won’t run anymore.”

In this dialogue between a child and his father, notice how the father’s

skills in listening and his sensitivity to his child’s behavior helped him engage

in this kind of conversation. Consider, too, the impressive reasoning that

goes on in a child’s mind—the way of stringing together concepts, the com-

plex associations of language and death.

A Mature Concept of Death Some people believe that children do not think about death through infancy,

toddlerhood, and the preschool years. As this story illustrates, however, it is

more realistic to expect that children will have experiences with death from

very early ages. A study conducted by Mark Speece to investigate the impact of

death experiences on children ages one to three helps confi rm this. 2 Speece

says, “It seems safe to conclude that death experiences occur in the lives of

a sizable proportion of children of this age and that those children who do

have such experiences attempt to deal with and integrate their specifi c death

experiences into their understanding of the world in general.”

Slightly over half of the children Speece studied had some experience

with death: in some cases, a human death (for example, a grandparent, a

cousin, a neighbor); in others, a nonhuman death, such as that of a pet.

Speece found that these young children responded to death in observable

ways. Some children actively looked for the deceased pet or person. One

child became angry when a pet bird that had died would not come back to

life. Children questioned the immobility of the deceased and what happens

after death, and expressed concern about the welfare of the living.

Through observing and interacting with children at different ages, psy-

chologists have described how children gain a mature understanding of

death. In reviewing more than 100 such studies, Mark Speece and Sandor

Brent conclude, “It is now generally accepted that the concept of death is not

a single, unidimensional concept but is, rather, made up of several relatively

distinct subconcepts.” 3 A formal statement of the empirical, or observable,

facts about death includes four primary components: 4

1. Universality. All living things must eventually die. Death is all-inclusive, inevitable, and unavoidable (although unpredictable in its exact timing;

that is, death may occur at any moment to any living thing).

2. Irreversibility. Death is irrevocable and fi nal. Organisms that die cannot be made alive again. (This is separate from a belief in a spiritual afterlife.)

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52 c h a p t e r 2 Learning About Death: Socialization

3. Nonfunctionality. Death involves the cessation of all physiological func- tioning. All life-defi ning bodily functions and capabilities cease at death.

4. Causality. There are biological reasons for the occurrence of death. This component includes a recognition of both internal (e.g., disease) and

external (e.g., physical trauma) causes of death.

A fi fth component, personal mortality, may be added to this list. A subcom- ponent of universality, it makes explicit the understanding not only that all

living things die but also that each living thing will die (“I will die”).

In addition, individuals with a mature understanding of death typically

hold nonempirical ideas about it as well. 5 Such nonempirical ideas—that is, ideas not subject to scientifi c proof—deal mainly with the notion that human

beings survive in some form beyond the death of the physical body. What

happens to an individual’s “personality” after he or she dies? Does the self

or soul continue to exist after the death of the physical body? If so, what

is the nature of this “afterlife”? Developing personally meaningful answers

to such questions, which involve what Speece and Brent term “noncorporeal

© N

ic k D

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n e

s

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Understanding Death Through the Life Course 53

continuity,” is, for many individuals, part of the process of acquiring a mature

understanding of death.

Most children understand by about three or four years of age that death

is a changed state. The major aspects of a mature concept of death are mas-

tered in a relatively fi xed sequential order between the ages of fi ve and ten. 6

Studies investigating this sequence have generally found that understanding

the irreversibility of death occurs fi rst, by age fi ve or six, with the recogni-

tion that the dead cannot come back to life. Between the ages of fi ve and

eight, a major shift occurs in how children think about biological phenomena

and, specifi cally, how the human body functions to maintain life. 7 In early

school years, children come to understand that death affects all living things

and that it is characterized by bodily processes ceasing to function. By ages

seven to ten, all basic components of a mature concept of death have been

acquired. “Death is conceptualized as a fundamentally biological event that

inevitably happens to all living things and is ultimately caused by an irre-

versible breakdown in the functioning of the body.” 8 Of course, some chil-

dren take longer than others to come to this understanding, and some may

even resist or defend against acknowledging information related to a mature

understanding of death. 9

The ever-expanding understanding of death during childhood is further

refi ned during adolescence and early adulthood, as individuals consider the

social and emotional impact of death on close relationships and contemplate

the value of religious or philosophical answers to the meaning of death.

Thus, a mature understanding of death goes beyond a biological focus to an

appreciation for the life lost, the characteristics that make the loss of life a

tragedy. 10

What a person “knows” about death may change from time to time. We

may hold confl icting or contradictory notions about death, especially our

own. When facing a distressing situation, an understanding of the facts may

give way to a more childlike attitude, such as the notion that we can bargain

where death is concerned. A patient told that he or she has only six months

to live may imagine that by some magical act, some bargain with God or the

universe, the death sentence can be postponed. Thus, although the main

evolution toward a mature understanding of death occurs during childhood,

how a person understands death fl uctuates among different ways of knowing

throughout life. Later in this chapter, we discuss the distinctive developmen-

tal transitions that pertain to adulthood.

Understanding Death Through the Life Course The evolving understanding of death is a process of continuous adjustment

and refi nement. It is part of human development, which refers to the changes

in physical, psychological, and social behavior experienced across the life

span. 11 By observing children’s behavior, developmental psychologists devise

theories, or models, to describe the characteristic concerns and interests of

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54 c h a p t e r 2 Learning About Death: Socialization

children at various ages. These models are like maps that describe the main

features of the territory of childhood at different stages of development. The

models are useful for describing the characteristics of a typical child at, say,

age two or age seven.

Children vary in their individual rates of development—not only phys-

ically, but also emotionally, socially, and cognitively. Thus, with respect to

a child’s understanding of death, paying attention to the sequence of devel- opment is more pertinent than trying to correlate understanding to a spe-

cifi c age. Experience plays an important role. A child who has had fi rsthand encounters with death may arrive at a more mature understanding of death

than is typical of other children of the same age.

Children are active thinkers and learners. Very young children appear

to make theory-like assumptions about the world, and they use basic reason-

ing to make causal explanations about physical, biological, and psychological

events. 12 In recent decades, studies have shown infants and young children

behaving in ways that imply an understanding of physical and perceptual

phenomena at ages younger than previously thought possible. 13

In tracking the development of the understanding of death in children,

it is useful to have a framework within which to place the distinctive attitudes

and behaviors that pertain to various phases of childhood. The formal study

of children’s understanding of death can be traced to the pioneering work

of Paul Schilder and David Wechsler (1934). 14 However, studies conducted

in the early 1940s by Sylvia Anthony in England and Maria Nagy in Hungary

have received greater attention.

To summarize, according to Anthony, children under the age of two

have no understanding of “dead,” by fi ve they have a limited concept, and by

nine they can give general explanations for death; in addition, young chil-

dren engage in magical thinking (that is, the notion that, for example, angry

thoughts or feelings can cause someone’s death). 15

Nagy found three developmental stages in children’s understanding of

death between the ages of three and ten. Her research showed that, in the

fi rst stage (ages three to fi ve), children understood death as somehow being

less alive; the dead “live on” under changed circumstances and can return

to normal life. In the second stage (ages fi ve to nine), children understood

We are reading the newspaper on the terrace in our suite in a New York hotel. It

is a faultless fall day. Out two-year-old daughter is sitting contentedly beside us,

drinking a bottle. She climbs off her chair and squats down, inspecting something

on the ground. She pulls the bottle out of her mouth, calls to me and points to a

large, motionless bumble bee. She is alarmed, shaking her head back and forth,

as if to say “No, no, no!” “The bee stopped,” she says. Then she makes a command:

“Make it start.”

Carol Blue, Mortality

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Understanding Death Through the Life Course 55

death as fi nal but as avoidable and lacking inevitability and personal refer-

ence (“I will die”). In the third stage (ages nine and older), children rec-

ognized death as the result of a biological process that is fi nal, inevitable,

universal, and personal. 16

Although research generally has indicated that most children have

acquired a mature concept of death around the age of nine, recent studies

show that children begin to conceptualize death as a biological event at the

same time they construct a “biological model” of how the human body func-

tions. 17 By preschool age, an animate/inanimate distinction serves “as the

center of a vast cluster of conceptual distinctions,” including a naïve theory

of biology. 18 Only after children begin to think purposefully about the bio-

logical functions of life-sustaining body parts (e.g., the heart is for pumping

blood) do they become “life theorizers,” able to reason that, without these

parts, one would die. 19 Older children are more apt than younger children

to state that bodily functions cease at death. 20 In the discussion that follows,

children’s development is placed within the framework of two major theories

or models of human development—namely, those devised by Erik Erikson

and Jean Piaget.

The model of human development devised by Erikson focuses on the

stages of psychosocial development, or the psychosocial milestones, that occur successively throughout a person’s life (see Figure 2-1 ). 21 Each stage involves

a crisis, or turning point, that requires a response so that the individual can

gain mastery over various issues and further develop a sense of identity. For

Figure 2-1 Stages of Psychosocial Development Proposed by Erikson

0 1 3 6 11 19 40 65 651

Time

trust versus mistrust

autonomy versus shame

initiative versus guilt

industry versus inferiority

identity versus confusion

intimacy versus isolation

generativity versus stagnation

integrity versus despair

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56 c h a p t e r 2 Learning About Death: Socialization

Erikson, the basic needs of connectedness and independence complement and support each other in the successful resolution of each stage. As you think

about various stages and the crises associated with them, keep in mind that

Erikson believed that all the issues surrounding the development of iden-

tity and the mastery of various tasks and skills are present at every period

of a person’s life. This means that adults deal with issues or crises initially

described as having occurred during childhood. Each of the major issues in

development is “recycled” whenever events in one’s life elicit it.

Jean Piaget’s focus was on the cognitive transformations that occur during childhood (see Table  2-1 ). 22 According to Piaget, the basic unit of under-

standing is a schema or scheme, defi ned as “a pattern of knowing something.” Development occurs through two complementary processes: assimilation and accommodation. The fi rst term implies that we apply our current schemes to new information and incorporate this information into existing schemes.

The second term refers to the process of adjusting or modifying our current

schemes to handle new information.

Age (approximate)

Developmental Period Characteristics

Birth–2 years Sensorimotor Focused on senses and motor abilities; learns object

exists even when not observable (object permanence)

and begins to remember and imagine ideas and expe-

riences (mental representation).

2–7 years Preoperational Development of symbolic thinking and language to

understand the world.

(2–4 years) Preconceptual subperiod: sense of magi- cal omnipotence; self as center of world; egocentric

thought; all natural objects have feelings and inten-

tion (will).

(4–6 years) Prelogical subperiod: beginning prob- lem solving; seeing is believing; trial and error; under-

standing of other points of view; more socialized

speech; gradual decentering of self and discovery of

correct relationships.

7–12 years Concrete operational Applies logical abilities to understanding concrete

ideas; organizes and classifi es information; manipu-

lates ideas and experiences symbolically; able to think

backward and forward; notion of reversibility; can

think logically about things experienced.

12 1   years Formal operational Reasons logically about abstract ideas and experi-

ences; can think hypothetically about things never

experienced; deductive and inductive reasoning;

complexity of knowledge; many answers to questions;

interest in ethics, politics, social sciences.

t a b l e 2-1 Piaget’s Model of Cognitive Development

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Understanding Death Through the Life Course 57

Although we are constantly reaching new levels of understanding, Piaget

said that at times so many new levels of understanding converge that there

occurs a major reorganization in the structure of our thinking. Accordingly,

Piaget distinguished four different periods of cognitive development based

on the characteristic ways in which individuals organize their experience

of the world: sensorimotor, preoperational, concrete operational, and formal opera- tional. Although children move through these stages in the same sequence, each child’s rate of development is unique.

In the following discussion of the years of childhood and adolescence, we

make use of both Erikson and Piaget in describing developmental patterns.

Infancy and Toddlerhood As shown in Figure  2-1 , Erikson characterizes the period from birth to

roughly one year as predominantly a time of developing a sense of basic trust toward the environment. The positive outcome of this developmental “crisis”

is hope. If the infant’s needs are not met, the result may be distrust. Other people in the environment—typically parents—play an important part in

development as the infant acquires a sense of trust in others as reliable and

nurturant. Moreover, he or she learns not only to trust others, but also that

the world is predictable. The death of a caregiver can disrupt building this

foundation of trusting others and trusting the environment. Similarly, a death

that affects other family members and puts them under stress can adversely

affect the infant’s developing sense of predictability about the world. When a

death occurs in the child’s environment, adults need to watch for nonverbal

cues that the child might understand more than the adults assume or than is

readily apparent. 23

During the next stage according to Erikson, toddlerhood (roughly one

to three years of age), the child grapples with issues of autonomy versus shame and doubt. The positive outcome is characterized as will. This is a period of “letting go” and “holding on” in both psychosocial and physical development.

Toilet training typically occurs during this time. Toddlers make giant gains

in object recognition and thinking between the ages of 18 and 24 months.

There is a developmental leap in their pretend play (for instance, pretending

a laundry basket is a car), a basic form of symbolic thinking. 24 As the tod-

dler explores the environment and develops greater independence, there are

inevitably clashes of wills between what the child wants to do and what others

want the child to do. Exercising independence is a hallmark of this stage. The

death of a signifi cant other, especially a primary caregiver, affects the child’s

task of pursuing independence and may cause a regression to earlier behav-

iors, such as clinging, crying, and being more demanding.

Turning to Piaget’s model, the fi rst two years of life are characterized as

the sensorimotor period, as a child develops and strengthens his or her sensory and motor, or physical, abilities. This period starts with the refl ex schemes

babies are born with and ends with elementary symbol use. At roughly 12 to

18 months, we see “infant scientists” at work with the environment as their

laboratory. “They perform miniature experiments in which they deliberately

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58 c h a p t e r 2 Learning About Death: Socialization

vary an action in order to see how this variation affects the outcome.” 25 As

the child accumulates experiences of the fl ow of events in the environment,

he or she gradually begins to perceive patterns that become generalized into

schemes, which tie together the common features of actions occurring at dif-

ferent times. Meg Jay says,

In the fi rst eighteen months of life, the brain experiences its fi rst growth spurt,

producing far more neurons than it can use. The infant brain overprepares,

readying itself for whatever life brings, such as to speak any language within

earshot. This is how we go from being one-year-olds who understand fewer than

one hundred words to being six-year-olds who know more than ten thousand. 26

Between about 14 and 24 months, most children make a transition into

the next period. They begin to show insight learning, budding symbol use,

and simple pretend play. With symbol use, children are no longer tied to the

here and now, nor do they need to act overtly on the environment to think

about causality and how things work.

In the beginning, a parent who leaves the room has simply vanished;

there is no thought, “My parent is in the other room.” Eventually, the child

acquires the concept of object permanence; an object continues to exist even when one cannot see, hear, or feel it. Piaget says, “a Copernican revolution

takes place,” with the result that “at the end of this sensory-motor evolution,

there are permanent objects, constituting a universe within which the child’s

own body exists also.” 27

Early Childhood In Erikson’s model, the preschool and kindergarten years (roughly three

to six years of age) involve issues of initiative versus guilt. The positive out- come is purpose. The child is convinced that she is a person; now she must fi nd out what kind of person she is going to be. 28 The child seeks his or her own direction and purpose yet is concerned about how parents (and other sig-

nifi cant adults) perceive these tentative efforts to express individuality. The

egocentric orientation of the infant gives way to the socially integrated self of

the older child.

Children tend to fi rst acknowledge death in the preschool years. Children

may become fascinated with the idea of “gone” or “all gone.” For the young

child, being dead is an altered state of living or a diminished form of life. A

Driving my three-year-old daughter to day care before work, I noticed a family of

dead raccoons on the road. I quickly sped past, hoping she wouldn’t spot them.

No such luck.

“Mommy, what was that?”

“Some wood must have fallen from a truck,” I fi bbed.

“Oh,” she said. “Is that what killed all those raccoons?”

Tammy Maas

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Understanding Death Through the Life Course 59

four-year-old girl told Robert Kastenbaum, “They have only dead people to

talk to, and dead people don’t listen, and they don’t play, and they miss all the

TV shows they liked.” 29 Children in this period typically consider that death

is something that happens only to the very sick or aged, and it can be avoided

with healthy living and by avoiding situations that are fatal (e.g., car crashes). 30

This period marks the beginning of the child’s moral sense, the ability

to function within socially sanctioned modes of behavior. During this period,

situations arise that induce feelings of guilt. For instance, a child who has

fantasies of doing away with a parent—expressed perhaps by the frustrated

scream, “I wish you were dead!”—may feel guilty or shameful about having

such thoughts. Refl ecting emerging communication skills, the child’s concept

of death expands quite rapidly during the preschool and kindergarten years.

The body becomes important to children’s self-image as they race around

on tricycles, learn to cut small pieces of paper precisely, and generally gain

greater control over their bodies. During this period, bodily mutilation is one

of the death-related fears that may manifest. This preoccupation with the

body can be illustrated: A fi ve-year-old witnessed the death of his younger

brother, who was killed when the wheel of a truck rolled over his head. The

parents, who were considering having a wake in their home, asked the surviv-

ing son how he might feel if his younger brother’s body were brought into

the house for a wake. His question was “Does he look hurt?” Concern about

bodily disfi gurement is characteristic of this stage of psychosocial develop-

ment (see Figure 2-2 ). Children in this age group need to be given accurate

information about a death and what caused it so they will not draw errone-

ous conclusions. Common expressions of grief at this period include sadness,

regression, play reenactment, and magical thinking.

In Piaget’s model, early childhood is characterized as the preoperational period. Cognitive development centers on learning to use language and sym-

bols to represent objects, a huge shift in human development. Because so

many changes in thinking emerge during the transition from the preschool

to the school years, this period has come to be called the fi ve-to-seven-year shift. How does Piaget’s model apply to children’s concepts of death? A study

conducted by Gerald Koocher supplies a partial answer. Children were asked

four questions about death. 31 (You might want to answer these questions for

yourself.) The fi rst question was, What makes things die? Children in the

preoperational stage used fantasy reasoning, magical thinking, and realistic

causes of death (sometimes expressed in egocentric terms). Here are sample

responses:

• Gia: “When they eat bad things, like if you went with a stranger and they

gave you a candy bar with poison on it. [ The researcher asks, “Anything else?” ] Yes, you can die if you swallow a dirty bug.”

• Emilio: “They eat poison and stuff, pills. You’d better wait until your

Mom gives them to you. [ Anything else? ] Drinking poison water and stuff like going swimming alone.”

• Louis: “A bird might get real sick and die if you catch it. [ Anything else? ] They could eat the wrong foods like aluminum foil. That’s all I can think of.”

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60 c h a p t e r 2 Learning About Death: Socialization

The understanding of death during the early childhood years is also illus-

trated in a study done by Helen Swain. 32 Most children in this study expressed

the notion that death is reversible, attributing the return of life to the good

effects of ambulances, hospitals, or doctors, whose help is often summoned

magically, as if a dead person could ring up the hospital and say, “Will you

send me an ambulance over here? I’m dead and I need you to fi x me up.”

About two-thirds of the children said that death is unlikely or avoidable or is

brought about only by unusual events such as an accident or a catastrophe.

About one-third expressed disbelief that death could happen to them or to

their families. Nearly half were uncertain about whether they would ever die

or else thought they would die only in the remote future.

Middle Childhood or School-Age Period In Erikson’s model, the years from about six to the beginning of

puberty correspond to the stage of industry versus inferiority. The positive outcome of this stage is competence. This is the “industrial age,” a period when the child is busy in school, interacting with peers in a variety of ways.

The theme is “I am what I learn.” As a child’s efforts begin to gain recogni-

tion and bring satisfaction, he or she may be anxious about those areas in

Figure 2-2 Accident Drawing by a Five-Year-Old In this drawing by a fi ve-year-old who witnessed his younger brother’s accidental death, the surviving child is depicted as riding a Big Wheel on the left side of the truck that ran over his brother. The four wheels of the truck are shown, and the younger brother’s head is drawn next to the wheel farthest to the right. This drawing is similar to one drawn by the child on the night of the fatal accident, when he told his parents, “I can’t sleep because I can’t get the pictures out of my head.” The act of externalizing these disturbing images by making a drawing had therapeutic value for this child in coming to terms with the traumatic expe- rience of his sibling’s death.

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Understanding Death Through the Life Course 61

which there is a lack of control or sense of inadequacy. An example is seen

in reactions of children to the terrorist attacks of 2001. According to Grace

Crist, children in the eight-to-eleven age range had a diffi cult time navigat-

ing what had happened because they weren’t old enough to fully grasp the

big picture the way adolescents can. At that age, she says, children need

details and concrete information to feel a sense of control, but the details of

9/11 were gruesome, making the event frightening and almost impossible

to comprehend. 33

Common grief reactions in the middle childhood period include school

and learning problems, phobias, anger, and hypochondriasis. The death of a

parent during the school-age years is likely to deprive a child of an important

source of recognition. During these years of development, as children learn

new tasks, they are also comparing themselves with their peers. When one

nine-year-old moved to a different school shortly after her mother’s death,

she didn’t want her new acquaintances to know about the death. When ques-

tioned about this, she replied, “Having a dead mother makes me too different

from other kids.”

In Piaget’s framework, this period is denoted by the term concrete oper- ations. The child begins to use logic to solve problems and to think logi- cally about things without having to have their relationships demonstrated

directly. The ability to do arithmetic, for instance, requires the recognition

that numbers are symbols for quantities. Children at this stage are able to

Childhood activities such as “playing dead” can be a means of experimenting with various concepts, trying them on for size, and thus arriving at a more comprehensive and manage- able sense of reality.

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62 c h a p t e r 2 Learning About Death: Socialization

manipulate concepts in a logical fashion, although typically they do not

engage in abstract thinking. In other words, the ability to think logically is

applied to objects but not yet to hypotheses, which require the ability to carry

out “operations on operations.” The characteristic mode of thought in this

developmental period emphasizes real-life situations or concrete instances of

a problem, not hypothetical or theoretical problems.

During this period, children name both intentional and unintentional

means by which a person may die, and they are familiar with a wide range

of causes of death. When a death occurs, children are likely to be concerned

about their own safety and the safety of other family members. Here are some

responses from the children in Koocher’s study when asked about causes of

death:

• Beatrice: “Knife, arrow, guns, and lots of stuff. You want me to tell you

all of them? [ As many as you want. ] Hatchets and animals, and fi res and explosions, too.”

• José: “Cancer, heart attacks, poison, guns, bullets, or if someone drops a

boulder on you.” • Catherine: “Accidents, cars, guns, or a knife. Old age, sickness, taking

dope, or drowning.”

Adolescence The period of life called adolescence is conceptualized in terms of three

stages: early adolescence, from about eleven to fourteen years, which begins with puberty and involves a shift in attachment from parents to peers; middle adolescence, about ages fi fteen to seventeen, marked by the development of individual self-image, experimentation, and striving for competency, mas-

tery, and control; and late adolescence, the years from about eighteen to the early twenties, distinguished by increased self-acceptance, concern for oth-

ers, and an increasingly future-oriented view of the world. 34 Ken Doka says

the key developmental issues of adolescence are often called the three I ’s: identity, independence, and intimacy. 35 One writer says,

Childhood is important, but more and more I am curious about what went on

in high school. High school and our twenties are not only the time when we

have our most self-defi ning experiences, study after study shows they are also

the time when we have our most self-defi ning memories. 36

It has been pointed out that adolescence is “a period when young people

draw on ‘repertoires’ characteristic of both adulthood and childhood.” 37

In Erikson’s model, adolescence is marked by the crisis of identity versus confusion (sometimes characterized as role confusion or identity diffusion).

The positive outcome of this crisis is fi delity. Identity has been defi ned as “the way in which we adopt certain strategies of action to maintain a connection

with others, with our past, and with our own aspirations.” 38

Adolescence is associated with physical and hormonal changes brought

about by puberty. It is also a time when, as with the period associated with

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Understanding Death Through the Life Course 63

the fi rst eighteen months of life, “thousands of new connections sprout”

in the wiring of the brain, “exponentially increasing our capacity of new

learning.” Again, the brain overprepares, this time for the “uncertainty of

adult life.” 39

This is usually a time for switching schools, with adolescents going from

elementary to middle and high schools, where they encounter different poli-

cies and focuses. “Adolescents are confronted with a host of unique transi-

tional issues,” says Robin Paletti; besides physical changes, “teenagers must

also negotiate pressing psychosocial concerns surrounding the attainment

of independence, peer acceptance, and self-esteem.” 40 Another writer says,

“The psychosocial modality of this stage is to be oneself or not to be one-

self.” 41 As they change into adults and approach the end of their school years,

adolescents recognize that they will soon have to leave home and make major

decisions about college education and career paths. “With independence

looming, the adolescent must negotiate some degree of detachment from the

family, provoking feelings of loss.” 42

A bridge is established between the past—the years of childhood and

dependency—and the future—the years of adulthood and independence.

The central question is, Who am I as an emotional, thinking, physical, and

sexual being?

Remember what it was like being a teenager? Becoming more your own

person? Striving to express your own ideas and beliefs? Sorting out the

tangle of all that’s happening to you? Deciding what you want for your

life? Adolescence can be confusing and challenging. The achievement of

goals and dreams seems nearly within one’s grasp; death threatens that

achievement. When a close death occurs, common grief reactions during

adolescence include denial, depression, anger, somatization (conversion of

a mental state into physical symptoms), mood swings, and philosophical

questioning. Surviving a close death may also result in a more rapid “grow-

ing up.”

In Piaget’s model, adolescence is characterized by the use of formal operations. The fourth and fi nal phase in Piaget’s theory, this period begins at about the age of eleven or twelve and extends into adulthood, although

a person’s fundamental way of seeing the world is thought to be fairly well

established by about age fi fteen. With the arrival of formal operational think-

ing, the individual is able to “think about thinking”—that is, to formulate

concepts that are abstract or symbolic. Relations of correspondence or impli-

cation between complex sets of statements can be perceived, analogies recog-

nized, and assumptions or deductions made. It becomes possible to predict

outcomes without having to try them in the real world. In a chess game, for

example, formal operations of thought allow players to consider a number of

complicated strategies and to predict the likely result of each move, without

having to touch a single piece on the board.

In Koocher’s study, most of the children who used formal operations of

thought were twelve or older, although a few were as young as nine or ten.

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64 c h a p t e r 2 Learning About Death: Socialization

The children interviewed by Koocher refl ected a mature understanding of

death in their responses to the question, What makes things die?

• António: “You mean death in a physical sense? [ Yes. ] Destruction of a vital organ or life force within us.”

• George: “They get old and their body gets all worn out, and their organs

don’t work as well as they used to.” • Paula: “When the heart stops, blood stops circulating. You stop breathing,

and that’s it. [ Anything else? ] Well, there’s lots of ways it can get started, but that’s what really happens.”

Although adolescents typically demonstrate a mature understanding of

death, this does not necessarily mean that there are no differences in the

ways adolescents and adults understand and cope with death. For example,

an adolescent’s understanding of the universality of death may be infl uenced

by a sense of invulnerability (“It can’t happen to me”). The concept of per-

sonal death may not be easily accepted. In forging a sense of identity, the

adolescent is confronted by the need to “reconcile that identity with ultimate

disintegration and not being.” 43

Emerging Adulthood Although adolescence historically has been defi ned as occupying ages

eleven or twelve through eighteen or twenty, some developmentalists have

proposed a category, emerging adulthood, for the period from the late teens through the twenties, especially ages eighteen to twenty-fi ve. For most young

people today, adulthood no longer begins when adolescence ends. Social sci-

entists point out, “Societies have not yet become fully aware of, or begun fully

to address, the ramifi cations of the longer and more varied transition into

adult life.” 44

Many individuals in this age range enter a moratorium, postponing com-

mitments and identity decisions. This delay is often associated with the time

needed to gain an education or to make choices about a career. This is a

time when many possibilities and directions in work, love, and worldview can

be imagined. People of this age group no longer view themselves as adoles-

cents, but they may not see themselves entirely as adults either. “Emerging

adults can pursue novel and intense experiences more freely than adoles-

cents because they are less likely to be monitored by parents and can pursue

them more freely than adults because they are less constrained by roles.” 45

The prevalence of certain types of risk behavior—including unprotected sex,

substance abuse, risky driving, and binge drinking—appears to peak during

the years of emerging adulthood. Like adolescents in this regard, emerging

adults may think they are “beyond death.”

Early Adulthood Human development does not stop with childhood’s end. The patterns of

coping with loss continue to evolve throughout a person’s life span. Just as we

associate certain developmental tasks and abilities with children of different

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Understanding Death Through the Life Course 65

ages, so, too, we distinguish distinctive phases and transitions during adult life.

All too often, we are sensitive to the developmental stages of childhood but

tend to ignore the changes that occur in the last sixty or more years of life. 46

Earlier in this chapter, we discussed the fi rst fi ve stages of psychosocial

development proposed by Erik Erikson—namely, those pertaining to the

years of childhood and adolescence. The last three stages of psychosocial

development, according to Erikson’s model, occur during adulthood. As

in childhood, each stage of adult life requires a particular developmental

response, and each stage builds on previous ones.

Early adulthood (nineteen to forty years) is represented by tension between intimacy and isolation. The positive outcome is love. This stage involves vari- ous forms of commitment and interaction, including sex, friendship, coop-

eration, partnership, and affi liation. Ken Doka describes this as “a time of

looking outward, of beginning families and a career.” 47 Because mature love

takes the risk of commitment, the death of a loved one may be most devastat-

ing during this stage and the next. 48

Middle Adulthood The next psychosocial stage according to Erikson is middle adulthood

(forty to sixty or sixty-fi ve years), and it is characterized by the crisis of gen- erativity versus stagnation and self-absorption. The positive outcome is care. “Faith in the future, a belief in the species, and the ability to care about

others seem to be prerequisites for development in this stage,” whereas self-

indulgence, boredom, and lack of psychological growth signal a lack of gen-

erativity. 49 This stage is characterized by a widening commitment to take

care of the people, things, and ideas one has learned to care for. Ken Doka

characterizes this period as having “a more settled quality” in that “ jobs,

careers, family, and friendship networks have probably stabilized.” 50 Michele

Paludi says, “Middle adulthood appears to be a prime period for experienc-

ing fear of death since it is during this stage of the life cycle that the death of

one’s parents typically occurs.” 51

“Bloom County,” drawing by Berke Breathed, © 1984 by Washington Post Writers Group

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66 c h a p t e r 2 Learning About Death: Socialization

Later Adulthood In reaching late adulthood, the eighth and fi nal stage of the life cycle, the

crisis to be resolved is that of integrity versus despair. The positive outcome of this stage of life is wisdom. “People must live with what they have built over their lifetime.” 52 If the middle-aged adult is aware of mortality in a general

sense, the older person can be described as aware of his or her own fi nitude. 53 Patricia Miller says that integrity involves “acceptance of the limitations of

life, a sense of being part of a larger history that includes previous genera-

tions, a sense of owning the wisdom of the ages, and a fi nal integration of all

the previous stages.” She adds that the antithesis of integrity is despair, which

has been described as “regret for what one has done or not done with one’s

life, fear of approaching death, and disgust with oneself.” 54 With respect to

this, the psychologist M. Brewster Smith stated, “Fear of death seems to me

partly a refl ection of feeling cheated by life.” 55

Viewing the developmental phases as connected, each building on the

ones before, the crisis of this period is especially powerful because of physi-

cal decline, outward signs of aging, vulnerability to chronic diseases, and the

approaching certainty of death. It is marked by the thought, “This is the life

I’ve had; there is no other; this is it. I don’t have options to go back and

change things in any signifi cant way.” Successfully completing the challenges

of this developmental period gives us the strength of wisdom, which Erikson

describes as “informed and detached concern with life itself in the face of

death itself.” 56

The Evolution of a Mature Concept of Death Through successive periods of development, individuals progress toward

a mature understanding of death and exhibit characteristic responses to loss.

Earlier, we looked at children’s responses to the question, What makes things

die? Their answers to other questions posed by Koocher also correspond to

developmental stages. Asked, “How do you make dead things come back to

life?” children who thought of death as reversible gave answers like “You can

help them; give them hot food and keep them healthy so it won’t happen

again.” Another child said, “No one ever taught me about that, but maybe you

could give them some kind of medicine and take them to the hospital to get

better.” Children in later developmental stages recognized death as perma-

nent: “If it was a tree, you could water it. If it’s a person, you could rush them

to the emergency room, but it would do no good if they were dead already.”

Another child said, “Maybe some day we’ll be able to do it, but not now. Scien-

tists are working on that problem.”

Asked, “When will you die?” younger children gave answers ranging from

“When I’m seven” (from a six-year-old) to “Three hundred years.” In contrast,

My granddaughter was helping me cut onions and it stung her eyes. I said, “You’ll

live.” Skylar answered, “Of course I’ll live. I’m six. . . .”

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Agents of Socialization 67

older children expected to live a statistically correct life span or a bit more;

the usual age at which death was expected was about eighty.

In answer to the researchers’ question, “What will happen when you die?”

one nine-and-a-half-year-old said, “They’ll help me come back alive.” The

researcher asked, “Who?” “My father, my mother, and my grandfather,” the

child responded. “They’ll keep me in bed and feed me and keep me away

from rat poison and stuff.” According to some models, a child of nine would

understand that none of those measures would work. Thus, this example

illustrates the point that age-and-stage correlations provide, at best, a rule of

thumb concerning how children develop.

In answer to the same question, an eight-and-a-half-year-old replied, “You

go to heaven and all that will be left of you will be a skeleton. My friend has

some fossils. A fossil is just a skeleton.” Notice how this child used comparison

to help interpret what happens when death occurs. An eleven-year-old said,

“I’ll feel dizzy and tired and pass out, and then they’ll bury me and I’ll rot

away. You just disintegrate and only your bones will be left.”

A twelve-year-old said, “I’ll have a nice funeral and be buried and leave

all my money to my son.” One ten-year-old said, “If I tell you, you’ll laugh.”

The researcher assured the child, “No, I won’t. I want to know what you really

think.” Thus encouraged, the child continued, “I think I’m going to be rein-

carnated as a plant or animal, whatever they need at that particular time.”

The ability to imagine what things might be like in the future is seen in this

child’s response.

Agents of Socialization Acquiring a mature understanding of death is part of the developmental

process known as socialization— that is, the process by which an individual becomes identifi ed as a member of a particular culture, learning and inter-

nalizing the norms, values, rules, and behaviors of society. 57 Classically, pri-

mary socialization refers to the preparation of a child for participation in

adult society. However, socialization is best seen not as “a process of acquiring

a unitary culture” but as involving the development of capacities for diverse

cultural practices across the entire life course. 58 For people living in modern,

industrialized countries, this life course now spans, with reasonable certainty,

50 to 70 years, and even beyond. 59 How we are socialized seems signifi cantly

tied to the fact that we will one day die. “Because death is universal and inevi-

table, it plays a role in shaping the organization and experience of life.” 60

Although the main phases of socialization occur during the years of child-

hood, it does not end with the age of majority. On the contrary, it continues

throughout life as individuals develop new attitudes, values, and beliefs, as

well as new social roles. Nor is it a one-way process whereby individuals simply

learn to fi t into society. Society’s norms and values are modifi ed as its mem-

bers redefi ne their social roles and obligations. These are “bi-directional

socializing processes that lead to individualized arrangements with changing

social contexts.” 61

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68 c h a p t e r 2 Learning About Death: Socialization

Socialization has a variety of infl uences, beginning with the family and

extending to peer groups, school and work situations, social clubs, on to

vicarious socialization through the popular media and the global “transcul-

tural” environment. As Hannelore Wass says, “Children adopt many values

and beliefs from signifi cant adults in their world [including] parents, teach-

ers, public fi gures, sports heroes, and famous entertainers.” 62 Today, children

and adults are exposed to a broader range of infl uences on their socialization

than at any other time in history.

Resocialization, a term that refers to the “uprooting and restructuring of basic attitudes, values, or identities,” occurs when adults take on new roles that

require replacing their existing values and modes of behavior. 63 This occurs, for

example, with religious conversion, starting a new job, getting married, having

children, or surviving the death of a mate. Widowhood, for example, involves

changes in many areas of life, as new roles and activities are taken on. Richard

Settersten says, “Resocialization seems increasingly necessary for everyone in a

fast-paced and ever-changing world in which life spans seven or more decades.” 64

Secondary socialization is a term used to describe the learning of new rules and behaviors when one becomes a member of a smaller group within the

larger society, such as the military, a profession, an urban gang, or a new

neighborhood. It occurs, too, when a child enters school with its new rules

and expectations. Secondary socialization is generally understood as involv-

ing smaller changes than those occurring in primary socialization.

People tend to acquire their learning about dying and death on an ad

hoc basis—that is, in a disorganized and impromptu fashion. Formal educa-

tion about death is offered through courses, seminars, and the like, but these

avenues of socialization are not part of most people’s experience. The term

tactical socialization refers to strategies that, for example, hospice caregivers use to informally teach people about death and dying. 65 Tactical socialization

involves actively attempting to change people’s perceptions and behaviors

about some aspect of their social world.

Family The family is the foundational social institution in all societies, although

the defi nition of “family” varies from place to place and time to time. In

the routines of daily life, the beliefs and values of parents are transmitted

to their children. The family is the fi rst source of death education in our

lives, and its infl uence continues throughout our lives. 66 It’s important to

recognize that the dead, especially deceased family members, can also serve

as agents of socialization, infl uencing the living in many ways. Richard Set-

tersten observes, “The infl uence of the dead may be just as great—or even

greater—than that of the living.” 67

Think back to your own childhood. What messages did you receive about

death that remain to this day in the back of your mind? Possibly some messages

were conveyed directly: “This is what death is” or “This is how we behave in rela-

tion to death.” Perhaps some messages were indirect: “Let’s not talk about it . . . . ”

How would the rest of that sentence go? Let’s not talk about it . . . because it’s

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Agents of Socialization 69

“Mom, if there was a dead rabbit in our house, I would ask you if I could poke it.

Then when you said no, I would do it anyway because I want to see if it is alive.”

A four-year-old

not something that people talk about? When, as a child, one woman encoun-

tered a dead animal on the highway, she was told, “You shouldn’t look at it.”

Her mother admonished, “Put your head down; children shouldn’t see that.”

This is a parental message about appropriate behavior toward death.

Other parental messages about death are communicated unconsciously.

Consider the notion of replaceability. A child’s pet dies, and the parent says,

“It’s okay, dear, we’ll get another one.” Children differ in their emotional

response to the death of a family pet; some grieve intensely when a beloved

pet dies. Quickly replacing it may not allow time for acknowledging the loss.

What lesson about death is taught? Imagine a situation in which a mother’s

grief over her mate’s death is interrupted by her child’s remark, “Don’t worry,

Mommy, we’ll get you another one.”

The way we learn about death tends to be a result of happenstance rather

than of systematic instruction. It is not always possible to pinpoint the genesis

of ideas that an individual acquires about death. Consider the following inci-

dent, involving two siblings ages eight and ten. When asked to draw a picture

of a funeral (see Figure 2-3 ), they got out their colored pencils and immersed

themselves in the task. After a while, Heather (ten) said to Matt (eight), “Hey,

you’ve got smiles on those faces! This is supposed to be a funeral. What are

they doing with smiles on their faces?” In her model of appropriate death-

related behavior, people don’t smile at funerals; to her younger brother, smiles

were perfectly acceptable. One can only guess the infl uences that provoke

such strong statements about what kind of behavior is appropriate at funerals.

The lessons about death that are learned in the family are conveyed by

actions as well as words. A woman now in her thirties tells the following story:

“I remember a time when my mother ran over a cat. I wasn’t with her in the

car, but I recall my mother coming home and just totally falling apart. She ran

into the bedroom and cried for hours. Since that time, I’ve been extremely

conscientious about not killing anything. If there’s an insect on me or in my

house, I’ll pick it up and carry it outside.” Parental attitudes, and the attitudes

of other family members, shape the values and behaviors not only of the child

but also of the adult that the child will become, and they infl uence how that

adult conveys attitudes toward death to his or her own children.

School and Peers Schools teach more than “reading, ’riting, and ’rithmetic.” The social

world of a child is dramatically broadened during the school years. Hobbies

and sports also connect children to a community and a set of social norms.

“The scraps of lore which children learn from each other are at once more

real, more immediately serviceable, and more vastly entertaining to them

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70 c h a p t e r 2 Learning About Death: Socialization

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Agents of Socialization 71

Figure 2-3 Children’s Drawings of a Funeral Instructed to draw a picture of a funeral, a sister (age ten) and brother (eight) did so. The ten-year-old, whose drawing is at the left, emphasizes the emotional responses of the survivors. We see the picture as if we are looking in (and down) upon their grief. The fi gures in the fi rst two pews have tears streaming down their faces, and one woman shouts, “No!” At ten, this child refl ects on the sor- rowful and unwelcome nature of death. When questioned about the empty pews, she said they were for anyone who came late.

The eight-year-old’s drawing (above) is viewed from a similar perspective (looking in and down at the scene). Here, we see the survivors grouped around a fl ag-draped and fl ower-bedecked coffi n. The fi gures are portrayed with smiles on their faces. The focus in this drawing is on the symbols of death (for exam- ple, the casket) and the ceremony rather than on the emotions. During the drawing session, the older sister commented that her brother’s picture was “too happy” for a funeral scene.

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72 c h a p t e r 2 Learning About Death: Socialization

than anything which they learn from grown-ups.” 68 Even before the school

years, children enter the social world of their peer group as they play with

other children of the same age and general social status. Recall how, in chas-

ing games, a touch with the tip of a fi nger can have a noxious effect, as if the

chaser were evil, magic, or diseased, and the touch was contagious. 69 Simi-

larly, in songs and rhymes, children share death imagery, as in the classic “As

the Hearse Goes By,” which includes the lines

Did you ever think as the hearse goes by

That you may be the next to die?

The worms crawl in, the worms crawl out,

The worms play pinochle on your snout.

With the broadening of a child’s social network, there is an increase in

learning about death.

Later in life, educational and work settings, clubs and organizations, lei-

sure pursuits, friends and neighbors, and so forth provide further opportuni-

ties for peer groups and other social networks to exert a powerful infl uence

on socialization through the life course.

Mass Media and Children’s Literature Television, movies, radio, newspapers, magazines, books, CDs, DVDs, and

the Internet—these media have a powerful socializing infl uence. Although

the manner in which death-related content is presented in media intended

for children can be evaluated as having both good and bad qualities, these

Disregarding my warning about the toxin I had added to a little refl ecting pond

behind our home because it was full of mosquito larvae, our son Mark carefully

poured a jar of tadpoles into the little pond and watched all of them die in an

instant. I heard his screams and ran outdoors to see what had happened. Huge

tears were streaming down his face. I picked him up to check his body to see if he

had any damage other than from watching all his little tadpoles fl oating with their

white bellies in the air.

He gasped deeply with his arms around my neck and sobbed, “Daddy . . . does

this mean that I’ll die? Will you die, too, Daddy?” I did my best to assure him that I

was not going to die then, nor would he, but that death was a part of our lives and

he would certainly be cared for.

And all of a sudden I was aware of what Gerard Manley Hopkins was saying

so beautifully in his poem I had read years before. In “Spring and Fall: To a Young

Child,” he was letting us know that children at an early age (Mark was about four

years old) could fi rmly grasp the concept that everything that lives will ultimately

die. During my training in child psychiatry I had been taught that children under

the age of eight or nine could not grasp the concept of death. Mark was half that

age and knew innately what my professors could not grasp, namely, that it is obvi-

ous even to children that everything that lives will die.

William M. Lamers, Jr.

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Agents of Socialization 73

media still serve as avenues for learning about death. 70 Media messages com-

municate cultural attitudes toward death to children, even when the message

is not purposely directed to them, as with news reports of disasters. When

President John F. Kennedy was assassinated, a classic study found that chil-

dren tended to select from the details presented by the media those aspects

that were consistent with their developmental concerns. 71 Younger children

worried about the appearance of the president’s body and the effects of the

death on his family; older children expressed concerns about the impact of

Kennedy’s death on the political system.

Many classic children’s stories and fairy tales depict death, near deaths,

or the threat of death. 72 There are “tales of children abandoned in woods; of

daughters poisoned by their mothers’ hands; of sons forced to betray their

siblings; of men and women struck down by wolves, or imprisoned in window-

less towers.” 73 Death has often had a place in children’s literature, and this

is especially true of the earliest versions of familiar stories that parents and

other adults share with children. Elizabeth Lamers says, “American children

taught to read with textbooks such as McGuffey’s Eclectic Readers found that death was presented as tragic, but inevitable, and many of the death-related

stories conveyed a moral lesson.” 74 In the nineteenth century, the violence

in children’s stories was usually graphic and gory so that it would make the

desired moral impression. 75

Cultural values related to death are also presented in children’s stories.

Consider, for example, the contrasts between different versions of the tale of

Little Red Riding Hood. One version, “Petite Rouge,” situates Riding Hood

in the swamps and bayous of Louisiana, and another, “Pretty Salma,” locates

her in an African marketplace. 76 In the traditional version of the story, the

wolf eats Little Red Riding Hood, but she is saved by a woodsman who kills

Little Red Riding Hood . . . “Dear me, Grandmamma, what great arms you have!”

The wolf replied: “They are so much better to hug you with, my child.”

“Why, Grandmamma, what great legs you have got!”

“That is to run the better, my child!”

“But, Grandmamma, what great ears you’ve got!”

“That is to hear the better, my child.”

“But, Grandmamma, what great eyes you’ve got!”

“They are so much better to see you with, my child.”

Then the little girl, who was now very much frightened, said: “Oh, Grand-

mamma, what great teeth you have got!”

“THEY ARE THE BETTER TO EAT YOU UP!”

With these words the wicked wolf fell upon Little Red Riding Hood and ate

her up in a moment.

Journeys Through Bookland, Volume One

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74 c h a p t e r 2 Learning About Death: Socialization

the wolf and slits its stomach, allowing Little Red Riding Hood to emerge

unharmed. In more recent versions, Little Red Riding Hood’s screams alert

the woodsman, who chases the wolf and then returns to announce that she

will be bothered no more (the killing of the wolf occurs offstage and is not

mentioned). 77

The Chinese tale of “Lon Po Po” (“Granny Wolf ”) comes from an oral

tradition thought to be over a thousand years old. In this version of the

story, three young children are left by themselves while their mother goes

away to visit their grandmother. The wolf, disguised as Po Po (Grand-

mother), persuades the children to open the locked door of their house.

When they do, he quickly blows out the light. By making perceptive inqui-

ries, however, the oldest child cleverly discovers the wolf ’s true identity and,

with her younger siblings, escapes to the top of a ginkgo tree. Through

trickery, the children convince the wolf to step into a basket so that they

can haul him up to enjoy the ginkgo nuts. Joining together, the children

start hauling up the basket. But, just as it nearly reaches the top of the tree,

they let the basket drop to the ground. The story says, “Not only did the

wolf bump his head, but he broke his heart to pieces.” 78 Climbing down

This grandmother and granddaughter read a story about loss as they share a special moment. Occasions for discussing death arise naturally out of our interactions with chil- dren. Often, the most important contribution an adult can make to a child’s learning is simply to be a good listener.

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Agents of Socialization 75

to the branches just above the wolf, the children discover that he is “truly

dead.” Unlike the Western version, which has a solitary child facing the

threat of the wolf by herself and ultimately being saved by someone else,

the Chinese folk tale emphasizes the value of being part of a group effort

to do away with the wolf.

Some children’s stories are written with the specifi c aim of answering

their questions about dying and death. In many such books, especially those

for young children, death is presented as part of the natural cycle. These

stories express the idea that, like the transition from one season to the next,

each ending in life is followed by renewal. In choosing a book to read with

a younger child or suggesting one for an older reader, it is important to fi rst

review the book yourself to evaluate how it presents information about death.

Books should be appropriate for a particular situation. For example, When Dinosaurs Die: A Guide to Understanding Death was selected when one young boy’s kindergarten teacher died unexpectedly. Each time he read and reread

this book with his parents, he raised different questions about his teacher’s

death. Books are published on such topics as learning about and understand-

ing death, the death of a parent, grandparent, sibling, and other relatives and

friends, as well as pets (see Figure 2-4 at the end of this chapter for a selection

of books about death for children and teens).

It is also important to pay attention to the language the author uses to

describe dying, death, and bereavement. Euphemisms such as “closure,” “mov-

ing on,” or “getting over the loss” may signal that an author is unfamiliar with

the theories and insights that apply to understanding loss. A story that refers

to death as sleep should raise a red fl ag about the ideas it is communicating

to children. Straightforward words such as died, dead, sorrow, and funeral

suggest the use of honest and accurate terminology. A book can give an adult

and a child an opportunity to begin talking about each other’s experiences.

Lullabies also contain themes of death and violence. 79 In every human

culture and in every historical period, adults have sung to children. It is

said that, with the fi rst lullaby a mother sings to her child, death education

begins. 80 Consider the message in this well-known lullaby:

Rockabye baby, in the treetops.

When the wind blows, the cradle will rock.

When the bough breaks, the cradle will fall.

Down will come baby, cradle and all.

Some lullabies are mourning songs, which describe the death or funeral

of a child; others are threat songs that warn of violence if a child does not go

to sleep or perform some other action in the expected manner.

Of two hundred nursery rhymes examined in one study, about half

described the wonder and beauty of life, whereas the other half dealt with

the ways in which humans and animals die or are mistreated. 81 Death-related

themes in these rhymes include accounts of murder, choking to death, tor-

ment and cruelty, maiming, misery and sorrow, as well as stories of lost or

abandoned children and depictions of poverty and want.

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76 c h a p t e r 2 Learning About Death: Socialization

Religion Contemplating one’s place in the universe is a crucial aspect of human

development, and religions the world over have traditionally been a fertile

avenue for such contemplation. Religion is not only a basis for morality and

human relationships; it can also give meaning to life. 82 As a fundamental

element of culture, religion and, more broadly, spirituality have the poten-

tial to shape individual lives and personalities. 83 Many concepts central to

religious traditions “are not as opaque to young children as often thought.” 84

It has been noted that “while more young people than ever claim to have no

religion, there seems to be a growing interest in ‘spirituality’ among them.” 85

In the United States, more than 90 percent of the population is affi liated

with a religious tradition. 86 These traditions are naturally part of a child’s

socialization. (The role of religion and religious belief is discussed in more

detail in Chapter 14.)

Teachable Moments In the course of their daily lives, opportunities abound for children to learn

about dying and death. 87 Consider, for example, a mother who discovers her

eleven-year-old son sitting at her new computer writing his will. Taken aback,

she pauses for a moment as thoughts race through her head: Why is he writing

a will? How did an eleven-year-old become interested in giving away his favor-

ite treasures? Does he believe he is going to die soon? What should I do? What

can I say? Gathering her courage, she cautiously adjusts her tone to suggest a

neutral stance and asks, “What has made you think about writing a will?”

Turning to her, the joy of accomplishment lighting up his face, the boy

says, “I was looking at the menu on your computer and found Willmaker. The program came up, and all I have to do is fi ll in the blanks. It’s easy, see? Then

I can print out my very own will.”

Thus we encounter the concept of the teachable moment, a phrase used by educators to describe opportunities for learning that arise out of ordinary

experiences. Because of their immediacy, such naturally occurring events

are ideal for learning. The learner’s questions, enthusiasm, and motivation

guide the educational process. If we assume that learning always fl ows in a

single direction, from adult to child, we miss the quintessential quality of

education as an interactive process. In the example of the young boy fi lling

in the blanks of a computerized will-making program, the mother appears to

occupy most clearly the role of the learner. She learns something about her

son’s exploration of the new computer and, more important, she learns the

crucial lesson of gathering information before reacting.

Suppose this mother, acting out of initial shock at her son’s apparent

interest in death, had hastily responded, “Stop that! Children shouldn’t be

thinking about wills or about dying!” A lesson about death would surely be

taught, but it wouldn’t promote a healthy understanding. It is useful to ask,

What is being taught? Does the “teaching” result from a conscious design? Or is it unintentionally conveying unhealthy messages about death?

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Teachable Moments 77

Let’s return to our story of the mother and son. Having elicited informa-

tion without acting on her initial anxiety, the mother can use this conversa-

tion as an opportunity to discuss death with her son. She might call attention

to the entry for “Designated Guardian for Minor Children,” informing her

son about the steps she has taken to ensure his well-being (“Did I tell you

that Aunt Martha and Uncle John are listed in my will as your guardians?”)

as well as responding to his concerns (“No, I do not intend to die for a long

time”). They might spend a few minutes talking about other aspects of death

and how people prepare for it. An atmosphere of openness is promoted as

information is exchanged between adult and child. Much learning can take

place in a brief conversation.

Teachable moments are often defi ned in the context of unplanned or

unexpected occurrences, but it is useful to recognize that parents, educa-

tors, and other adults can intentionally create situations that encourage

such opportunities for learning about death. 88 There is no rule that we

must wait until such events happen spontaneously. Indeed, in the example

given earlier, the mother used her son’s experience with the computer pro-

gram as a way of introducing their subsequent discussion about death. Simi-

larly, in fi lms produced for children, death is frequently part of the plot,

and this can lead to a natural discussion about how grief, for example, is

portrayed among the various characters. 89 The key to making the most of

such opportunities is adequate preparation by trusted adults in the child’s

environment.

Teachable moments take place not only between adults and children but

also between adults. While on an airplane trip, an executive for a large cor-

poration engaged one of this book’s authors in conversation. Upon learn-

ing the subject of this textbook, his tone changed a bit as he said, “Could

I ask your opinion on a personal matter?” The question involved a family

dispute about whether the man’s fi ve-year-old son should attend his grand-

father’s burial ceremony at Arlington National Cemetery. He was concerned

that the military ceremony—with uniforms, soldiers, and a twenty-one-gun

salute—would frighten his son. After he shared additional information about

his family and child, suggestions were offered about ways that parental sup-

port could be provided to the child during the funeral rites. Hearing these

suggestions made it possible for the man to reconsider his earlier decision to

Recently my seven-year-old son hopped in my lap and we watched the evening

news together. The concluding line of a report on environmental pollution was a

quote from U.N. scientists predicting that in twenty years the world would be un-

inhabitable. As the TV switched to a Madison Avenue jingle designed to encour-

age us to purchase a non-greasy hair tonic, my son turned to me with a terribly

small voice and asked: “Dad, how old will I be when we all die?”

Robert D. Barr, The Social Studies Professional

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78 c h a p t e r 2 Learning About Death: Socialization

exclude the child. With specifi c recommendations in hand, he decided that

his son should be present at his grandfather’s funeral. You do not have to be

the author of a textbook to offer information that is helpful to people who

are coping with death-related issues. In reading this book, you will gain infor-

mation that can be appropriately shared.

The Death of a Companion Animal One mother described the responses of her daughters to the deaths of a

new litter of baby rabbits. 90 Upon learning the news, the seven-year-old

burst into tears and howled, “I don’t want them dead.” The fi ve-year-old at

fi rst stood silently and then asked to call her father at work. She told him,

“If you had been here, Daddy, you could have been the rabbits’ doctor,”

refl ecting a belief, appropriate for her age, that it should have been possible

somehow to save the baby rabbits or restore them to life. Later, when the

children began to dig a grave to bury the dead rabbits, the seven-year-old

stopped crying for the fi rst time since learning the news, while the fi ve-year-

old kept repeating, “The baby rabbits are dead, the baby rabbits are dead,”

in a monotone.

In the days following the rabbits’ deaths, the girls asked many ques-

tions. The seven-year-old was particularly interested in questioning a family

friend, who was a widow, about her dead husband. How often did she think

about him, and why did people have to be taken away from those who loved

them, she wanted to know. The fi ve-year-old, meanwhile, continued to mourn

silently until her mother encouraged her to express her feelings. Then she

began to sob. Finally, she said, “I’m glad I’m only fi ve; you only die when

you’re old.”

The younger child’s fi rst concern was for herself, the fear that she her-

self could die. The older child worried about the durability of relationships.

Although each child had a distinctive response to the loss, both children

showed a need to be close to their parents during the days following the

deaths of the rabbits, and they told the story of the rabbits’ deaths again and

again as they dealt with their experience.

Adults may wonder how best to help a child cope with the death of a

beloved pet. Should one minimize the loss? Obtain a replacement animal?

Or should the death be seen as a natural opportunity to help the child con-

sider what death means and explore his or her feelings about the loss? “Pets,

whose lives are shorter than [those of] humans, can teach children about the

life cycle, including loss.” 91

Of course, it is not only children who are affected by the death of a pet.

Kelly McCutcheon and Stephen Fleming point out that “the loss of a pet

often involves responsibility for life and death which can make grieving espe-

cially diffi cult. When a pet is seriously ill, the owner is faced with the major

decision of whether the pet’s life is worth continuing or if the pet should be

euthanized.” 92

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The Death of a Companion Animal 79

Pets can mean many different things to their “pet parents.” 93 For some

people, a pet is viewed as a best friend. A pet may be a bridge to the past, a

reminder of happier times or of poignant events. A pet can be a source of

support during a loss or other times of stress. For people who are coping with

serious illness, a pet may be both a source of comfort and a reason for living.

As has been wisely said, “The unique bond with a particular pet can never be

duplicated.” 94 We may bond again with another pet, but we can never replace

the one lost.

Barbara Ambros writes about the changing view of animal spirits in

Japan, where pets who had died were regarded as recently as the mid-1990s

as becoming vengeful, threatening spirits and now a decade or so later are

viewed as loving, faithful spiritual companions. Ambros says, “Pets are often

buried and memorialized with rites due to a family member,” noting that

many pet owners “seem to have a strong urge to perpetuate the bond that

they felt with their pet even after the pet’s death.” 95 A similar transition, albeit

without the occult overtones, is found in an account by Michelle Linn-Gust,

describing how the role of dogs in families has shifted from hunting and pro-

tection to “membership” in the family. 96

The strong attachment felt toward an animal companion is shown in this homemade tomb- stone and burial plot. Experiencing grief and memorializing a beloved pet are natural accompaniments to such a loss.

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80 c h a p t e r 2 Learning About Death: Socialization

A woman described the reaction of her husband to the death of Iggy, a

desert iguana. 97 When the iguana died, her husband “cried throughout the

shoebox burial in the backyard.” He later said that he was crying “for every

pet he had ever loved and lost.” The death of a pet can evoke numbness and

disbelief, preoccupation with the loss, being drawn toward reminders of the

pet, anger, depression, and the whole range of mental and emotional quali-

ties associated with grief following a signifi cant loss. Rather than viewing a

pet as a possession, many people feel that a pet is not only a companion but

“part of the family.” 98

Those who counsel individuals who are grieving over the loss of a pet

emphasize that feelings should be expressed by adults as well as children.

The circumstances of an animal’s death can infl uence the grief reaction; for

instance, the loss of a pet whose death occurred because of an accident may

result in grief of longer duration than that of a pet who died a natural or

even a euthanized death. 99 “Pet parents” may experience feelings of guilt and

direct responsibility for a companion animal’s death by euthanasia; after all,

the animal cannot communicate a wish to die explicitly through language in

the way humans can in a living will or other advance directive.

When a decision is made to euthanize an animal, some experts advise

informing children about the process. 100 They can be told that the animal

is in the process of dying and that the veterinarian will assist in this pro-

cess by giving an injection that helps the pet die without suffering. Chil-

dren should also be told that this injection is a powerful medicine that is

given only to animals, so the child will not fear getting a vaccination or

other injection.

Although attachments between humans and pets can be very strong,

mourning the loss of a pet sometimes elicits ridicule, or worse. After Hur-

ricane Katrina, some people in authority were unconcerned about stranded

companion animals and did not consider them important. Reportedly, rather

than argue with survivors about saving a family dog, some local authorities

simply shot pets, disregarding the fact that many people who live with an

animal consider it important enough to risk their own personal safety to keep

a pet from harm. 101 It has been observed that “victims of disaster are often

accidentally or forcibly separated from their pets, sometimes permanently,

just at the time they need one another most.” 102

People sometimes say that the bereaved pet owner’s grief is excessive

or that it’s an overreaction. After all, “It was only an animal, a mere pet.”

However, as Allan Kellehear and Jan Fook point out, “Despite the popular

tendency in some quarters to trivialize such loss, the general literature on

pet–human relations portrays bereaved owners as every bit as beset with

the same power and range of emotions as for other kinds of human loss.” 103

In many parts of the country, pet cemeteries exist, and they provide

options for the fi nal disposition of a companion animal’s remains. The Gate-

way Pet Cemetery located in Southern California, for example, offers both

burial and cremation. Veterinary schools can be good sources of information

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The Mature Concept of Death Revisited 81

about disposition options as well as about end-of-life care of companion ani-

mals, including “hospice care for pets.” 104

When the bond between an animal and its carer is broken by death,

the signifi cance of that loss should be recognized as a natural occasion for

mourning. 105 This is true for adults as well as children. Cheri Barton Ross

explains,

A child might decide to wear the cat’s collar to feel close to a cat that has died.

Some children choose to cuddle or sleep with the pet’s bedding. One woman

shared that she saved her dog’s collar and wore it as a garter—for something

blue—under her wedding gown in honor of the dog with whom she had

grown up. 106

Suffi cient time for mourning the loss should be allowed before a new

animal is acquired. “For some owners, grieving may be facilitated by the

presence of another pet, but for others, replacement may never be appro-

priate.” 107 The right time for another pet is likely to be when grief has been

integrated suffi ciently to enable one to reinvest emotionally in a new pet. As

Avery Weisman observes, “The depth of a human–animal bond often exceeds

that between a person and close kith and kin.” 108

The Mature Concept of Death Revisited The process of socialization is complex and ongoing. With new experiences

of loss and death, we modify previously held beliefs, exchanging them for

new ones that provide a better fi t with our current understanding of death

and its meaning in our lives. A “mature” concept of death, acquired dur-

ing childhood, becomes a foundation for further development in adult-

hood. 109 Sandor Brent and Mark Speece note that a basic understanding

of death is “the stable nucleus, or core, of a connotational sphere that the

child continues to enrich and elaborate throughout the remainder of life by

the addition of all kinds of exceptions, conditions, questions, doubts, and

so forth.” Instead of the “neat, clean, sharply delineated concepts of formal

I like especially the small town cemeteries of America where the children come

for picnics and games, as we did when I was growing up—wandering among the

stones on our own, with no adults about, to regard the mystery and inevitability of

death, on its terms and ours. I remember we would watch the funerals from afar in

a hushed awe, and I believe that was when I became obsessed not with death itself

but with the singular community of death and life together—and life’s secrets,

life’s fears, life’s surprises.

Willie Morris, Shifting Interludes

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82 c h a p t e r 2 Learning About Death: Socialization

scientifi c theories of reality,” the end result of this process may be a kind of

“fuzzy” concept that acknowledges the reality of death while leaving room

for elaborations about its meaning. Thus, the binary, either-or logic that

young children use to grasp the core components of a mature concept of

death is a precursor to the greater sophistication in understanding death

that comes later in life. 110

David Plath says,

We are born alone and we die alone, each an organism genetically unique.

But we mature or decline together: In the company of others we mutually

domesticate the wild genetic pulse as we go about shaping ourselves into

persons after the vision of our group’s heritage. Perhaps the growth and aging

of an organism can be described well enough in terms of stages and transitions

within the individual as a monad entity. But in a social animal the life courses

have to be described in terms of a collective fabricating of selves, a mutual

building of biographies. 111

It is said that the single most important thing one can do to infl uence

the development of an infant is to “decide where on earth—in what human

community—that infant is going to grow up.” 112 Understanding ourselves as

cultural beings, we are better able to understand others as cultural beings.

Even though we identify (or are identifi ed by others) with a particular group,

we are also individuals who sometimes do things our own way. Psychologists

tell us that every person is composed of “multiple identities” and that the abil-

ity to manage different identities is an important aspect of the self. 113 Culture

does not determine behavior but, rather, gives us a “repertoire of ideas and

possible actions” through which we understand ourselves, our environment,

and our experiences. 114

Albert Bandura says, “Theorists who approach human development from

a life-span perspective treat the environment not as a situational entity, but as

a varied succession of life events that differ in their power to affect the direc-

tion lives take.” 115 The social circles in which one moves, the kinds of people

who populate those settings make some types of “intersects” more probable

than others. Bandura cites the example of a child living in a crime-ridden

neighborhood as being likely to experience chance encounters quite differ-

ent from those experienced by a child residing at a prep school.

Take a moment to consider your own circumstances. Do you live in a

rural, urban, or small-town environment? What region of the country do you

live in, the North, East, South, or West? Was your school environment ethni-

cally and religiously diverse, or was it not? Your response to death is likely

to be infl uenced by such factors. Life experiences are powerful in shaping

a person’s attitudes and beliefs about death. A person may not become fully

aware of the impact of childhood experiences with death until adulthood. A

ten-year-old’s agonized phrase, “It’s sickening, don’t talk about it!” can sur-

vive into adulthood.

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The Mature Concept of Death Revisited 83

Books for Younger Children

Cathy Blanford. Something Happened. Illustrated by Phyllis Childers. Western Springs, Ill.: Cathy Blan- ford, 2008. A clearly illustrated book that discusses pregnancy loss in language easy for young chil-

dren to understand. Also has information for grieving parents to help their children. Ages 3–7.

Marc Brown. When Dinosaurs Die: A Guide to Understanding Death. Illustrated by Laurie Krasny Brown. Boston: Little, Brown, 1996. This cartoon-like book offers comfort and reassurance to children by

addressing their fears about death, explaining in simple language the feelings people may have

when a loved one dies and ways of remembering someone who has died. Ages 3–8.

Margaret Wise Brown. The Dead Bird. Illustrated by Remy Charlip. New York: Morrow, 2004. A simple story in which children fi nd a dead bird and conduct a funeral and burial. Ages 4–8.

Bill Cochran. The Forever Dog. Illustrated by Dan Andreasen. New York: HarperCollins, 2007. Mike makes a Forever Plan with his dog Corky to be best friends forever; it works beautifully until Corky dies

unexpectedly. In his grief, Mike is angry at Corky for breaking his promise. With his mother’s help,

Mike realizes the Forever Plan is going to work differently. Corky will be in his heart forever. Ages 4–8.

Bill Cosby. The Day I Saw My Father Cry. Illustrated by Varnette P. Honeywood. New York: Scholastic, 2000. The sudden death of a family friend brings lessons in experiencing and expressing grief.

Ages 4–10.

Mary Newell DePalma. A Grand Old Tree. New York: A. A. Levine, 2005. Clearly illustrated easy- reader picture book about the life cycle. The grand old tree slowly crumbles and becomes part

of the earth. The roots of her "grandchildren" sink deep into the earth and are home to many

creatures. Ages 4–8.

DyAnne DiSalvo-Ryan. A Dog Like Jack. New York: Holiday House, 2001. Story of loving and losing an aged pet. An epilogue contains suggestions for parents about pet loss. Ages 4–8.

Joan Drescher. The Moon Balloon: A Journey of Hope and Discovery for Children and Families. Waltham, Mass.: Arvest Press, 2005. A colorful book about hot-air balloons, each of which contains a feeling

that a child might have when coping with change. Examples of the balloons include the angry bal-

loon, the tear balloon, the stress balloon, the love balloon, and the giggle balloon. Gives children

an opportunity to draw or write about their feelings and offers helpful tips for adults. Ages 6–11.

Wolf Erlbruch. Duck, Death and the Tulip. Wellington, New Zealand: Gecko Press, 2008. With a gor- geously drawn colored-pencil style, this book explores a relationship between a duck and Death.

The duck becomes friends with Death; they go to the pond where Death (drawn as a clothed

skull) becomes chilled. Duck offers to warm Death, spreading her body and feathers over Death.

When Duck wakes in the morning, she is still alive and the story continues until the seasons

change and she becomes chilled, dying in the night. Death carries her to the great river, places a

tulip on her breast. “For a long time he watched her. When she was lost to sight, he was almost a

little moved. But that’s life, thought Death.” A good book to demystify death and begin a discus-

sion. Ages 4–up.

Anne Fontaine. Ocho Loved Flowers. Illustrated by Obadinah. Seattle: Stoneleigh Press, 2007. A story about Annie and her cat Ocho. Ocho becomes ill and the veterinarian tells Annie and her mom

that Ocho has only one month to live. During Ocho’s last month, Annie learns how to help her

mom care for him. After Ocho dies, Annie buys fl owers in memory of Ocho. Ages 4–8.

(continued)

Figure 2-4 Books About Death for Children and Teens Prepared with the assistance of Dr. Carol F. Berns, cofounder of the Children’s Bereavement Center, Miami, Florida. Additional resources can be found on The Last Dance website.

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84 c h a p t e r 2 Learning About Death: Socialization

Books for Younger Children (continued)

Eiko Kadono. Grandpa’s Soup. Illustrated by Satomi Ichikawa. Grand Rapids, Mich.: Eerdmans, 1999. After Grandma’s death, Grandpa fi xes her soup recipe for his friends, including his mice friends.

Ages 4–8.

Laurie A. Kanyer. 25 Things to Do When Grandpa Passes Away, Mom and Dad Get Divorced, or the Dog Dies. Seattle: Parenting Press, 2004. Offers education to parents or other adults who are working with

grieving children. The second half of the book describes twenty-fi ve activities to help children

experiencing loss, including art and craft activities as well as high-energy outdoor activities.

Ages 6–11.

Essie Lafl amme. Caring for Mama Bear: A Story of Love. Illustrated by Marie Crane-Yvon. Naples, Fla.: Quality of Life Publishing. 2010. Despite her declining health, Mama Bear’s days are sprinkled

with laughter, family, and love thanks to her sons the Brother Bears. Mama Bear’s last weeks are

spent at a Hospice House and she is comfortable and feels loved. This story is good for families

served by hospice and includes tips and resources for parents. Ages 7–10.

Marisol Munoz-Kiehne. Since My Brother Died: Desde que Murio Mi Hermano. Illustrated by Susanna Pitzer. Omaha, Neb.: Centering Corporation. 2008. A young boy talks about how his life has changed

since his brother’s death, yet he is comforted knowing that he will always love and remember him.

The boy’s journey is told in English and Spanish and the book includes a resource for parents and

professionals. Ages 5–12.

Ellen Sabin. The Healing Book. New York: Watering Can Press, 2006. A memory book fi lled with page after page of opportunities for children to work through grief-related feelings as well

as remember the person who died. Excellent tool for adults working with grieving children.

Ages 6–13.

Harold Ivan Smith and Joy Johnson. What Does That Mean? Omaha, Neb.: Centering Corporation, 2006. A dictionary of death, dying, and grief terms for children. Offers age-appropriate defi nitions of

words that grieving children hear but may not understand. Ages 6–12.

Patricia Smith. Janna and the Kings. Illustrated by Aaron Boyd. New York: Lee and Low Books, Inc., 2003. A tender story of Janna, an African American girl, who spends Saturdays with her grand-

father and his buddies, the Kings. When Granddaddy dies, Janna is devastated. But when his

old friends welcome her, they talk and share memories and she feels his love once again. Ages

5 and up.

Pat Thomas. I Miss You: A First Look at Death. Illustrated by Lesley Harker. Hauppauge, N.Y.: Barron’s, 2001. "Every day someone is born and every day someone dies" begins this frank and sensitive

look at death, including how people die, funerals, a survivor’s feelings, and how people of differ-

ent cultures engage in death rituals. Ages 4–8.

E. B. White. Charlotte’s Web. Illustrated by Garth Williams. New York: Harper & Row, 1952. Classic story describes grief experienced at the death of a close friend—Charlotte, a spider—and the continu-

ing of life through her offspring. Ages 3–up.

Jeanette Winter. September Roses. New York: Farrar, Straus & Giroux, 2004. South African sisters who raise roses come to New York on September 11, 2001. Addresses the sorrow of the terrorist attack

and the response of those living through the disaster. A picture book, although not one a child

can read because the text is in cursive. Ages 4–8.

Harriet Ziefert. Ode to Humpty Dumpty. Illustrated by Seymour Chwast. New York: Houghton Miff- lin, 2001. The ultimate book for understanding rituals. A town comes together to memorialize

Humpty’s death. Ages 5–13.

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The Mature Concept of Death Revisited 85

Books for Older Children and Teens

The Dougy Center (Portland, Ore.). After a Death: An Activity Book for Children/Después de un fallecimiento, 2007; After a Murder: A Workbook for Grieving Kids, 2002; After a Suicide: A Workbook for Grieving Kids, 2001. Interactive workbooks in which children learn from other children who have experienced

a death. These workbooks encourage children to express their thoughts and feelings through a

variety of activities, including drawings, puzzles, word games, helpful stories, and advice from

other kids and adults. Ages 9–up.

Dina Friedman. Playing Dad’s Song. New York: Farrar, Straus & Giroux, 2006. When Gus was nine, his father died in the attack on the World Trade Center. Gus struggles with missing his father and,

at the same time, does not want anyone to ask him about his father. He feels isolated because he is

the only person he knows who had a parent die on 9/11. He uses music for comfort and to honor

the memory of his father. Ages 9–12.

Carole Geitner. If Only. New York: Scholastic Press, 2012. Corinna, a typical eighth grader, whose mother has just died of cancer, gives voice to her experiences of loss, grief, relationships with

friends, and other teen concerns in this sensitive and honest book. Ages 12 and up.

Marc Gellman and Thomas Hartman. Bad Stuff in the News: A Guide to Handling the Headlines. New York: SeaStar Books, 2002. After seeing a big offi ce building crash to the ground or seeing kids

shooting other kids at school, you might think the world is so scary that the only safe place is

hiding under your bed. Written to help kids understand and cope with dangers in the world.

Includes terrorism, kids killing kids, disasters (both natural and human caused), death through

abuse, dangerous sports, diseases that kill, and more. Simple and easy to read. Ages 10–13.

Earl Grollman and Joy Johnson. A Complete Book About Death for Kids. Omaha, Neb.: Centering Cor- poration, 2006. Comprehensive information to help explain death to older children. Complex

concepts are clearly defi ned. Written in easy-to-understand language. Ages 9–12.

Amy Hest. Remembering Mrs. Rossi. Illustrated by Heather Maione. Somerville, Mass.: Candlewick Press, 2007. Annie Rossi is eight years old when her mother, a sixth-grade teacher, dies. Her father does

his best to do all of the things that Annie’s mom did, but no one can replace Annie’s mom. Annie is

helped when her mother’s class creates a special memory book about her (included at the end of this

novel). With few books addressing the death of a mother, this one is a standout. Ages 9–12.

Gloria Horsley and Heidi Horsley. Teen Grief Relief. Highland City, Fla.: Rainbow Books, 2007. Informa- tion for teens and their parents about ways grieving teens can be helped. Easy to read. Includes

vignettes from teens who have "been there," as well as activities teens can do to cope with feelings

of sadness, anger, and guilt. Ages 12–up.

Carrie Stark Hugus. Crossing 13: A Memoir of a Father’s Suicide. Denver: Affi rm Publications, 2008. A teen- age girl discovers her father dead from suicide. Young survivors will identify with and benefi t from

understanding that their confusing, and often frightening, grief responses are normal. Ages 12–up.

Davida Wills Hurwin. A Time for Dancing. New York: Puffi n, 1997; reissued 2009. In this powerful novel about how terminal illness affects the lives of friends and others around them, two teenage girls

who have been best friends since childhood face mortality when one is diagnosed with histiocytic

lymphoma, a deadly cancer. Ages 12 and up.

Amy Goldman Koss. Side Effects. New Milford, Conn.: Roaring Brook Press, 2006. The story of teenage Izzy’s bout with cancer. Excellently detailed view of Izzy’s and her family’s coping mechanisms.

Teens will identify with her, whether they or someone they know has cancer or they are just curi-

ous about life-threatening illness. Ages 9–12.

(continued)

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86 c h a p t e r 2 Learning About Death: Socialization

Books for Older Children and Teens (continued)

Erika Leeuwenburgh and Ellen Goldring. Why Did You Die: Activities to Help Children Cope with Grief and Loss. Oakland, Calif.: Instant Help Books, 2008. Offers detailed, helpful activities for children who have experienced a death. The fi rst part of the book offers practical information for parents

and other adults to help a grieving child. The second half of the book has activities to help griev-

ing children. Ages 9 and up.

Wendy Mass. Jeremy Fink and the Meaning of Life. New York: Little, Brown, 2006. When Jeremy was eight, his father died in a car accident. A few months before he turns thirteen, he receives a mysteri-

ous wooden box in the mail that his father had created for him before his death. According to

Jeremy’s father, this box contained the Meaning of Life. There is only one problem: There are no

keys! Jeremy spends the summer fi nding the keys to unlock this precious gift from his beloved

father. Ages 9–12.

Sheryl McFarlane. The Smell of Paint. Brighton, Mass.: Fitzhenry & Whiteside, 2006. Story of Jess, a high school freshman, whose mother is diagnosed with incurable bone cancer. Jess tries to deal

with her mother’s illness by herself, not wanting even her closest friends to know. Explores Jess’s

complicated relationship with her dying mother. Ages 12 and up.

Katherine Paterson. Bridge to Terabithia. Illustrations by Donna Diamond. New York: HarperTrophy, 1987; reissued HarperTeen, 2009. In this Newberry award winner, fi fth grader Jess’s rural world

expands when he meets his new neighbor, a tomboy named Leslie. They become best friends

and create a secret kingdom in the woods named Terabithia. When Leslie drowns, Jess’s life is

changed forever. Ages 11 and up.

Lila Perl. Dying To Know: About Death, Funeral Customs, and Final Resting Places. Brookfi eld, Conn.: Twenty-First Century Books, 2001. This small book uses photographs and text to acquaint the

reader with death customs and practices in the United States and other parts of the world. Orga-

nized into sections that address attitudes and practices from different religions and countries, as

well as historical information. Ages 12–18.

Margo Rabb. Cures for Heartbreak. New York: Random House, 2008. This book deals with grief and typical teen issues in a straightforward manner with wit and wisdom and a dabbling of sarcasm.

Fifteen-year-old Mia Perlman struggles to make sense of her mother’s death, her father’s illness,

and her relationship with her sister. Mia’s voice and those of the other characters are genuine,

powerful, and raw. Ages 14 and up.

Jordan Sonnenblick. Drums, Girls, and Dangerous Pie. New York: Scholastic, 2006. Jeffery is diagnosed with leukemia. Big brother protector Steven says, "So how come when I wasn’t looking Jeffy got

cancer." Written in the voice of the older sibling, the story touches on many aspects of living with

life-threatening illness, including the strain put on his entire family. Ages 11–14.

Staff of the New York Times. A Nation Challenged: A Visual History of 9/11 and Its Aftermath (Young Read- er’s Edition). New York: Scholastic, 2002. Combines stories published in the newspaper and Pulit- zer Prize-winning photographs to present an account of terrifying events in an age-appropriate

fashion. Ages 9–14.

Peter Lane Taylor and Nicola Christos. The Secret of Priest’s Grotto: A Holocaust Survival Story. Minneapo- lis: Kar-Ben, 2007. Remarkable story of the survival of Jewish families who lived in a gypsum cave

called Popwa Yama in the Ukraine for 344 days to escape the Gestapo. Includes excerpts from the

privately published memoir of Esther Stermer, We Fight to Survive, that recount the dark epoch— the darkness being both literal and fi gurative. Ages 9–12.

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Further Readings 87

Terry Trueman. Hurricane: A Novel. New York: HarperCollins, 2008. José, from La Rupa, Honduras, tells the story of surviving a disastrous hurricane. José narrates the story of his life before and

after the hurricane. Ages 9–12.

Jamie Lee Wheeler. Weird Is Normal When Teenagers Grieve. Naples, Fla.: Quality of Life Publishing. 2010. Jenny is compelling and forthright as she speaks of her father’s illness and death when she

was fourteen years old. Her sage words and style are rich beyond her years, making this book an

excellent resource for teens and adults. At the end of each chapter are bullet points for easy read-

ing and suggestions. Ages 12 and up.

Kazumi Yumoto. The Friends. Translated by Cathy Hirano. New York: Farrar, Straus & Giroux, 1996; reissued, 2005. In a story that is both universal and rooted in the country and culture from which

it comes, three young boys’ fascination with death leads them to form an unexpected friendship

with an old man through which they confront their fears and learn to accept the inevitable with a

sense of joy in life. Ages 9 and up.

Nan Zastrow. Ask Me . . . 30 Things I Want You to Know: How to be a Friend to a Survivor of Suicide. Omaha, Neb.: Centering Corporation, 2008. Straightforward book about helping survivors of suicide.

These tips will assist family members and friends of survivors when they are at a loss as to how to

help. Ages 16 and up.

Further Readings David Clark, ed. The Sociology of Death: Theory, Culture, Practice. Cambridge, Mass.:

Blackwell, 1993.

Lynn Schofi eld Clark. From Angels to Aliens: Teenagers, the Media, and the Supernatural. New York: Oxford University Press, 2003.

Lynne Ann DeSpelder and Albert Lee Strickland. “Culture, Socialization, and Death

Education.” In Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 323–331. New York: Routledge, 2013.

Patricia H. Miller. Theories of Developmental Psychology, 4th ed. New York: Worth, 2002. Clive F. Seale. Constructing Death: The Sociology of Dying and Bereavement. Cambridge:

Cambridge University Press, 1998.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e .

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In this celebration of Día de los Muertos, or Day of the Dead, held in a California community, a child enters into the festivities by drawing a skull, an activity that reinforces her identity as a participant in age-old traditions that mark her culture’s particular attitudes and behaviors relative to death. In pluralistic societies, such celebrations both perpetuate cultural traditions and allow them to be shared with people from the wider community, who may choose to adopt elements of those traditions in their own lives, thereby creating a distinctive sense of local identity with respect to death-related customs and practices.

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89

C H A P T E R 3

Perspectives on Death:

Historical and Cultural

A lthough death is fundamentally a biological fact, socially shaped ideas and assumptions create its meaning. Consider, for instance, Hindus who live in England and

their encounter with cultural imperatives related to death rituals. 1 In India, where there

are few undertakers or funeral directors, funeral arrangements are usually made by the

deceased’s family. Cremation is a public event, and the principal mourner lights the sacred

fl ame of the funeral pyre; in Britain, the body is placed inside a coffi n and concealed from

view inside the cremator, which is operated by employees of the crematorium. “For the

mourners there is neither the smoke to sting their eyes, nor the fi re to singe their hair, nor

the smell of burning fl esh to bring the poignant immediacy and reality of the experience

to their consciousness.”

This example illustrates how the multicultural nature of today’s societies brings chal-

lenges to traditional cultural identities. Such challenges apply not only to members of immi-

grant populations but to people generally. Most people worldwide now develop a bicultural

or “hybrid” identity that “combines their local cultural identity with an identity linked to

elements of the global culture.” 2

Culture can be defi ned as “all that in human society which is socially rather than bio-

logically transmitted.” 3 Broadening our perspective to include cultures other than our

own increases the range of choices available in our encounters with death. In becoming

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90 c h a p t e r 3 Perspectives on Death: Historical and Cultural

culturally competent, we gain the capacity to respond appropriately and skill- fully to the diversity encountered in culturally pluralistic societies.

People tend to view the world from a single perspective—their own—and

to apply their own cultural criteria as benchmarks for judging the values of

other communities. Stereotypes are sometimes used as a learning strategy

to organize and interpret information, but in fact there may be more differ-

ences within cultural groups than between cultural groups. Engaging the

ideas and customs of other cultures is an antidote to ethnocentrism —that is, the fallacy of making judgments about others in terms of one’s own cultural

assumptions and biases.

Society is defi ned as “a group of people who share a common culture, a common territory, and a common identity; and who feel themselves to consti-

tute a unifi ed and distinct entity which involves interacting in socially struc-

tured relationships.” 4 Much as in studying the human body, where we look at

the structure and function of various organs and their interrelationships, we

can view society as an organic whole in which constituent parts work together

to maintain each other and the whole society. The structural view of society refers to the “enduring and patterned aspects which provide the context and

background against which people live out their daily lives.” 5

Social institutions are related in such a way that a change in one leads

to changes in others (see Figure  3-1 ). For example, in northeastern Brazil,

Figure 3-1 Social Structure

Family Religion

EconomyEducation

Political system

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Perspectives on Death: Historical and Cultural 91

a region where many people live in extreme poverty, political authorities do

not bother to keep accurate statistics about infant mortality among the poor. 6

Looked at from the perspective of social structure, this example illustrates

how the economy has an impact on the political system, with consequences

that, in turn, affect the social reality of poor Brazilian families.

This view of society helps us appreciate the institutionalized bases of atti-

tudes and behaviors toward death. In North America, cultural expectations

about death refl ect a social reality consistent with a technology-oriented and

bureaucratic society. An appropriate death is one that occurs naturally and is

correctly timed—that is, occurs in old age. 7 The bureaucratic aspect of death

in modern societies is designed to prevent disruptions and preserve the equi-

librium of social life. 8 In this structural framework, death tends to be moved

to the periphery of social life. 9

Symbolic interactionism refers to the idea that people are actively responsive to, and indeed the creators of, the social structures and processes in their

lives. In a study of dying Canadian “First Nation” patients and their griev-

ing families in urban hospital settings, researchers found that European

Canadian caregivers and Native Canadian patients bring to their encoun-

ters differing interpretations of appropriate care. 10 Engaging one another

in interactions to resolve confl ict between these differing views resulted in

changes in attitudes and behaviors of both caregivers and patients. As new

“meanings” emerged, the hospital “culture” changed.

When we conform to social norms, our behavior is reinforced or

rewarded; when we fail to conform, our behavior is punished or goes

unrewarded. Social learning also occurs through vicarious reinforcement, which takes place when a person observes others reinforced for a behav-

ior but has not been directly reinforced himself or herself. We may not

even be aware that we are conforming to some social norms, because they

are embedded in our way of life. We accept them as natural, “the way

things work.”

For instance, in societies today, people are unlikely to consider dispos-

ing of a relative’s corpse by placing it on a scaffold outdoors where it will

gradually decompose; yet, to Native Americans living on the Great Plains

in the nineteenth century, platform burial was natural as part of their

social norms.

In culturally diverse societies, we have ample opportunities to apply these

insights in expanding our understanding of customs and behaviors associ-

ated with dying, death, and bereavement. A young Latina who had recently

attended her fi rst Anglo funeral said that she was “genuinely puzzled” at the

absence of storytelling and gentle humor about the deceased’s life. “Everyone

was respectful of the family,” she said, “but I was surprised that it was all so

serious. I’m used to people talking and laughing at funerals.” By recognizing

that social norms function much like the rules of a game or the script of a

drama, we can observe their infl uence in the ways people grieve and the cer-

emonies they enact to commemorate death.

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92 c h a p t e r 3 Perspectives on Death: Historical and Cultural

Cultures can be thought of as occupying a continuum from “death-

welcoming” to “death-denying.” 11 Paul Koudounaris reminds us,

While we tend to think of death as representing an unequivocal, non-

negotiable, and irreducible status, its defi nition and interpretation are matters

of context. In the modern Western world, we have come to consider death

as a boundary. In many other cultures, it is not—it is conceived simply as a

transition, and a dialogue between the living and the dead forms a meaningful

part of social discourse. 12

As you read about various cultures, consider where you might place each

of them on the welcoming–denying continuum. Consider, too, where your

own cultures—the national, ethnic or subcultural, and family groups of

which you are a member—might fi t on such a continuum.

Traditional Cultures Human concern for the dead predates written history. It is not known

whether the earliest burials were intended to maintain continuity or com-

munication with the dead or to protect against the harmful power of unbur-

ied dead or wandering spirits. 13 Burial of the dead may have begun as a way

to avoid unpleasant odors, disease, or dangerous scavengers. In any event,

human remains recovered in Europe from the Upper Paleolithic period,

about forty thousand to ten thousand years ago, are recognized as intentional

burials, accompanied by manufactured objects, personal effects, and other

grave goods. 14

In some burials, the corpse is stained with red ochre and placed in a fetal

posture, suggesting revitalization of the body and rebirth (see Figure 3-2 ). 15

Ornamental shells, stone implements, and food were sometimes buried with

the dead, implying belief that such items would be useful in the journey from

the land of the living to the land of the dead. Such evidence reminds us that

“the dead do not bury themselves, but are treated and disposed of by the liv-

ing.” 16 The Italian philosopher Giambattista Vico classifi ed burial of the dead

as a basic social institution and pointed out that humanity received its Latin

name humanitas from the Latin root word humare, which means “to bury.” 17

Origin of Death The precursors of human attitudes, values, and practices are found in

myths—that is, stories that explain ideas or beliefs common to the worldview

of a people. What do such stories tell us about how death became part of

human experience? In some myths, death becomes part of human experi-

ence because ancestral parents or an archetypal fi gure transgressed divine or

natural law, through either poor judgment or disobedience (see Figure 3-3 ).

These stories sometimes involve a test of some person or group. When the test

is failed, death becomes a reality. A story told by the Luba of Africa describes

how God created a paradise for the fi rst human beings and endowed it with

everything needed for their sustenance; however, they were forbidden to eat

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Traditional Cultures 93

Figure 3-2 Neanderthal Burial

When the fi rst man, the father of the human race, was being buried, a god passed

by the grave and inquired what it meant, for he had never seen a grave before. Upon

receiving the information from those about the place of interment that they had just

buried their father, he said: “Do not bury him, dig up the body again.” “No,” they

replied, “we cannot do that. He has been dead for four days and smells.” “Not so,”

entreated the god, “dig him up and I promise you that he will live again.” But they

refused to carry out the divine injunction. Then the god declared, “By disobeying

me, you have sealed your own fate. Had you dug up your ancestor, you would have

found him alive, and you yourselves when you passed from this world should have

been buried as bananas are for four days, after which you shall have been dug up, not

rotten, but ripe. But now, as a punishment for your disobedience, you shall die and

rot.” And whenever they hear this sad tale the Fijians say: “Oh, that those children

had dug up that body!”

Figure 3-3 Fijian Story (Traditional): The Origin of Death

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94 c h a p t e r 3 Perspectives on Death: Historical and Cultural

the bananas in the middle of the fi eld. When humans ate the bananas, it was

decreed that humankind would die after a lifetime of toil. This motif is akin

to the biblical story of Adam and Eve’s transgression in the Garden of Eden,

an account of death’s origin that persists in the religious traditions of Juda-

ism, Christianity, and Islam.

In some myths, a crucial act that would have ensured immortality was

not properly carried out; an omission rather than an action introduces death to humankind. Some stories tell of a messenger who was supposed to deliver the

message of eternal life, but the message was garbled due to malice or forgetful-

ness, or it did not arrive on time. Among the Winnebago of North America,

the trickster fi gure, Hare, is an example of this motif (see Figure  3-4 ).

Momentarily forgetting his purpose, Hare failed to deliver the life-saving

message. In a variant of this motif, two messengers were sent—one bringing

immortality, the other bringing death—and the messenger bringing death

arrived fi rst.

In the “death in a bundle” motif, death is introduced into human experi-

ence when a bundle containing the mortal fate of all humankind is opened,

either inadvertently or because of poor choice. A story from Greek mythology

told by Aesop is an expression of this motif (see Figure 3-5 ).

These myths echo a theme that is surprisingly familiar: Death comes

from outside; it cuts short an existence that otherwise would be immortal. We

understand the biological processes of disease and aging yet still feel that if

only this defect could be repaired, we could remain alive. We fi nd ourselves

believing that death is foreign, not really part of us.

Names of the Dead A common practice related to the dead is name avoidance: For instance,

the deceased might be referred to as “that one,” or allusions may be made

to particular traits or special qualities a person was known for during his

or her lifetime. Thus, “Uncle Joe,” who gained renown as an expert fi sher-

man, might be referred to after his death as “that relative who caught many

When Hare heard of Death, he started for his lodge & arrived there crying,

shrieking, My uncles & my aunts must not die! And then the thought assailed him: To all things death will come! He cast his thoughts upon the precipices & they began to fall & crumble. Upon the rocks he cast his thoughts & they became shattered. Under the

earth he cast his thoughts & all the things living there stopped moving & their limbs

stiffened in death. Up above, toward the skies, he cast his thoughts & the birds fl ying

there suddenly fell to the earth & were dead.

After he entered his lodge he took his blanket and, wrapping it around him,

lay down crying. Not the whole earth will suffi ce for all those who will die. Oh, there will not be enough earth for them in many places! There he lay in his corner wrapped up in his blanket, silent.

Figure 3-4 Winnebago Myth: When Hare Heard of Death

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Traditional Cultures 95

fi sh.” A woman who had displayed extraordinary bravery might be referred

to as “that one who showed courage.” In some cultures, the deceased is not

referred to by name but only by his or her relationship to the speaker.

Name avoidance can be so complete that living people with the same

name as the deceased must adopt new names. Among the Penan Geng of

central Borneo, naming practices involving death are incorporated into all

forms of social discourse. 18 When a person dies, “death names” are given to

closest kin. Thus, as a person goes through life, he or she may have a series

of names and titles referring to different categories of relationship to the

deceased.

Some cultures, instead of avoiding the deceased’s name, give it special

emphasis. For example, the name may be conferred on a newborn child.

Such naming takes place out of a desire to honor the memory of a loved one

or to ensure that the soul of the dead person is reincarnated. Among tradi-

tional Hawaiians, for example, a child may be named for an ancestor or even

named by the gods. Such names are especially important because they are

bestowed by gods and communicated through dreams. It is said that naming

a child for a relative who has died allows the name to live again. 19

Causes of Death Allan Kellehear’s description and analysis of the social history of dying—

from the Stone Age, to the Pastoral Age with the rise of settled populations,

to the Age of the City and the “tame death,” and fi nally the present Cosmo-

politan Age—sheds light on how the meaning of death has changed over

time (see Table 3-1 ).

Even with a meaningful explanation about how death came into the

world, there remains the question, What causes individual human beings to die? The immediate cause of a death from accidental injuries or wounds sus-

tained in battle is clear, but the ultimate cause is open to question: Why did

It was a hot, sultry summer afternoon, and Eros, tired with play and faint from

the heat, took shelter in a cool, dark cave. It happened to be the cave of Death

himself.

Eros, wanting only to rest, threw himself down carelessly—so carelessly that all

his arrows fell out of his quiver.

When he woke he found they had mingled with the arrows of Death, which lay

scattered about the fl oor of the cave. They were so alike Eros could not tell the dif-

ference. He knew, however, how many had been in his quiver, and eventually he gath-

ered up the right number.

Of course, Eros took some that belonged to Death and left some of his own

behind. And so it is today that we often see the hearts of the old and the dying struck

by bolts of Love; and sometimes we see the hearts of the young captured by Death.

Figure 3-5 Aesop: Eros and Death

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96 c h a p t e r 3 Perspectives on Death: Historical and Cultural

this fatal event happen to this person at this particular time? Might it be due to

some evil infl uence, possibly shaped by magic? An explanation may be sought

in supernatural causes. Although not subject to proof or disproof, such expla-

nations comfort the bereaved by helping make sense of what otherwise seems

inexplicable. The search for answers takes place within an environment that

encompasses both the living and the dead. Did the person offend the ancestors

or neglect to carry out the prescribed rites for the dead?

When a child dies among the Senufo people of Africa’s Ivory Coast, for

example, it disturbs the whole community. Illness and death signal the fact

that something is “out of balance.” To restore a sense of security and proper

order, animal sacrifi ces are offered to purify and protect the community from

further calamity. 20 The health of the whole community depends on maintain-

ing a proper relationship with the environment, including its unseen aspects.

THE STONE AGE THE PASTOR AL AGE “Dawn of Mortal Awareness” “Rise of Settled Populations”

Cause of Death Cause of Death Sudden from trauma, human and animal

predators, childbearing, accidents.

A short awareness of dying. Dying seen as

good or bad if the dead were adequately

prepared by survivors for the otherworld

journey.

Otherworld Journey Survivors provided grave goods for other

world journey that is fraught with tests and tri-

als; thus, others in the community arranged

the social responsibilities on behalf of the

“dying.” Biological death is not the end point

of dying, rather, the end point is extinction of

one’s identity in the otherworld.

The Challenge Anticipating death: Results in behaviors that are characterized as:

Defensive—looking for omens to ward off

death, predict the coming of death, identify

risks that bring death and avoid them.

Acceptance—planning, learning, preparing.

Death is either lucky (merciful) or unlucky

(bad) for communities, not the individual.

Living in close proximity with animals resulted in

ecopathogenic infections, bacteria from cows, lice,

chickens, fl eas. Transmission of crowd-type diseases,

infections, parasitic diseases, tuberculosis, and

smallpox.

A longer awareness of dying. Epidemics led to search

for social or spiritual causes, thus imprisonment

or death by burning, drowning, torturing of those

deemed responsible.

The Good Death Good death a natural component of the good life

where dying had its privileges and obligations. Dying

people provided goods for survivors (inheritance).

Dying was “tame,” that is, its physical rigors and ulti-

mate destination were known and understood as a

collective fate.

The Challenge Preparing for death: Distributing inheritance, religious preparations; redistribution of goods as well as emo-

tional impact of loss as part of the community. Death

is good or bad for both individuals and community.

t a b l e 3-1 A Social History of Dying

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Traditional Cultures 97

Power of the Dead In cultures that maintain bonds between the living and the dead, “the

land echoes with the voices of the ancestors.” 21 The community is a partner-

ship of living and dead. Together, the living and the dead constitute the clan,

the tribe, the people. In Balinese society, for example, the village territory

belongs to the ancestors, and the living members of the community maintain

contact with them to ensure their livelihood and well-being. 22 This under-

standing is implicit when people refer to the “founding fathers” of a nation

or college, who are spoken of metaphorically as “being with us in spirit” as liv-

ing members of the group celebrate their common purpose with those who

preceded them.

THE AGE OF THE CITY THE COSMOPOLITAN AGE “The Tame Death” “Dying as a Trial”

Cause of Death Cause of Death Major degenerative diseases: cancer, heart

disease, neurological disease.

Dying from AIDS, frailty; organ failure and

dementia.

A long dying. Urban social complexity moved

dying from the community to a contract of

social relationships based on private services

and fees paid. Increasing need to tame the

uncomfortable physical and social aspects of

dying. Professionals involved in efforts to tame

the chaos and uncertainty of impending death.

Dying occurs over so long a period that it is

confused with chronic illness. Time for dying

unclear. Actual “dying persons” diffi cult to

identify. Soaring life expectancy in rich countries.

Globalization bringing “new” or revived infections:

TB, HIV, SARS.

The Well-Managed Death Power sharing with contractual service pro-

viders extended over a longer period of dying

and heavily invested in medical management

in the fi nal hours or days of dying.

The Challenge Taming death: Death is good or bad depend- ing on how well the dying is managed by

professionals. How that “wild thing” is tamed

depends on a level of prosperity and available

health services.

The outcome of good/bad dying is trans-

ferred solely to the individual. The com-

munity is replaced by contracts with

professionals.

The Shameful Death Marked by “dying out of time,” either too early or

too late in terms of value to society. Global social

and economic arrangements blur social divisions,

such as location, gender, religion, ethnicity, and

social class.

The Challenge Timing death: Preparing for or timing death is elusive. Stigmatized deaths both because people

live too long (affl uence) or die too soon (poverty).

Death is good or bad based on trials and tests of

this world (residential care or poverty experiences);

fear of losing control over timing of death grows

globally.

t a b l e 3-1 A Social History of Dying (continued)

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98 c h a p t e r 3 Perspectives on Death: Historical and Cultural

In traditional societies, grief may be expressed with loud wails or with

silent tears, but almost always there is deep respect for the still-powerful

soul of the deceased. If the soul or spirit of the deceased is not treated

properly, harm may result. Of special concern are evil-intentioned spirits

that wander about aimlessly, seeking to disrupt the well-being of the living.

Such spirits are often associated with catastrophic deaths, such as those

occurring during childbirth. Conducting prescribed funeral rites ensures

the successful journey of the soul into the realm of the dead, a journey that

benefi ts the living.

As unseen members of an ongoing social order, the dead are often allies

who can perform services for the living—as interpreters, intermediaries,

and ambassadors in the realm beyond the reach of our physical senses. Such

communication with the dead can be facilitated by a shaman, a visionary in the community who, entering into a trance, projects his or her conscious-

ness to the realm beyond this world and becomes an intermediary between

the worlds of living and dead. 23 The shaman contacts the dead and reports

back messages that will benefi t the living. Because the dead are not bound

by human time, necromancy (from the Greek, meaning “corpse-prophecy”) offers access to past and future events. 24 In the rhythm and fl ow of communal

life, the deceased—in death as in life—is part of the whole.

Western Culture Beginning in the early Middle Ages, about the year 400, and continuing for

a thousand years, people in Western European culture shared a view of the

universe as bound together by natural and divine law. 25 The Church infl u-

enced the manner in which people died, and offered hope for the afterlife.

This outlook generally prevailed until the European Renaissance, or cultural

rebirth, which began in Italy in the fourteenth century and lasted into the

seventeenth century.

During the early medieval period, people viewed death as a natural

component of life and with the understanding that “we shall all die.” This

refl ected a sense of death as the collective destiny of humankind. The dead

were “asleep”—in the Church’s keeping—with assurance of resurrection at

the apocalyptic return of Christ. With this faith, people tended not to fear

what awaited them after death. Although this period has been called the Age

of Faith, some writers argue that, because of the pervasive infl uence of the

Church, it should be called the Age of Religious Culture. 26

This sense of a common, collective destiny began to change during the

period of the High Middle Ages, about 1000–1450, transforming into an

emphasis on the destiny of the individual. The collective idea that “every-

one dies” was replaced by an individual acknowledgment, “I will die my own

death.” This change occurred over the course of several centuries and coin-

cided with a general enrichment of life and culture.

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Western Culture 99

The scientifi c revolution of the 1500s and 1600s ushered in the Enlight-

enment, with its emphasis on reason and intellect, in the 1700s. Conventional

wisdom was challenged by competing ideas in the religious marketplace and

by the revolutionary discoveries of scientists and explorers. This era marked

the birth of a modern worldview. People began to feel more ambivalent about

death and the afterlife. Death was no longer something to be contemplated

only in the realm of the sacred. It became an event that could be manipu-

lated and shaped by human beings.

These modernizing trends accelerated with an industrial revolution from

about 1750 to 1900. This 150-year period was a time of rapid technological

innovation, mechanization, and urbanization, accompanied by progress in

public health and medicine. The attitude toward death during this period

emphasized the death of the other, “thy death.”

Along with an emphasis on “thy death,” the meaning of death focused on

separation from the beloved, giving rise to impassioned expressions of grief

and desires to memorialize the dead. Hence was born the ideal of the “beau-

tiful death,” in which the sad beauty of a loved one’s death elicits feelings of

melancholy tinged with optimism for eventual reunion with the beloved in a

heavenly home. With the death of her prince consort, Albert, in 1861, Queen

Victoria of Great Britain set the trend for elaborate funeral etiquette and

mourning customs as well as a cult of widowhood. 27 She wore a black mourn-

ing bonnet for the rest of her life and often communed with Prince Albert

at his grave in the Royal Mausoleum, where she herself was laid to rest after

her death in 1901. One custom of the time was “mourning jewelry,” rings and

brooches, sometimes containing locks of hair, in remembrance of departed

loved ones. 28

Through more than a thousand years in Western culture, attitudes toward

death refl ected a progression from an emphasis on collective destiny in which

“we all shall die,” to the more personal awareness of “one’s own death,” and

then to a preoccupation with the deaths of loved ones, “thy death.” Despite

these changes in emphasis, French historian Philippe Ariès characterizes

virtually the whole of this period as one of “tamed death.” Death was an

ordinary human experience, not something to be hidden away from view or

excluded from social life.

According to Ariès, the long era of “tamed death” came to an end

early in the twentieth century. World War I (1914–1918) was a major turn-

ing point in modern history. It marked the advent of “total war,” which

affected civilians as well as combatants. It also demonstrated the increas-

ing importance of technology in virtually every aspect of life. In health

care, technology would bring about the “medicalization” of dying. The

deathbed scene moved from home to hospital. Whereas dying had been a

public and communal event, now it became private. 29 Events that had been

part of people’s ordinary lives were now under the control of profession-

als. Customary signs of mourning all but disappeared. The prevailing atti-

tude toward death could be described by such terms as “forbidden death,”

“invisible death,” and “death denied.”

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100 c h a p t e r 3 Perspectives on Death: Historical and Cultural

The Deathbed Scene “I see and know that my death is near”: Thus did the dying person dur-

ing the Middle Ages acknowledge impending death. Anticipated by natural

signs or by inner certainty, dying was understood as manageable. On pious

deathbeds, the dying offered their suffering to God with the expectation that

everything would take place in a customary manner. Sudden death was rare;

even wounds in battle seldom brought instantaneous death. (The possibil-

ity of unexpected death was fearful because it caught victims unaware and

unable to properly close earthly accounts and turn toward the divine.) Those

who kept vigil around the deathbed could confi dently say that the dying per-

son “feels her time has come” or “knows he will soon be dead.”

Marked by simple and solemn ceremony, dying occurred within the

context of familiar practices. Ariès describes a typical Christian death dur-

ing the early Middle Ages: Lying down, with the head facing east toward

Jerusalem and arms crossed over the chest, the dying person expressed

sadness at his or her impending end and began “a discreet recollection of

beloved beings and things.” Family and friends gathered around the death-

bed to receive the dying person’s pardon for any wrongs they might have

done, and all were commended to God. Next, the dying person turned his

or her attention away from the earthly realm and toward the divine. With

the customary rites completed, nothing more need be said: The dying per-

son was prepared for death.

Death Knells During many centuries one item of expense for survivors was the fee that must

be paid for the ringing of the soul bell. Every cathedral and church of medieval

Christendom had such a bell, almost always the largest one in the bell tower.

By the time John Donne wrote the immortal line “for whom the bell tolls,”

ringing of the soul bell—in a distinctive pattern, or knell—was popularly taken to

be merely a public notice that a death had occurred. This use of the soul bell came

into importance relatively late, however.

Not simply in Christian Europe but also among primitive tribes and highly

developed non-Christian cultures of the Orient, bells have been linked with

death. Notes from bells (rung in special fashion) served to help convince a spirit

that there was no need to remain close to a useless dead body. At the same time,

noise made by bells was considered to be especially effective in driving away the

evil spirits who prowled about hoping to seize a newly released soul or to put obsta-

cles in its path.

Ringing of the soul (or passing) bell was long considered so vital that bell

ringers demanded, and got, big fees for using it. Still in general use by the British

as late as the era of King Charles II in the seventeenth century, bell ringers then

regulated the number of strokes of the passing bell so that the general public

could determine the age, sex, and social status of the deceased.

Webb Garrison, Strange Facts About Death

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Western Culture 101

Dying was more or less a public ceremony, with the dying person in

charge. The recumbent fi gure in the deathbed, surrounded by family, friends,

children, and even passersby, remained the customary deathbed scene until

the late nineteenth century, although subtle changes did occur over time. For

example, as the destiny of the individual gained more emphasis around the

twelfth century, there were corresponding changes in the deathbed scene.

Besides the entourage of public participants, there now hovered an invisible

army of celestial fi gures, angels and demons, battling for possession of the

dying person’s soul. How a person died became profoundly important. Death became the speculum mortis, the mirror in which the dying person could dis- cover his or her destiny by tallying the moral balance sheet of his or her life.

This emphasis on individual responsibility for the destiny of one’s soul was

communicated in the memento mori of the time, “Remember, you must die!” This precept was inscribed on all sorts of objects and trinkets as reminders

that death comes to everyone, and there are no exceptions.

During the following centuries, there was little change in the outward

aspects of the deathbed scene; family and friends still gathered as participants

This deathbed vigil in a Spanish village is characteristic of the way in which human beings have responded to death for thousands of years. Only recently have such scenes been superseded in modern societies by the specter of dying alone, perhaps unconscious, amid the impersonal technological gadgetry of an unfamiliar institutional environment.

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102 c h a p t e r 3 Perspectives on Death: Historical and Cultural

in the public ritual of a person’s dying. But religion was less prominent in the

thoughts of the dying person or the grief of survivors. People now compared

the act of dying to the emergence of a butterfl y from its cocoon. A secular

hope for immortality and eventual reunion with loved ones became more

important than churchly images of heaven and hell. Gradually, the focus

changed from the dying person to his or her survivors.

By the mid-twentieth century, however, the rituals of dying had been

overtaken by a technological process in which death occurs by “a series of

little steps.” Ariès says, “All these little silent deaths have replaced and erased

the great dramatic act of death.”

Burial Customs With the rise of Christianity in the early Middle Ages, believers adopted

the idea that the saintliness of Christian martyrs was powerful, even in

death, and that these saints of the Church could help others avoid the pit-

falls of sin and the horrors of hell. 30 It became advantageous to be buried

near the grave of a martyr to gain merit by proximity. (A modern analogy

might be that of a movie fan being buried near a fi lm star at Forest Lawn or

a veteran requesting burial near a Medal of Honor winner, although medi-

eval folk were generally more concerned with the welfare of their souls than

with earthly prestige.)

As Christian pilgrims began journeying to venerate martyrs, altars, chap-

els, and eventually churches were built on or near the martyrs’ graves. Ini-

tially, only notables and saints of the Church received such honored burial,

but eventually ordinary folk came to be buried in common graves located in

the churchyards and surrounds of churches and cathedrals.

Charnel Houses Burial within churchyards led to the development of charnel houses,

arcades and galleries where the bones of the dead were entrusted to the

Church. “The charnels were built on consecrated ground and the bones

themselves were considered blessed, as it was believed that they would be

resurrected and clothed in divine glory at the Parousia, or Second Com-

ing of Christ.” 31 Limbs and skulls were arranged along various parts of the

churchyard, as well as within and near the church. (In Paris, it is possible to

visit catacombs where, as one visitor exclaimed, “piles of femurs and skulls”

are “stacked eight feet high and ten yards deep, as neatly as lumber in an

Oregon mill yard.”) 32 The bones in these charnels came from common

graves, which were periodically opened so that the bones could be safely kept

by the Church until the Resurrection.

A similar instance of the desiccation and preservation of corpses is found

in Sicily, “where the relationship between the living and the dead is especially

strong.” 33

Why would anyone exhibit decaying bodies? One suggestion is that the

practice may be a “residual echo” of a much older, pre-Christian belief in

the shamanistic power of corpses. Another is that the practice was done to

illustrate the inevitability of death and the foolishness of vain human pride.

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Western Culture 103

The public nature of charnel houses and other such exhibits refl ects a

familiarity with death and with the dead. As Romans had congregated in

the Forum, their counterparts in the Middle Ages met in charnel houses,

which functioned as public squares. There, they would fi nd shops and mer-

chants, conduct business, dance, gamble, or simply enjoy being together. “As

yet unborn,” Ariès says, “was the modern idea that the dead person should

be installed in a sort of house unto himself, a house of which he was the

This ossuary located at a European monastery is a survival of the medieval charnel house, a gallery of skeletons and skulls and bones.

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104 c h a p t e r 3 Perspectives on Death: Historical and Cultural

perpetual owner or at least the long-term tenant, a house in which he would

be at home and from which he could not be evicted.”

Memorializing the Dead About the twelfth century, as part of an increasing emphasis on individu-

alism, a desire arose to preserve the identity of the person buried in a par-

ticular place. Simple grave markers of the “Here lies John Doe” variety began

to appear, as did elaborate effi gies—that is, images or representations of the

dead—at the burials of notables. The thirteenth-century sepulchral effi gy of

Jean d’Alluye depicts a recumbent knight in chain mail, sword girded and

shield at his side, feet resting on the image of a lion, a vivid expression of the

intellectual and social milieu of the age of chivalry, with its tension between

faith and heroism. Although effi gies were created only for people at the high-

est social rank, they give us clues about how people of the time viewed death.

Effi gies refl ect the emerging belief that the bereaved could main-

tain bonds with the deceased by perpetuating their memory. Over time, such memorialization became increasingly important. By the time of the

Renaissance, as secular ideas competed with religious beliefs, burials began

to take place in cemeteries that were not associated with churches. The open-

ing of the Cemetery of Père Lachaise outside Paris in 1804 signaled the cul-

mination of a dramatic change in Western attitudes toward life and death. 34

In the United States, the rural cemetery movement began in the 1830s

with the aim of replacing the simple, untended graveyards of the Puritans with

lush, well-kept cemeteries like Mount Auburn in Cambridge, Massachusetts,

and Woodlawn in New York City. Places like Spring Grove in Cincinnati, Ohio,

established in 1844 and occupying 733 acres, including a large, undeveloped

area of woodland at its center, promoted a new concept of cemetery design in

which landscape took precedence over monuments. 35 In parklike settings, the

bereaved visited private graves and communed in memory with the deceased. 36

The deceased were imagined to be in a heaven where survivors hoped to be

eventually reunited with their loved ones. An interest in occult practices, such

as séances and communication with spirits, grew popular. 37 There was a sense

of sentimentality that made death seem less fi nal or severe.

Today, except for occasional memorials to the war dead, cemeteries gener-

ally do not encourage monuments that interrupt the fl at expanses of embed-

ded “grave markers.” In the opinion of architectural historian James Curl,

The neglected cemeteries, poorly designed crematoria, and abysmal tombstone

designs of the present insult life itself, for death is an inevitable consequence of

birth. By treating the disposal of the dead as though the problem were one of

refuse-collection, society devalues life. 38

The Dance of  Death With origins in the ecstatic dances of pre-Christian times, artistic themes

involving the danse macabre, or Dance of Death, came to fullest expression in the late thirteenth and early fourteenth centuries. 39 (These themes are

termed macabre because they tend to produce horror in a beholder.) Partly a

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Western Culture 105

reaction to war, famine, and poverty, the Dance of Death was infl uenced pri-

marily by the mass deaths caused by the plague, or Black Death, which came

to Europe via a Black Sea port in 1347. 40 When the fi rst wave of pestilence

ended in 1351, a quarter of the European population had died. The plague

disrupted the customary ways of death. “Death was no longer the kind care-

taker of souls awaiting resurrection.” 41 As the plague reminded individuals

of their own “fragile grasp on life,” it prompted some of them to spend their

hours in revelry and orgies—the celebration of a victory, however tempo-

rary, over death. As a cultural and artistic phenomenon, the Dance of Death

refl ects ideas about the inevitability and impartiality of death. The danse macabre was expressed through drama, poetry, music, and the

visual arts. It was sometimes performed as a masque, a short entertainment in

which actors costumed as skeletons danced gaily with fi gures representing peo-

ple at all levels of society. Paintings of the Dance of Death depict individuals

being escorted to graveyards by skeletons and corpses, a grim reminder of the

universality of death. The Dance of Death conveys the notion that, regardless

of rank or status, death comes to all people and to each person. In the oldest

The somber mood of Hans Holbein’s depiction of Die Totentanz, or Dance of Death, con- trasts with the treatment of the same theme by Mexican artist José Guadalupe Posada. In Holbein’s medieval woodblock print, The Child, we see the anxiety of family members as the skeletal fi gure of Death ominously takes a child; in Posada’s print, there is a sense of gaiety and festivity. Although expressed differently, the two works convey a common message: Death comes to people in all walks of life; no one is exempt.

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106 c h a p t e r 3 Perspectives on Death: Historical and Cultural

versions of the Dance of Death, the fi gure of death seems scarcely to touch the

living as it singles them out. Death has a personal meaning but is part of the

natural order. In later versions, people are depicted as forcibly taken by death.

By about the fi fteenth century, death was portrayed as causing a radical,

violent, and complete break between the living and the dead. This is refl ected

in ghastly themes that involve cadavers and the deterioration of the corpse.

The dance of death seems to have been part of a general obsession with

death in the late Middle Ages. In the fi fteenth and sixteenth centuries, sculp-

tures of the burial of Christ were popular throughout Western Europe. In

contrast to depictions of the dance of death, they were usually not macabre.

However, they were likely a response to the same phenomenon: widespread

death and suffering. Johan Mackenbach says,

By providing an example of dignifi ed behavior, entombments may have played

a part in development of self-restraint by mourners, just as the artes moriendi [art of dying] of the same period provided guidance on the behavior of the dying.

It is only after about 1540 that a more vivid, baroque style developed and that

expression of emotion became less restrained. In later entombments, Mary

faints, and mouths open to cry. 42

This was also the era of public anatomy dissections, which were attended

by ordinary townspeople as well as surgeons and medical students. At the

University of Leiden, the “Anatomical Theater” was held in the apse of a

church, where human remains were artistically displayed and posed in dra-

matic gestures. Frank Gonzalez-Crussi cites the example of a child’s arm “clad

in an infant’s lace sleeve” and, held in the child’s hand, “between thumb and

index fi nger—as gracefully as an artist’s model might hold a fl ower by the

stem—a human eye by the optical nerve.” 43

By the eighteenth and nineteenth centuries, the relationship between

love and death, which had been confi ned mostly to religious martyrdom, was

extended to include romantic love. Romances like those of Tristan and Isolde

or Romeo and Juliet promoted the idea that where there is love, death can be

beautiful, even desirable.

Originally a reaction to fear of sudden death caused by an epidemic of

plague, the danse macabre emphasizes the uncertainties of human existence,

the knowledge that death can come when least expected and disrupt the

most loving relationships. These themes of death’s universality and inevitabil-

ity are also portrayed in the Mexican celebration of Día de los Muertos , the

Day of the Dead, and artists draw upon these themes to convey the epidemic

nature of AIDS as well as threatening aspects of other potential catastrophes.

More subtly, images associated with the Dance of Death persist as skeletons

on children’s Halloween costumes.

Death Masks The making of a death mask is an ancient practice, going back to early

Egyptian and Roman cultures. 44 In ancient Egypt, where mummifi cation of

the body was an important part of the funeral process, a special element of

death rites was the creation of a sculpted mask that would be placed on the

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Western Culture 107

face of the dead person. The best known example of this is the mask prepared

for Tutankhamen, the youthful Egyptian king who died around 1352 BCE.

In European culture, by the Middle Ages, a shift occurred from the use

of sculpted masks to the creation of actual death masks. These were typically

of royalty and nobility, as well as of other eminent persons, such as poets and

philosophers. Examples of this latter category include Dante, Pascal, and Vol-

taire. A death mask is a wax, plaster, or clay cast taken of a person’s face soon

after death. This cast is used to make a reproduction of the face to provide

a memento for bereaved survivors or to create a portrait of the dead per-

son. Death masks also function as memento mori, a reminder to the living that death awaits us all, that we are mortal, similar to the message of the death’s-

head, or human skull, found on early gravestones.

With the death of Isaac Newton (1643–1727), the creation of a death

mask, formerly an honor reserved for members of royalty and the nobility,

was extended to an ordinary citizen, a testimony to his human genius as well

as the changing social values of the Enlightenment.

A fascinating story about death masks concerns Resusci Anne, also

known as CPR Annie, a model used since the beginning of CPR (cardiopul-

monary resuscitation) training in the 1960s and still the most popular CPR

manikin face.

The designer of Resusci Anne was a Norwegian toy maker, Asmund

Laerdal, who had also devised artifi cial wounds for use in military training.

When his friend, Dr. Peter Safer, the father of CPR, asked him to design a

device for the new CPR training, Laerdal agreed to participate.

Laerdal decided that the best way to learn resuscitation would be to prac-

tice on a manikin; all that was needed was the perfect face. While visiting his

parents, Laerdal noticed a mask of a woman’s face on their wall. This image

was actually a death mask known as “L’Inconnu de la Seine,” which means

“the unknown woman of the Seine.”

This mask is of a beautiful young woman who apparently died by suicide

in the river Seine in Paris around the late 1880s. After she was pulled out of

the river, workers at the Paris Morgue were struck by her beauty and decided

to memorialize it by creating a death mask. Over time, as reproductions of

the death mask became available, people, captivated by her beauty and her

unknown identity, began to display the mask as art in homes across Europe.

Her beguiling smile has been compared to the enigmatic smile of Mona

Lisa, whose portrait was painted by Italian Renaissance artist and polymath,

Leonardo da Vinci. Now, because of her death mask, the unknown beautiful

young woman who drowned is symbolically resuscitated, again and again, in

CPR classes around the world.

Invisible Death? In tracing the manner in which attitudes and behaviors relative to dying

and death have changed, a common theme emerges: Human beings always

seek to manage death in ways appropriate for their cultural and historical cir-

cumstances. Comparing current practices with those of earlier generations,

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108 c h a p t e r 3 Perspectives on Death: Historical and Cultural

dying and death have become less visible, less part of common experience.

For many people today, death is seen as one more disease to conquer. Death

is “managed” and “prolonged” as care providers seek mastery. Yet, many oth-

ers of us seek more meaningful ways of encountering death. We are not satis-

fi ed with “one size fi ts all.”

Present attitudes and practices are increasingly starting to refl ect a diver-

sity of choices and options as people become dissatisfi ed with the tendency to

compartmentalize, professionalize, and medicalize dying and death. Explor-

ing other cultures can allow us to better appreciate our own attitudes and

practices, as well as perhaps introduce us to new possibilities and ways of

encountering death. 45 Even when other cultures appear exotic in comparison

with what is familiar to us, closer examination usually reveals signifi cant cor-

respondences between the “foreign” and the “familiar.”

Cultural Viewpoints In reading about cultural practices in the following sections, keep in mind the

diversity that exists among individuals within a particular cultural heritage.

The descriptor “Asian,” for example, encompasses individuals of Chinese,

Japanese, Korean, Hmong, Vietnamese, Cambodian, and other ancestries—

individuals who share certain commonalities while having unique traditions.

Within each of these traditions, there is further diversity among individuals.

People of Native American Heritage Across the United States, there are more than fi ve hundred federally rec-

ognized Native American nations, each endowed with unique traditions. 46

Death customs have varied widely, not only geographically, but also through

time. 47 It is important to recognize that historical practices were affected by

the dramatic social upheavals that accompanied the “westward expansion-

ism” of white society. 48 Within two generations of white contact, it is estimated

that 80 percent of the Native people of the Pacifi c Northwest died from newly

introduced diseases to which they had no immunity. Natives throughout the

Americas experienced a similar pattern. Scholars note:

The changes were so comprehensive, the readjustments so massive, the level

of human suffering so catastrophic, we can only guess what the experiences

of the people might have been. . . . the terrifying sweep of unaccountable and

unstoppable death must be understood as a constant backdrop to the history of

American Indians. 49

Maria Yellow Horse Brave Heart describes the “historical trauma”

and “historical unresolved grief ” that accompanies this intergenerational

trauma. 50 The Takini (a Lakota word meaning “to come back to life”) Net-

work seeks to address these issues and promote healing among Native people.

In general, Native Americans view death as a normal part of an ongoing

life cycle; it is something that does not terminate one’s existence but trans-

forms it. 51 Native Americans believe the souls of the dead pass into a spirit

world and become part of the spiritual forces that infl uence every aspect of

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Cultural Viewpoints 109

their lives. However, fear of the dead is very real among some tribes, and

some are reluctant to deal with a dead body. Some tribes rely on a mortuary

to prepare the deceased for last rites; others maintain their traditional prac-

tices to the extent possible.

Of special importance is reverence toward the dead, who are often

believed to serve as guardian spirits or special envoys to the spirit world.

Chief Seattle (leader of the Suquamish people) said, “To us the ashes of our

In January 1879, frontier photographer L. A. Huffman recorded this scene showing the platform burial of a Sioux warrior who had died only a few days before. In the Great Plains, it was customary to expose the corpse on a scaffold or platform above ground or to place it in the limbs of a tree. This hastened decom- position of the body and aided the soul’s journey to the spirit world. Later, the sun-bleached skeleton would be retrieved for burial in sacred grounds.

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110 c h a p t e r 3 Perspectives on Death: Historical and Cultural

ancestors are sacred and their resting place is hallowed ground. . . . Be just

and deal kindly with my people, for the dead are not powerless. Dead, did I

say? There is no death, only a change of worlds.” 52

The land, the whole of the physical environment, is the basic source of

American Indian identity and ultimate source of spiritual power. 53 As Old

Chief Joseph of the Nez Percé lay dying, he told his son, “Never forget my

dying words. This country holds your father’s body. Never sell the bones of

your father and mother.” 54 These words were remembered by Younger Chief

Joseph as he led warriors into battle to preserve the sanctity of the lands that

held the bones of the ancestral dead. (Disputes about the disposition of arti-

facts and bones retrieved from sacred burial places by archaeologists and oth-

ers led the U.S. Congress to enact the Native American Graves Protection

and Repatriation Act in 1990 with the purpose of reuniting Native American

skeletal remains, funerary items, and ceremonial objects with living members

of the cultures that produced them.) 55

Within Native American societies, there is an emphasis on “living one

day at a time, with purpose, grateful for life’s blessings, in the knowledge

that it could all end abruptly.” 56 This relationship to death is typifi ed in the

Lakota battle cry: “It’s a good day to die!” Stephen Levine says,

This embodies the possibilities of a life reviewed and completed. A life in which

even death is not excluded. I am speaking here of a whole death that succeeds

a whole life. . . . When everything is brought up to date, and the heart is turned

toward itself, it is a good day to die. 57

Death may come at any time, and we are wise to be prepared. This out-

look is evident in the emphasis Cree people place on being careful to say

farewells before leaving on a lengthy or diffi cult journey; unforeseen death

may intervene. 58

For Native Americans, death songs summarize a person’s life and acknowl- edge death as the completion of being, the fi nal act in the drama of earthly

existence. In some cases, a death song was “composed spontaneously at the

very moment of death” and “chanted with the last breath of the dying per-

son.” 59 These death songs express a resolve to meet death fully, to accept it

with one’s whole being, not in defeat and desperation, but with equanimity

and composure.

Time is generally viewed not as linear and progress oriented but rather

as cyclic. Åke Hultkrantz says that Native Americans are “mainly interested

Two Death Songs In the great night my heart will go out

Toward me the darkness comes rattling

In the great night my heart will go out

Papago song by Juana Manwell

(Owl Woman)

The odor of death,

I smell the odor of death

In front of my body.

A song of the Dakota tribe

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Cultural Viewpoints 111

in how this cycle affects people in this life”; they have “only a vague notion

of another existence after death.” 60 Rigid beliefs about the state of the dead

or the afterlife tend to be of little or no importance. Instead, Hultkrantz

says, “One individual might hold several ideas about the dead at the same

time [because] different situations call for different interpretations of the

fate of humans after death.” The Wind River Shoshoni, for example, have a

variety of beliefs about death: The dead may travel to another world or may

remain on earth as ghosts; they may be born again as people or may trans-

migrate into “insects, birds, or even inanimate objects like wood and rocks.”

Hultkrantz says that “most Shoshoni express only a slight interest in the next

life and often declare that they know nothing about it.”

Historical accounts tell us that the Ohlone of the California coast adorned

the corpse with feathers, fl owers, and beads, and then wrapped it in blankets

and skins. Dance regalia, weapons, a medicine bundle, and other items owned

by the deceased were gathered together and, with the corpse, placed on a

funeral pyre. Destroying the deceased’s possessions helped to facilitate the

soul’s journey to the “Island of the Dead.” This action also removed remind-

ers that might cause the ghost to remain near the living. During the danger-

ous period, which lasted from six months to a year, the Ohlone considered

it disrespectful to utter the deceased’s name. In The Ohlone Way, Malcolm Margolin writes, “While the mere thought of a dead person brought sorrow,

the mention of a dead person’s name brought absolute dread.” 61 Destroying

the deceased’s belongings and avoiding his or her name helped confi rm the

separation of the dead from the living. A similar belief is echoed in a Yokut

funeral chant that says, “You are going where you are going; don’t look back

for your family.”

It has been suggested that sedentary tribes, such as the Pueblo and

Navajo, express more fear of the dead than nomadic hunters and gatherers,

such as the Sioux and Apache. 62 This contrast was found in a study among

Burial Oration You are dead.

You will go above there to the trail.

That is the spirit trail.

Go there to the beautiful trail.

May it please you not to walk about where I am.

You are dead.

Go there to the beautiful trail above.

That is your way.

Look at the place where you used to wander.

The north trail, the mountains where you used to wander,

you are leaving.

Listen to me: go there!

Wintu tribe

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112 c h a p t e r 3 Perspectives on Death: Historical and Cultural

the Cocopa and Hopi. 63 When a Cocopa dies, surviving family members wail

in an “ecstasy of violent grief behavior” that lasts twenty-four hours or more,

continuing until the body is cremated. Clothes, food, and other items are

burned with the body. Although the deceased needs these goods in the after-

life, the Cocopa also hope this will help persuade the spirit of the dead per-

son to pass on from the earth. Later, a ceremony is held commemorating the

deceased. Although the deceased’s name cannot be spoken at other times, at

this special mourning ceremony, those who have passed into the spirit world

are publicly summoned, and their presence may be impersonated by living

members of the tribe. The ceremony is intended to both honor the dead

and persuade lurking spirits to come out into the open and leave the earthly

realm. Whereas the initial cremation ritual is focused on the grief of the

bereaved family, the subsequent mourning ceremony is focused on affi rming

the integrity of the family and the community.

Unlike the Cocopa, the Hopi strive to keep death at a distance. It threat-

ens the “middle way” of order, control, and measured deliberation. This atti-

tude is refl ected in Hopi funeral rituals, which are attended by few people

and held privately. Mourners are reticent about expressing grief. The Hopi

want the whole matter to be “quickly over and best forgotten.” They have no

desire to invite dead ancestors to a communal gathering. Once a person’s

spirit leaves the body, it is a different class of being, no longer Hopi. Thus,

it is important to make sure that the “dichotomy of quick and dead is sharp

and clear.”

As these descriptions of the Cocopa and the Hopi show, different social

groups may create distinctive responses to death even when they occupy a

similar cultural situation. Both Hopi and Cocopa fear the dead, but they

cope with this fear differently: The Hopi want to completely avoid the dead,

whereas the Cocopa invite the spirits of the dead to join them in ritual cel-

ebration, even if only temporarily and under controlled circumstances.

Refl ecting on the different emphases within Hopi and Cocopa societies

can help us evaluate our own attitudes and values relative to death. What do

you fi nd valuable about each of these ways of coping with death?

People of African Heritage It is said that, for Africans, life is afterlife. 64 Many African peoples believe

a person’s soul remains “alive” and active as long as at least one individual

remains who has known the deceased and remembers his or her name. Death

does not extinguish a person’s participation in the life and activities of his

family and community but rather opens a way to a connection and partici-

pation that is different from the mundane mode of the living. 65 The term

ancestor worship has been used to describe customs such as prayer, sacrifi ce, or libation, and other acts of respect or reverence shown to the deceased mem-

bers of a community. However, the respect and rites accorded ancestors are

not rites of worship but methods of communication. 66

As generations come and go and memory fades, the long-dead ancestral

members of the community are replaced by the more recently deceased. 67

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Cultural Viewpoints 113

Thus, the ongoing community of the “living dead” consists of ancestors who

are recalled in the minds of the living. Dominique Zahan says,

The ancestral community is in a constant state of renewal which is affected in

two ways. First, the “newly dead” invariably keep the earthward side of their

universe updated and on its feet. Second, there is the continual disappearance

of a part of them, the heavenly side, which has become useless because of the

weaknesses in the collective memory of those in this world. 68

This is illustrated by the system of age grouping: Among the Nandi in

Kenya, for example, once past childhood, a male member of the tribe moves

through the junior and senior warrior levels and eventually enters the age

group of senior elders; he next becomes an old man and ultimately, at death,

an ancestor, one of the living dead, whose personality is remembered by sur-

vivors. When he is no longer remembered, he merges with the anonymous

dead. The Nandi believe that, by this time, the dead person’s “soul stuff ”

may have reappeared in a newborn child of the tribe, thus continuing the

recurrent pattern of a person’s passage through the levels of the age-group

system. 69

Kofi Asare Opoku says that the traditional African attitude toward death

is essentially positive because “it is comprehensively integrated into the

totality of life.” 70 Death is merely the passage from the human world to the

spirit world. 71 This attitude can be found in the festive sounds of trumpets

and drums played at African funerals. “Music,” says Francis Bebey, “is a chal-

lenge to human destiny; a refusal to accept the transience of this life; and

an attempt to transform the fi nality of death into another kind of living.” 72

In Africa today, reverence toward the dead retains its importance.

When the body of a Nigerian villager of the Ibo people was shipped by air

from the United States to her home village, the coffi n arrived in damaged

condition. Somewhere in transit, her body had been wrapped in burlap and

turned upside down—violating strict tribal taboos concerning abuse of a

corpse. Despite the family’s offerings of yams, money, and wine to appease

the insult, tribal members reported seeing the woman’s spirit roaming

about, and relatives began to experience reversals of fortune, which they

characterized as a “curse” due to mistreatment of their dead relative. The

woman’s son said, “My mother was treated as if she were nothing.” Thus,

her spirit was angry and not at peace. In bringing suit against the airline

to which the body had been entrusted, the son said, “If this had been done

to us by an individual, my whole tribe would have gone to war. If I win the

case, it would be like bringing back someone’s head. It would prove I’m a

warrior . . . it will show the gods I have done something against someone

who shamed my mother.” 73

If we knew the home of Death, we would set it on fi re.

Acholi funeral song

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114 c h a p t e r 3 Perspectives on Death: Historical and Cultural

The LoDagaa of Northern Ghana The richness of traditional African funeral customs is illustrated by the

practices carried out among the LoDagaa, whose funeral ceremonies span at

least a six-month period and sometimes continue over several years. 74 They

occur in four distinct, successive phases, each focusing on specifi c aspects of

death and bereavement.

The fi rst stage begins at a person’s death and lasts six or seven days.

During the fi rst several days, the body is prepared for burial, the deceased

is mourned by the community, rites are performed to acknowledge the

A woman and child in mourning are depicted in this Yombe memo- rial fi gure from Zaire. Installed in a shed constructed on the grave, such adornments are thought to provide the deceased with compan- ionship or protection in the afterlife.

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Cultural Viewpoints 115

separation of the deceased from the living, kinship ties are affi rmed, and

some of the social and family roles occupied by the deceased are redistrib-

uted. The public ceremonies, which last about three days, conclude with the

burial of the corpse. The remaining three or four days of this fi rst stage are

devoted to private ceremonies in which preparations are made for redistrib-

uting the dead person’s property.

About three weeks later, in a second ceremony, the cause of death is estab-

lished. Rather than considering a snakebite, for example, to be the cause of

a person’s death, the LoDagaa view the bite as an intermediate agent but not

the sole cause of death. The real cause of death lies in a network of spiritual

and human relationships. Inquiries are made to uncover any tension that

may have existed between the deceased and others.

At the beginning of the rainy season, a third stage of the funeral is held.

These rites mark a transitional period in the deceased’s passing from the role

of the living to that of an ancestor. At this stage, a provisional ancestral shrine

is placed on the grave.

The fourth and fi nal stage of LoDagaa ceremonies occurs after the har-

vest. A fi nal ancestral shrine is constructed and placed on the grave, and close

relatives of the deceased are formally released from mourning. The care of

offspring is formally transferred to the deceased’s tribal “brothers,” and fi nal

rites conclude redistribution of the deceased’s property.

These extended mourning ceremonies serve two main purposes: First,

they separate the dead person from the bereaved family and from the wider community of the living; social roles formerly held by the deceased are

assigned to living persons. Second, they gather together, or aggregate; that is, the dead person joins with the ancestors, and the bereaved are reincorpo-

rated into the community in a way that refl ects their new status. This rhythm

of separation and gathering together is common to funeral rites of all cul-

tures. LoDagaa funerals are noteworthy because of the formality with which

these functions are accomplished. They provide a model of explicitness in

mourning that can be compared and contrasted with our own.

This explicitness is evident in the LoDagaa’s use of “mourning restraints”

made of leather, fabric, and string. These restraints, which are usually tied

around a person’s wrist, indicate the degree of relationship of the bereaved to

the deceased. At a man’s funeral, for example, his father, mother, and widow

wear restraints made of hide; his brothers and sisters wear fi ber restraints;

and his children wear restraints made of string tied around the ankle. The

strongest restraints are worn by mourners who had the closest relation-

ship with the deceased, usually through kinship and marriage but some-

times through friendship bonds. Persons with less intimate relationships to

the deceased wear weaker mourning restraints. In all cases, one end of the

mourning restraint is attached to the bereaved, while the other end is held

by a “mourning companion,” who assumes responsibility for the bereaved’s

behavior during the period of intense grief.

The LoDagaa mourning restraints serve two related purposes. First,

as objects that can be seen and felt, they validate that the intensity of the

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116 c h a p t e r 3 Perspectives on Death: Historical and Cultural

bereaved person’s grief is appropriate for his or her relationship with the

deceased. Second, they discourage expressions of grief that exceed the norms

of the community.

In Africa, as elsewhere, social and economic forces of modern times

threaten traditions. Even so, customs are carried forward in innovative ways.

Among the Yoruba of southwestern Nigeria, for example, obituary publica-

tion provides a modern forum for an ancient custom. In newspaper obitu-

aries paid for by family and friends, the deceased’s status and prestige are

denoted by, among other things, the size of the obituary, which can occupy a

full page. Olatunde Bayo Lawuyi says it is common to “mark the return of the

dead [through obituary publications] every ten years,” although this practice

lessens over time. 75 The publication of obituaries, Lawuyi says, “demonstrates

the possibility of continuity in ancestral beliefs” and “is a symbolic manifesta-

tion of a tradition that has taken a new cultural form.”

Traditions Among African Americans As Ronald Barrett points out, elements of traditional West African prac-

tices retain their importance for many African Americans. 76 One of the

strongest ties between Africans and their descendants in the United States is

evident in the signifi cance given to funeral traditions. 77 In the black church,

funerals are called “homegoing” services; sermons and songs refer to themes

of “going home.” Family members often desire to give the deceased a “big

send-off ” in the form of an elaborate funeral. Respectful display of the body

is important. Barrett says, “The success and survival of most African Ameri-

can funeral homes has historically depended on the physical appearance of

loved ones during viewing, which is an important part of African American

homegoing celebrations.” 78 LaVone Hazell says,

At times economics underlie cultural decisions regarding the funeral rite. One

widow who was making arrangements summed up a pervasive feeling within

the African American community, saying, “After working so hard all his life,

my husband didn’t have much to show for his efforts. The last thing I can do

for him is to give him a fi ne and proper burial.” With these words, she used his

entire insurance policy on the funeral. 79

Dying is referred to as a “transition,” and belief in the possibility of an

ongoing relationship with the person who has passed and of one day being

reunited with the deceased loved one is commonly expressed. Family mem-

bers and extended family are likely to place great importance on gathering at

the bedside of a dying patient. Trusting God for health and desiring to hold

on to a loved one as long as possible may result in insisting on life-sustaining

treatments and avoiding preparations for death. African Americans are less

likely than some other groups to complete advance directives or agree to

DNR (do not resuscitate) orders. This may be partly out of a concern, due

to historical factors, that the health care system would give up on them or

provide less than optimal care. Comparatively low use of hospice and other

end-of-life services is due in part to similar factors. “Some African Americans

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Cultural Viewpoints 117

may view illness and death as yet another struggle to overcome.” 80 Further,

accepting a prognosis of terminality may be seen as a lack of faith. People

commonly feel that “God is in charge,” in control of fate and the timing of

death. As a result, they are content to “leave it in God’s hands.”

African Americans are a diverse group united by a common legacy and a his-

tory of oppression and discrimination that has shaped their cultural identity. 81

This legacy “grew from deep African roots, gained a paradoxical strength and

resilience from the horrors of mid-passage, and fl owered in the slave funeral—a

value laden and unifying social event which the slave community in the United

States was able to preserve from both physical and ideological onslaughts

of the master class.” 82 This heritage infl uences the attitudes and beliefs of

African Americans, a group that encompasses individuals of various African,

Caribbean, and South American descent. 83 Barrett points out that, in general,

“blacks may be characterized as having a holistic view of death and dying, in

that birth and death are understood to be part of a cycle or continuum.” 84

People of Hispanic Heritage People of Hispanic, or Latino, heritage comprise one of the fastest-

growing population groups in the United States. Some are fairly recent arriv-

als; others were living in the Southwest before it became part of the United

States. Interconnectedness and interdependence, especially within the family

( familismo ), are highly valued. 85 In decisions about medical care, family is an important voice.

Among people of Cuban heritage, bereavement is generally expressed

openly, with loud crying and other physical manifestations. After death, fam-

ily and friends gather for a wake, or valorio, lasting several days. These wakes may take the form of novenas, or devotions, consisting of periods of prayer for nine consecutive days, with the fi nal day having the atmosphere of a fi esta.

People of Puerto Rican and other Latino heritage have similar practices

regarding wakes and novenas.

It is rare to see a hearse or mortuary in rural areas of Brazil. The deceased

is likely to be kept in the home until the body is buried, and burial may be in

the plot with other family members to “keep the family together.” 86

In Guatemala, it is customary to place the deceased in a simple wooden

coffi n or casket, which is carried by key family members through town from

the church to the cemetery while onlookers show their respect, mourn, and

offer fl owers. “At Indian funerals, the Mayan priest may spin the coffi n at the

grave to fool the devil and point the spirit of the deceased toward heaven.” 87

In the United States, Mexicans are the largest segment of the Hispanic

population, with over 60 percent of Hispanics being of Mexican descent.

The second-largest group, with 9 percent of the Hispanic population, are

Puerto Ricans. 88 Although Latinos share many cultural traits, the various

groups within the Hispanic population—Cuban, Mexican, Puerto Rican,

South American, Central American, and so on—are culturally and socially

diverse. 89

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118 c h a p t e r 3 Perspectives on Death: Historical and Cultural

Attitudes Toward Death in Mexico Mexicans tend to view death as a natural part of life. Mexican poetry is

fi lled with similes comparing life’s fragility to a dream, a fl ower, a river, or a

passing breeze. 90 “Because the overall outlook for many Mexicans is one of

fatalism, pride may be taken in stoic acceptance of life’s adversities.” 91 People

often confront death with humorous sarcasm. Death elicits an emotional

response of impatience, disdain, or irony. It is cast as an equalizer that not

even the wealthiest or most privileged can escape.

The skeleton has been called “Mexico’s national totem.” 92 People from

all walks of life, the professor as well as the pilot, are portrayed as calavera (skulls or bones), the central icon of Día de los Muertos, the Day of the Dead. The intimate association of life and death is seen in one of the most common

Day of the Dead motifs: a skeletal bride and groom, donned in white wedding

dress and tuxedo. The calavera sculpted in sugar, clay, or papier-mâché or

created from elaborate paper cuttings are a reminder that all of us will one

day become “dead ones.” Under each person’s skin are those bones, and the

calavera send the message that we need to recognize that fact and become

accustomed to the idea that we will die.

The popular engravings of Mexican artist José Guadalupe Posada resem-

ble the medieval danse macabre. Posada created what has become the most

universally depicted of all calaveras—La Catrina—a female skeleton fop-

pishly attired to satirize the pretensions of Mexico’s upper classes. Posada

also illustrated verses, like this one by poet Constancio S. Suárez:

It is a most sincere truth

that this adage makes us see:

only one who was never born

can never a death’s-head be. 93

A striking awareness of death is displayed in graffi ti and ornaments that

decorate cars and buses. In churches, the suffering Savior is portrayed with

bloody vividness. Obituaries are framed with conspicuous black borders.

Surrounded by references to death, the Mexican, says Octavio Paz, “ jokes

about it, caresses it, sleeps with it, celebrates it [and makes it] one of his favor-

ite toys and his most steadfast love.” More soberly, Paz adds, “Death defi nes

life. . . . Each of us dies the death he has made for himself. . . . Death, like

life, is not transferable.” 94 Folk sayings speak to this connection between

death and identity: “Tell me how you die and I will tell you who you are.”

Día de los Muertos When Spanish priests arrived in Mexico, they attempted in vain to sup-

press Aztec rituals. But they also brought elements from the medieval tradi-

tion of the Feast of Fools (associated with carnival, carne vale, “farewell to the fl esh”), where everything is open to criticism, ridicule, and mockery. This

humorous tradition is part of Día de los Muertos, which is now celebrated

during the Catholic feasts of All Saints’ and All Souls’ Days, the Christian

feast of commemoration for the dead. 95 The fi rst of these is often devoted

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Cultural Viewpoints 119

to los angelitos, young children who have died and who are remembered on November 1. The fi esta of Día de los Muertos combines ancient indigenous

customs with introduced Catholic traditions. Besides its celebration in parts

of Mexico, the fi esta is also celebrated in other countries of Latin America,

including Argentina, Bolivia, Ecuador, Guatemala, Honduras, Nicaragua,

Panama, and Peru.

Observances of Day of the Dead are part of folk culture throughout Latin

America, testifying to the belief that one’s own well-being depends in part on

respectfully remembering the dead. “These rituals are rooted in a common

feeling of moral obligation to the deceased.” 96 Death is satirized while memo-

ries of deceased loved ones are cherished by the living.

During late October, the markets of the villages and towns are fi lled

with special handmade items for the fi esta. In the marketplace, there are tall

candles for lighting the gravesite and cempazuchitl (yellow marigolds used in

The sugar skull, or calavera , is widely available in the marketplace. Made of sugar and water and decorated with refl ective eyes and facial markings made of icing, sugar skulls often have a place at the top for your own name. (In eating your skull, you symbolically become a compadre or companion of death rather than its adversary). Sugar is also used to construct animals who accompany the dead on their journey to and from Mictlan, the place of the dead. The names of deceased relatives are often placed on ornaments such as this skull and these coffi ns to assure the spirits of the dead that they are not forgotten. This practice also provides solace to the living in the form of tangible symbols of the presence of deceased loved ones.

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120 c h a p t e r 3 Perspectives on Death: Historical and Cultural

Mesoamerica since pre-Columbian times to honor the dead), whose petals

traditionally are strewn to guide the dead on the path to the family home.

Some of the most interesting cosas de muertos (things of the dead) are designed to be eaten by the living. Pan de muerto (bread of the dead) is an essential food for the fi esta. It is generally made from a light, sweet yeast batter and baked

into a characteristic shape depending upon the region of the country. For

example, the pan de muerto typical of Mexico City is a round loaf topped

by stylized skull and crossbones. Sugar-candy skulls, tissue-paper skeletons,

and cardboard coffi ns poke fun at death. Pulling on a string at the end of a

cardboard coffi n might open the top and pull up a skull-shaped muerto (dead one) to a sitting position.

Stanley Brandes has highlighted some of the characteristics of an artistic

representation of the Day of the Dead: 97

1. It is ephemeral. It exists to celebrate the moment and is made for momen- tary consumption.

2. It is humorous; it evokes laughter rather than sadness, enjoyment rather than pain.

3. It is comical. The toys and candies are often designed for play; they often have moving parts.

4. It is small, light, and transportable. It generally fi ts in your hand. 5. It is designed for living people, not for the deceased.

As a part of the festival, families go to the panteón (cemetery) to pre- pare for the return of their dead. The rituals of cleaning graves, repainting

crosses, pulling weeds, redecorating stones, and decorating with fl owers is

both a rejuvenation of the gravesite and a display of welcome for the dead.

Even in the “perpetual care” cemeteries of the United States where Día de los

Muertos is celebrated, families will gather at graves to clean and decorate them

in anticipation of their dead ones’ return. A party-like atmosphere occurs in

the graveyards, with families, including children, visiting with one another

and their dead loved ones. At night during the fi esta in Xoxo, Oaxaca, the

small cemetery is ablaze with lights from tall candles placed around the graves.

A mariache band circulates, playing tunes for the living and the dead while vendors sell food and drink.

During the festival, families build an altar de muertos, or ofrenda (altar where offerings are placed) in the home. The placement, size, and materi-

als used to construct the altar for the dead vary. Pictures of the deceased,

sacred images such as pictures of Mary, Jesus, or other religious notables such

as the Virgin de Guadalupe, are placed on the altar. Food for the ofrenda

might include a dish of chicken mole —a spicy sauce of some fi fty ingredients, including chili peppers, peanuts, and chocolate—or other dishes that were

favorites of the deceased. Items familiar to deceased loved ones, such as a

package of a particular brand of cigarettes or a bottle of mescal, are set out to

entice their spirits to return to the family during the fi esta.

The tall candles, or ceras, used in the festival are placed both on the ofrenda and on the grave. It is believed that the spirits of the dead need

light to fi nd their way back to the living on their journey to join us. In some

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Cultural Viewpoints 121

communities, the quantity of candles signifi es the number of dead ones who

are being welcomed home.

Families set off large fi recrackers to announce to the dead that it is time

to come. In some communities, the dead will join the living in a meal. The

sweets, bread, and other delicious items on the ofrenda are fi rst given to the

dead. The living will eventually eat them but only after much of their essence

and fl avor has been consumed by the dead. Among the most traditional

observances of the fi esta are those on the Island of Janitzio in Michoacán and

in the Zapotec villages in the Valley of Oaxaca.

Día de los Muertos is a time for revolting against ordinary modes of

thought and action; the celebration reunites “contradictory elements and

principles in order to bring about a renascence of life.” 98 Jorge Valadez says,

The rituals honoring and remembering the dead not only bring members

of the community together; they also reinforce the belief that death is a

transitional phase in which individuals continue to exist in a different plane

while maintaining an important relationship with the living. 99

Celebrants challenge the boundaries that ordinarily separate the dead

from the living. Davíd Carrasco says, “The souls of the dead reassure the liv-

ing of their continued protection, and the living reassure the dead that they

will remember and nurture them in their daily lives.” 100 It is important that

families pay their respects to the dead, but mourners are cautioned against

shedding too many tears; excessive grief may make the pathway traveled by

At a Day of the Dead festival in the United States, a young woman receives elaborate makeup resembling a sugar skull, or calavera. The artist, who has won awards for her skillful masks, says, “It’s refreshing to know that more people are looking at Día de los Muertos; and not just the look, but the tradition.”

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122 c h a p t e r 3 Perspectives on Death: Historical and Cultural

the dead slippery, burdening them with a tortuous journey as they return to

the world of the living at this special time of celebration.

The mainstreaming of this celebration is an example of the “Latiniza-

tion” of U.S. culture, an occurrence over the past thirty years as a result of

the biggest migration fl ow in the history of the continent. One important

reason for the “Mexicanness” of the Day of the Dead in the United States is

that Chicano activists in California were engaged in struggles for civil rights

during the 1960s and 1970s. They began to organize indigenous-inspired

Day of the Dead processions and ofrenda exhibits as a way to honor Mexican

American heritage. 101 One participant in Day of the Dead festivities in the

United States explains,

There is no venue in American tradition which lets us honor and celebrate

our dead. Once people have died, their memory becomes a private matter for

the family. . . . There is no public remembrance past the funeral. It’s as if they

were swept under the carpet and we move on to the next thing. With Día de los

Muertos, the entire community is involved [in a] public acknowledgment of

the dead. 102

People of Asian Heritage Generally speaking, Asian cultures value interdependence and affi liation

over independence and individualism. Harmony, a quality manifested in proper conduct, is especially important in interpersonal relationships. In China, for

example, this emphasis stems from the fact that descendants of a common

ancestor share a lineage that may go back centuries. Important in this regard

is the Chinese ideal of hsiao, which translates as “fi liality” or “fi lial piety.” Asian heritage encompasses the cultures of India, China, Taiwan, Japan,

and Korea. The many diverse cultures of Southeast Asia —Cambodian,

Laotian, Hmong, Thai, Burmese, Vietnamese, Indonesian, Singaporean,

Malaysian, and Filipino—can be added under the geographical rubric

Pchum Ben, the Cambodian Festival of the Dead The International Financial Fund and the Global Bank are distressed . . . by

Cambodia’s failure to adapt its cultural traditions to modern conditions . . . With the

country’s labor force rising in the early hours to take offerings to departed ancestors,

there must be an enormous decline in labor productivity . . . Cambodia cannot afford

such an annual blow to its ability to compete in this era of globalization . . . In most

Western, developed countries, communion with the dead is restricted to one night per

year, known as Halloween . . . This means that Cambodia is spending at least fourteen

times as much time as necessary in appeasing its ghosts . . . Cambodian ghosts . . . may

well feel offended by a shift to a one-day observance. However . . . Cambodian ghosts

are no less patriotic than their counterparts in the developed countries, and can be

counted on to make this sacrifi ce in the national interest.

Phnom Penh Post

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Cultural Viewpoints 123

“Asian,” while acknowledging highly variable distinctions and differences.

For example, some of these cultures are predominantly Hindu, others are

mainly Buddhist, yet others are Islamic, while still others follow animist-

infl uenced practices or are a mixture of religions.

Filipinos are generally classed within Asian culture; however, diversity in

the Philippine Islands and colonization by the Spanish make it problematic

to classify Filipinos within a single category. 103 This points up the importance

of recognizing that signifi cant differences exist among the various “Asian”

cultures.

The Hmong, an Asian ethnic group from the mountainous regions of

China, Vietnam, Laos, and Thailand, view life as a journey; death is a phase

one goes through when passing from this plane of existence to the next.

“Hmong funerals are distinctive with many rituals and may last many days to

honor the deceased and their ancestors. The older or more revered the per-

son, the longer the funeral.” 104 The primary religious leader is the shaman,

or tu txiv neeb, who attends to both health and spiritual problems. Animal sac- rifi ce may be made to honor the deceased. In the mountains of their home-

lands, Hmong funeral customs include fi ring mortars to alert the village

that a death has occurred and slaughtering oxen and buffalo for the funeral

ceremony. In the signifi cantly different social environment of mostly urban

settings in North America, the traditional elements of Hmong funeral ritual

cannot be readily accommodated and have been dramatically changed. 105

Like other Buddhists, Thais believe that a person is reborn after death,

the place of rebirth depending on that person’s karma. During the funeral, family members may pray for themselves to be reborn in the same family with

the same relationship to the deceased in their next life.

In traditional Hindu households, death is a communal affair. Family

members perform all the rites and rituals, with males dealing with the male

body and females with the female body, from washing, anointing, and dress-

ing, to the construction of the bier on which the corpse is laid and secured

with ropes. Last rites are called antyesti, and their purpose is to purify the deceased and comfort the bereaved. The deceased is cremated within

twenty-four hours following death for both hygienic and spiritual reasons, as

Hindus believe a swifter cremation results in more complete release of the

soul. Hindus living in the United States may keep their family members’

ashes to scatter later in holy rivers upon return to their homeland. 106

For Sikhs, widely recognized for their turban headdress and whose reli-

gion originated in northern India in the fi fteenth century, an interdependent

approach to decision making is preferred. Thus, many Sikh families choose

not to inform the patient of his or her diagnosis or prognosis, believing that

such information may hasten the course of death. 107

Somewhat similarly, traditional Filipinos may not want to plan for death

or discuss advance directives because doing so may be “tempting fate.”

When a person is seriously ill or dying, family members may provide per-

sonal care themselves. Following death, some Filipino families celebrate

nine days of novenas (discussed in connection with Hispanic heritage).

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124 c h a p t e r 3 Perspectives on Death: Historical and Cultural

Filipinos generally believe that life continues beyond death, and caring for

the spiritual needs of the dying or dead is a way to ensure the peaceful rest

of the soul or spirit.

Ancestors typically occupy a central place in Asian families as deceased

members continue to have reciprocal relationships with the living members

of the household. 108 When speaking of ancestors, Vietnamese mention the

word thiêng, meaning “awe-inspiring” and “able to comply with prayers.” 109 The living and the dead are dependent on each other; the living perform

the necessary ancestral rites, while the dead dispense blessings to their

descendants. There is eternal reciprocity between dead ancestors and their

heirs. 110 The Chinese philosopher Mencius said that the most unfi lial act was

to leave no heirs, because there would be no one to perform the necessary

ancestral rites. In fact, a recent study notes that in Japan’s modern society,

some older persons are facing being without “appropriate grave successors”

(descendants) and, because of that, fi nd it diffi cult to imagine their postmor-

tem transformation into ancestors, a situation that causes them to be anxious

about death. 111

In Chinese funerals, specifi c mourning garments show degrees of

kinship between bereaved and deceased (similar to the LoDagaa use of

mourning restraints). Following Taoist traditions, Chinese death rituals

use ancient principles of fêng-shui (literally, “wind-water”), an art of divi- nation concerned with the proper positioning of elements in harmonious

relation to one another. It is said that “fêng-shui connects life and death.” 112

Fêng-shui aids in determining an auspicious, or favorable, site for dwellings,

Chuang Tzu’s wife died. When Hui Tzu went to convey his condolences, he

found Chuang Tzu sitting with his legs sprawled out, pounding on a tub and

singing.

“You lived with her, she brought up your children, and grew old,” said Hui

Tzu. “It should be enough simply not to weep at her death. But pounding on a tub

and singing—this is going too far, isn’t it?”

Chuang Tzu said, “You’re wrong. When she fi rst died, do you think I didn’t

grieve like anyone else? But I looked back to her beginning and the time before

she was born. Not only the time before she was born, but the time before she had a

body. Not only the time before she had a body, but the time before she had a spirit.

In the midst of the jumble of wonder and mystery, a change took place and she had

a spirit. Another change and she had a body. Another change and she was born.

Now there’s been another change and she’s dead. It’s just like the progression of

the four seasons, spring, summer, fall, winter.

“Now she’s going to lie down peacefully in a vast room. If I were to follow after

her bawling and sobbing, it would show that I don’t understand anything about

fate. So I stopped.”

Chuang Tzu

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Cultural Viewpoints 125

a matter important for both living and dead, as failure to do so can cause

sorrow. Thus, Chinese cemeteries are usually situated on elevated, sloping

ground—preferably involving mountains behind and sea in front—with a

view of fertile fi elds, which the ancestors are leaving for their descendants.

During funeral ceremonies, the foot of the casket is positioned facing the

door so that the spirit or soul of the deceased will have an unobstructed

pathway into the next world. Attention to such details assures the bereaved

family that everything is done properly to facilitate the ancestor’s afterlife

journey.

For tradition-minded Japanese, respect for the ancestors provides ways

to maintain psychological and emotional links between the living and the

dead. 113 However, these links can also give rise to fear of death and concerns

about “death pollution,” where death and the bad luck it brings can be con-

taminating. Indeed, “One of the major purposes of the ancestral rites is to

move the soul of the newly dead from its ritually polluting, still-earthbound

state, into a purifi ed collectivity of the long-dead ancestors of the house and

community.” 114 The dead gradually lose their individuality and, after a time,

merge with the spirits of the ancestors. Historically, in Japan,

it was the task of the court poets to write laments for the deceased members

of the imperial family, usually when they were lying in state at a temporary

shrine ( arikinomiya ) prior to interment. It was believed that such poems of mourning would comfort the dead and keep them from returning to this world,

dissatisfi ed by the neglect of the living, to torment people. 115

Similar fears about death and its pollution are common in Chinese com-

munities. Andy Ho and Cecelia Chan report:

Common taboos include not talking about death; having no contact with the

sick and the dying; avoiding proximity to coffi ns and dead bodies including

their clothing and belongings; and not mentioning the names of dead people

for fear of calling back their spirits. Contacts with family members of the

deceased are avoided, as they are believed to be bearers of ill fortune and

ritually polluted by death. Avoiding the use or invocation of the Chinese word

for death ( si ), also meaning four, is commonplace. 116

During the typical Japanese funeral service, incense is offered and priests

read Buddhist scriptures. At this time, the deceased is given a special posthu-

mous or “Buddhist name,” which indicates that the material aspect of the

person is extinguished. This name ( kaimyo ) is eventually inscribed on an ihai, or memorial tablet, that is placed in the family’s butsudan, or household altar. After the body is cremated, the ashes and some pieces of bone are placed in

an urn, which will be interred at the family’s grave.

Besides the butsudan in the home, the other main focus of Japanese

ancestral rites is the haka, the family grave, where ashes of family members are interred. These family memorials may have space for a dozen or more

urns. The grave must be maintained properly, which includes cleaning it

˘

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126 c h a p t e r 3 Perspectives on Death: Historical and Cultural

and making offerings to the dead. As with the butsudan, the haka is a place

of ritual. Incense and fl owers are offered to ancestors, and water is poured

over the gravestone, a gesture of purifi cation that dates back to antiquity and

that people may now perform without fully recognizing its ancient meaning

and symbolism. This tradition of ancestor veneration, or sosen sūhai, frames

This butsudan, prominently situated in the home of a Japanese American family in California, is representative of altars found in Japanese homes, where deceased relatives and ancestors are honored through prayers, gifts of food, and other ways of showing respect. As a focal point for ongoing relationships between the living and dead members of a household, the butsudan is a place where such relationships are demonstrated through concrete actions.

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Cultural Viewpoints 127

responses to death and loss; the transition to ancestorhood depends not on

moral worth but on family loyalty. 117

In a study of Japanese practices, Christine Valentine reports that “proper

treatment of the dead” and the reinforcement of familiar and social ties con-

tinue to frame Japanese understandings of bereavement, compared to the

Western emphasis on the “therapeutic needs of the bereaved and recover-

ing personal autonomy.” 118 Allan Kellehear and Daisuke Tanaka note that

Western culture has been shaped by Judeo-Christian assumptions: When

people die, they either go to another “realm” or perhaps simply disintegrate.

Either way, the dead leave us; they are not here. But the cosmology of Shinto

and Buddhism in Japan stresses the view that, although the dead do exist in

another world, that world is not sharply divided from the world of the living.

The dead and the living have access to each other. 119

For the Japanese, it is quite ordinary to talk to their ancestors, either

at the gravesite or at the family altar in the home, often in conversational

ways, telling the deceased about things that are going on in life or asking for

advice. Through such activities, the connection between the dead and the

living is maintained.

The Chinese behave similarly in honoring ancestors. Traditionally, an

ancestor’s soul is embodied in a spirit tablet —a rectangular piece of wood upon which is engraved the deceased’s name, title, and birth and death

dates—that is kept on the family’s home altar. Many Chinese families main-

tain memorial walls in their homes, sometimes substituting photographs

for spirit tablets, as a way to maintain the presence of the dead within the

family.

Paper Offerings Paper offerings are objects made of paper, many of them handmade and

one of a kind, which, by being burnt up, are offered to the beings residing

beyond the world of the living: the gods, the ghosts, and the ancestors. 120

Burning accomplishes the vital transformation that sends the items beyond

the confi nes of the living world. The residents of the next world are provided

with symbolic money (called Hell Money or Hell Notes) and gold and silver,

the latter in the form of ingots and coins made of paper. This “money,” which

the dead person will spend in the other world, is contributed by mourners

and burned in a container during the funeral and on other occasions. Offer-

ings to departed kinsmen are a signifi cant part of both funeral rituals and

Death-Song If they ask for me

Say: He had some

Business

In another world.

Sokan

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128 c h a p t e r 3 Perspectives on Death: Historical and Cultural

rituals of commemoration. The dead are dependents after death, needing

the family to supply what they require.

Ancient categories of offerings such as transportation, clothing, housing,

and daily necessities are retained, but their specifi c contents are kept up to

date. “Replicas of standard desk telephones have given way to mobile phones;

as the mobile phones themselves become more compact and intricate, so do

their counterparts in paper.” 121

Traditional belief demands that deceased members of families be remem-

bered, and the ties between the dead and the living maintained. One way to

do this is to give gifts to the dead at regular intervals. The busiest times of

year are the Lunar New Year and the ch’ing ming festival honoring the dead, when shops are packed with customers buying gifts for the ancestors. 122

Ch’ing ming and O - bon Festivals The Chinese celebrate the return of deceased ancestors in a spring festi-

val known as ch’ing ming, which has been called a kind of Chinese Memorial

In the entry to this Hong Kong funeral hall are paper offerings, costing fi ve to six thou- sand U.S. dollars, that will be burnt for the deceased to send him or her successfully into the afterlife. The Chinese characters, “Jiao Fu,” worn by the two fi gures identify them as sedan chair carriers (porters for a palanquin). Beside the sedan chair carriers, there is a large mansion for the deceased and a Mercedes with driver (a combination of modern and traditional artifacts). A mahjong table is situated behind the car, and the mansion is deco- rated with protectors and servants to ease the transition of the deceased into the afterlife. The numbers 1628 on the Mercedes convey the meaning: “always a straight road to easy wealth.”

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Cultural Viewpoints 129

Day. Families visit graves and burn paper offerings as a way of showing regard

and care for their ancestors.

The Japanese festival of bon or o-bon is similar to the Chinese ch’ing ming. Usually observed each year in August, o-bon marks the return of ances-

tral spirits to their families. Known in English as the Festival of the Dead, the

Feast of Lanterns (because lamps are lit to guide the spirits on their journeys

home), the Feast of All Souls, or simply the midsummer festival, o-bon is an

expression of ancient customs relating to the souls of the dead and the rever-

ence due them by the living. In traditional belief, the ancestral spirits and

gods descend from their mountain abodes to confer their blessings upon the

living. 123

People of Jewish Heritage Generally, Jews do not speculate much about life after death. Rather,

their focus is on conduct in one’s present life. Janice Selekman says, “Death is

an expected part of the life cycle; yet, each day is to be appreciated and lived

as fully as possible. . . . The goal is to appreciate things and people while one

still has them.” 124

As for death rites, a deathbed confessional prayer called the Viddui may be said by the dying person or recited by somebody for him or her. Jewish

funerals and burials usually take place within twenty-four to forty-eight hours

after death. Shivah is the term designating the seven-day period that begins with burial. During this period, mourners are “sitting Shivah.” This is a time

for condolences. Kaddish, the Jewish “mourner’s prayer,” is said in the com- pany of others. Rather than speaking of death, however, it praises God and

reaffi rms faith.

Although there are differences in timing, it is customary for a tombstone

to be placed after the Kaddish period is complete and within one year of

the death. At this time, a graveside service, called an unveiling, is held. The

anniversary of the death is called a yahrzeit. Upon visiting the gravesite, it is customary to place a small stone on the grave to indicate that someone has

visited.

Jews have experienced pogroms and exiles throughout their history. The

Nazi Holocaust, during World War II, has been a shaping event on Jewish

identity, and it continues to affect the lives of American Jews and, specifi cally,

the children of survivors.

People of Celtic Heritage In ancient times, Celtic people occupied much of central and western

Europe, ranging from the British Isles in the west to Turkey and the Black

Sea coasts in the east, from Belgium in the north, south to Spain and Italy.

It is commonly agreed that all of the European cultures can trace their

roots to Celtic origins. 125 The societies of the Celts were led by warriors who

justifi ed their authority by skill, courage, and good fortune in battle. Fame

after death was the hallmark of human achievement. As someone larger

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130 c h a p t e r 3 Perspectives on Death: Historical and Cultural

than life but less than divine, the hero was viewed as being in contact with

supernatural powers and the Otherworld, the world beyond present reality. Both burial and cremation were practiced at various times in Celtic

history. The Celts were often buried with personal effects, clothes, jewelry,

and other items that apparently refl ected belief in immortality. Articles

held dear by the deceased were burned or buried so that they could con-

tinue to serve in another life. The status of the deceased and his or her

place in the community were indicated by the extent and type of grave

goods. Based on archaeological evidence, scholars believe that the Celts

enacted elaborate funeral ceremonies involving clan gatherings and feast-

ing at funeral banquets. In one especially lavish burial, probably of a chief-

tain, tomb furnishings included a large bronze couch on which the body

was placed, as well as a four-wheeled vehicle that may have been a hearse or

have represented a chariot for traveling to the Otherworld. The tomb con-

tained bronze dishes and drinking horns, enough to accommodate nine

people, the number considered ideal for a drinking party, suggesting a

ritual feast.

There was a strong sense of communication between the world of the

living and the world of the dead. Memory toasts were drunk in honor of the

dead. Generally, the dead were helpful to their descendants, especially when

reverence was paid to them. Death was viewed as simply a changing of place.

Life went on in all its forms in another world, a world of the dead, the Other-

world. When people died in that world, they could be reborn in this world.

Thus, a constant exchange of souls took place between the two worlds: Death

in the Otherworld brought a soul to this world, and death in this world took

a soul to the Otherworld.

Contact between the living and the dead was especially possible during

the breach in time known as Samhain (November 1), which marked the end of one year and the dawn of the next, according to the Celtic calendar. As the

most important festival of the year, the harvest feast of Samhain lasted several

days, a time when supernatural communications with the gods as well as the

dead could take place. At that time, the walls between this world and the

“other” were most transparent, the souls of the dead driven toward the living

“like swirling leaves.” 126

The Celtic priesthood, known as Druids, presided over the sacrifi cial rites and interpreted omens. 127 They acted as intermediaries between the

world of humankind and the domain of the supernatural. Their main

teaching appears to have been immortality of the soul as a future bodily

life, not merely as spirit or shadow of life after death. Indeed, the Celts seem

to have been among the fi rst peoples to develop a belief in personal immor-

tality. Such beliefs helped the Celts face the fear of death and made them

brave in battle.

The part played by battle-goddesses, battle-maids, or valkyries is important in both Nordic and Celtic traditions and can be traced back before the Viking

Age. Valkyries were thought to haunt the battlefi eld, where they rejoiced in

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Cultural Viewpoints 131

the bloodshed and deaths of warriors. Described as wearing swords, carrying

spears, and riding over air and sea, they were viewed as apportioning victory

or defeat in battle and welcoming fallen heroes into Valhalla, a place of heav- enly honor and glory. The phrase “being a guest in Valhalla” was synonymous

with death. Valhalla literally means “hall of the slain.” Of great height, it is

roofed with golden shields, and its rafters are spears. Valhalla was viewed not

as the dwelling place of all the dead but as a place for outstanding heroes.

The Celtic attitude toward death in battle can be summarized as follows: “To

be a warrior among warriors was the ideal life for the Celt, but to die in a fi ght

surrounded by friends, poets and a hundred dead enemies was the supreme

consummation.” 128 One writer observes that present attitudes may be similar:

“If you watch the commercials that accompany all televised sporting events,

you’ll note this is still our collective idea of heaven, with scantily clad bim-

bettes bearing bounteous beer to Victorious Men as their envious admirers

leap about shouting Woo.” 129

The Celts, who valued skill in words nearly as much as skill in battle,

delighting in word-games and intricate poetic language, also made nota-

ble contributions to world literature, perhaps most famously in the legend

of K ing Arthur. Traces of Celtic myth are also found in Chaucer and in

Shakespeare’s The Tempest and As You Like It, as well as more recently in Tolkien’s Lord of the Rings, which contains strong echoes of the Otherworld and includes Druid-like characters in the forms of the magicians Gandalf

and Saruman. In Tolkien’s The Hobbit, the ring lord is called the Necroman- cer, a name from Nordic mythology that means “enchanter” or “wizard” and refers to the sorcerer’s skill of speaking with the dead to gain knowl-

edge. There is an elegiac note in Old English poetry, like Beowulf, in which there is a sense of grief at the awareness that all things are passing away

and life is on loan. 130

Long after Ireland was converted to Christianity, beliefs and customs

associated with Samhain continued. In the mid-twentieth century, for exam-

ple, arrangements of bread and produce were prepared in rural Irish homes

on November 1, “a bowl of water placed on the table,” and the doors left

unlatched “to let in the souls.” 131 A traditional practice in Ireland was for

the deceased to be “laid out” at home for a fi nal farewell. In ancient times,

at wakes, Gaelic women engaged in “keening,” or loud wailing, while men

socialized with drinking and conversation. The wake is still an important tra-

dition in contemporary Irish and Irish American families. “A wake is a time

of melancholy, rejoicing, pain, and hopefulness as well as a time to share food

and drink in honor of the deceased.” 132

Today, more people claim some sort of Celtic identity than at any other

time in history. Celtic religious beliefs are being rediscovered as part of the

modern resurgence of pagan, nature-venerating, polytheistic religions. (The

literal meaning of the word pagan is “rural” or “country dweller.”) The keen- ing sounds of dirges and laments played on bagpipes and uilleann pipes are

part of many funeral processions, especially of police offi cers and fi refi ghters

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132 c h a p t e r 3 Perspectives on Death: Historical and Cultural

killed in the line of duty. In short, the Celtic heritage is an important compo-

nent of European and European American culture.

People of Arab Heritage Arabs trace their ancestry and traditions to the nomadic desert tribes

of the Arabian Peninsula. This cultural heritage is associated with a wide

geographic area of North Africa and Southwest Asia, including the countries

of Jordan, Iraq, Kuwait, Bahrain, Qatar, the United Arab Emirates, Oman,

Yemen, and Saudi Arabia, as well as Algeria, Lebanon, Libya, Morocco,

Palestine, Somalia, Sudan, Syria, and Tunisia. Bedouin is the term applied to all Arabic-speaking, nomadic tribes in the Middle East.

Different groups of Arabs have distinctive traditions and religious beliefs,

as well as differences based on ethnic, linguistic, tribal, regional, religious,

socioeconomic, and national identities. Although many Arabs are Muslim, the

terms Arab and Muslim are not synonymous. Nevertheless, this section will focus on Muslim beliefs and practices regarding death.

For most Muslims, death and the afterlife are central tenets of faith. 133

Allah determines how long a person will live. Earthly life is a preparation for

eternal life, and death is accepted as God’s will. Because of this, discussion of

advance directives or end-of-life care may be unwelcome.

Extended periods of mourning may be perceived by some Muslims as

contrary to the will of God. Even so, individuals may react dramatically to

the death of a family member and engage in strong and expressive grieving.

Family, friendship, and social support are sources of strength and comfort,

especially in times of illness or crisis.

Among Muslims, as the time of death nears, the deathbed, or at least the

person’s face, is turned toward Mecca. Islam calls for burial of the deceased

as soon as possible. The burial ritual includes cleaning the body and wrap-

ping it in a white cotton shroud. Verses from the Qur’an are read and prayer

is recited before the body is buried in a simple tomb. For devout Muslims, life

or death is the will of God.

People of Oceanian Heritage The indigenous peoples of the Pacifi c Islands, or Oceanians, are people who

are descended from the original peoples of Hawaii and other Pacifi c islands,

including people of Polynesian, Melanesian, and Micronesian background.

They differ in language and culture across many subgroups. 134 The largest

Polynesian groups are Hawaiian, Samoan, and Tongan; the largest Micronesian

group is Chamorros/Guamanian; and the largest Melanesian group is Fijian. 135

Key areas of culture for Pacifi c Islanders are family networks, spirituality,

balance, harmony, and values such as are expressed in the Hawaiian terms

lokahi (unity and harmony), pono (goodness, uprightness, proper procedure), ’ohana (kingroup and social supports), kokua (mutual help and cooperation), and kuleana (responsibility). These values are evident in the following discus- sion of culture in Hawaii.

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Mixed Plate: Cultural Diversity in Hawaii 133

Mixed Plate: Cultural Diversity in Hawaii The population of Hawaii represents a rich ethnic and cultural blend. The

boundaries between different population groups in Hawaii are loosened

through social interaction, becoming “soft instead of hard, often overlapping

rather than sharply defi ned,” resulting in a situation wherein “no group has

totally surrendered the core of its traditional cultural identity.” 136 (This may

foreshadow what the mainland United States and much of the larger global

environment will look like in a few more decades.)

Hawaii is “the only region [in the United States] where all racial groups

are minorities and where most of the population has its roots in the Pacifi c

Islands or Asia instead of Europe or Africa.” 137 Hawaii was settled by Poly-

nesians who sailed to the Hawaiian archipelago and whose fi rst contact with

Europeans came in 1778 with exploration of the Pacifi c by Captain James

Cook. 138 Later, successive waves of immigrants came—including Chinese,

Japanese, Portuguese, Okinawans, Koreans, and Filipinos. Today’s residents

include Caucasians from Europe and North America, Samoans, Vietnamese,

Laotians, and Cambodians, as well as African Americans, Latin Americans,

Pakistanis, Tongans, Fijians, Micronesians, immigrants from other parts of

Oceania, and others. The pan-ethnic identity of being a “local” represents “the common identity of people of Hawaii and their shared appreciation of the

land, peoples, and cultures of the islands.” 139

Each group has its own story, unique history, and corresponding tradi-

tions. Most have their own cultural networks, with their own ways of keep-

ing tradition alive, as well as providing mutual support in times of need.

The diversity in Hawaii illustrates the possibility of preserving the cultural

richness of distinctive traditions by accommodating and assimilating their

expression.

Characteristics of Hawaii’s Peoples The extended family group, or ’ohana, is at the center of traditional

Hawaiian values. 140 Children have an important place in family gather-

ings, including funerals. The intimate relationships of the ’ohana involve

close bonds between living family members and their ancestors. 141 Ancestral

remains are sacred, especially those of the ali’i, members of the royal family. Indeed, as George Kanahele says, the Hawaiians’ love of family is the basis of

their love of the land:

In a religious society in which ancestors were deifi ed as ’aumakua [gods] and genealogy elevated to prominent status, a place, a home, was much more valued

because of its ties with the ancestors. A Hawaiian’s birthplace was celebrated

not simply because he happened to be born there, but because it was also the

place where so many generations of his ancestors were born before him. It was a

constant reminder of the vitality of the bloodline and of the preciousness of life

past, present, and future. 142

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134 c h a p t e r 3 Perspectives on Death: Historical and Cultural

To be spiritual means to recognize interdependence and strive for har-

mony among human beings, the land, and higher powers (including both

God, called ke akua, and personal ancestral guides, called ’aumakua ). 143 Hawaiian identity is spoken of in terms of connectedness to lands, language,

and family. 144

Among the earliest immigrants to Hawaii were the Chinese. Like the

Hawaiians, Chinese cultural values emphasize the importance of fam-

ily and relationships. 145 They also retain elements of traditional funer-

als and mourning. 146 For example, Chinese funerals in Hawaii typically

include paper offerings (such as those discussed earlier in this chapter).

Papier-mâché “servant dolls” are placed in front of the casket, and a Tao-

ist priest chants instructions about how to take care of the deceased in

Heaven. The boy servant might be told, “Take care of your master; fetch

him water and fi rewood.” To the girl servant, the priest might say, “Keep

the house clean, and when you go shopping, don’t waste your master’s

money.” In the Taoist funeral, which lasts nearly all day, the priest chants

and musicians play instruments while family members perform rituals at

the priest’s direction.

Most cultural groups living in Hawaii share a valuing of family ties and

respect for ancestors. John F. McDermott says,

In all groups, except perhaps the Caucasian, the extended family plays a

central role. There is an emphasis on the family as a key social unit, and on

family cohesion, family interdependence, and loyalty to the family as central

guiding values. The individual is seen as part of a larger network, and duties

and obligations, as well as much of the sense of personal security, derive from

that context. . . . Caucasians, too, value the family, but they face the world as

individuals. 147

It is appropriate to think of Caucasians as one of many groups that con-

stitute the “cultural mosaic” of the islands. Newcomers often fi nd that this

social reality requires some adjustment. Caucasians who move to Hawaii from

the United States mainland do not think of themselves as migrants; they view

themselves as representing mainstream culture and usually expect others,

not themselves, to adapt. 148 Those who remain in Hawaii, however, adapt to

the unique culture of Hawaii and assume a “local” identity, which is shared by

all the groups living in Hawaii.

Death and Local Identity The various ethnic groups in Hawaii tend to maintain a distinctive iden-

tity and culture while sharing elements of their identity and culture with the

overall community. As different ethnic groups became part of the cultural mix

in Hawaii, a common language, called pidgin, developed and became a sym- bol of local identity. Borrowing words and grammar from the native tongues

of its speakers, pidgin is not only an expressive means of communication

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Mixed Plate: Cultural Diversity in Hawaii 135

among people of disparate backgrounds but also a way for people to identify

with their adopted homeland. Today, speaking pidgin allows people to tran-

scend cultural boundaries and establish rapport with each other on the basis

of “local” identity.

A Caucasian nurse describes how pidgin was useful in talking with a

Filipino man who was dying. As the man’s body wasted away, he was fright-

ened. Offering comfort, the nurse told him, “Spirit good, body pau [fi n- ished].” In using a pidgin word, borrowed from the Hawaiian language,

she was able to affi rm, in a culturally appropriate and comforting way, the

strength of his spirit while acknowledging that the life in his body was being

consumed by disease.

Local identity is fostered by familiarity with customs practiced by the dif-

ferent ethnic groups and by fl exibility in adopting elements of those customs

into one’s own life. For instance, the native Hawaiian tradition of feasting

at important ceremonial events is widespread among Hawaii’s residents. At

funerals, mourners often gather after the ritual to share food and conver-

sation. Mortuaries in Hawaii accommodate this by having kitchen and din-

ing facilities where food can be prepared, brought by mourners (potluck), or

catered and served to gathered family and friends.

Similarly, funeral announcements in Hawaii usually include the notice

“Aloha attire requested,” to which mourners respond by wearing colorful

shirts or mu’u (long “missionary” dresses), along with beautiful and fragrant fl ower leis. The lei is very special in Hawaiian culture, and different fl owers

and leis carry symbolic meanings. For example, a hala lei is associated with the breath ( ha ) and connotes passing away or dying. The ginger, or ’awapuhi, lei is a symbol of things that pass too soon, as indicated in the Hawaiian folk

saying, “ ’Awapuhi lau pala wale, ” or “Ginger leaves yellow too quickly.” 149 In the customs of feasting after a funeral and wearing fl ower leis, traditions asso-

ciated with the indigenous Hawaiians have been adopted as expressions of

local identity and community feeling.

Given the religions practiced in Hawaii—Christianity, Buddhism, and

Taoism, among others—mortuaries are generally set up to offer appropri-

ate accoutrements and symbols for each of these traditions. The central

portion of the altar at one mortuary is designed as a revolving display so

that images and symbols of the appropriate religious tradition can be easily

moved into view.

Hawaii’s diverse inhabitants have not minimized differences between dif-

ferent ethnic groups so much as learned to appreciate and make room for

their expression. The fastest-growing ethnic group in Hawaii is “mixed race,”

or hapa. 150 When people marry outside their heritage group, thereby join- ing in kinship with families from different cultural traditions, their customs,

beliefs, and practices blend together in a new family. As spouses from differ-

ent traditions adopt elements of each other’s culture, their children naturally

become acquainted with both cultures.

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136 c h a p t e r 3 Perspectives on Death: Historical and Cultural

Death in Contemporary Multicultural Societies Modern societies are composed of a number of social groups, each with dis-

tinctive customs and lifestyles. The presence of a cultural mosaic created by

different ethnic and cultural groups can enrich a society. 151 People some-

times talk or write about “the American way of death,” but this phrase con-

ceals what, in fact, are many different “ways of death,” refl ecting attitudes,

beliefs, and customs of culturally diverse groups. David Olson and John

DeFrain remind us that “tremendous diversity exists among people who are

commonly grouped together.” 152

The ways we cope with death are not created out of thin air. The root

meaning of tradition is “to hand down.” Each generation receives culture from the preceding generation, alters it, and passes it on. This is seen in the

fi lm Bend It Like Beckam, which tells of a young girl’s search for identity in

In contemporary societies, where a variety of cultural traditions are practiced by different ethnic and subcultural groups, people may fi nd themselves “trying on” customs and practices that differ from those of their own heritage group. The opportunity to participate in the rites and ceremonies of other cultures, to assume a “local identity,” even if only temporarily, can broaden our understand- ing and expand our range of choices for revitalizing even those customs with which we are most familiar.

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Further Readings 137

twenty-fi rst-century London. She seeks to renegotiate an identity that com-

bines her ancestral cultural and the culture of a new homeland, occupying

what has been termed third space. 153 The ancestral culture in this case is that of immigrant and fi rst-generation Punjabi Sikh Indians, and the fi lm shows

the struggles tradition-bound cultures must go through as they enter a more

freedom-loving modern world.

Ethnicity and other cultural factors have an impact on such matters as

coping with life-threatening illness, the perception of pain, social support for

the dying, manifestations of grief, mourning styles, and funeral customs. 154

Spanish-speaking people in northern New Mexico continue to practice tra-

ditional forms of recuerdo, or remembrance, which memorialize the dead and comfort the bereaved. 155 Presented as a written narrative or ballad, the

recuerdo tells the story of a person’s life in an epic, lyrical, and heroic man-

ner. This is a kind of farewell, a leave-taking, or la despedida, on behalf of a deceased person. Such memorials frequently contain reminders of the transi-

tory nature of life and express the notion that life is on loan from God for

only a short time.

As Robert Harrison reminds us, mourning rituals are missing something

important if they do not “provide the means, or language, to cope with one’s

own mortality even as they help one cope with the death of others.” 156

Further Readings Fredrik Fahlander and Terje Oestigaard. The Materiality of Death: Bodies, Burials,

Beliefs. Oxford: British Archaeologial Reports, 2008. Ronald L. Grimes. Deeply into the Bone: Re-Inventing Rites of Passage. Berkeley: University

of California Press, 2000.

Robert Pogue Harrison. The Dominion of the Dead. Chicago: University of Chicago Press, 2003.

Allan Kellehear. A Social History of Dying. New York: Cambridge University Press, 2007. Paul Koudounaris. The Empire of Death: A Cultural History of Ossuaries and Charnel

Houses. London: Thames & Hudson, 2011. Claudio Lomnitz. Death and the Idea of Mexico. Cambridge, Mass.: MIT Press, 2005. Regina M. Marchi. Day of the Dead in the USA: The Migration and Transformation of a Cul-

tural Phenomenon. New Brunswick, N.J.: Rutgers University Press, 2009. Elaine Nichols, ed. The Last Miles of the Way: African-American Homegoing Traditions,

1890-Present. Columbia: South Carolina State Museum, 1989. Mike Parker Pearson. The Archaeology of Death and Burial. College Station: Texas A&M

University Press, 2000.

Charles Wilkinson. Blood Struggle: The Rise of Modern Indian Nations. New York: Norton, 2005.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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A death that occurs under suspicious or uncertain circumstances prompts an investigation to determine cause of death. Thus, law enforcement agencies are part of a society’s death system—the networks of people, places, times, objects, and symbols that shape an individual’s relationship to mortality.

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139

C H A P T E R 4

Death Systems:

Mortality and Society

S ociety has an interest in such matters as devising the rules governing organ dona- tion and transplantation, defi ning and making determinations of death, classifying modes

of death into useful categories, regulating the manner in which investigative duties are car-

ried out by coroners and medical examiners, and assessing the degree of criminal intent or

negligence when a violent death has occurred. Kaleidoscopic in their diversity, all of these

are part of the “death system,” a term coined by Robert Kastenbaum to describe “the inter-

personal, sociophysical, and symbolic network through which an individual’s relationship to

mortality is mediated by his or her society.” 1

The components of a death system include people (funeral directors, life insurance agents,

weapons designers, people who care for the dying), places (cemeteries, funeral homes, battle-

fi elds, war memorials, disaster sites), times (memorial days and religious commemorations such

as Good Friday, anniversaries of important battles, Halloween), objects (obituaries, tombstones,

hearses, the electric chair), and symbols (black armbands, funeral music, skull and crossbones,

language used to talk about death). In today’s societies, the Internet has also become a signifi -

cant part of the death system (a thanatechnological death system). 2

Although the functions of a death system vary among different societies and at different

times in the same society, a death system includes these elements:

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140 c h a p t e r 4 Death Systems: Mortality and Society

1. Warnings and predictions about potentially life-threatening events (storms,

tornadoes, and other disasters, as well as advice to specifi c individuals, such

as doctors’ reports of laboratory results or mechanics’ warnings about

faulty brakes)

2. Preventing death (emergency and acute medical care, public health ini-

tiatives, antismoking campaigns)

3. Caring for the dying (nurses, trauma workers, family caregivers, hospice

staff)

4. Disposing of the dead (mortuaries, cemetery plots, memorialization pro-

cesses, identifi cation of bodies in disasters)

5. Social consolidation after death (coping with grief, maintaining commu-

nity bonds, settling estates)

6. Making sense of death (religious or scientifi c explanations, consolation

literature, last words)

7. Killing (capital punishment, war, hunting, raising and marketing of

animals)

There are interconnections and mutual infl uences among these functions.

It should be obvious, however, that the elements composing a death system

touch on virtually every aspect of social and individual life, ranging from the

use of euphemisms on sympathy cards to the medicalization of death. The

death system is concerned with managing the phenomenon of death in all

its varied manifestations. These include preventing death, disposing of the

dead, making sense of death, endorsing socially sanctioned death, and some-

times camoufl aging the impact of death on our lives. 3 The death system also

defi nes rules of grieving that “determine who, when, where, how, how long,

and for whom people should be sanctioned to grieve;” that is, the “shoulds”

and “should nots” that govern individual responses to loss. 4 This is called the

“policing” of grief. Similarly, the circumstances surrounding an individual’s

dying typically occur as a result of decisions made through “a social process

of negotiation of meanings.” 5 Throughout this text, we highlight different

aspects of the death system. In the following pages, we focus particularly on

the death system’s impact as it relates to defi ning and certifying death, assess-

ing homicidal acts, regulating organ donation and transplantation, and

administering capital punishment. As Kastenbaum says, “the death system

regards mortality as intrinsic to all facets of societal functioning.” 6

Certifi cation of Death Death certifi cates refl ect both a private and a public function in the death

system. At fi rst glance, the document used to certify the facts of death

appears straightforward, a concise summary of the pertinent data regard-

ing the deceased and the mode and place of death. However, this seemingly

simple document has broader implications than one might imagine. Besides

its value and purpose as a legal document that affects disposition of property

rights, life insurance benefi ts, pension payments, and so on, the utility of the

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The Coroner and the Medical Examiner 141

death certifi cate extends to such diverse matters as aiding in crime detection,

tracing genealogy, and gaining knowledge about the incidence of disease

and other aspects of physical and psychological health.

In fact, the offi cial registration of death is considered the most important

legal procedure following a death. A death certifi cate constitutes legal proof

of death, and death certifi cates are required by all jurisdictions in the United

States. Although death certifi cates vary somewhat from state to state, most fol-

low the format outlined by the United States Standard Certifi cate of Death.

Funeral directors are generally responsible for completing and fi ling death

certifi cates. “The funeral director obtains personal data from the best source

available (usually next of kin) and cause-of-death information from the attend-

ing physician, medical examiner, or coroner.” 7 When complete, the certifi cate

is fi led with the registration authority in the state where the death occurred.

The typical death certifi cate (see Figure  4-1 ) provides for four differ-

ent modes of death: accidental, suicidal, homicidal, and natural. However, as Edwin Shneidman points out, the cause of death isn’t necessarily the same as the mode of death. 8 For example, if a death is caused by asphyxiation due to drowning, should it be classifi ed as an accident, a suicide, or a homicide? Any

of these modes might apply.

Underlying the distinction between mode and cause is a more com-

plex issue of intentions and subconscious factors, the states of mind and

actions, that may have contributed directly or indirectly to the death. For

instance, if an intoxicated person jumps into a swimming pool with no one

else present and drowns, is the death accidental or suicidal? Does it make a

difference whether the alcohol abuse was related to emotional distress and

despondency? What is the mode of death if the cocktails were served by a

too-generous host? What if the person serving the excessive alcohol were also

an heir of the person who died?

Obviously, intentions and subconscious factors can be more complex than

the relatively elementary distinctions concerning mode and cause of death

now listed on most death certifi cates. A study done in Marin County, Califor-

nia, to assess the conventional classifi cations of mode of death as well as the

lethality of the deceased’s intention revealed that some deaths classifi ed as

natural, accidental, and homicidal were precipitated by the deceased’s own

actions; that is, the deceased had lethal intentions against himself or herself.

(The use of a psychological autopsy as an investigative tool for reconstructing the intentions and factors leading up to a death is discussed in Chapter 12.)

Because death certifi cates force physicians to simplify what might be a com-

plex medical situation, lack of training is said to be the greatest contributor to

the poor quality of mortality data. 9

The Coroner and the Medical Examiner Most deaths in the United States result from disease, and the physician attend-

ing the patient certifi es the cause of death. However, when death occurs in

suspicious circumstances or suddenly, and there is no physician to certify

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142 c h a p t e r 4 Death Systems: Mortality and Society

Figure 4-1 Certifi cate of Death in Use in California

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The Coroner and the Medical Examiner 143

cause of death, the cause must be determined by a coroner or medical exam-

iner, also known as a death investigator. 10 Coroners are usually elected offi cials; medical examiners are usually appointed. The main difference between the

two positions, however, has to do with training. Whereas coroners may not

possess any special background or training, medical examiners are physi-

cians, generally with advanced training and certifi cation in anatomical and

forensic pathology (the application of medical knowledge to questions of law). A Chinese book written in the thirteenth century describes how investi-

gators of the time could distinguish a natural death from an unnatural death

by, for example, noting damaged cartilage on the neck and pressure marks

on the throat, suggesting death by strangulation. 11

Observation and analysis are still at the core of forensic examination.

Stefan Timmermans says,

Death investigators are called when something goes seriously wrong. The deceased

should have lived. Their death was either unexpected or premature, or the

circumstances suggest violence, accident, destructive behavior, abuse, or simple

ambiguity. These deaths are suspicious because they occurred out of the ordinary. 12

Cause of death is determined by an investigation that makes use of sci-

entifi c procedures, possibly including an autopsy (described later in this

chapter), toxicology and bacteriology tests, chemical analyses, and any other

A member of the coroner’s staff notifi es a family about the sudden, unexpected death of a husband and father. Details about the accident and efforts at life-saving intervention are provided in a gentle, open manner, using the family’s questions to guide the discussion. A police offi cer who was on the scene stands by to provide more information if it is requested.

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144 c h a p t e r 4 Death Systems: Mortality and Society

studies that are needed to arrive at adequate fi ndings. The investigator’s que-

ries eventually result in a thanatography, a written account of a person’s death. 13 The results of such postmortem examination can play a crucial role in

court cases and insurance settlements. Such proceedings may be important

not only to law enforcement agencies but also to the families involved: The

mode of death—whether due to foul play, negligence, suicide, accident, or

natural causes—can have a signifi cant emotional effect on survivors. It may

also have an economic effect; for example, some life insurance policies cover

only accidental death, whereas others pay twice the face value of the contract

in the case of accidental death (double indemnity).

Besides their responsibilities for investigating the cause of death in ques-

tionable circumstances, coroners and medical examiners often play a key role

in community health programs, such as suicide prevention and drug abuse

education.

One death investigator said, “I can’t give people back their loved ones.

I can’t restore their happiness or innocence, can’t give back their lives the

way they were before. But I can give them the truth. Then they will be free to

grieve for the dead, and then free to start living again.” 14

Autopsies An autopsy (from the Greek autopsia, meaning “seeing with one’s own eyes”) is a detailed medical examination of a body after death to determine cause

of death or investigate the nature of changes caused by disease. Once the

abdominal cavity is exposed, organs are removed for examination of their

internal structure, and small samples may be taken for later analysis. After

the autopsy is completed, organs not needed for further study are replaced in

the body cavity, and all incisions are closed.

The situations which call for autopsies and the manner in which they

are carried out are matters for the death system. The deceased’s family may

request an autopsy to determine whether any genetic or infectious condi-

tions led to death, or to help resolve questions about possible malpractice.

An autopsy may be performed for legal or offi cial reasons (as mentioned in

connection with the role of the coroner or medical examiner) or as part of a

hospital’s teaching or research program. Unlike autopsies performed as part

of medical training or at a family’s request, those done as part of an investiga-

tion conducted by a coroner or medical examiner are required by law.

Except when required by law, an autopsy can be performed only after the

next of kin’s consent is obtained or when the deceased has donated his or her

body for autopsy under the provisions of the Uniform Anatomical Gift Act.

Students in medical school practice human dissection in the anatomy lab as

one of their early tasks. For many, this is their fi rst encounter with a human

cadaver, and it is part of the “white coat” initiation that marks entry into the

medical profession. Traditionally, such labs gave students little or no infor-

mation about the cadavers they were assigned for dissection. The cadavers

were given numbers, not names. Recently, some medical schools have been

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Autopsies 145

When a coroner’s preliminary investigation reveals the need to scientifi cally determine the cause of death, the corpse is brought to the morgue, where it is held until an autopsy can be performed.

The autopsy, or medical examination to determine the cause of death, is conducted under the coroner’s direction when the circumstances of a death are violent, suspicious, or unexplained, or when a death is medically unattended and a doctor is unable to certify the cause of death. All homicides, accidents, and suicides come under the coroner’s or medical examiner’s jurisdiction.

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146 c h a p t e r 4 Death Systems: Mortality and Society

returning identity to the donors whose bodies are dissected. Videos of donors

explaining their reasons for bequeathing their remains are shown, and stu-

dents learn to view the human cadavers under their care not as anonymous

cadavers but as their “fi rst patients.” 15

Forensic techniques for identifying remains are used by the Army Cen-

tral Identifi cation Laboratory in Hawaii (CILHI) at Hickam Air Force Base,

which is responsible for searching for, recovering, and identifying armed

service members killed or listed as missing. 16 Organized into three sections,

CILHI includes teams devoted to search and recovery, casualty data analysis,

and scientifi c examination of physical evidence in the lab itself. In the lab,

recovered remains and other evidence are examined by physical anthropolo-

gists and other experts.

Techniques for identifying human remains have become increasingly

sophisticated, allowing positive identifi cation to be made not only from frag-

ments of hair or bone but also from DNA analysis based on relatively few

cells. In 2003, when the space shuttle Columbia broke apart as it reentered Earth’s atmosphere, search teams recovered remains from all seven astro-

nauts and forwarded them to the Charles C. Carson Center for Mortuary

Affairs at Dover Air Force Base in Delaware. Forensic analysis provided at the

Carson Center also had been used to identify the remains of the Challenger astronauts in 1986 and the Pentagon victims of the September 2001 terrorist

attack. Experts say that disasters such as the attack on the World Trade Cen-

ter pushed the science of identifi cation technologies to use new methods of

chemical analysis and analytical software, enhancing their ability to identify

burned or pulverized remains and to work with smaller biological samples of

the genetic code that every human cell contains. 17

In conclusively establishing cause of death, autopsies serve a number of

important purposes in law and medicine (see Table 4-1 ). Physician John Lantos

says, “Postmortem examinations have long been recognized as one of the best

teaching tools in medicine. They are the fi nal check on whether what we did

and what we thought we ought to be doing were correct or whether we missed

something.” 18 Because autopsies are required in just a few circumstances,

t a b l e 4-1 Reasons for Autopsies

1. Establish the cause of death 2. Assist in determining the mode of death (i.e., homicide, suicide, etc.) 3. Compare the premortem and postmortem fi ndings 4. Produce accurate vital statistics 5. Monitor public health 6. Assess the quality of medical practice 7. Instruct medical students and physicians 8. Identify new and changing diseases 9. Evaluate the effectiveness of therapies such as drugs, surgical techniques, and

prostheses 10. Reassure family members 11. Protect against false liability claims and settle valid claims quickly and fairly

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Assessing Homicide 147

however, many hospitals have discontinued autopsies or no longer have full

autopsy facilities. This situation is despite the fact that studies show autopsy

results contradicting presumed cause of death in about one-third to nearly

half of cases. 19 Consider this fi gure in light of the fact that the autopsy rate at

nonteaching hospitals averages less than 10 percent, and many hospitals have

autopsy rates at or near 0 percent despite many deaths. The autopsy rate for

deaths in nursing homes is apparently not known. The autopsy, says George

Lundberg, editor of the Journal of the American Medical Association, is “appar- ently the victim of a vast cultural delusion of denial.” For various reasons, it’s as

if the result voiced is “do not bother me with the truth.” Lundberg says, “The

autopsy remains the essence of modern clinical science. It is the one place

where truth can be sought, found, and told without confl ict of interest.” 20

Recently, private autopsy services have become available to conduct

autopsies for a fee on behalf of hospitals and individual clients, many of

whom are family members seeking information about hereditary diseases or

who suspect malpractice and want evidence that may be obtained through an

autopsy. With genetics being found to play a bigger role in a wider range of

conditions, some experts believe that accurately knowing a family member’s

cause of death provides information that can potentially save lives.

Assessing Homicide Community standards play a role in determining how an act of killing is

assessed by a society and its legal-political-judicial system. Homicide —the kill- ing of one human being by another—is separated into two categories, crimi-

nal and noncriminal, and each of these categories has further distinctions.

For example, an act of homicide is considered excusable or justifi able when

a person who kills another is found to have acted within certain legal rights,

such as that of self-defense, or when the killing is judged an accident involv-

ing no gross negligence.

Justifi able homicide nearly doubled in the decade from 2000 to 2010.

More individuals are killing other individuals and claiming self-defense, a

trend most pronounced in states with “stand your ground” laws that grant

more leeway for people to attack and even kill someone who is threaten-

ing them. A 2012 article in The Wall Street Journal pointed out that in about 60 percent of justifi able homicide cases where the relationship between killer

and victim was known, the pair were strangers, a statistic that differs sharply

from nonjustifi able homicide cases, where more than three-quarters of

victims knew their killers. 21

Thus, although a murder is necessarily a homicide, a homicide is not

always a murder. The law has traditionally recognized two main distinctions

within the category of criminal homicide: murder and manslaughter. Murder is associated with acts carried out with deliberate intention (“malice afore-

thought”), and the category of fi rst-degree murder, or “capital murder” in

some states, is used to designate killings that are carefully planned (e.g., mur-

der for hire), involve multiple victims or police offi cers as victims, or take

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148 c h a p t e r 4 Death Systems: Mortality and Society

place in conjunction with other serious crimes. Manslaughter is defi ned as

wrongful, unplanned killing done without express or implied malice.

State laws differ in how they distinguish various categories of manslaughter.

The basic divide is between voluntary and involuntary manslaughter, although

some states do not make this distinction. An example of voluntary manslaughter is that of a person who, after being provoked, kills another person in a fi ght.

Such a person is said to have acted in the heat of passion without consider-

ing the consequences. When homicide results from criminal carelessness but is

unintentional, it is termed an act of involuntary manslaughter, as in the case of a fatal automobile accident caused by reckless driving or a death caused by gross

negligence. When alcohol is involved, the penalties can be stiff.

Some states that do not make the distinction between voluntary and invol-

untary combine them as “manslaughter” and add the category criminally negligent homicide—an act in which a person ought to have been aware of a substantial

and unjustifi able risk of such nature and degree that it is a gross deviation from

the standard of care that an ordinary person would have exercised.

In a study of more than three hundred killings that occurred in a major

American city, it was found that more than half of the suspects were released

before reaching trial. 22 To understand why some homicide cases are not

brought to trial, it is necessary to look at how the circumstances of a homi-

cidal act infl uence its investigation and how the judicial processes determine

whether an accused killer is brought to trial.

The medical-legal investigation of an act of homicide generally includes

three components: (1) an autopsy to determine the offi cial cause of death;

(2) a police investigation to ascertain the facts and gather evidence pertinent

to the killing; and (3) various judicial and quasi-judicial procedures carried

out by the district attorney’s offi ce and the court system to determine whether

there is suffi cient cause to bring a case to trial.

Fundamental to this investigation is the acknowledgment that homicide

is an interpersonal act. That is, it involves a relationship between the killer

and the victim: They may have had close domestic ties, have been members

of the same family or otherwise related; they may have been friends or associ-

ates; or they may have been strangers. In the study referred to above, it was

found that “the closer, or more intimate, the relationship is between a killer

and his victim, the less likely it is that the killer will be severely punished for

his act.” In other words, killing a stranger was more likely to result in a stiff

penalty than was killing a friend or family member.

The circumstances surrounding a killing, the relationship between the

killer and the victim, and the killer’s motivation and intention are all weighed

to determine how an act of homicide is assessed within the judicial system. Bas-

ing its standards on cultural attitudes, the criminal justice system, including the

police investigation, sets about the task of determining whether an act of homi-

cide is lawful or unlawful. If it is lawful, the killer is released, and the case is

closed. If it is unlawful, a further determination is made as to whether the kill-

ing in question was an act of murder, manslaughter, or negligent homicide—

and there are various degrees of criminal intent within each of these categories

as well. The following set of fi gures for the United States is instructive: 23

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Assessing Homicide 149

• 22,000—Number of criminal homicides reported (murder and non-negli- gent manslaughter)

• 15,000—Number of arrests reported of persons charged with criminal homicide

• 13,500—Number of homicide cases prosecuted (about 90 percent of per- sons arrested)

• 10,000—Estimated number of homicide convictions (about two-thirds of those arrested and nearly three-fourths of those prosecuted)

• 2,000–4,000—Estimated number of death-eligible defendants convicted of fi rst-degree murder because of “aggravating circumstances” on which a

jury can impose a death sentence • 300—Average number of death sentences imposed annually (about one-

tenth of death-eligible defendants) • 55—Average number of executions per year

What are the cultural assumptions by which an act of homicide is judged?

Research shows that the legal outcome for a person who kills his wife’s lover

is quite different from the outcome for a person who combines killing with

theft, robbery, or similar criminal acts. An extensive investigation conducted

by the Los Angeles Times found that people who killed strangers were more

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150 c h a p t e r 4 Death Systems: Mortality and Society

likely to get tough treatment from the criminal justice system than those who

killed lovers, relatives, or other people they knew. One police investigator

said that when “innocent victims, God-fearing people, end up murdered,”

other cases “take a back seat” because such killing causes neighborhood ter-

ror and therefore must be resolved quickly. However, he added, referring to

gang shootings, “When ‘Snoopy’ kills ‘Chilly Willie,’ nobody cares.” 24

Society is usually reluctant to become involved in matters that fall within

the domain of the family. This appears to be true even with family homi-

cide involving a child victim. Situational elements within a family may result

in penalties being imposed on the basis of statutes defi ning manslaughter

or child abuse rather than murder. 25 There are exceptions, however, as in

cases of mothers who intentionally kill their children. 26 Nevertheless, a close

relationship is believed to involve its own set of mutual responsibilities and

obligations—its own “code of justice”—that provides social sanctions for acts

that occur within the relationship.

Killings that occur within the family unit or between persons who know

one another tend to be viewed as less of a threat to society at large. In contrast,

the killer who chooses a stranger as his victim overtly threatens the preserva-

tion of the social order. Thus, society devotes its attention to acts of homicide

that threaten the preservation of law and order within the larger society.

Capital Punishment In 2010, forty-six individuals were executed in the United States and, at year’s

end, about 3,200 were under sentence of death. 27 Most murderers who receive

the death penalty are involved in intraracial offenses—that is, cases of whites

killing whites or blacks killing blacks. In theory, capital punishment serves

a twofold purpose: (1) It punishes the offender and (2) deters other poten-

tial offenders. “The theory of deterrence is based on the idea that criminal

behavior can be deterred if punishment is swift, certain, and severe enough

to counter the benefi ts or pleasure gained from committing crime.” 28

Although the death penalty has been applied to various offenses since

ancient times, the argument is made that it is needlessly cruel and overrated

as a deterrent to murder. According to Glenn Vernon,

Investigations into the ineffectiveness of the death penalty as a deterrent to

murder revealed that some murderers were so busy with other things during

the events preceding the murder that they simply did not think of the death

penalty, and that others were interacting with their victims in such an extremely

emotional manner that the consequences of their murderous acts were not even

taken into account. 29

In the United States, most statutes require that a sentence of death be

imposed only after evidence is submitted to establish that “aggravating,” as

opposed to “mitigating,” factors were present in the crime. If aggravating fac-

tors are found, and the sentence is death, then the case is reviewed by an

appellate court. Apart from certain crimes on which the Supreme Court has

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Defi ning Death 151

not ruled (the most notable being treason), the only capital crime (crime

punishable with death) in the United States is murder. 30

Is it inconsistent for society to try to prevent murder by itself engaging in

killing? Does capital punishment reinforce the idea that violence solves prob-

lems? Citing evidence from psychology and behavioral therapy, which empha-

sizes the effects of positive reinforcement, Robert Kastenbaum and Ruth

Aisenberg say that “there is little evidence to suggest that imposing massive pun-

ishment on one individual will ‘improve’ the behavior of others; on the contrary,

it may reinforce hostile fantasies and murderous tendencies.” 31 The greatest risk

for a potential murderer, they contend, is not the risk of execution “but the risk

of being killed by the police, the intended victim, or some bystander.”

Yet another argument against capital punishment is the concern for the

number of death-row inmates who have been released after evidence of their

innocence has been discovered, some of them just days before their sched-

uled executions. Between 1973 and 2002, more than one hundred death-row

inmates were released due to evidence of their innocence that came to light

during their imprisonment. 32

If capital punishment is not an effective deterrent to murder, are there

other options? Comparing our present-day system with early Anglo-Saxon and

English law and with many non-Western legal systems as well, Henry Lunds-

gaarde says, “Modern criminal law has completely transformed the ancient

view of homicide as a wrong against a victim and his family to its modern ver-

sion that views homicide as an offense against the state.” 33 In short, the mod-

ern tendency is to view crime as a social problem. The separation of civil and

criminal law—or, more specifi cally, the separation of personal obligation and

criminal liability—eliminates the killer’s liability to the victim as person. Instead, the violent act is viewed as having been committed against the public at large.

Defi ning Death How death is defi ned and how a determination of death is made are signifi cant

matters for a death system to resolve. At fi rst, the defi nition of death might

seem obvious: A person dies, is dead, and the corpse is disposed of. But as soon

as someone asks, “What do you mean by ‘a person dies’?” this simple defi nition

begins to unravel. Finding a reliable way to defi ne death and to determine when

it has occurred can become quite complex. Furthermore, as Allan Kellehear

points out, “these problems are not simply biomedical in nature, but funda-

mentally shaped and driven by a series of important sociological infl uences.” 34

Think about how you would defi ne death. When would you consider your- self to be dead? How would you know that death had occurred in someone

else? The answers to these questions range from the defi nite (“when decay and

putrefaction have set in”) to the subtler (“when I can no longer take care of

myself ”). A person using the fi rst method for making a determination of death

would hardly be pleased to be judged dead by the standards of the second.

There are historical accounts of people being considered dead who, in

fact, were in a condition that only mimicked biological death. As a safeguard

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152 c h a p t e r 4 Death Systems: Mortality and Society

Figure 4-2 Coffi n Bell-Pull Device To prevent premature burial in cases of doubtful death, devices such as this French “life-preserving” coffi n were invented and patented. If activated, the box above the ground opened to let in air and light, the fl ag rose, a bell rang, and a light came on to signal that the buried person was still alive. The person who had been mis- taken for dead could also call out, and his or her voice would be amplifi ed by the device. The fear of being buried alive stemmed from the period of great plagues and epidemics when, in the hasty disposition of the dead, a mistaken determina- tion of death might result from a state of illness that only mimicked death.

against the threat of being buried alive, in earlier times some people arranged

for their bodies to be placed in coffi ns with bells or some other attention-

getting device that the “corpse” could activate after burial should conscious-

ness return after a mistaken determination of death (see Figure 4-2 ).

The present concern with defi ning death is, of course, more sophisticated

and draws upon scientifi c data. Yet, even though it is possible to determine

when death has occurred by observing certain signs that life has ceased, these

signs may be interpreted differently depending on how death is defi ned. In

other words, the way we defi ne death establishes the criteria that are used to

determine that a person has died. Five steps can be distinguished in the pro-

cess of making decisions about the death of a human being: 35

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Defi ning Death 153

1. Establish a conceptual understanding of what constitutes death—that is,

a defi nition of death.

2. Decide upon the criteria and procedures that will be used in making a

determination that death has occurred.

3. Apply these criteria and procedures in a particular case to determine if a person’s condition meets the criteria.

4. If the criteria are met, the person is pronounced dead. 5. Attest the person’s death on a certifi cate of record.

Conventional Signs of Death and New Technology Historically, the death of the human organism has been determined by the

absence of heartbeat and breathing. Most deaths are still determined by

the absence of these vital signs. However, when respirators, ventilators, and

other life-support systems are used to artifi cially sustain vital physiological

processes, conventional means of determining death by absence of heart-

beat and breathing are inadequate. Someone using the conventional vital

signs of heartbeat and breathing could declare a patient with permanent

loss of brain function “alive” on the basis of artifi cially maintained cardiopul- monary functions.

A number of years ago, before all the discussion about defi ning brain death and

maintaining life on a respirator and so on, a patient of mine, a young pregnant

woman at term, suddenly developed extremely high blood pressure. Then she had

a stroke and the baby’s heartbeat stopped, so we supported her by artifi cially main-

taining blood pressure and other vital functions, including breathing. But she had

a complete brain death immediately. And she had lost the baby. We got an EEG

[electroencephalogram], and it was completely fl at. We repeated it twenty-four

hours later, and again it was completely fl at.

It was the worst tragedy I’ve ever seen, because in just a few minutes she was

gone and the baby was gone—just within moments. I talked with her husband, her

mother, and her father. (Now, this was long before the issues surrounding defi ni-

tion of death had become so contentious that the lawyers got involved.) I told

them that the thing to do was turn off the machine. Just as I had not read about all

this, they as a family had not read about it. It seemed quite logical to me.

So we picked a time when we were going to do it, and they all came and waited

outside the door. I told them again what I was going to do, and they said to go

ahead and do it. I went in and turned off the machine. The nurse and I watched

her, and in fi ve minutes her pulse rate had stopped. I think this is the proper way

to handle this sort of situation when brain death is involved. I think it has a nega-

tive effect to continue life support systems for weeks and months. It was a tragedy,

and given the tragedy, what options do you have? Continue the life support system

or don’t continue it. To me, there’s no argument whatsoever to continue the life

support system.

Quoted from Death and Dying: The Physician’s Perspective, a videotape by Elizabeth Bradbury

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154 c h a p t e r 4 Death Systems: Mortality and Society

Therefore, the concept of brain death was created as a means of deter- mining whether a person is alive or dead when conventional vital signs are

ambiguous because of supportive medical technology. (When brain death

occurs, brain stem functions—including spontaneous breathing—are lost,

but heartbeat and other vegetative functions related to internal homeostasis

can continue because these functions are not completely dependent on the

integrity of the brain stem.) 36 Rather than replacing the conventional clinical

criteria for determining death—pulse, heartbeat, and respiration—the crite-

ria for brain death supplement them.

However, brain death has been called “an imprecise term.” In 2007 testi-

mony before the President’s Council on Bioethics, Alan Shewman said, “Con-

trary to popular belief, brain death is not a settled issue.” He pointed to a

number of issues indicating “conceptual confusion underlying the superfi cial

consensus.” 37 We discuss some of these issues later in this chapter.

In contrast to clinical death, a determination of death made according to accepted medical criteria (either the cessation of heartbeat and breathing or

the criteria for establishing brain death), cellular death refers to a process that results when heartbeat, respiration, and brain activity cease. In this sense,

“the process of death is a gradual event where organs and cells die at differ-

ent rates depending on their resistance to the lack of oxygen.” 38

When a person’s breathing and heartbeat are stopped temporarily, as

occurs during certain surgical procedures, people sometimes say that the

person was “clinically dead” for a period of time. However, such language is

imprecise when the cessation of vital functions is reversible.

Cellular death encompasses the breakdown of metabolic processes and

results in complete nonfunctionality. Thus, in this sense, the defi nition of

death is “we die because our cells die.” 39 Living cells require a continuous

input of energy; without it, they degrade into a nonliving collection of mol-

ecules. Cellular death is an irreversible process of deterioration in the body’s

systems and organs. Without oxygen, cells vary in their survival potential.

The cells of skin and connective tissues may survive for several hours; the

neurons of the brain last only fi ve to eight minutes. When there is a loss of

neurons in the midbrain and medulla, the brain center that controls breath-

ing is destroyed; the death of neurons in the cerebral cortex destroys intel-

lectual capacity. The breakdown of metabolic processes, the sum of which is

life, causes a loss of organic functions—that is, death. As the cells and tissues

of the body die, advanced signs of death become evident: the lack of certain

refl exes in the eyes, the fall of body temperature ( algor mortis ), the purple- red discoloration of parts of the body as blood settles ( livor mortis ), and the rigidity of muscles ( rigor mortis ). In a biological sense, death can be defi ned as the cessation of life due to irreversible changes in cell metabolism. Fol-

lowing these signs, putrefaction and decomposition continue as the corpse

is reduced to simpler forms of matter, accompanied by a strong, unpleasant

odor. Rarely, a cadaveric spasm occurs in which muscular stiffening takes place that crystallizes the last action one did prior to death (e.g., holding a knife

tightly); this can be signifi cant in forensic investigations.

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Defi ning Death 155

Medical technologies make it possible to manipulate the dying process

in such a way that some parts of the body stop functioning while other parts

can be artifi cially maintained. Thus, cell death may affect some organs of

the body, causing irreversible breakdown, while other organs of the body

are still functioning. The capacity of modern medicine to alter the natural

sequence and process of cellular death has created a need to rethink how

death is defi ned and institute new procedures for determining when death

has occurred.

Conceptual and Empirical Criteria What is death? How can we determine that a person has died? These ques-

tions, though closely related, involve separate issues that must be distin-

guished. Medical ethicist Robert Veatch outlines four levels that must be

addressed in our inquiry concerning the defi nition and determination of

death. 40 The fi rst level involves formally defi ning death. Essentially, this is a conceptual or philosophical endeavor. According to Veatch, “Death means

a complete change in the status of a living entity characterized by the irre-

versible loss of those characteristics that are essentially signifi cant to it.”

Although this defi nition may sound rather abstract on fi rst reading, it is really

quite precise. It encompasses the deaths not only of human beings but also

of nonhuman animals, plants, and cells and indeed can even be understood

metaphorically as applying to social phenomena, such as the organization of

societies or cultures.

To fl esh out this defi nition, we must turn to Veatch’s second level of

inquiry, again a conceptual or philosophical question: What is so essen-

tially signifi cant about life that its loss is termed death? Some possible answers include the fl ow of vital bodily fl uids (breath and blood, for example), the

soul, and, in more recent defi nitions, consciousness. Each of these possible

answers is examined more closely in the next section.

The third level that Veatch distinguishes has to do with the locus of death: Where in the organism should one look to determine whether death has

occurred? This question moves us from the conceptual realm to an empirical

Life is fundamentally based on the maintenance of individual and collective cell

function, dependent on the provision of nutrients and oxygen. Cell biology has

demonstrated that a layer of human cells, separated from the human organism,

may be grown in laboratory culture as long as they are bathed in a sterile supply

of nutrients and oxygen. The human being, a complex arrangement of trillions of

cells organized into organ systems, requires a cardiopulmonary delivery system

(lung, heart, and circulatory system) for oxygen and nutrients to reach the cells.

The development and evolution of modern cardiopulmonary resuscitation evolv-

ing into cardiopulmonary support technologies have been important advances

informing our concepts of life and death.

Sam D. Shemie

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156 c h a p t e r 4 Death Systems: Mortality and Society

inquiry—that is, one based on observation or experience. Notice, however,

that the answer to this question depends on the conceptual understanding

used to defi ne death.

How death is determined—that is, the criteria used to establish the difference between life and death—depends on how death is defi ned. What is it about life that makes its absence signify death? What signs should be used to make this determination? Questions about the meaning of life and death are important to caregivers as well as patients who occupy hospi- tal intensive-care units.

© M

a rk

T u

sc h

m a n

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Defi ning Death 157

Veatch’s fourth level deals with the following question: What technical

tests must be applied at the locus of death to determine if an individual is

living or dead?

So, to recap these levels of inquiry: Step one involves formally defi ning

death. Step two adds further content to the defi nition by pinpointing the

signifi cant difference between life and death. Step three locates where one

should look for signs of this signifi cant change. And step four gives us some

tests, or a set of criteria, that can be used to determine whether an organism

is alive or dead. With this process in mind, we now have the tools to examine

four different approaches to the defi nition and determination of death.

Four Approaches to the Defi nition and Determination of Death All four of the following approaches to defi ning and determining death

begin with the formal defi nition of death given earlier by Veatch. From that

shared beginning, each approach fi nds its particular way through subsequent

levels of inquiry. As you’ll see, each of these approaches relates death to a

loss: the fi rst, of the fl ow of vital fl uids; the second, of the soul by the body;

the third, of the capacity for bodily integration; the fourth, of the capacity for

social interaction. In considering the merits of the various approaches, notice

how death is determined according to the way it is defi ned.

Irreversible Loss of Flow of Vital Fluids The fi rst approach focuses on the cessation of the fl ow of vital bodily

fl uids. With this conceptual understanding of death, one looks to the heart,

blood vessels, lungs, and respiratory tract as the locus of death. To determine

whether an individual is alive or dead, one would observe the breathing,

feel the pulse, and listen to the heartbeat. In addition to these conventional

tests, we can include the modern methods of electrocardiogram and direct

measurement of oxygen and carbon dioxide levels in the blood because they

focus on the same loci and criteria for determining death.

This approach to defi ning death is adequate for making a determination

of death in most cases, even today. When vital functions are artifi cially sus-

tained by machines, however, no clear determination of death can be made

by this defi nition. Consider, for example, a patient connected to a heart-lung

machine that keeps the vital fl uids of blood and breath fl owing through the

body. According to this defi nition, the patient is alive. If the patient is discon-

nected from the machine, these vital functions cease, and by this defi nition

the patient is dead.

Thus, the ambiguity of this fi rst approach results from defi ning death on

the basis of physiological criteria that, although intimately related to life pro-

cesses, do not appear to constitute the most signifi cant criteria for identifying

human life.

Irreversible Loss of the Soul from the Body In the second approach to defi ning death—one used in many cultures

worldwide and from time immemorial—the criterion is the presence or

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158 c h a p t e r 4 Death Systems: Mortality and Society

Knowing What a Human Being Is Rolling Thunder often repeated, “We do so many unnatural things, we don’t know

what’s natural anymore.” One day he and I were sitting on the ground out in the

desert. He was describing a young Indian apprentice from another tribe and mak-

ing designs in the sand with a stick. Suddenly he said, “You people don’t even know

what a human being is!” I did not see the connection between the subject at hand

and that sudden exclamation, but I had learned to understand what he meant by

“you people.” It was not a judgmental fi nger-pointing to be taken personally, but a

sort of generalized identifi cation to be applied wherever it fi t. “You can look right

at someone’s empty body and think that you’re lookin’ at the person when they’re

not even there. Time and time again, you people speed to the scene of an accident,

pick up an empty body and take it down the highway at eighty miles an hour, leav-

ing the person miles behind, not knowing what the heck is going on!”

As an example, he then described to me an episode in which he went into the

hospital to assist a young lady—a friend of friends—who had been in a head-on

collision and was a long time in a coma.

“But the moment I took a good look at the body, I could see she wasn’t even

there. I had to fi nd her—go get her—and she was way out in the fi eld where the

car’d fl ipped over the cliff, and she was sittin’ on a rock. Her friend who was driv-

ing was killed. And this one sittin’ on the rock, she didn’t even know where she

was. But, boy, she was determined to stay there. She was totally disoriented. I had

to pull her, nearly force her back. Only time we can do that is when we know their

own will isn’t working—otherwise we always leave it up to their own choice.

“Well, in the early days, most everyone could tell when a person wasn’t in their

body. That was just natural to see that. That’s been lost now, mostly. Only thing

I can say is, until you learn to understand these things, you should never, never

move an unconscious body. Unconscious means the person is not in there. So treat

the body on the scene and never, never move it. Not until you learn how. People

can’t fi nd their own way back to the body—not when they’ve been pulled loose

that way by some accident or something. Time and time again, traumatized peo-

ple get abandoned that way. Time and time again, people die in a coma because

of that.”

Quoted in Doug Boyd, Mystics, Magicians, and Medicine People: Tales of a Wanderer

absence of the soul in the body. Within this framework, as long as the soul

is present, the person is alive; when the soul leaves, the body dies. Some reli-

gious traditions defi ne death in precisely this way.

The locus of the soul has not been scientifi cally established (nor has its

existence), although some believe the soul is related to the breath or the heart

or, perhaps, as seventeenth-century philosopher René Descartes believed, to

the pineal body, a small protrusion from the center of the brain. For those

who hold this concept, the criteria for determining death would presum-

ably involve some means of ascertaining death at the particular locus where

the soul is thought to reside. In a study done in 1907, dying people were

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Defi ning Death 159

placed on a sensitive scale to determine whether any weight loss occurred at

the moment of death. Researchers noted a loss averaging from one to two

ounces, which led to speculations about whether the loss indicated the depar-

ture of the soul from the body at death. 41

To people living in modern societies, this approach to defi ning death

seems irrelevant. Our fi rst diffi culty would be to adequately defi ne the soul.

Even if this diffi culty could be overcome, we would need some way to ascer-

tain whether the soul was present or absent at a given time. Moreover, this

defi nition of death forces an examination of whether death occurs because

the soul departs from the body or, conversely, whether the soul departs from

the body because death has occurred. In other words, does the soul “ani-

mate” the body, giving it life, or do the physiological processes of vitality in

the body provide a vessel wherein the soul resides? Such questions may lead

to fascinating speculations, but they do little to solve the dilemmas posed by

medical practice in a scientifi c age.

Irreversible Loss of the Capacity for Bodily Integration In the third approach, death is defi ned as the irreversible loss of the

capacity for bodily integration. That is, “an organism dies when it loses the

power to preserve and sustain its self-organizing organization permanently

and irreversibly”; in other words, “death is the loss of syntropic capacity or

ability.” 42 This approach is more sophisticated than the fi rst because it refers

not just to the conventional physiological signs of vitality in the body (the

fl ow of breath and blood) but also to the more generalized capability of the

body to regulate its own functioning. The approach recognizes the fact that

a human being is an integrated organism with capacities for internal regula-

tion through complex homeostatic feedback mechanisms.

This defi nition at least partly resolves the ambiguity of the fi rst defi nition

because a determination of death would not be made merely because a per-

son’s physiological functioning was being maintained by a machine. Rather,

a determination of death would be made when the organism no longer had

the capacity for bodily integration. The locus for such a determination is cur-

rently considered to be the central nervous system—more specifi cally, the

brain. The determination of death that results from this defi nition is often

characterized as brain death (although this term is potentially misleading

because it focuses attention on the death of part of the organism, not the

whole organism).

According to standards published in 1968 by the Harvard Medical School

Ad Hoc Committee to Examine the Defi nition of Brain Death, brain death

involves four essential criteria: 43

1. Lack of receptivity and response to external stimuli

2. Absence of spontaneous muscular movement and spontaneous breathing

3. Absence of observable refl exes, including brain and spinal refl exes

4. Absence of brain activity, as signifi ed by a fl at electroencephalogram

(EEG)

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160 c h a p t e r 4 Death Systems: Mortality and Society

The Harvard criteria require a second set of tests to be performed after

twenty-four hours have elapsed, and they exclude cases of hypothermia (body

temperature below 90 degrees Fahrenheit) as well as situations involving cen-

tral nervous system depressants, such as barbiturates. After the Harvard defi -

nition of brain death, heart-beating brain-dead donors (HBDD) became the

major source of transplantable organs, and such donors remain the major

source of transplantable organs worldwide. 44

In 2010, the American Academy of Neurology published an updated

guideline on determining brain death to provide more clarity. 45 According

to the guideline, there are three signs that a person’s brain has permanently

stopped functioning. First, the person is comatose and the cause of the coma

is known. Second, all brain stem refl exes have permanently stopped work-

ing. Third, breathing has permanently stopped. A ventilator, or breathing

machine, is needed to keep the body functioning. Further, the guideline con-

cludes that tests such as EEG or cerebral fl ow studies are not needed for a

diagnosis of brain death.

Allan Kellehear observes, “The Harvard deliberations were historically

signifi cant because the formulations of brain death developed by their ad

hoc committee established the basic criteria from which all subsequent revi-

sions and debates have derived.” 46 Procedures for applying these criteria,

which have become known as the “whole-brain” defi nition of death, have

been widely adopted when conventional means of determining death are not

conclusive. However, over the years, not all experts believe these criteria are

unassailable. 47 Some ethicists argue that the clinical tests currently used to

determine brain death do not actually satisfy all of the criteria; specifi cally,

varying degrees and kinds of brain function have been found in some indi-

viduals pronounced brain dead according to the standard tests. This fi nding

suggests that the tests may not always suffi ce to show “permanent cessation of

functioning of the entire brain.” Furthermore, “the tests for brain death are

about as good as the operators in charge of the tests and the people inter-

preting them.” 48

In light of these objections to “brain death” standards, some experts

advocate returning to cardiorespiratory criteria as the defi nition of death. “In

medical practice and law, the separation between being alive and being dead

should not be ambiguous.” 49 However, simply abandoning current methods

of determining brain death could create problems because organ transplan-

tation would likely be characterized as a kind of legally sanctioned killing.

Irreversible Loss of the Capacity for Consciousness or Social Interaction Although the Harvard criteria are widely accepted in clinical settings,

some people believe that they fail to specify what is signifi cant about human life. Veatch, for example, says that it is the higher functions of the brain—not

merely refl ex networks that regulate such physiological processes as blood

pressure and respiration—that defi ne the essential characteristics of a human

being. Thus, the fourth approach to defi ning death emphasizes the capacity

for consciousness and social interaction. The premise of this approach is that,

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Defi ning Death 161

for a person to be truly human, not only must certain biological processes

function, but the social dimension of life—consciousness or personhood—

must also be present. Being alive implies a capacity for conscious interaction

with one’s environment and with other human beings. Therefore, according

to this defi nition, death is determined by the irreversible loss of the capacity

for social interaction. The death of a person is synonymous with the death of a human being.

Using this approach, where should we look to determine whether an indi-

vidual is alive or dead? Current scientifi c evidence points to the neocortex,

the outer surface of the brain, where processes essential to consciousness and

social interaction are located. In this case, the EEG alone would provide an

adequate measure for determining death.

In the debate about how death should be defi ned, this fourth approach

is known as a “higher-brain” theory, which contrasts with the “whole-brain”

theory discussed earlier. Karen Gervais represents the higher-brain approach

when she writes, “It is loss of consciousness and not loss of biological func-

tioning that should determine when human life is over.” 50 Furthermore, she

says, “By emphasizing the brain’s integrating role in the human organism,

the whole-brain theory of death reduces to a lower-brain theory of death.”

In commenting on the search for a more precise defi nition of human death,

Gervais concludes that we are confronted with a basic choice about the def-

inition of human life—namely, whether we consider a human being as an

organism or as a person. The current whole-brain defi nition of death, says Robert Veatch, estab-

lishes a view of what is essential to being alive that is not shared by all ethnic or religious groups. 51 He argues that, rather than imposing one approach on

everyone, the right to “opt out” could be made available to individuals whose

beliefs about how to defi ne the death of a human being are in confl ict with

the whole-brain approach of the Harvard criteria. Although these criteria

have been an accepted part of medical practice for more than four decades,

questions about defi ning death are not yet fully resolved.

Failure to accept clinical defi nitions of brain death in all its different versions, by

the general public or families, is often attributed to their “confusion” about what

death actually “looks” like.

Brain dead patients look alive—they are pink and breathing; they sometimes

respond to surgical incision with elevated blood pressure and respiration; they are

capable of reproduction; they develop bedsores and pneumonia, something that

cadavers don’t do; and they move in their beds, mimicking restlessness, and grasp-

ing at deliberate or accidental stimuli. This is not “confusion,” “misapprehension,”

or “misconceptions” by the general public about those who are brain dead. By

most social criteria, the brain dead do appear alive.

Allan Kellehear

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162 c h a p t e r 4 Death Systems: Mortality and Society

The Uniform Determination of Death Act The defi nition of death touches upon many aspects of our lives. Criminal

prosecution, inheritance, taxation, treatment of the corpse, and mourning

are all affected by the way society “draws the dividing line between life and

death.” 52 After publication of the criteria for establishing brain death in

1968, public and legislative discussion began to take place about the need to

revise the legal defi nition of death so as to refl ect medical realities.

Finally, in the early 1980s, a presidential commission drafted a model

statute that met with broad acceptance and eventually led to uniform laws

throughout the United States: the Uniform Determination of Death Act (see

Figure  4-3 ). The President’s Commission for the Study of Ethical Problems

in Medicine said that the Uniform Determination of Death Act “addresses

the matter of ‘defi ning’ death at the level of general physiological standards

rather than at the level of more abstract concepts or the level of more precise

criteria and tests” because such standards and criteria change over time as

knowledge and techniques are refi ned. 53

To avoid obsolescence as technology advances, the Act does not specify

an exact means of diagnosing death. The Act acknowledges that, in most

cases, irreversible circulatory and respiratory cessation provides an obvious

and suffi cient basis for making a determination of death. In other words,

these cases permit death to be diagnosed on the basis that breathing and

blood fl ow have stopped and cannot be restored. Thus, if a patient is not

being supported on a respirator, there is no need to evaluate brain function

before making a determination of death.

The commission said that a statutory defi nition of death should be sepa-

rate and distinct from any provisions concerning organ donation. In contrast

to earlier proposals, which stated that a person would be “considered dead”

when their stated criteria were met, the language of the Uniform Determina-

tion of Death Act is clearer and more direct. It states that a person who meets

the standards set forth in the law “is dead.”

Confusion about the defi nition of death had arisen, the commission said,

“because the same technology not only keeps heart and lungs functioning in

some who have irretrievably lost all brain functions, but also sustains other,

Figure 4-3 Uniform Determination of Death Act

Uniform Determination of Death Act

1. [ Determination of Death. ] An individual who has sustained either (1) irreversible ces- sation of circulatory and respiratory functions, or (2) irreversible cessation of all

functions of the entire brain, including the brain stem, is dead. A determination

of death must be made in accordance with accepted medical standards.

2. [ Uniformity of Construction and Application. ] This Act shall be applied and construed to effectuate its general purpose to make uniform the law with respect to the sub-

ject of this Act among states enacting it.

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Defi ning Death 163

less severely injured patients.” The result is a “blurring of the important dis-

tinction between patients who are dead and those who are or may be dying. ” The commission concluded that “proof of an irreversible absence of func-

tions in the entire brain, including the brain stem, provides a highly reliable

means of declaring death for respirator-maintained bodies.” The commission

noted that the Harvard Committee’s defi nition of brain death had been reli-

able and that “no case has yet been found that met these criteria and regained

any brain functions despite continuation of respirator support.”

Death is an absolute and single phenomenon, the commission said, arguing

that it would radically change the meaning of death to expand the defi nition of

death to include persons who have lost all cognitive functions but are still able

to breathe spontaneously. When brain-stem functions remain—for example,

when respiration occurs naturally but there is no cognitive awareness—the

patient’s condition is described as a “persistent vegetative state” (discussed in

Chapter 6). Sustained by medical and nursing care, including artifi cial feeding

and antibiotics to fi ght recurrent infections, such patients may survive for years

without a respirator. (The longest such survival, according to the commission’s

report, was over thirty-seven years.)

The commission cited the nearly universal acceptance of the “whole-

brain” concept by both the medical community and the general public. A

higher-brain formulation, which would require agreement about the mean-

ing of personhood, does not enjoy such consensus. At the present level of

understanding and technique, the commission said, “The ‘higher brain’

may well exist only as a metaphorical concept, not in reality.” In summing up

the work of the President’s Commission for the Study of Ethical Problems in

Medicine, Albert Jonsen says that it “brought conceptual clarity to a confused

issue and helped to make good law.” 54

Because guidelines for diagnosing brain death are implemented at the

level of the hospital, however, there is wide variability in practice. This can

result in differences that are important for determination of death and ini-

tiation of transplant procedures. With an increasing number of non-heart-

beating donors (NHBD), some doctors believe

we should move away from an unattainable certifi cation of biological death as

the sine qua non for organ donation; we should openly admit that NHBD death cannot be defi ned at a time when organ retrieval is possible and that all we

are able to defi ne are socially, morally, and scientifi cally acceptable criteria for

organ donation. 55

Others suggest more radical alternatives, “deeming it reasonable and fea-

sible to remove organs for transplantation . . . when the patient is either per-

manently unconscious or when death is imminent.” 56 Kellehear says,

The problem of death is not only a simple technical problem of the brain and

its workings but also about how experiences of mortality are mediated by social

understandings of death and dying. . . . This means understanding death and

dying at the place where biology and biography meet at their intersections with

society and history. 57

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164 c h a p t e r 4 Death Systems: Mortality and Society

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In 1968, at Stanford University Medical Center, Dr. Norman Shumway performed the fi rst successful human heart transplant in the United States. “The father of heart transplantation,” Shumway was known as a reticent man who did not like to tout his many accomplishments. Advances in transplantation procedures and related medical therapies make such operations more feasible, yet they also raise questions that are diffi cult, at times painful, to resolve.

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Organ Transplantation and Organ Donation 165

Organ Transplantation and Organ Donation Of all the innovative medical techniques for saving the lives of patients who

were once considered hopelessly ill, perhaps the most dramatic is organ trans- plantation, which is defi ned as “the transfer of living tissues or cells from a donor to a recipient, with the intention of maintaining the functional integ-

rity of the transplanted tissue in the recipient.” 58 Since the day in 1954 when

the fi rst kidney transplant, from one identical twin to another, was per-

formed at Peter Bent Brigham Hospital in Boston, organ transplantation has

evolved to become part of standard medical practice. In 1967, public interest

was heightened as Christiaan Barnard accomplished the fi rst successful adult

heart transplant. Other noteworthy events in the history of transplantation

include widespread agreement on the defi nition of brain death in 1968 and

discovery of the immunosuppressive drug cyclosporine in 1976. 59 In 2012,

the fi rst “breathing lung” transplant was performed in the United States, with

the help of an experimental organ-preserving device known as the Organ

Care System, which keeps donor lungs “breathing” in a near-physiologic state

outside the body during transport. 60 The success of organ transplantation is

due largely to such factors as newer immunosuppressants, better patient selec-

tion, and earlier intervention, as well as better understanding of the issues

related to histocompatibility, the ability of tissues to accept a transplant from

a different individual without rejecting it. The growing number of patients

on waiting lists for transplants involving the heart, kidney, liver, pancreas,

and lung is indicative of the widespread public acceptance of transplantation.

The ideal candidate for a transplant is a patient whose condition is dete-

riorating despite the best conventional medical treatment available and for

whom a transplant offers a reasonable likelihood of recovery. For some trans-

plants, most often a kidney, the donor is a living person; sometimes donor

and recipient are members of the same family. When a living donor is unavail-

able, or when the needed organ (a heart, for example) cannot be taken from

a living human being, the organ can be removed from the body of a person

who has been declared dead and whose organs are kept viable for transplan-

tation by artifi cially sustaining physiological functions. About three of every

four organs that are transplanted are recovered from deceased donors. 61

These donors are declared dead by the criteria of either (1) cardiac death —that is, death declared on the basis of cardiopulmonary criteria (irre- versible cessation of circulatory and respiratory function) or (2) brain death (irreversible loss of all functions of the entire brain, including the brain

stem). According to the “dead donor rule,” organ donation should not hasten

or cause death. “As currently practiced, donation after cardiac death raises

more concerns than donation after brain death” because the process is more

complex and “the potential donor is not dead when life-sustaining measures

cease.” 62 The intervals between withdrawing care, pronouncing death, and

recovering organs are very brief. One professor of medicine said, “The end-

of-life experience is changed because organ procurement begins immedi-

ately after death has occurred.” 63

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166 c h a p t e r 4 Death Systems: Mortality and Society

Although organ donation is viewed by advocates as offering families “a

way to fi nd meaning in the death,” David Meagher reports bereaved family

members saying that they cannot recall the moment when consent for dona-

tion was obtained; in only a small percentage of cases were organ donations

discussed before the death. In short, “Family members or others responsi-

ble for making donation decisions have reported confusion and uncertainty

around the moment of the request,” with the result that “family members felt

superfl uous and ignored afterward.” 64

The Uniform Anatomical Gift Act (UAGA), approved in 1968 by the

National Conference of Commissions on Uniform State Laws and enacted

in some form in all fi fty states, provides for the donation of the body or spe-

cifi c body parts upon the death of the donor. Because of the shortage of

donated organs, the Act was revised in 1987 and again in 2006 to simplify

organ donation. The Uniform Anatomical Gift Act covers such matters as

how anatomical gifts can be made and provides a list of individuals who can

authorize organ donation in the absence of donation arrangements made

before death. The 2006 revision strengthens prior language barring others

from attempting to override an individual’s decision to make or refuse to

make an anatomical gift. Hospitals are required to have procedures in place

that encourage donations. The 2006 revision modifi ed the Act “to permit the

use of life support systems at or near death for the purpose of maximizing

procurement of organs medically suitable for transplantation.” 65

Some observers note that the primary intent of the 2006 revision was to

solve the organ shortage problem. They point out that this creates a poten-

tial for confl ict with care at the end of life in that it prioritizes care of donor

organs over care and comfort of the dying person. Similarly, other physicians

and ethicists are emphatic that “care of dying patients takes precedence over

organs.” 66 It is also argued that “the traditional concepts of life and death are

simply inadequate in the settings in which we have to make decisions, in the

face of the continuing progress of resuscitation techniques, and the social

needs represented by modern transplant medicine.” 67

Margaret Lock calls attention to several reasons for the “growing short-

age” of organs: First, there are fewer deaths from car accidents than was the

case just a few decades ago, because of better automobile safety devices. Sec-

ond, trauma units are more effective than they once were in keeping patients

with severe head injuries from becoming brain dead. Third, with a rapidly

aging population the potential donor pool has decreased. Another factor

that contributes to the impression of shortage is the increasing number of

patients deemed eligible for transplants, ranging from infants to the elderly

and including patients with comorbidities (that is, other medical conditions).

Finally, second or third transplants are now routinely done when earlier ones

fail. “In other words,” Lock says, “the transplant world has broadened its

sights and has itself created an increased ‘need’ for organs at a time when

there are many fewer potential donors.” 68

Because not enough organs are donated to meet demand, physicians

and organ procurement agencies must function as gatekeepers in choosing

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Organ Transplantation and Organ Donation 167

among prospective recipients. For example, many transplant centers will not

accept people without insurance or those over age 75. What criteria should

be used to allocate organs? Should it be the urgency of the patient’s need?

Or should it be effi cacy, the likelihood of a benefi cial result? Every day, with

over 100,000 people on the waiting list, about a dozen people die because

not enough organs are available. 69 In 1984, the U.S. Congress enacted the

National Organ Transplant Act, which instituted a central offi ce to help

match donated organs with potential recipients.

The United Network for Organ Sharing (UNOS) operates the Organ

Procurement and Transplantation Network (OPTN) under contract with the

federal government. The networks are collectively known as OPTN/UNOS,

and they maintain lists of people waiting for transplants and track the sta-

tus of donated organs, with the goal of ensuring both the fairness of distri-

bution and the competence of medical centers where organ transplants are

performed.

Advocates of organ transplantation conduct public information cam-

paigns to educate people about the benefi ts of organ donation and to

encourage more individuals to donate. 70 Some potential recipients of organs

advertise their need on billboards, in newspapers, or on personal Web sites,

hoping a sympathetic person will make a directed donation naming them as the specifi c recipient. 71 Web sites (such as MatchingDonors.com) help donors

and recipients fi nd each other so that a directed donation can be made.

Patients also increase their chances of obtaining a transplant by enrolling at

more than one transplant center—a practice known as multiple listing. Each

of these evaluations and enrollments can cost tens of thousands of dollars. 72

The current system favors patients with the means to rush to geographic areas

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168 c h a p t e r 4 Death Systems: Mortality and Society

where there is less competition for organs. For example, computer executive

Steve Jobs fl ew in his personal jet from California, with one of the longest

transplant lists, to Memphis, where the wait list was shorter, to receive a liver

transplant in 2009. 73

Because so many patients are on waiting lists for organs, and because

waiting lists are growing faster than the supply of organs, questions have

been raised about the effectiveness of the voluntary approach to organ dona-

tion. Some people suggest that donating one’s organs after death is a moral

duty, and therefore organ donation should be required except when a per- son intentionally “opts out” by signing a refusal to donate. This approach

is known as presumed consent. Although it has not been tried in the United States, a number of European countries have enacted laws creating presumed

consent, or what some call “default to donation.” The main ethical objection

is a perceived loss of personal autonomy—the belief that it is wrong to take

someone’s organs without that person’s explicit consent.

Many people who have donor cards do not understand why anyone would

be reluctant to donate: “To me, it’s obvious. If you’re not using your organs,

let somebody else have them.” What prevents people from donating their

organs? Research has found that knowledge and attitudes, both of which are

cognitive variables, are weak predictors of donor card status. More infl uential

are noncognitive variables, which include a variety of “ick factors” related to

posthumous mutilation, respect for the dead, and disgust or squeamishness

about having one’s organs inside another person; “ jinx factors” related to

anxieties or superstitions about misfortune that could result from signing a

donor card; medical mistrust and skepticism about premature declaration

of death; and concerns about body integrity, or the need to maintain the

integrity of the body after death lest one face serious afterlife consequences. 74

Native Americans, among others, may hold a belief that one must have all

body parts upon death, as a “whole body is needed in the afterlife.” 75

Questions about organ donation ultimately come down to personal val-

ues and particular views about the nature of the human body and the way it

is perceived. Among the main views are these: 76

1. The body as machine. A mechanistic view of the body, in which organs are “extracted,” “salvaged,” and “replaced.”

2. The body as an ecological resource. A form of recycling within the global bio- mass, in which organs are “harvested,” “retrieved,” or “recovered.”

3. The body as a potential gift. A view that emphasizes ownership, in which organs are “donated,” “gifted,” and “received.”

4. The body as a commodity. The body as a profi table resource from which organs are “procured” and possibly bought and sold.

Because a human body is a valuable resource, the suggestion has been

put forward to make commerce in human organs legal. 77 Under the provi-

sions of the National Organ Transplant Act, it is currently illegal to buy or

sell human organs and tissues (except blood). If this were changed, a person’s

heirs might earn money through selling the deceased’s vital organs. Some

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Organ Transplantation and Organ Donation 169

people envision the possibility of a “futures market” in human organs, with

prices fl uctuating according to supply and demand. Those who favor making

human organs a commodity argue that, as a result of market forces, short-

ages or surpluses of organs for transplantation would be eliminated. In some

areas of the world, there already exists an active “black market” in transplant-

able organs (notably kidneys). There appears to be growing support to indi-

rectly compensate people who donate organs, possibly through tax credits or

grants to help pay for funeral expenses. Generally, the consensus at present is

that commercialization is not preferable to the gift model of organ donation.

Most bodies that enter the “cadaver trade” are acquired legally; however,

donors may have only a vague notion of how a donated body will be used,

not realizing that not all are used for organ transplantation. Besides being

used to teach anatomy to medical students, cadavers are used for research

experiments and for seminars to demonstrate the latest medical or surgical

gadgetry. 78 The federal government regulates organ procurement organiza-

tions, but it doesn’t regulate the use of bodies and body parts for research

and education.

Confl ict sometimes occurs between organ procurement agencies and

medical examiners (whose role in the death system is discussed later in this

chapter). Because coroners and medical examiners have jurisdiction over

“suspicious” deaths, organ recovery in such cases depends not only on the

permission of next of kin but also on the coroner’s or medical examiner’s

approval. That is to say, organ and tissue procurement sometimes “pits the

living against the dead and transplant surgery against criminal justice.” 79

Some procurement organizations have succeeded in changing some medical

examiner statutes to make the legal requirement of death investigation sec-

ondary to organ removal. Some believe that “the determination to procure

Designed to increase public awareness of organ donation, this billboard on a Florida high- way calls particular attention to donations that can save the lives of children.

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170 c h a p t e r 4 Death Systems: Mortality and Society

organs has become so powerful there is almost a predatory obliviousness to

where the organs come from and how the donors died.” 80 Nancy Scheper-

Hughes remarks, “Wherever transplant surgery moves, it challenges custom-

ary laws and traditional local practices bearing on the body, death, and social

relations.” 81

Medical Ethics: A Cross-Cultural Example In Japan, ethical, moral, and legal questions involving the defi nition of death

and organ transplantation have been matters of controversy for decades. 82

Debate began in 1968, when Japanese surgeon Dr. Jur ̄o Wada performed the

world’s second heart transplant, using an organ from a brain-dead donor.

Initially admired for his scientifi c achievement, Wada was soon subjected to

intense questioning about alleged disregard for the rights of both donor and

recipient. He was accused of illegal human experimentation and of poor

judgment in the manner in which he determined the donor’s death. At the

time, the criteria for establishing brain death were new, and no public con-

sensus existed in Japan concerning this novel defi nition of death. The Wada

case left a legacy of mistrust about brain death and transplantation in Japan.

Among technologically advanced countries, Japan is unique in its reli-

ance on living donors. Although most scientifi c and technological advances

This old lady was in the hospital and her family wanted to put her in a nursing

home. She didn’t want to go, and she hung herself with her hospital bathrobe.

The hospital nurses put her in bed and when the family came, they told them,

“Grandma has died. Her heart stopped.” They did not mention anything about

the suicide. But when the hospital called the medical examiner, they explained

how they had found her. The medical examiner conducts a thorough investiga-

tion and calls it a suicide and mentions hanging as [one of the] circumstances.

The family goes ballistic. For the next two years they call him every week. He has

several meetings with them to explain his fi ndings. Nothing helps. Then after two

years, he has another meeting with them and asks them, “What would make you

happy?” They say that they don’t like suicide. That’s when he makes his mistake.

He says, “Okay, I can’t make it a natural death, but I can leave the death undeter-

mined.” So he changes the death certifi cate. About two weeks later, he is contacted

by the sheriff. The family has gone to the sheriff and says that he was incompetent

because he missed a homicide. The medical examiner explains to the sheriff what

has happened, and the sheriff tells the family that he will not investigate. The

family accuses the medical examiner of manipulating the sheriff and goes to the

attorney general. He in turn checks with the medical examiner and decides not to

pursue the case. The family now accuses the attorney general of covering up the

examiner’s mistakes. They take their case to the board of medical licensure, and

the medical examiner almost lost his license.

Stefan Timmermans, Postmortem: How Medical Examiners Explain Suspicious Deaths

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Medical Ethics: A Cross-Cultural Example 171

are eagerly adopted in Japan, questions about brain death resulted in a reluc-

tance to actively pursue organ transplantation. Only in 1997 did Japan pass

its Organ Transplant Law, which legalized organ procurement from brain-

dead donors, although children were still prohibited from donating due to

their “inability to make a mature decision.” In 2009, this ban was lifted by a

law allowing donations by children under fi fteen. 83

The 1997 law also allowed organs to be taken only from brain-dead

patients who had given prior written permission for donation of their organs.

The 2009 law gave relatives authority to consent to donation when the

patient’s intentions were unclear.

Japan’s debate illustrates how culture infl uences attitudes and practices

related to dying and death. Although the circumstances surrounding the

Wada case have had a lingering effect, a sense of mistrust between physicians

and patients has long been prevalent in Japan. Until quite recently, most phy-

sicians practiced a kind of “closed door” medicine in which patients were

neither given information about their health nor permitted to criticize their

physicians. The practice of uso mo hoben, or expedient lies, was justifi ed by the belief that patients “want to be told warm lies rather than confronting the

cold truth.” 84 In the Japanese medical system, the consensus has been that

patients should leave decision making to their physicians and family mem-

bers. Many people feel this kind of paternalism is especially worrisome in

the context of transplantation procedures. It is feared that, in determining

brain death, doctors might give no information to family members and per-

haps even lie to them. People also worry that the criteria for brain death

may be applied too readily. There is widespread feeling that the defi nition

of brain death is such a critical issue that it should not be decided solely by

physicians. In addition, long-term mistrust raises concerns that a market for

organs could provoke abuses by physicians.

Traditional beliefs about death may have an even more important infl u-

ence on attitudes. In Japan, death traditionally has been viewed as a social

process, not a medically determined phenomenon. The respect shown to

ancestors through various practices attests to an extended process of social

death. Physicians may alter the conventional defi nition of death, but the per-

sistence of traditional views reveals diverse opinions about the meaning of

death.

Many Japanese are concerned about keeping the body intact, not only

during life but also after death. The body is viewed as a gift from one’s par-

ents, one’s ancestors. Removal of organs from brain-dead bodies violates the

integrity of the body. An aversion to tampering with the corpse of a loved one

is related to beliefs that body and soul must be intact as the person goes to

the next world. The body must be perfect; if it is not, the soul may become

unhappy. Organ transplantation is viewed as mutilation of the body. Whereas

people in some societies tend to think of body organs as replaceable parts,

the Japanese tend to fi nd in every part of a deceased person’s body a frag-

ment of his or her mind and spirit. Related to this issue is Japan’s historical

concern about impurity. From this viewpoint, procedures involved in organ

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172 c h a p t e r 4 Death Systems: Mortality and Society

donation and transplantation defi le the body. A person considering organ

donation may be dissuaded by the notion that, if organs are taken, “My body

is no longer mine.”

Another important issue has to do with differing cultural ideas about

the “seat of the soul” or “center of the self.” In Western biomedicine, the

brain—the locus of rational thought—tends to occupy the most important

place among the various body parts. As the “seat of the mind,” it represents

the essence of humanness. In other traditions, the heart, not the brain, is

considered the seat of life. Equating life with the functioning of the brain is

alien to many Japanese, who place equal if not greater symbolic importance

on the heart. A person’s true center of spirit and consciousness, the “heart-

mind,” is traditionally located in the hara, or belly. As this example illustrates, the notion of brain death is culturally con-

structed. The notion of death as absence of brain function, separate from

other bodily functions, is inconsistent with the Japanese perspective on death

of the whole person. Making a determination of brain death creates confu-

sion because there remains a beating heart and a warm body. For many Japa-

nese, the procedures involved in organ donation and transplantation result

in a “death that cannot be seen,” an invisible death.

In addition to the cultural factors already mentioned, Japanese concerns

about organ donation and transplantation relate to traditional practices

involving the exchange of gifts. In Japan, there are fi ne-tuned rules govern-

ing the fl ow of gifts. Receiving a gift incurs an obligation to return the favor.

With organ donation, giving is viewed as one-way. The recipient of an organ

donation cannot offer a countergift. There is no way of repaying such a valu-

able gift. Moreover, the absence of a social relationship between donor and

receiver clouds organ donation with a shadow of commercialization.

The maintenance of cultural identity is important to most Japanese. To

unquestioningly adopt Western practices of organ donation and transplanta-

tion would involve abandoning history and thereby diminish cultural distinc-

tiveness. A culturally appropriate bioethics would therefore incorporate the

infl uences of Shinto, Buddhist, and Confucian thought as well as modern

Western traditions. In refl ecting on the Japanese example presented here,

we see that cultural differences need not be viewed as barriers that must be

overcome but can be seen as opportunities for learning about different ways

in which people deal with the complex issues surrounding dying and death.

The Impact of the Death System The concept of the death system is a helpful model for contemplating how

death shapes the social order and, in turn, our individual lives. As a network

of people, places, and times as well as objects and symbols, the death system

affects our collective and personal relationships to mortality in many ways.

In this chapter, we have seen how society develops public policies concerning

the defi nition of death, organ donation and transplantation, certifi cation of

death, the roles of coroners and medical examiners, and when and under

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Further Readings 173

what circumstances autopsies are performed. As you study topics related to

dying and death, you may fi nd it interesting to keep in mind how they fi t into

the death system. As Kastenbaum says, “Everything that makes a collection

of individuals into a society and keeps that society going has implications for

our relationship with death.” 85

Further Readings Stuart Banner. The Death Penalty: An American History. Cambridge, Mass.: Harvard

University Press, 2003.

Kai Erikson. A New Species of Trouble: Explorations in Disaster, Trauma, and Community. New York: W. W. Norton, 1994.

Michele Goodwin. Black Markets: The Supply and Demand of Body Parts. New York: Cam- bridge University Press, 2006.

Sue Holtkamp. Wrapped in Mourning: The Gift of Life and Organ Donor Family Trauma. New York: Brunner-Routledge, 2002.

Glennys Howarth. Death and Dying: A Sociological Introduction. Malden, Mass.: Polity, 2007.

Susan Orpett Long. Final Days: Japanese Culture and Choice at the End of Life. Honolulu: University of Hawaii Press, 2005.

Stuart J. Youngner, Robert M. Arnold, and Renie Schapiro, eds. The Defi nition of Death: Contemporary Controversies. Baltimore: Johns Hopkins University Press, 1999.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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F S

A C

o ll

e c ti

o n

, L

ib r a r y o

f C

o n

g re

ss

In 1935, medical care in Reedsville, West Virginia, seems less formal than that received in the urban clinics and hospitals of today. Although the practice of medicine has been enhanced by new methods of diagnosis and treatment, most people still believe that the relationship between physician and patient is central to the outcome of an illness.

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175

C H A P T E R 5

Health Care: Patients, Staff,

and Institutions

Think about the end of your life. Most people say they want to live their last days amid the familiar surroundings of home, surrounded by loved ones. But the nature of an

illness or lack of necessary support can oblige the dying person to be cared for in an insti-

tutional health care setting. Often, an “interventional cascade” surrounds the patient with

technology, resulting in unwanted aggressive care at the end of life. “The potential gain in

survival even from perfect therapy may be small.” 1

Oriented toward the goal of sustaining life, the health care system sometimes falls short

in meeting the needs of dying patients and their families. In 1900, about 80 percent of

deaths in the United States occurred in the home. Now, most deaths take place in institu-

tional settings, mainly hospitals and nursing homes. Ira Byock points out that, at present,

just over one-fi fth of Americans are at home when they die; over 30 percent die in nursing

homes; and hospitals remain the site of over 50 percent of deaths in most parts of the coun-

try. Moreover, nearly 40 percent of those who die in a hospital spend their last days in an ICU

(intensive care unit). 2

In the past, physicians did as much to console as to cure patients; consolation and

comfort were often all that medicine could offer. Now, if treatment is not a cure, we may

feel cheated. Physicians become scapegoats if their therapies do not lead to the desired

outcome.

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176 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Each of the three major categories of institutional medical care—

hospitals, nursing homes, and hospices—is intended optimally to serve a

specifi c purpose within the overall health care delivery system. Patients with

life-threatening illness usually receive a combination of acute and supportive

care. As conditions change, institutional care may alternate with home care.

Hospitals are devoted mainly to acute intensive care of a limited dura- tion. Aggressive medical techniques are used to diagnose symptoms, provide

treatment, and sustain life. The typical patient expects to regain well-being

after a short period of treatment and then return to normal life. Patients with

chronic or life-threatening illness may alternate between receiving acute care

in hospitals and obtaining supportive care in nursing homes, from hospices,

or at home. Some hospitals are evolving toward an integrated approach by

offering a “portfolio” of health care services, which can include outpatient

and extended care, as well as palliative care. (“Palliate” originates from the

Greek and translates as “to cloak,” meaning care that is meant to cloak or

prevent the experience of pain or other distressing symptoms. In the context

of modern medicine, “palliative” was originally used by Dr. Balfour Mount at

Royal Victoria Hospital in Canada.) 3

Nursing homes (a category that includes convalescent and extended-care facilities) provide long-term residential care for people who are chronically ill

and those whose illness does not require acute, intensive care. Most patients

in nursing homes eventually return to the community. A smaller percentage

of patients includes those who require ongoing supportive care, as well as

those who die while being cared for in a nursing home. “Increasingly, the

nursing home is the place of care and death for older Americans.” 4

Hospice care is distinguished by its orientation toward the needs of dying patients and their families. The mission of hospice care is to comfort the

patient rather than to cure a disease. Hospice is not necessarily a place but,

rather, a program of caring. Care that matches the aims of hospice can be pro- vided in various settings, including a palliative medicine department within

a hospital, a nursing home or residential-care facility, a community hospice,

or the home. These options for hospice and palliative care are examined in

more detail later in this chapter. (Palliative care services for children are dis-

cussed in Chapter 10.)

Modern Health Care A person admitted to a health care facility expects to receive medical and

nursing care appropriate to his or her particular malady. Each element of the

health care system—patient, staff, and institution—contributes to the overall

quality and nature of health care (see Figure 5-1 ). To effi ciently use staff and

facilities, procedures are standardized and routine. When an elderly aunt was

dying at home, she could be spoon-fed her favorite homemade soup by a family

member. In a hospital or nursing home, she is likely to receive a standard diet,

perhaps served impersonally by a harried and overworked aide. Charles Rosen-

berg observed that “we expect a great deal of our hospitals: alleviation of pain,

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Modern Health Care 177

extension of life, [and] management of death and the awkward and painful

circumstances surrounding its approach.” 5

A patient’s experience is shaped by rules, regulations, and conventions—

written and unwritten. The family of a dying patient may be relegated to a

deathwatch in the corridor or the waiting room down the hall, with one per-

son at a time squeezing into the patient’s room to keep a bedside vigil. There

may be no private space where relatives can meet to discuss concerns with

doctors or nurses. Grieving relatives may feel obliged to contain or repress

their emotions. In situations that involve dying patients, “the goal must not

be simply to provide expert medical care to an individual patient, but to help

give voice and connection and meaning to a family.” 6

Figure 5-1 Classic and Ideal Caring Situations

M.D. Supreme

Leader

Lawyers Ethicists

Philosophers

Lab technicians

Resident housestaff

Psychiatrists

Ward technicians

Chaplains

Social workers

Resident staff

Psychiatrists Ward

technicians

Chaplains

M.D.

Nurses

Nurses

Subservients

Lawyers

Friends

Social workers

Patient

Family Philosophers

Family

Ethicists

The Ideal Caring Situation

The Classic Caring Situation

Patient

Family

Friends

M in

ister

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178 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Abstraction and standardization are aspects of the scientifi c method,

which is the basis for many of the life-saving medical advances we applaud.

Less welcome is what happens when these mechanisms make medicine less

humane. For instance, reductionism occurs when complex phenomena,

such as those present in medicine and patient care, are reduced to overly

simple terms that distort the phenomena. It also occurs when only a piece of

a given system is acknowledged or considered, instead of the whole system.

Another error or aberration is depersonalization, which occurs when dying

patients are given less attention because physicians and nurses avoid contact

due to their own death anxiety or because of the belief that “nothing more

can be done.”

Health Care Financing Our individual and social choices about fi nancing health care infl uence

the options available for care of the seriously ill and dying. As Paul Insel and

Walton Roth observe, “Health care is fi nanced by a combination of private

and public insurance plans, patient out-of-pocket payments, and government

assistance.” 7 Spending for health care appears to be unlimited because “the

richer a country becomes, the more it will tend to spend.” 8

The United States spends more on health than any other industrialized

country. Daniel Callahan says, “There must be limits. American health care

is radically American: individualistic, scientifi cally ambitious, market intoxi-

cated, suspicious of government, and profi t-driven.” 9 Further, “The improve-

ment of health, the relief of suffering, and the forestalling of death are as

open-ended as the exploration of outer space.” 10

The rising costs of health care are due partly to a “technological imper-

ative” that promises an unprecedented range of tools for combating dis-

ease. Callahan says there are “many carrots and few sticks” with regard to

the rapid rise in technology (see Table  5-1 ). 11 The constant advances in

medical technology effectively extend life longer and longer, which often

makes it hard to know when to stop treatment. Some technologists appear

• A long-standing love of technology in all areas of life • The belief that technology saves lives and relieves suffering • The notion that it is wrong to decide which treatments are not cost-worthy • Consumer demand and expectations • Aggressive promotion and marketing of medical technologies • Direct-to-consumer advertising of medical technologies • Competition in the hospital marketplace • “Defensive medicine” as a prophylactic against malpractice charges • Health care as a growth industry (new jobs and construction) • Better fees and reimbursements for technology use than for talking to patients or

sitting by the bedside of the dying person • Belief in endless technological progress

t a b l e 5-1 Some Factors Spurring Medical Technology

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Modern Health Care 179

to believe that “death is nothing but a series of preventable diseases to be

picked off one by one.” 12

The most important aim of a health care system should be to help a person go

from being a young person to becoming an old person. However, once a person

has achieved that goal, there ought to be a reduced obligation on the part of a

health system to help someone become indefi nitely older, much less as old as

that person might like. 13

Medical advances can be a mixed blessing. Earlier detection of disease,

for example, may result in a cure that otherwise would not have been pos-

sible, or it may result only in the patient’s being aware of his or her disease for

a longer period of time. 14 The ability of medicine to predict death at an early

stage in some diseases has led to the emergence of a category of experience

called “terminal illness.” 15 With earlier diagnosis and sophisticated medical

care, the “terminal” stage of an illness may now last more than a decade.

Callahan says,

We can readily agree that medical progress and technological innovation have

been an enormous human benefi t. . . . They have helped to lower death rates

from lethal diseases, extended average life expectancies, relieved us of many

forms of physical and mental suffering, and have given us a confi dence about

living into old age, and a good old age at that, in ways impossible for past

generations to imagine. Yet if the cost of all those benefi ts begins to exceed

what we can now afford, how do we decide when enough is enough, and just

what might count as “enough”? 16

Reportedly, a quarter of the Medicare budget is spent on the last year

of patients’ lives and 40 percent of that amount is spent in the last 30 days. 17

George Lundberg, a physician and professor of health policy at Stanford

Medical School, says, “We should stop paying physicians and institutions to

prolong dying with false hope, bravado, and intensive therapy that only adds

to their profi t margin.” 18

Of course, it is not just doctors who rush to take advantage of newer and

newer technologies. Callahan says, “An astonishing 40 percent of Americans

believe that medical technology can always save their lives. The old joke that

Americans believe death is just one more disease to be cured is no longer a

joke.” 19 He asks these questions: 20

• Should death be seen as the greatest evil that medicine should seek to

combat, or would a better quality of life within a fi nite life span be a bet-

ter goal? • Do the elderly need better access to intensive care units and more high-

tech medicine to extend their lives, or better long-term and home care

and improved economic and social support? • Does it make any sense that the healthier we get in this country, the more

we spend on health care, not less? • Should we be spending three times more of our gross domestic product

on health care than on education, when forty years ago these amounts

were about the same?

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180 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Do investments in medical technology result in a better quality of care?

The answer seems to be yes. The impact of rising costs, however, raises the

question, Is society obligated to provide every medical intervention that a

patient believes might be benefi cial?

Rationing Scarce Resources To alleviate pressures on the health care system, experts suggest that

resources must be rationed. Rationing refers to the allocation of scarce resources among competing individuals. In health care, it is defi ned as any

system that limits the amount of health care a person can receive. Rationing

occurs when not all care expected to be benefi cial is provided to all patients

and, particularly, when a medical benefi t valued by a patient must be withheld

because of cost. Although physicians have always functioned as gatekeepers

in decisions concerning access to therapies deemed best for a patient’s wel-

fare, the new era of managed care means that they now face the prospect of being forced to engage in “restrictive” gatekeeping and “bedside” rationing,

roles that many people view as morally illegitimate in medicine. (Managed

care refers to an arrangement for health care in which an organization—

such as a health maintenance organization [HMO], a doctor-hospital net-

work, or an insurance company—attempts to control costs by acting as an

intermediary between the person seeking care and the physician.) Indeed,

some physicians express concern that trends toward closer management are

leading to “industrialization” of medicine in which medical care begins to

resemble a factory operation.

Daniel Callahan suggests that a “principle of symmetry” is useful in

acknowledging the limits of medical care. 21 He says, “A technology should

be judged by its likelihood of enhancing a good balance between the exten-

sion and saving of life and the quality of life.” Conversely, “a health care sys-

tem that develops and institutionalizes a life-saving technology which has the

common result of leaving people chronically ill or with poor quality of life

ignores the principle of symmetry.”

When my father went back to the hospital a year ago, he was clearly close to the

end: His lungs and liver were barely functioning, his abdomen was fi lling with

fl uid, and he could no longer lift himself out of bed. The hospital’s doctors none-

theless treated him aggressively, punching a hole in his chest to insert a drainage

tube, which quickly led to uncontrolled bleeding, an infection, and a plunge in

blood pressure. Within 12 hours, my father was in a coma, with no chance of recov-

ery, sustained only by a ventilator and a tangle of multiple IV drips. He spent four

days in the ICU, until I overcame the resistance of two doctors and had the ma-

chines turned off, as per my dad’s living will. Medicare paid upward of $20,000 for

these last days of my father’s life, during which he received little comfort, moments

of agonizing pain and fear, and all the medical care in the world, and then some.

William Falk, The Week

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The Caregiver-Patient Relationship 181

Decisions about allocating scarce medical resources are not just the

purview of experts and legislators. The choices each of us makes in pursuit

of well-being infl uence the health care system and contribute to shaping its

character. Madeline Jacobs says, “Modern technology blurs the defi nitions

of good care—what does it mean to heal, especially at the end of life?” 22

Instead of facing costly and likely futile treatments at the end of life, for

instance, we may choose to sign an advance directive that makes known our

wishes about receiving life-sustaining medical therapies (advance directives

are discussed in Chapter 6). “Medicine overreaches itself,” Callahan says,

“when it sets as its implicit goal that of curing all diseases and infi nitely

forestalling death.”

The Caregiver-Patient Relationship Aesculapius—according to Greek legend, the fi rst physician—was elevated to

the pantheon of gods and, along with Hygeia and Panacea, ruled over health

and illness. Medicine—given its association with the elemental experiences

of birth, life, and death—carries high symbolic importance. Arthur Frank

says, “Medicine is a play of boundaries,” explaining that “medicine requires both the aura of distance and the approachability that requires renouncing

some measure of aura.” 23 Paternalism, the assumption of parentlike author- ity by medical practitioners, is seen as infringing on a patient’s autonomy or

freedom to make medical decisions. 24 Thus, in the present era, the “Aescula-

pian authority” of physicians is being challenged.

The physician-patient relationship can be viewed as an alliance wherein

the physician is an educator, counselor, and expert but not the sole decision

maker. 25 (In primary care medicine, the term “doctor” can include individu-

als who have earned the clinical-oriented degree “DNP,” which signifi es Doc-

tors of Nursing Practice, or, as some physicians call them, “Noctors.”)

Patients’ experiences in coping with illness help shape the missions of

health care. 26 The social contract between physicians and patients includes

qualities of a covenantal relationship, which implies a mutuality of interests between providers and patients. 27 This kind of relationship is fostered when

providers get to know the patient, empower him or her to share in decision

making, and work within the constraints of the situation to respect and

accommodate patient choices.

Shared decision making is crucial in medicine generally and perhaps

especially in end-of-life care. Preferences or questions about end-of-life care

should be part of the discussion when choosing a doctor. Does the doctor

have experience caring for people at the end of life? Is he or she willing and

able to provide care in a variety of settings—hospital, nursing facility, hos-

pice or palliative care, or the home? Is the doctor familiar with community

resources? Any wishes about limiting treatment at the end of life should be

discussed. The bottom line is, Will the system accommodate the patient’s and

his or her family’s preferences and plans?

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182 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Disclosing a Life-Threatening Diagnosis If you were diagnosed as having a life-threatening illness, would you want

to know? Some people say, “Of course, I want to know everything that’s going

on with me!” Others answer, “Spare the truth, I’d rather not know that I

could die; ignorance is bliss.” The person who has spent a lifetime as a fi ghter

against the odds is likely to have a different response from the person whose

typical pattern of coping involves efforts to shun stress. Consider your own

attitudes and preferences. Keeping information from a patient may leave him

or her in what Avery Weisman called “a state of lonely apprehension.” 28

Surveys indicate that most people do want to be told if diagnosed with

a life-threatening illness, but the questions of when and how such informa- tion should be communicated are more diffi cult to answer. Physicians need

to present news of a life-threatening diagnosis in a manner that will serve

the best interests of the patient. In deciding how to do this, the doctor must

consider the patient’s personality, emotional constitution, and capacity for

continued function under stress. The patient’s familial and sociocultural

environment may also be important.

Doctors may worry that knowing all the details about a life-threatening

illness could adversely affect a patient’s ability to cope. Is minimizing the

threat of an illness sometimes in a patient’s best interest? Physicians gener-

ally subscribe to the belief that hope must be encouraged. Thus, although

physicians may disclose the general facts of a life-threatening illness, details

may be withheld until the patient takes the initiative by asking specifi c ques-

tions. Members of some cultural and ethnic groups prefer “concealment”

rather than full disclosure. 29 That is, families may be aware of a diagnosis

or prognosis and attempt to hide the truth from the patient. Furthermore, a

patient may not be accustomed to making decisions about his or her medical

care; family members may have an important voice. Communication train-

ing for physicians generally emphasizes dyadic skills between the physician

and separate family members; however, insights available from family systems

studies and family therapy can be usefully adapted to goals-of-care family

conferences. 30

Communicating the diagnosis is a crucial event in patient care. How

this is done can infl uence a patient’s attitude toward the illness, response to

treatment, and ability to cope. The content of such a conversation depends

I clearly made Dr. Mueh nervous. He was clearly up to his ears in patients and

spread very thin.

He took 90 minutes to talk to me and my wife about my disease. He started

out with terminal care and told me I’d get all the narcotics I would need to elimi-

nate pain and that tubes could be used to provide nourishment.

I was amazed that he talked that way, as if I were dying.

Pierre Bowman, Honolulu Star-Bulletin

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The Caregiver-Patient Relationship 183

on a number of factors, including the doctor’s preferences for breaking bad

news, the patient’s receptivity to the facts, and the expected prognosis. In

conversations that involve a terminal diagnosis, both physicians and patients

may be cautious about mentioning dying or death. Patients may be shocked

when fi rst given a diagnosis of serious or life-threatening illness, unable to

ask questions that will occur to them later. Thus, details can be given in seg-

ments. Breaking bad news is not so much a single event as a process.

In his book Counseling Individuals with Life-Threatening Illness, Ken Doka offers eight principles that are important when delivering bad news: 31

1. Keep it simple.

2. Ask yourself, “What does this diagnosis mean to the patient?”

3. Meet on “cool ground” fi rst. Get to know a patient prior to presenting the

news.

4. Wait for questions.

5. Do not argue with denial.

6. Ask questions yourself.

7. Do not destroy all hope.

8. Do not say anything that is untrue.

Besides providing a truthful report of the diagnosis, doctors generally

should offer advice about the proposed course of treatment and side effects,

providing as much detail as the patient desires. A good question to ask is,

How much do you want to know about your illness? 32 Ample time should be

available to explore the patient’s questions and concerns. 33

Achieving Clear Communication Clear communication does not happen automatically. Candace West,

a sociologist who conducted a study of how doctors and patients relate to

each other, found what she calls a “communications chasm” that hinders the

healing process. 34 She observed a lack of “social cement”—the introductions,

greetings, laughter, and use of patients’ names—that is naturally part of ordi-

nary social interactions. West also found that physicians tend to “advance

questions which restrict patients’ options for answers,” and patients tend to

be hesitant about questioning their doctors.

Physicians should “listen” with their eyes as well as their ears, paying

attention to the nonverbal communication of gestures and body language

that reveal a patient’s unease or anxiety about what is being discussed. The

technology of medical interventions can be an obstacle to effective commu-

nication. 35 Richard Sandor, a physician, says, “We detect subtle disturbances

of heart rhythm, manipulate faltering blood pressure to within a few millime-

ters of mercury, and regulate minute changes in blood chemistry, but what

about the person who is dying?” 36 In the art of medicine, accurate communica- tion has been called “the single most valuable asset of the skilled doctor.” 37

Communication is an interactive and transactional process: One can-

not not communicate. For instance, think about nonverbal communication, which includes not only facial expressions, gestures, and body postures, but

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184 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

also iconics —objects that convey meaningful information (such as clothing and jewelry)—and proxemics (space and time). For example, consider the time it takes a caregiver to respond to a patient’s request for help, or the physical

distance established when a physician stands behind a desk while talking to

a seated patient. Such labels as M.D. and R.N., as well as such titles as doctor,

nurse, and patient, are symbolic identifi ers that infl uence communication. 38

In most medical communications, patients are addressed by their fi rst names,

whereas doctors are addressed by their titles. 39

When patients express a desire to talk about death, caregivers may

respond with various strategies that either curtail or encourage such conver-

sations, including (1) reassurance (“You’re doing so well”), (2) denial (“Oh,

you’ll live to be a hundred”), (3) changing the subject (“Let’s talk about some-

thing more cheerful”), (4) fatalism (“Well, we all have to die sometime”),

and (5) discussion (“What happened to make you feel that way?”). Trained to

save lives, caregivers may feel helpless when they are not able to offer a cure.

Jeanne Quint Benoliel says that “open communication does not necessarily

mean open talk about death, but it does mean openness to the patient’s ver-

balized concerns.” 40

Responding to the emotional and spiritual needs of patients and their

families can be as important as caring for physical needs. A nurse who steps

into the room, sits down by the patient’s bed, and displays a willingness

to listen is likely to be more effective in providing comfort than one who

breezes in, remains standing, and quips, “How’re we today? Did we sleep

well?” Skillful communication helps in attaining the goals of health care for

the whole person.

Doctors and patients sometimes collude to maintain false optimism

about recovery by communicating in ways that allow the focus to be on cur-

rent treatment activities, with disregard for long-term prognosis. 41 The doc-

tor does not want to pronounce a “death sentence,” and the patient does not

want to hear it.

Writing about his own experiences with serious illness, Norman Cousins

pointed out that it is possible to communicate a life-threatening diagnosis as

a “challenge rather than a verdict.” 42 Communication can promote either a

positive attitude, with faith in the ultimate outcome, or a negative attitude,

Maxine was silent. “Is it even worth being treated?” she fi nally asked.

“You are the only one who can answer that question,” I said. “If we don’t treat

it, it will quickly spread to other cranial nerves and parts of the brain and spinal

cord. The quality of your life would be markedly impaired. I want to help sustain

as much quality of life for as long as possible.”

Maxine opened her eyes.

“I don’t want to die,” she said, beginning to sob. “I didn’t think it would hap-

pen so fast, so soon. I’m not really ready to die.”

Jerome Groopman, “Dying Words”

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Care of the Dying 185

with corresponding feelings of despondence and despair. Clear communica-

tion can play an important role in motivating the patient’s own “healing sys-

tem,” creating the potential for a positive outcome regardless of the ultimate

prognosis.

Providing Total Care Caring for seriously ill and dying patients involves attending not just to a

patient’s physical needs but also to his or her mental, emotional, and spiritual

needs. This is “whole person” care. 43 Such care usually means continuity of

contact between at least one caregiver and the patient, opportunity for the

patient to keep informed of his or her condition and prognosis, patient par-

ticipation in decisions that affect him or her, and behavior by staff members

that elicits the patient’s trust and confi dence. 44 When these guidelines are in

place, care can be both personal and comprehensive. As death approaches, the patient’s family is likely to experience a transi-

tion that has been characterized as the patient’s “fading away.” 45 A period of

chaos, confusion, fear, and uncertainty may ensue: “Nothing feels solid any-

more.” This transition involves a task of redefi nition as family members cope

with the burden of letting go of the old before picking up the new. Families

often fi nd themselves caring for a dying loved one while simultaneously try-

ing to carry on with the normal business of life. Total care means also attend-

ing to needs of the patient’s family.

Care of the Dying When Elisabeth Kübler-Ross set out to educate interns in an urban hospital

about the dying, she wanted to let terminally ill patients make their own case.

Informing staff members of her plan, she was told that no one was dying

on their wards; there were only some patients who were “very critically ill.” 46

Kübler-Ross’s efforts to focus attention on terminally ill patients became an

impetus toward compassionate care of the dying.

Dying, like birthing, is a natural event, sometimes better witnessed than

managed. Caregivers are called upon to put aside their own beliefs to dis-

cover what’s appropriate for a particular person in a particular situation.

Care of the dying, as Balfour Mount observes, involves both heart and mind:

“The dying need the friendship of the heart with its caring, acceptance, vul-

nerability and reciprocity. They also need the skills of the mind embodied in

competent medical care. Neither alone is suffi cient.” 47

The timeline for dying has changed over the last several generations.

Not only do we, on average, tend to live longer, but we are also more likely

to live with chronic disease and disability for months or even years before

we die. Most of us will need some level of care during our last days, weeks,

months, or even years of life. As life draws to a close, end-of-life care may

involve some combination of home care, hospital stays, nursing home care,

and hospice or palliative care. ( Palliative care refers to treatment intended to relieve the symptoms or reduce the severity of an illness without curing the

underlying disease.)

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186 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Would you prefer to spend your last days or weeks at home, cared for by

relatives and friends? Or would you rather have access to sophisticated medi-

cal technologies available in a hospital? The course of a disease may be unpre-

dictable, preventing a person from choosing the place where he or she will die

or the exact nature of medical care received. Even so, it is prudent to consider

possible options. When death is expected, perhaps foreseen as the fi nal chap-

ter of a long illness, there is usually some choice about where death will occur.

Dr. Elisabeth Kübler-Ross, seen here with a patient who has been diagnosed with a life- threatening illness, is widely recognized for her pioneering efforts toward increased aware- ness on the part of the patient, family, and medical staff relative to the issues that arise in caring for the dying.

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Care of the Dying 187

Hospice and Palliative Care The goal of medicine is to restore or sustain a sense of equanimity and

personal integrity despite disturbances caused by illness. Often, however,

the message heard by dying patients and their families is that nothing more

can be done. 48 The response of hospice and palliative care is that, on the

contrary, much can be done to help the dying person continue living until death, even though recovery or cure is not possible. These models of care

go beyond physical needs and seek to relieve suffering by providing total

care: physical, psychological, spiritual, and existential. 49 At the end of life,

a patient’s personal story is not adequately told by what’s written on the

medical chart.

A useful mnemonic is the 3Cs: high-quality care is competent, compas-

sionate, and coordinated. 50 Such care is provided by a team that may include

physicians, nurses, social workers, pharmacists, physical and occupational

therapists, chaplains, home health aides, and trained volunteers, as well as

family members and friends. This team-oriented approach is intended to pro-

vide state-of-the-art care to treat pain and other distressing symptoms, as well

as to provide emotional and spiritual support tailored to the needs of the

patient and his or her family.

The World Health Organization defi nes palliative care as

an approach that improves the quality of life of patients and their families

facing the problems associated with life-threatening illness, through the

prevention and relief of suffering by means of early identifi cation and

impeccable assessment and treatment of pain and other problems, physical,

psychosocial, and spiritual. 51

Stephen Connor describes palliative care as a “human right.” 52 Yet, a

study revealed that palliative care was not being provided at all in half the

countries of the world. 53

The Patient’s Story In learning to think like a medical scientist, I was forgetting the whole patient. To

help the patient in times of suffering, the physician must know the patient: not

only as a case but as a person. Each patient has a history, a unique story to tell,

which goes beyond the information in the medical history. Different patients have

different senses of what makes life important to them, what they want out of life,

and how far they are willing to go to preserve it. The patient’s full story, like any

person’s story, includes his or her cultural background, childhood circumstances,

career, family, religious life, and so on. It includes the patient’s self-understanding,

appearance, manner of expression, temperament, and character. In short, it in-

cludes those attributes that make the patient a person—and not only a person, but

this particular person.

Richard B. Gunderman, “Medicine and the Question of Suffering”

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188 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

As Joan Teno and Stephen Connor point out, “The central difference

between hospice and hospital-based palliative care programs is that the latter can admit and serve patients who are still receiving curative therapies. Most

hospice programs are Medicare certifi ed, and the Medicare Hospice Benefi t

generally requires that a patient be given a prognosis of six months or less

if the illness runs its normal course. Thus, hospice is a health care system

under which the patient decides to forgo curative treatments for the terminal

illness. Making a decision about hospice care can be a challenge in which

the patient faces a seemingly all-or-nothing decision. The Medicare Hospice

Benefi t has, in effect, “put hospice in a box with regard to treatment choice,”

in that patients who want to keep some option of survival open have been

excluded. 54 Patients referred to a palliative care service are not required to

meet a similar prognostic requirement (see Table 5-2 ). 55 This distinction will

become clearer as we discuss the challenges of care for patients with life-

limiting illnesses. For now, consider Teno and Connor’s apt summary: “In

short, all care provided by hospices is palliative; however, not all palliative

care is provided by hospices.”

Although the terms hospice care and palliative care are sometimes used interchangeably, as mentioned above, they also can be differentiated. For

example, the Merck Manual of Diagnosis and Therapy, a standard medical text- book, defi nes hospice as a type of care specifi cally designed to minimize suf- fering for dying patients and their family members; it forgoes most diagnostic

testing and life-prolonging treatments in favor of symptom relief, education

of patients and family members about appropriate care, and comfort care. 56

Such programs, which are available in virtually all regions of the United

States except for a small number of rural areas, can be considered as con-

forming to the “standard defi nition” of hospice.

Stephen Connor lists the following among the essential components of

hospice programs: 57

1. The patient and his/her family are the unit of care.

2. Care is provided in the home or in an inpatient facility.

3. Symptom management is the focus of treatment.

4. Treatment is directed toward the “whole person.”

5. Care is interdisciplinary.

6. Services are available twenty-four hours a day, seven days a week.

Hospice doesn’t prescribe a particular “way of dying.” 58 Rather, it seeks to

create an environment in which the “seemingly disordered process of dying”

can be lived out in a manner that fi ts the needs and beliefs of the person who

is dying. 59 The growth of hospice refl ects changing expectations about end-

of-life care, “from cure to care, extension of life to quality of life.” 60

According to the National Hospice and Palliative Care Organization

(NHPCO), about 5,300 hospice programs in the United States provided care

to an estimated 1.65 million patients in 2011; and about 1,059,000 patients

died under hospice care, nearly 45 percent of all deaths in the United States

that year. 61 In the 1970s, cancer patients made up the largest percentage of

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Care of the Dying 189

hospice admissions; today, they account for less than half of hospice admis-

sions (37.7 percent), with the majority being patients with chronic illnesses,

including unspecifi ed debility, dementia, heart disease, and lung disease.

More than 98 percent of families indicate they would recommend hospice

services to others. 62

Besides providing a relatively consistent package of services and bene-

fi ts designed to meet the needs of patients and families facing life-limiting

Hospice Programs Hospital-Based Palliative Care

Patient

population

Life-limiting illness; expected

prognosis 6 months or less

if illness runs its normal

course.

Any stage of advanced or life-

limiting illness.

Sites of care Home, nursing home, assisted

living facility, hospital, free-

standing hospice unit.

Hospital. Provision of services

elsewhere (e.g., nursing homes)

varies.

Services

provided

Pain and symptom manage-

ment, psychosocial and

spiritual support; interdisci-

plinary team; medical equip-

ment, medications, supplies;

family bereavement support

for 1 year after death.

Services vary, from single

health care provider to interdis-

ciplinary team.

Length of stay Average length of stay is

2 months; median, 20 days.

Varies, may be episodic care

based on needs.

Reimbursement Set payment per day enrolled,

at 1 of 4 levels of care: rou-

tine home care, continuous

home care, general inpatient

care, inpatient respite care.

Reimbursement through

existing channels, including

CPT (current procedure

terminology) and DRGs

(diagnosis-related groups).

Payment for professional or

facility services.

Role of primary

care provider

(PCP)

Usually continues to provide

overall management of care.

Hospice medical director

consults with PCP.

PCP often requests formal con-

sult with palliative care team.

Palliative care service or hospi-

talist may manage care during

inpatient stays.

Key differences Focus on caring for patient

and family or caregivers at

the end of life after efforts

at curative treatment are no

longer effective or patient

decides to stop treatment

with curative intent.

Focus on palliative care

throughout the continuum of

a life-limiting illness. Can be

delivered concurrently with

curative or life-prolonging

therapies.

t a b l e 5-2 Comparison of Hospice and Hospital-Based Palliative Care

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190 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

illness, hospice programs are mandated to provide bereavement follow-up to

every family they serve. Patient care is provided in the place the patient calls

home, which includes nursing homes and residential facilities as well as pri-

vate residences. Most of the time hospice care takes place in patients’ homes

with family members as primary caregivers. “Entering hospice care” usually

means affi liating with a hospice program —that is, arranging to receive the ser- vices of a local hospice.

Hospitals are increasingly incorporating principles of hospice and pal-

liative care into their mission. 63 When nurses are given time to get to know

patients and their families, when caregivers are assigned responsibility for

individual patients rather than tasks, when supportive relationships exist

among staff members, and when there is a policy of open disclosure of diag-

nosis and prognosis, care of the dying in both hospitals and hospice programs

embodies comparable ideals and philosophy regarding end-of-life care. Pal-

liative care is strictly defi ned as care that affords relief, not necessarily cure;

however, it can be combined with curative treatments, allowing patients to

battle the effects of disease while benefi ting from efforts to improve quality

of life.

Hospice and palliative care physician Ira Byock points out that “inten-

sivists and palliative care professionals both care for the sickest patients in

the healthcare system. As with patients in an ICU, those referred for pallia-

tive care consultation or admitted to hospice programs have life-threatening

conditions, often involving multiple organ system failure or insuffi ciency.” 64

In assessing the quality of palliative care or hospice, it is useful to ask, Is the

This exceptionally beautiful and functional facility at Hospice MariaTeresa Chiantore Seràgnoli in Bentivoglio (Bologna), Italy, shelters and cares for cancer and palliative care patients, with the aim of improving quality and dignity of life. Each unit opens onto a private garden where families and friends may visit with patients. It is also a training hospice for the University of Bologna’s Accademia della Scienze di Medicina Palliativa.

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Care of the Dying 191

interdisciplinary team competent? Is there continuity and coordination of

care in the services provided? Is care focused on the patient and family? How

easy is it to access care? Is the program committed to quality? 65 The goal is

to help people live as fully as possible until the end of their lives. Byock says,

“Even when it is not possible to add many days to life, the opportunity exists

to add life to one’s days.” 66

The Origins of Hospice and Palliative Care The roots of hospice and palliative care are found in age-old customs of

hospitality and in “places of welcome” maintained by early Christians to care

for pilgrims and travelers. 67 (The words hotel, hospice, and hospital derive from the Latin hospitium, meaning “a place that receives guests.”) Whereas Roman hospitals were built on a “military model of effi ciency” to provide quick

repair of gladiators and slaves, Christian hospices aided injured travelers, the

hopelessly ill, and victims of disasters. The dying received special honor, for

they were seen as spiritual pilgrims close to God. Among the earliest hospices

were those founded in the fourth century by a disciple of Saint Jerome named

Fabiola, a wealthy Roman widow who became patron and nurse in caring for

the sick and dying. Within the Judeo-Christian religious tradition, the basis

for hospice care is found in the concepts of diakonia (serving and caring for others), metanoia (turning within to a deeper self or divine power), and kairos (a unique moment of fulfi llment). 68

The most infl uential model of modern hospice care is St. Christopher’s

Hospice in Sydenham, England, founded in 1967 by Dr. Cicely Saunders. 69

(Saunders fi rst trained as a nurse, then as a medical social worker, and fi nally

as a physician.) 70 During the 1940s, while training as a medical social worker,

Saunders met David Tasma, a Jewish refugee from Poland who was dying of

inoperable cancer. They formulated the vision of a haven where people could

fi nd relief from pain and die with dignity. When Tasma died in 1948, he left a

small bequest to Saunders, saying, “I’ll be a window in your home.” Nineteen

years later, with the opening of St. Christopher’s Hospice, the vision became

a reality as a window was dedicated to Tasma’s memory. 71

Named for the patron saint of travelers, St. Christopher’s promotes accep-

tance of dying within an atmosphere of tranquility. St. Christopher’s refl ects

what Saunders called a “high person, low technology and hardware” system

of health care. 72 The wards and rooms at St. Christopher’s are fi lled with

fl owers, photographs, and personal items. Patients are encouraged to pursue

their familiar interests and pleasures. Extensive visiting hours allow for inter-

action between patients and their families, including children and even fam-

ily pets. When a patient is dying, family, friends, and staff members gather

around the bed for farewells. After death, family and friends may spend time

with the body if they wish.

Home care is an important adjunct to residential care at St. Christopher’s,

allowing the benefi ts of hospice care to be extended to nonresidential

patients and families. The hospice staff plans medication schedules, and

hospice nurses visit patients to monitor their conditions. Over the years,

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192 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

St. Christopher’s has exemplifi ed many features associated with hospice care,

such as providing adequate pain control, treating the patient and his or her

family as the unit of care, and achieving the best possible quality of life for

dying patients.

In 1963, a visit by Cicely Saunders to the school of nursing at Yale

University stimulated interest in hospice care in the United States. When

Saunders again visited Yale in 1966, Florence Wald, as dean of Yale’s gradu-

ate school of nursing, organized a meeting attended by Saunders, Elisa-

beth Kübler-Ross, Colin Murray Parkes, and others interested in improving

care of the dying. Wald, who had worked with terminally ill patients and

their families for more than a decade, was instrumental in establishing the

fi rst American hospice, which opened in New Haven, Connecticut, in 1974.

Its fi rst medical director was Dr. Sylvia Lack, who had previously served at

St. Christopher’s.

In its early years, hospice was a counterculture among the conventional

clinical disciplines in its approach to care. A sign of the positive change that

has occurred since that time is the approval (in 2006) of hospice and pal-

liative medicine as a new subspecialty by the American Board of Medical

Specialties. 73 Advances in palliative care have been a response to the percep-

tion that all too often care for dying patients had become ill considered and

inhumane. 74

Other key events in the modern history of hospice and palliative care

include establishment of a hospital-based palliative care team at St. Luke’s

Hospital in New York City in 1974 and publication of assumptions and prin-

ciples for terminal care by the International Work Group on Death, Dying,

and Bereavement in 1979. 75 Also, in the early 1970s, at Hospice of Marin in

California, Dr. William Lamers developed innovative approaches to home

care for terminally ill patients. This “home care” model of hospice quickly

spread, sponsored by a range of groups from churches and interfaith groups

to junior leagues. 76 Hospice programs, Lamers says, were created out of a

desire to improve the quality of life for patients with incurable illness, patients

who were being slighted in “a health care system that stressed aggressive ther-

apies aimed at cure or rehabilitation, but that seemed to offer disincentives

for care aimed at relief of illness.” 77

Challenges for Hospice and Palliative Care There are challenges in making hospice and palliative care more widely

available at life’s end. 78 First, because most care is provided in patients’

homes, the presence of a primary caregiver available twenty-four hours a day

is a near-requirement for receiving hospice services. A primary caregiver may

be the patient’s spouse, partner, or parent, although other relatives—as well

as someone paid by the family or funded by public agencies—can fi ll this

role. Caregivers must be able to accomplish a variety of health-related tasks,

such as monitoring vital signs, assessing pain, and administering proper dos-

ages of medications.

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Care of the Dying 193

Another challenge is funding. Hospice services are covered by Medicare/

Medicaid programs as well as by most private health plans, but there are lim-

its on who qualifi es. Under the Medicare Hospice Benefi t, a patient must pro-

vide a doctor’s certifi cation that his or her life expectancy is six months or

less if the illness trajectory follows its normal course. A review of the accuracy

of physicians’ clinical predictions of survival in terminally ill patients found

that they “consistently overestimate survival.” 79 Nicholas Christakis, a hospice

physician, says that most doctors decline to prognosticate at all; when they

do, they overestimate the patient’s remaining days by a factor of two to fi ve.

He says, “Most doctors stick to an unspoken code: Don’t foresee. If you do,

don’t foretell. And, if you do that, keep it upbeat and vague.” 80

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194 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Because of diffi culties in stating with certainty that a patient’s expected

prognosis is less than six months, the “six-months” rule may exclude

patients who have conditions diffi cult to predict. It also results in both

physicians and patients deferring hospice until a later stage of illness than

is preferable. Because of potential confusion about the six-months rule,

the head of the Health Care Financing Administration, which admin-

isters the hospice benefi t, pointed out that it is a misperception that

patients who outlive the six-months rule automatically lose their cover-

age. 81 The pertinent section of the law states, “six months or less if the ill-

ness runs its normal course.” 82 Also, patients already enrolled in hospice

who outlive this limit can be recertifi ed by a hospice physician, allowing

continued care.

Despite this assurance, the challenge faced by hospices is illustrated by

the story of San Diego Hospice, one of the largest community-owned, non-

profi t hospices in the country, which in its heyday reportedly cared for nearly

one thousand patients a day, terminally ill children as well as adults. Its

demise and eventual bankruptcy occurred when it faced a Medicare audit

that appeared to question its admission practices and the qualifi cations

of patients to receive federal reimbursement for hospice care. At issue was

whether San Diego Hospice “allowed patients to stay on service when it could

not be proved that they were dying.” 83

Another challenge faced by hospice is broadening access for under-

served patient populations. According to NHPCO, in 2011, nearly 83 per-

cent of patients were white/Caucasian, about 9 percent were black or African

American, and the remaining patients were identifi ed as Asian, Hawaiian,

Pacifi c Islander, American Indian, multiracial, or other race. Of the total

patient population, about 6 percent were identifi ed as of Hispanic or Latino

origin, a small percentage considering that this group constitutes approxi-

mately 17 percent of the U.S. population. 84

African American participation is not much greater. For historical rea-

sons, people of color tend to distrust social institutions. 85 A study found that

requiring cancer patients to give up curative treatment is detrimental to the

neediest patients and contributes to racial disparities in hospice use. 86 More-

over, ethnic groups may have traditions of family and community support

when coping with illness and death, whereas most hospice programs refl ect

mainstream, middle-class values. 87 Richard Payne says,

African Americans are signifi cantly less likely to prepare a living will, to talk

to their doctors about end-of-life care, or to participate in a hospice program.

When death is inevitable and imminent, blacks are twice as likely as whites to

request life-sustaining treatments that can make dying a miserable experience

for both patients and their families. . . . In my experience, many patients,

especially African Americans and members of other medically underserved

minority groups, tend to think of “palliative care” as “giving up hope.” I suspect

this is so because many African Americans fear their cultural and personal

values will not be respected when they are dying. 88

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Care of the Dying 195

When end-of-life decisions are being made, there is potential confl ict

between European American values of individualism and self-determination

and the Afrocentric emphasis on collectivity and family. “Cookie-cutter ser-

vices that fail to consider the contextual domain in which death and dying

occur are likely to be rejected by those who most need assistance at the end

of life.” 89

In its early years, hospice was distinguished by the enthusiasm of pioneer-

activists who sought to offer services not available from mainstream social

service agencies or in conventional medical settings and to provide services

on a not-for-profi t basis. Now, however, the greatest growth in the number

of hospice programs has been establishment of for-profi t hospices, which

account for about half the total number of programs. 90 According to experts,

“Outcome measurement and evaluation is no longer just an option if a hos-

pice or palliative care program is to succeed and establish credibility in the

current environment.” 91 Bureaucracy and routinization have become addi-

tional challenges to hospice care. This prompts the question, Has the phi-

losophy of hospice changed?

Inge Corless, an expert in palliative/hospice care, asks: In our zeal to

provide hospice care, are we becoming as paternalistic as the medical prac-

tices we often criticize? Do patients need to comply with hospice ideology to

receive services? Must all hospice clients engage in a dialogue about death?

What gives us the hubris to think we know best? 92

Critics familiar with the evolution of hospice see a subtle shift from the

concept of striving for a “good” death to a more prescriptive “peaceful”

death. 93 In the early days, hospices experimented with various approaches

to the delivery of services. Now, says Corless, the “politicization of reim-

bursement for hospice care” brings regulations requiring that all pro-

grams seeking certifi cation comply with a set of standards based on one

model of care.” 94

The Future of Hospice and Palliative Care William Lamers suggests that new forms of hospice and palliative care

may be needed to meet the challenges of caring for the dying. 95 He outlines

three levels of care:

1. Traditional hospice care for persons with fairly defi nable short-term prog- noses (for example, advanced, incurable cancers)

2. Long-term hospice care for persons with an indeterminate diagnosis who do not require costly therapies to improve quality of life during a pro-

longed period of dying (for example, chronic, incurable neurologic dis-

orders, such as Alzheimer’s disease and amyotrophic lateral sclerosis, or

ALS)

3. High-tech hospice care for persons who require expensive therapies to maintain reasonable relief of symptoms in the face of a limited, although

uncertain, prognosis (for example, advanced AIDS)

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196 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

An innovative development intended to help individuals avoid having to

make a decision between palliative care and hospice is the open access model of hospice. “An open access hospice provides treatments that palliate symp- toms and enhance the quality of life, even if the treatments are considered

to be disease directed.” 96 This can be a risky decision for a hospice, however,

because the cost of care is increased without a corresponding increase in

reimbursement. There is also risk that Medicare may consider treatment too

aggressive or inappropriate for hospice and disallow coverage. Thus, whether

the open access model of hospice can be sustained is unclear.

A step toward easing this challenge of hospice has been made by

some private health insurers, who allow patients to receive curative ther-

apy and hospice care concurrently. Kaiser Permanente, for example, has

established an interdisciplinary home-based program, the Palliative Care

Project, which helps patients transition gradually from curative therapy to

palliative care.

Another potential solution to this challenge is to create a bridge that offers patients hospice services earlier than they can be provided under the Medi-

care Hospice Benefi t. “Bridge programs are based on the concept that pallia-

tive care experts have long advocated that end-of-life care can be enhanced

by better integration of palliative care throughout the continuum of care.” 97

Such programs are offered by a hospice in collaboration with a home health

agency or other care provider that provides pain and symptom manage-

ment, consultation, and other supportive services when a patient with a life-

limiting condition is not yet ready to elect the hospice benefi t. According to

the program of care offered by Partners HealthCare, a nonprofi t health sys-

tem founded by Brigham and Women’s Hospital and Massachusetts General

Hospice,

Bridge to Hospice is for people who are coping with a life limiting condition

and whose prognosis is uncertain. This program provides home care support

that they need now, with preparation for future support from hospice. Together,

we focus on improving the quality of life for our patients by anticipating and

managing possible changes that may occur in their care. This allows for early

identifi cation and a seamless transition from home health to hospice care. 98

The key points to remember about bridge programs is that they apply to a

patient who (1) has a life-limiting condition and is receiving curative treat-

ment, (2) requires pain and symptom management and meets the insurer’s

criteria for home health care, and (3) is hospice appropriate but declines

hospice care.

Home Care Medically supervised end-of-life care that is provided in a patient’s home

is often referred to as “hospice home care.” Such care is directed by phy-

sicians, coordinated by nurses, and usually supported by an interdisciplin-

ary team that may include volunteers, family members, and friends. Home

care offers a number of potential advantages as a setting for terminal care,

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Care of the Dying 197

including the obvious fact that the patient is at home, which, for most people, is a “center of meaningful activity and connectedness to family, friends, and

community.” 99

At home, instead of having to comply with a schedule of visiting hours

and other rules determined by institutional routine, the patient and his or

her family enjoy greater fl exibility. Home care lessens the need to “live to a

timetable” and provides a sense of normalcy that enhances opportunities for

the patient to maintain relationships and exercise self-determination. It also

allows for a mutuality of care and concern, which families often fi nd gratify-

ing in caring for an ailing family member.

However, to realize these attractive features, home care requires ade-

quate support, preparation, and commitment. Home care can be a twenty-

four-hour-a-day job. Whether family member, friend, paid home health aide,

Home care may not come immediately to mind when one thinks of health care systems, yet this centuries-old tradition of care for the ill and the dying is once again emerging as an option for many. Innovations in sophisticated medical life-support equipment often make it possible for the seriously ill to be cared for using a high level of medical technology within the home.

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198 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

or outside volunteer, someone must be available to manage the various tasks

that constitute appropriate care of the patient. Although about 40 percent of

adult caregivers are men, day-to-day personal and household care is typically

shouldered by women, who have traditionally fi lled the role of “family nurse”

and continue to do so, despite social progress in breaking down gender ste-

reotypes in other areas. Even so, family caregivers may be marginalized by

health care professionals and denied access to information they may need to

do a good job. 100

The strain of caring for a dying relative may cause the caregiver to be inat-

tentive to his or her own health care needs, with the result that the caregiver

becomes sick or run down. Thus, another phenomenon associated with home

care is secondary morbidity, which refers to “diffi culties in the physical, cogni- tive, emotional, or social spheres of functioning that may be experienced by

those closely involved with the terminally ill person.” 101 Secondary morbidity

can affect professional or volunteer caregivers as well as family members and

friends of the dying person. The patient care workload can be lightened by out-

side support services provided, for example, by visiting nurses. There are likely

to be times when it is appropriate to arrange respite care —temporary care that gives family members or other caregivers a welcome break.

Social Support Social support is a key component of care for patients with a life-threatening

illness. It can help patients gain better understanding of their illness and pro-

vide a forum for sharing ways to cope with fears and enhance physical and emo-

tional well-being. Caregivers are encouraged to cultivate a “listening mind” that

allows them to be present to the needs and concerns of both the patient and his

or her family. Frank Ostaseski, founding director of Zen Hospice Project, says,

“One of our central tasks is to be available when stories are ready to be told.” 102

Organizations dedicated to helping people with specifi c illnesses—for

example, cancer, heart disease, or Alzheimer’s—can be found through hos-

pitals and other community agencies. The Internet is another alternative

resource. It offers health and medical information, and some sites provide

social support. For example, online patient groups demonstrate shared con-

cern for a particular illness or malady and provide a forum for giving and

receiving both information and support. Allan Kellehear proposes a type of

“health-promoting palliative care” that enlists support “not merely in terms

of support groups but also as a wider community issue.” 103

At Stanford Hospital in California, volunteers are enlisted to make sure

that no one dies alone. 104 For a patient who outlives his or her close relatives,

is estranged from his or her children, or becomes ill far away from family,

volunteers come to the hospital and sit with a stranger in his or her fi nal

moments. Stanford’s “No One Dies Alone” program attempts to humanize

the often sterile, clinical setting of the hospital. The volunteers describe sit-

ting with the dying as deeply profound, an honor, and a privilege. Unlike the

nursing team, there’s no to-do list; it’s simply being present.

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Elder Care 199

Elder Care Round-the-clock care is sometimes needed to manage the illnesses and

debilities that may accompany old age. Listen to conversations about care

of a chronically ill older adult, and you may notice language like this: “She

couldn’t live by herself, so her son took her in,” or “He was failing and had to

be put in a nursing home.” A question like “What will we do with Dad when

he is too old and can’t manage by himself?” can refl ect both loving concern

and inadvertent disregard for the aged person. It is not surprising that old

people report feelings of being put away, taken in, done to, and otherwise

manipulated, their integrity ignored.

Institutional care is likely to be depersonalizing. Residents may feel

deprived of self-esteem and integrity. Rules and regulations dictate a style

of life that may be far from what the resident would choose for himself or

herself. Even a cherished picture of a loved one may fi nd no place in the resi-

dent’s room: not the bedstand (that’s for bedpans), not the wall (patients are

frequently moved)—so, where? The answer may be, nowhere.

Gerontologists—people who study the process and the problems of

aging—describe how the “psychological railroading” of routinized, bureau-

cratic environments can result in an institutional neurosis, the symptoms of which include “a gradual erosion of the uniqueness of one’s personality traits

so that residents become increasingly dependent on staff direction for even

the most mundane needs.” 105 Such favoring of institutional expediency over

the needs of living persons cannot be justifi ed.

In the United States, social service programs for older people can be

traced to the Depression of the 1930s and the passage of the Social Security

I Know (I’m Losing You) Have you ever touched your father’s back? No, my fi ngers tell me, as

they try to pull up a similar memory.

There are none. This is a place we have never traveled to, as I try

to lift his weary body onto the bedpan.

I recall a photo of him standing in front of our house. He is

large, healthy, a stocky body in a dark blue suit.

And now his bowels panic, feed his mind phony information,

and as I try to position him, my hands shift and the news shocks me

more than the sight of his balls.

O, bag of bones, this is all I’ll know of his body, the sharp ridge

of spine, the bedsores, the ribs rising up in place like new islands.

I feel him strain as he pushes, for nothing, feel his fi ngers grip

my shoulders. He is slipping to dust, my hands inform me, you’d better remember this.

Cornelius Eady

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200 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Act of 1935. The Old Age Assistance Act, enacted in 1950, became the fi rst

federal program to deal specifi cally with problems of the aged. Following

adoption of the Medicare and Medicaid programs in the mid-1960s, federal

assistance became a customary means of providing care for America’s elderly.

Nevertheless, questions about how to provide adequate, as well as cost-

effective, care of the aged continue to be of public concern, and they become

more important as life expectancy increases: Aged people are not only grow-

ing in numbers but also making up a larger proportion of the total population.

( Senescence, the state or process of becoming old, is discussed in Chapter 11.) Historically, the family has been a haven for ill and aged relatives, and

families continue to provide the major portion of care for aged relatives.

Indeed, most elders live in their own homes or with their families, who often

highly value the care they provide to an older relative. But aged people may

require more assistance than relatives or friends can realistically provide.

Home health care may be available to assist the older person in a variety of ways, ranging from medical and nursing visits to helping with preparation of

meals, exercise, and other maintenance needs, along with simple (but impor-

tant) visitation. The decision for institutional care is usually made when a

person is no longer able to live independently and his or her family is unable

to provide the level of care needed.

There are several alternatives to consider. Home sharing is one possibility. This is an option with various confi gurations: (1) an older homeowner who

prefers not to live alone or needs the income rents spare rooms to other older

persons, (2) several older adults rent a house or apartment, sharing kitchen

and other living spaces as well as household chores, (3) a faith-based or com-

munity group sponsors a large home shared by several individuals. Personal care homes, also called board-and-care homes, provide care for residents who need minimal assistance and are otherwise able to care for themselves.

Midway between independent living and institutionalization is a form of

care called congregate housing. This is usually a large facility with individual apartments or a group of small condominiums within a planned neighbor-

hood. This is an option for residents who are mobile and able to care for

themselves, although they share meals in a central dining room and enjoy

housekeeping services. Assisted living facilities provide for residents who can- not live independently, but do not require skilled nursing care. Assistance

may include help with bathing, meals, and housekeeping.

Continuing care retirement communities are designed to provide the level of care required by the changing needs of older people. Such communities offer

a variety of housing options and services on the same campus. This option

is distinguished by its organizational structure, which, like a series of con-

centric circles or graduated steps, provides the level of care needed by each

resident. Within such a community, some individuals essentially live inde-

pendently, preparing meals in their own apartments or eating in a common

dining room when they wish. This type of facility may include various fl oor

plans, from studio apartments to suites of three bedrooms plus den. Such

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Trauma and Emergency Care 201

communities typically offer a variety of recreational services, such as game

rooms, libraries, walking paths, and other social and cultural activities, as

well as transportation to shopping, art exhibits, and theater events. A person

moves to an assisted living unit when help is needed with activities of daily

living. A skilled nursing facility is also available on campus when needed, and

hospice care may be available on site. These various levels of care within the

same campus allow older people to enjoy a sense of security without losing

their independence, knowing that help is available when required.

Finally, skilled nursing facilities provide comprehensive care, furnishing medical and nursing services as well as dietary supervision.

Despite the image of old people being “dumped” in nursing homes by

uncaring relatives, this is rarely the reality. On the contrary, families often

delay obtaining care for elders because of reluctance to accept the fact that

more help is needed. Entering into institutional care is usually viewed as a

personal failure for both the aged person and his or her family. It is pictured

as the least desirable option, “a sort of confession to fi nal surrender, a half-

way stop on the route to death.” 106 However, it may be the only reasonable

course open to an aged person. The best outcome follows when adequate

information is gathered before making a decision about a particular facility

(see Table 5-3 ). In coming decades, novel types of elder care undoubtedly will

be created to accommodate “baby boomers.” 107 Perhaps most important for

individuals and as a society is the imperative to address the task of envision-

ing and creating a worthy place for the old who live among us.

Trauma and Emergency Care It was only little more than half a century ago that hearses stopped doing

double-duty as ambulances and emergency medical technicians (EMTs)

replaced “ambulance drivers.” This led to dramatic change as ERs began to

receive patients who previously would not have reached the hospital alive. 108

In the United States, modern hospital-based trauma care was initiated

in 1966 by Robert Freeark at Cook County Hospital in Chicago and William

Blaisdell at San Francisco General Hospital. Then, in 1969, R. Adams Cowley

formed a comprehensive system of trauma and emergency care by bringing

together the Maryland State Police and the Maryland Institute for Emergency

1. Make a list of local facilities offering the type of services needed. 2. Find out whether the facilities are licensed and certifi ed. 3. Visit the facilities. 4. Prepare a checklist of desirable features and evaluate each facility in light of the

needs of the person who would be moving in. 5. Determine the costs. 6. Make your decision.

t a b l e 5-3 Steps in Choosing a Nursing Care Facility

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202 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Medical Services to create the fi rst civilian helicopter medevac program. The

fi rst hospital-based helicopter program was established in 1972 at St. Anthony’s Hospital in Denver. These innovations refl ect the standard approach to emer-

gency treatment in the United States, which is termed “scoop and run,” mean-

ing that accident victims receive minimal on-site treatment from paramedics

and are rushed to emergency rooms or trauma centers. “Stay and play” is

used to describe an approach in which extensive on-site treatment and stabi-

lization are performed by doctors who arrive at the scene of the accident in

mobile hospital units. (This was the approach used to treat Diana, Princess of

Wales, when the Mercedes in which she was a passenger crashed in the Alma

tunnel in France.) 109

Many of the procedures now commonplace in trauma care have been

adapted from techniques used by the military in combat situations. These

include the use of helicopter air ambulances, advances in team surgery and

orthopedics, and treatment for burns and shock. In fact, the roots of modern

emergency and trauma care can be traced back to the Civil War, when Army

Major John Letterman developed a triage system for evacuating casualties.

Emergency personnel, including search-and-rescue workers and police offi cers, engage in the grim task of recovering and identifying the bodies of two people who died in the crash of a helicopter about a thousand yards offshore. Such work is stressful and involves an extensive network of helping professionals who typically receive little or no formal training in methods of coping with the impact of multiple encounters with death, an inevitable con- sequence of the performance of their duties.

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Trauma and Emergency Care 203

Aimed at reducing time between injury and care, triage involves assigning

priorities to patients based on the seriousness of their injuries. Highest prior-

ity is given to patients whose injuries are serious but survivable. Lower pri-

orities are assigned to patients with only a remote chance of survival and to

those with comparatively minor injuries.

In a recent year, more than 121,000 Americans died from injuries sus-

tained in accidents. 110 About 40 percent of these deaths involved motor vehicle

accidents, with falls, drownings, fi res, and poisoning and exposure to noxious

substances accounting for most of the rest. Experts in emergency care and

trauma (defi ned as physical injury) refer to the “golden hour” following acci- dental injury, of which the fi rst fi fteen minutes are especially critical. 111

Think about the compelling images associated with the drama of life-

or-death situations in the emergency room. 112 As one ER staffer said, “You

can be sitting there almost lulled to sleep during a quiet period, then sud-

denly everything is happening at once because there’s just been a fi ve-car

crackup.” Interventions must be rapidly and effi ciently mobilized if life is to

be sustained. Trauma patients are frequently comatose or incoherent due

to shock. The emergency room staff must take action that makes the dif-

ference between life and death while receiving little or no feedback from

the patient.

Caregivers disagree about whether family members should be present in

the ER (or at home when EMTs are called) during cardiac resuscitation. 113

Incorporating family members into such events can be quite challenging, yet

The worst thing I ever saw was either two babies and their grandmother burnt

to death, to nothing, to just charred black lumps that had to be picked up out of

smoking rubble, or a guy who wasn’t dead yet who was mashed half in two by a

truck. I saw a lot of death, and I worked at a small department in a little Mississippi

town. It may sound cold, but the dead who were already gone never bothered me

as much as the living ones, who were in great amounts of pain and shock, who had

to be assured that yes in fact they were not going to die but were going to live if

they would just take it easy and relax. You cannot think about a person’s pain and

do your most effi cient job; if your feelings about his feelings are weighing on your

mind more than how best to remove his crumpled car door from around his body,

you’re not doing him any good and should probably step aside and let somebody

else operate the tool.

Remove the car from the victim, not the other way around. You can be faced

with anything. A car upside down on top of two people, one dead, one alive. A

head-on collision, two dead, two alive, one each in each car. A car fl ipped up on

its side against a tree, the driver between the roof and the tree. A burning car with

live occupants trapped inside.

Rolling on a call has been likened to soldiers going into combat.

Larry Brown, On Fire

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204 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

some argue that the family deserves the opportunity to be present in what

may be the last minutes of the patient’s life. As Jerome Groopman points

out, “Resuscitations are generally gruesome—physicians occasionally have to

split ribs or cut into a windpipe in an effort to keep someone who is bleed-

ing or unconscious alive—and just fi fteen percent, at most, are successful.” 114

Still, some studies have shown that relatives who did not witness resuscitation efforts were more likely to experience anxiety, depression, and post-traumatic

symptoms afterwards. Nonetheless, there is a subgroup of the population

who appear to be at risk for a severe adverse reaction, including attempted

suicide, after witnessing resuscitation.

When a patient dies, members of the staff face the task of delivering bad

news to relatives. A doctor usually provides news of a patient’s death, perhaps

with other staff members on hand. The manner in which such news is com-

municated often will remain with survivors for a lifetime.

Death Notifi cation A notifi cation of death “announces a void in the social fabric.” 115 Medical

personnel are not the only group with the task of delivering “bad news.”

Emergency personnel, police offi cers, and fi refi ghters also seek appropriate

resources to do effective notifi cation. 116 R. Moroni Leash says, “Death noti-

fi cation is always traumatic. Diffi cult family dynamics and death scenarios

can make it much more complex.” 117 For military deaths, the policy of send-

ing a Western Union telegram has been replaced by a personal visit to the

next of kin: “We are here to inform you that your son. . . .” Those devastat-

ing, dreaded words delivered by a stranger who seems to be the grim reaper

launches survivors into the role of the bereaved, and grief is unpredictable.

After being told that his son had been killed in Iraq, a Florida man used

gasoline and a blowtorch to set fi re to the Marines’ van, severely burning

himself. 118 One writer said that notifi ers have the task of uttering “the fi rst

lines of a fi nal chapter in a family’s life.” 119

In a recent year in the United States, about 45,300 people were killed in

motor vehicle crashes, many involving drunk driving, and more than 18,000

died by homicide. 120 Often, deaths occur away from the next of kin, who must

be told the news. Selection of the notifi er is important, although this task

is frequently thrust unexpectedly on emergency personnel. More important

than who are how and when and even where. In a hospital, the notifi er is usually a physician who was involved in the

life-saving efforts. If a physician is not available and family are already pres-

ent, a nurse may give the notifi cation. As the person ultimately responsible for

treatment, however, the physician is thought best able to provide a detailed

explanation, and families tend to accept the reality more readily if a physi-

cian notifi es. However, good arguments can be made for bringing in a social

worker, chaplain, or counselor, perhaps even to deliver the initial news if the

physician is unavailable or has just fi nished “running the code” and needs

time to decompress.

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Death Notifi cation 205

When a death occurs “in the fi eld,” notifi cation may be done by police

offi cers, fi refi ghters, EMTs, or coroner’s staff. The primary notifi er is prefer-

ably someone who has ample time to discuss the death and who was present

with the victim or knows the details that led to the death, because families

often ask for more information. This may be someone who provided on-scene

medical assistance if family members happen on the scene or survive the acci-

dent and have questions about the condition of others.

Often, notifi cation does not occur at the scene of death, meaning that

next of kin must be identifi ed and contacted. This can present challenges

when the deceased is, for example, an undocumented migrant, a transient, or

a teenage runaway. The notifi er must be certain of the identity of the deceased

to prevent an erroneous notifi cation intended for someone else. Key elements

in notifi cation include timely announcement, control of the physical environ-

ment, details of the efforts to save the life, explanation of the cause(s) of death,

appropriate emotional support, and other resources that could be helpful to

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206 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

the bereaved. If it is necessary to make telephone contact, the notifi er should

plan to direct the conversation and avoid telling more than is appropriate for

the circumstance, especially if family dynamics and emotional stability are not

known. 121 Plans can be made to meet in person with the family.

Peter Rober and Paul Rosenblatt remind us that the death of a loved one

is always painful for a family, and “unexpected deaths are particularly tragic

and shattering.” 122 The process of making meaning of the loss begins with

notifi cation. As family members deal with the available information about

the circumstances of the death, they start to create a story about their loss.

The manner in which notifi cation is carried out can be signifi cant in shaping

the family’s experience of grief.

Leash suggests a “sequential notifi cation technique” to prepare the fam-

ily for the ultimate statement of death. He says, “Coordinate your statements

with their emotional responses. By so doing, you allow them to control the

fl ow of the conversation, preparing themselves as you proceed together.” 123 In

meeting with the family (in this scenario, at the hospital), follow these steps:

1. Ask the family members what they already know about the situation.

2. Bridging from what they know, give a brief description of events that led

up to the patient’s arrival at the hospital.

3. Give information regarding the resuscitative efforts made on behalf of

the patient.

4. Conclude with the victim’s response to treatment, the statement of death,

and a brief explanation of the cause of death.

Generally, the doctor’s announcement of the death was made within the fi rst or

fi rst two sentences, usually in the course of one long sentence. An interesting fea-

ture of his presentation, more common in the DOA situation than in announce-

ments of the deaths of hospital patients, was that in announcing the death he

provided, in some way, that the death be presented as having followed a course of

“dying.” In nearly every scene I witnessed, the doctor’s opening remarks contained

an historical reference. . . . This was true in accidental as well as “natural” deaths,

and true whether or not the physician had any basis for assuming a likely cause of

death. . . . Physicians seem to feel in such situations that historicizing their delivery

of news, no matter how much their limited knowledge of the case may restrict the

range of possibilities, helps not only reduce some of the shock values of “sudden

deaths” but aids in the very grasp of the news. The correctness of the physician’s

supposed cause of death is of secondary signifi cance relative to the sheer fact that

he provides some sequential formulation of its generation, some means whereby

the occurrence can be placed in a sequence of natural or accidental events. This

is felt particularly to be necessary in the DOA circumstance, where many deaths

occur with no apparent “reason,” particularly the so-called “sudden unexpected

death,” not uncommon among young adults.

David Sudnow, Passing On: The Social Organization of Dying

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Caregiver Stress and Compassion Fatigue 207

In terms of the death system, notifi cation relates to functions in such

areas as making sense of death, disposing of the dead, and consolidation

after death.

Caregiver Stress and Compassion Fatigue Health care professionals not only must possess necessary technical skills but

also must learn how to deal with their own anxieties about dying and death. 124

The goal of saving every patient may be worthy, but it is not realistic or practi-

cal in the context of trauma care, or, indeed, in that of medical care generally.

When the circumstances of a death provoke the caregiver’s own anxieties or

when a death is exceptionally tragic—the death of a child, for example, or

the death of several members of a family in an automobile accident on Christ-

mas Eve—it is likely to profoundly affect caregivers. 125 This observation also

applies to fi refi ghters, police offi cers, and other fi rst-responders (personnel who are fi rst to arrive at the scene of accidents, disasters, and other life-threatening

medical situations), as well as to search-and-rescue personnel. 126 Examples of

events likely to have a negative impact on emergency service personnel include

• Disasters • Incidents involving children • Events in which victims are known to personnel • Line-of-duty deaths

The impact of working in a death-saturated environment is evident on

the faces of rescue and recovery personnel when disaster occurs. Although it

is frequently suggested that such individuals receive critical incident stress man- agement (CISM) intervention following traumatic events, the particulars of how best to provide psychosocial aid are neither obvious nor generally agreed

upon. 127 Such interventions have received criticism for having little positive

effect; some argue that they actually worsen trauma. Others express the view

that CISM is ineffective with some groups and benefi cial for others.

The essential idea is to allow the person who has experienced trauma a

chance to talk about it without receiving judgment or criticism. One scenario

involves a three-step approach that addresses the trauma at various stages:

First, a defusing is done the day of the incident. The purpose of the defusing is to assure the people involved that their feelings are normal, alert them to

symptoms to watch for over the short term, and offer them a lifeline (in the

form of a telephone number to reach someone they can talk to). Defusings

are often informal, sometimes done at the scene. The defusing is followed

within two or three days by a debriefi ng, which gives affected individuals a chance to talk about their experiences, discuss coping strategies, identify

individuals who may be at risk, and inform them about resources in the com-

munity. A debriefi ng is typically the second level of intervention for people

directly affected by the incident, and it may be the fi rst for those not directly

involved. The fi nal step is to follow up to ensure that the individuals are safe and coping well or to refer them for professional counseling.

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208 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

Professionals who provide care for seriously ill and dying people may be

more familiar with death than the average person; however, experiences with

death can still be stressful, and the frequency of such experiences can lead to

compassion fatigue. The main sources of stress include feelings of inadequacy, nonreciprocal giving, and too many demands. The biggest threat tends to

occur when caregivers feel helpless, seemingly unable to improve the situa-

tion. They may ask, Was there something else that could have been done?

Caregivers may experience a litany of what-ifs when deaths occur. When

caring is defi ned as curing, caregivers are vulnerable to feelings of failure

when a patient dies. 128

Members of the Newburgh, New York, Volunteer Ambulance Corps are overcome with tears at the end of a memorial held for seven children killed at a local elementary school by a tornado. Emergency personnel who work in closely knit communities often have personal relationships with those they serve and thus may experience with special intensity the trag- edies that befall their neighbors.

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A Changing Health Care System 209

When the health care system or other people or phenomena interfere

with a carer’s ability to provide relief to a dying person’s suffering, the result

may be moral distress. “Moral distress occurs when the clinician knows the appropriate action to take, but is unable to carry it out and feels forced to give

care contrary to her values.” 129

In working day in and day out with individuals who are seriously ill and

dying, caregivers who become fatigued by grief may be tempted to take ref-

uge in hospital routine and standardized policies as a way of alleviating stress.

This can lead to emotional exhaustion, or burnout, defi ned as a reaction to stress in which a carer goes beyond a state of exhaustion and depression to

being “past caring.”

Danai Papadatou proposes what she terms a “relationship-centered”

approach, the basic idea of which is that “care cannot be perceived or under-

stood independently of the relationships in which it occurs.” 130 She says,

No matter how “expert” we become—or strive to appear—dying and bereaved

people remind us that we are human and equal in the face of death. We all

die—some sooner, others later. In this fi eld of work, we are all affected by the

transience of life, the irreversibility of death, the suffering that loss engenders,

and an existential quest for meaning.

The death of a patient whom caregivers have come to know well is likely

to evoke grief. Papadatou says, “We hold onto memories of patients who,

through their experience, provided us with opportunities to review our work,

our practices, and our lives.” 131

It is important for carers to maintain balance in all the professional and

personal dimensions of life: occupational, physical, intellectual, social, emo-

tional, and spiritual. When care for the caregiver is recognized as crucial to

being fi t to provide empathetic care, caregiver stress and compassion fatigue

can be minimized.

A Changing Health Care System Care of dying persons takes place within a health care system that is undergo-

ing rapid change. Some of these changes are due to fi nancial issues that simul-

taneously result in moves to ration scarce health care resources while other

initiatives seek to broaden access to health care for poor and underserved

A person’s in the room with me and they’re very close to dying and afraid. I can

feel the fear of death in myself. I’m working through my fear. I give them an op-

portunity, silent though it may be, to work through theirs. If I come into a room

saying, “Oh, there’s nothing to be afraid of. We go through death and then into

another rebirth,” that’s not very useful. That’s a way of not dealing with the power

of the moment—the suffering in that room in the fellow on the bed, and the suf-

fering in the mind of the fellow next to the bed.

Stephen Levine, A Gradual Awakening

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210 c h a p t e r 5 Health Care: Patients, Staff, and Institutions

segments of the population. There are various ways of measuring the out-

come of health care choices in relation to available resources. For example,

the concept of “quality-adjusted life years” (or QALYs) is concerned with a

balance between length of life and quality of life. 132 The idea behind QALYs is that individuals may be willing to accept a trade-off: A person might equate

the prospect of living fewer years in perfect health with the prospect of living more years in less-than-perfect health. Decisions about this trade-off and other matters inherent in the health care system must be made by society as well as

individuals.

The boundary where patient and staff meet—that is, the caregiver-patient

relationship—is crucial to the assessment of quality health care. Clear com-

munication is essential, especially in the context of serious or life-threatening

illness. Equally important in this context is the provision of total care to

patients with life-limiting diagnoses.

In response to this need, recent decades have seen dramatic growth in

hospices and palliative care. Although this type of care has become an impor-

tant part of the overall health care system, there are still challenges that must

be addressed to carry adequate care of the dying into the future. Some of the

main challenges have been discussed in this chapter.

Similarly, dramatic advances in trauma and emergency care have resulted

in life-saving innovations that bring benefi ts to a large number of patients

and their families. Notifi cation of death to families often contains informa-

tion regarding the resuscitative efforts made on behalf of the patient. As

the following chapter shows, however, CPR (cardiopulmonary resuscitation)

has brought many questions of its own when applied in the context of a life-

limited or dying patient. This is one of the most pressing questions concern-

ing end-of-life issues and ethics—and how such issues and ethics play out in

the health care system.

Options for elder care have expanded in recent years as well. Daniel

Callahan points out that “the retirement of the baby boomers will be the

great demographic event of the fi rst half of the twenty-fi rst century, just as the

birth of that generation was the great demographic event of the last half of

the twentieth century.” 133 In consequence, society will confront issues related

to aging and the aged—and their interaction with the health care system—in

new and possibly unforeseen ways.

Allan Kellehear says, “The question of seamless social support for end-

of-life care fi nds its answer, however ambitious and daunting the task, in

community care.” 134 We explore the model of compassionate cities and how it applies to end-of-life care in Chapter 15.

Further Readings Ira Byock. The Best Care Possible: A Physician’s Quest to Transform Care Through the End of

Life. New York: Avery Penguin, 2012. Daniel Callahan. Taming the Beloved Beast: How Medical Technology Costs Are Destroying

Our Health Care System. Princeton, N.J.: Princeton University Press, 2009.

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Further Readings 211

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

Helen Chapple. No Place for Dying: Hospitals and the Ideology of Dying. Walnut Creek, Calif.: Left Coast Press, 2010.

Stephen R. Connor. Hospice and Palliative Care: The Essential Guide, 2nd ed. New York: Routledge, 2009.

Marilyn J. Field and Christine K. Cassel, eds. Approaching Death: Improving Care at the End of Life. Washington, D.C.: National Academy Press, 1997.

Sharon R. Kaufman. . . . And a Time to Die: How American Hospitals Shape the End of Life. New York: Scribner, 2005.

Stanley Joel Reiser. Technological Medicine: The Changing World of Doctors and Patients. New York: Cambridge University Press, 2009.

Irene Renzenbrink, ed. Caregiver Stress and Staff Support in Illness, Dying, and Bereave- ment. New York: Oxford University Press, 2011.

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Adequate planning helps ensure that we do not unnecessarily add to the burdens carried by our survivors when we die. Such planning includes consideration not only of the disposition of our estate but also of the content of our advance directives. Although some end-of-life issues are easily decided, others may require us to intensely consider alternatives. Our thoughtful choices will likely refl ect our own personal and family values as well as social and cultural preferences.

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213

C H A P T E R 6

End-of-Life Issues

and Decisions

A sudden stroke severely incapacitated a divorced woman in her late fi fties who had been living independently. Nothing had been discussed or written about her wishes

in the event such an incapacitating event occurred. As her condition worsened, her four

brothers and sisters, fi ve children, their partners, and nieces and nephews began to discuss

what “Mom would have wanted.” Not surprisingly, many confl icting notions were expressed.

There were arguments by phone and in person. After the woman died, family members who

had been most vocal never spoke to one another again.

Choices concerning end-of-life care are best made by individuals, families, and caregivers,

who, acting together, form a community of interest with fi rsthand knowledge about a particu-

lar case and the will to make moral decisions. 1 Some decisions involve matters that can be dealt

with long before an individual is faced with the crisis of an illness or debility. These include

activities like making a will, establishing a living trust, obtaining life insurance, and completing

an advance directive to express wishes about medical treatment in the event one becomes inca-

pacitated. Other decisions are likely to arise when a person is near death. These include such

matters as choosing to withhold or withdraw treatments and considering physician-assisted

death or aid-in-dying. Finally, some issues are initiated earlier in life but are not completed

until after a person’s death. These include the settling of a person’s estate through probate and

the disbursement of proceeds from insurance and other death benefi ts to survivors.

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214 c h a p t e r 6 End-of-Life Issues and Decisions

Decision making in the end-of-life (EOL) context has been defi ned as

“the aspects of life-threatening illness/terminal illness that involve choices

and decisions about actions to be taken, for individuals, families, and profes-

sional caregivers.” 2 We expand this defi nition to include issues and decisions

that pertain more generally to the end of a person’s life, not just those that

pertain to the specifi c period when end-of-life care is provided.

The reason for thinking about ethics and developing skills to deal cre-

atively with ethical issues is not so that we can adopt some particular set of

principles, but, rather, so we can exercise powers of refl ection and consider

possibilities and options that enable us to think for ourselves. It seems there

is never a good time for EOL planning. We tend to say, “I’m an active person,

I’ve got things to do, I’ll get to it when there’s time.” The result, for most of us,

is that end-of-life planning is placed low on our list of priorities.

The end-of-life issues and decisions discussed in this chapter deserve

consideration at an early stage of life. When we acknowledge the inevitability

of death, we can prepare for it. Planning helps ensure that we do not add to

the burdens carried by our survivors. Many issues can be anticipated, consid-

ered, and discussed with close relatives and trusted friends. Thus, it is wise

to begin considering EOL issues and decisions as soon as possible and then

periodically review and revise choices throughout life.

Principles of Medical Ethics To provide a framework for discussing informed consent, withdrawing or

withholding medical treatment, euthanasia, physician-assisted death, and

other issues relevant to end-of-life care, it is worthwhile to review some

guiding principles of medical ethics. 3 To begin, ethics is concerned with the investigation of what is good and bad, especially as these concepts relate

to moral duties and obligations. Such an investigation results in a set of

moral principles or values that guide behavior. When we think of morals, or moral principles, we are dealing essentially with notions of right and

wrong. Although the two terms— morals and ethics —are closely related, we can distinguish them in one way by noting that morals involve conforming

to established codes or accepted notions of right and wrong, whereas eth-

ics involve more subtle or challenging questions. The pursuit of ethics is

characterized by efforts to answer the question, What is the good? and its

corollary, What is to be done?

In applying ethical principles to the realm of medicine, several concepts

have importance. The fi rst of these, autonomy, refers to an individual’s right to be self-governing—that is, to exercise self-direction, freedom, and moral

independence. Our personal autonomy is limited by the rights of others to

exercise their autonomy, and it also may be limited by society, which exercises

rights in the name of the community. One example is the requirement that

a traveler must obtain inoculations before being granted a visa to enter cer-

tain countries; the traveler’s autonomy is restricted by concerns about public

health imposed by the larger community.

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Informed Consent to Treatment 215

Thus, limits may be placed on a person’s autonomy and autonomy may be

challenged. Such challenges can include, among other things, the impact of

decisions on the welfare of the individual, the interests of others, including

caregivers, and society’s interest in the allocation of scarce resources. 4 Culture

and religious beliefs infl uence how individuals exercise their autonomy. For

some cultural groups, family members have a primary, or at least equal, voice

in decisions about a patient’s care. 5 Individual autonomy is offset by respect for

the values of others with whom one has a signifi cant relationship. If decisions

are made without considering their effect on the “family commons,” those

choices may be overridden. Thus, within limits, the principle of autonomy pro-

motes “respect for persons” as people negotiate the medical system.

Another fundamental principle in medical care is benefi cence, which involves doing good or conferring benefi ts that enhance personal or social

well-being. This principle is sometimes expressed by its counterpart, non- malefi cence, or the injunction to “do no harm.” In the context of caregiver- patient relationships, this principle requires that physicians not abandon a

patient even when a patient makes decisions or takes actions that the physi-

cian believes are ill advised. 6

Finally, medical ethics is concerned with the principle of justice. Like “the good,” justice is not easy to defi ne, although it includes qualities of

impartiality and fairness as well as right and proper action. Justice implies

going beyond one’s own feelings, prejudices, and desires to fi nd an appro-

priate balance among confl icting interests. As you consider the issues dis-

cussed in this chapter, keep in mind the fundamental ethical principles of

autonomy, benefi cence, and justice. Physician John Lantos says, “The goal of

medical ethics, it seems, should not be to develop rules that will minimize

the need for individual virtues but to develop virtues that will minimize the

need for rules.” 7

Informed Consent to Treatment Patients have a right to be informed about their medical condition and about

the proposed plan of treatment. We see our doctor to obtain medication to

cure the fl u or mend a broken arm, and we may give little thought to alter-

native treatments. We tend to rely on the physician’s judgment by accepting

the diagnosis and going along with the proposed treatment. By following

the doctor’s advice, we expect to achieve a speedy recovery. The etiology, or cause, of the disease or injury generally concerns us less than obtaining relief

from its symptoms. However, when an illness is serious or life threatening, a

patient’s informed consent is more signifi cant. Several treatment plans may

be presented, each with its own set of potential risks and benefi ts. Which

treatment promises the best results? The fewest undesirable side effects?

Principles of Informed Consent Informed consent is based on three legal principles: First, the patient

must be competent to give consent. Second, consent must be given freely. Third, consent must be based on an adequate understanding of the proposed

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216 c h a p t e r 6 End-of-Life Issues and Decisions

treatment, including any potential risks. Although the phrase informed consent did not achieve legal defi nition until 1957, its antecedents go back hundreds

of years to English common law. The President’s Commission for the Study of

Ethical Problems in Medicine remarked that “the legal doctrine of informed

consent imposes on physicians two general duties: to disclose information

about treatment to patients and to obtain their consent before proceed-

ing with treatment.” 8 Although informed consent involves inquiring about

patients’ desires to receive medical procedures to cure their conditions, in

terminal cases, the issue becomes less “informed consent” of how to cure

than “truth telling” about the end of life. 9

Informed consent ideally occurs within a context of shared decision mak-

ing based on mutual respect. Because people differ in their attitudes toward

autonomy and information gathering in medical care, the process of obtain-

ing informed consent must be fl exible. Some patients are more interested in

being informed than in being fully involved in decision making. Most physicians believe they have a duty to truthfully inform patients

about a life-threatening condition, but this has not always been the case. A

study in 1961 found that most doctors had a strong and general tendency to

withhold information. 10 None of the doctors surveyed at that time reported a policy of telling every patient about a life-threatening diagnosis. Only

about 12 percent said they would usually inform patients about a diagnosis

of incurable cancer. Even when patients were informed, the disease was often

described euphemistically. Doctors might tell the patient that he or she had

a “lesion” or a “mass.” Some doctors were more precise, using a description

such as “growth,” “tumor,” or “hyperplastic tissue.” In many instances, the

description was phrased to suggest that the cancer was benign, or adjectives

were used to temper the impact of the diagnosis. Thus, a tumor was said to be

Nurse: Did they mention anything about a tube through your nose? Patient: Yes, I’m gonna have a tube in my nose. Nurse: You’re going to have the tube down for a couple of days or longer. It

depends. So you’re going to be NPO, nothing by mouth, and also you’re going

to have IV fl uid.

Patient: I know. For three or four days, they told me that already. I don’t like it, though.

Nurse: You don’t have any choice. Patient: Yes, I don’t have any choice, I know. Nurse: Like it or not, you don’t have any choice. (laughter) After you come back,

we’ll ask you to do a lot of coughing and deep breathing to exercise your lungs.

Patient: Oh, we’ll see how I feel. Nurse: (emphasis) No matter how you feel, you have to do that!

President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Making Health Care Decisions: A Report on the Ethical and Legal Implications of the Patient–Practitioner Relationship

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Informed Consent to Treatment 217

“suspicious” or “degenerated.” Such descriptions allowed physicians to give

a general explanation of the medical situation while eliciting the patient’s

cooperation in the proposed course of treatment.

By the late 1970s, the climate of truth telling had seemingly changed

signifi cantly. A study done in 1977 found an almost complete reversal of atti-

tudes; about 97 percent of the doctors surveyed indicated that they would usu-

ally tell patients the truth about a diagnosis. 11 A review of this study, however,

revealed methodological and theoretical shortcomings that undermined the

claim of a shift in physicians’ behaviors. 12 The picture became a bit clearer

in a follow-up study (by the authors of the 1977 paper), which found that

doctors reported that they were willing to engage in some deception when

situations involved complicated or sensitive ethical issues. 13 Researchers said

that physicians “appear to justify their decisions in terms of the consequences

and to place a higher value on their patients’ welfare and keeping patients’

confi dences than truth telling for its own sake.”

Offering information about prognosis —that is, the expected course of the disease—can be a problem for physicians. It can be diffi cult to predict

life expectancy or predict how a disease will run its course in a particular

patient. Statistics about the usual course of a disease provide a rough idea of

the odds of survival, and a doctor’s clinical experience may also be a guide.

Still, because of uncertainty, some doctors prefer to offer hope by describing

recoveries without also mentioning the likelihood that most people who have

such a condition will die. 14 Daniel Callahan says, “Medicine fi nds it harder

and harder to locate the line between living and dying, and thus to know

when to stop treatment.” 15

Informed consent can be especially important when medical care is

provided by a team of specialists whose responsibilities are defi ned less by

patients’ needs than by particular diseases or organ systems. In some cases, it

may seem as if no doctor has responsibility for the overall care of the patient.

The patient may be unsure who to ask for information and advice.

To the extent that a course of treatment is elective, the outcome uncer-

tain, and the procedure experimental, informed consent becomes cor-

respondingly more important. For example, drawing a blood sample is a

common procedure that entails little risk to the patient. Consequently, we

do not expect to receive a detailed explanation of risks when we roll up our

sleeve for the needle. However, a complicated surgical procedure, one with

a nearly equal proportion of risks and benefi ts, makes a patient’s informed

consent crucial.

Preferences Regarding Informed Consent What constitutes suffi cient information on which the patient can base a

decision? Some patients take an active role in their treatment, even propos-

ing alternatives to their physician. Others prefer to follow the plan suggested

by their doctor, not wanting to know about potential risks or the percentage

of failures. Full disclosure is a help to some patients, a hindrance to others.

Such variation among patient attitudes presents a dilemma for the medical

practitioner.

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218 c h a p t e r 6 End-of-Life Issues and Decisions

Informed consent is a fundamental ethical principle in medicine. Even fairly routine procedures, such as mending a small fracture, may become complicated when the patient is leukemic, as is this child: Alternatives must be weighed more carefully before a course of treatment is chosen.

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Additionally, members of a patient’s family may have their own agen-

das that complicate informed consent and medical decision making. Margot

White and John Fletcher describe a case in which the spouse of a dying

patient told doctors, “You can’t tell my husband he’s dying; it will kill him.” 16

She insisted that the truth of her husband’s illness be withheld from him,

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Informed Consent to Treatment 219

refusing the doctors’ requests to speak with him about his condition and

his preferences for treatment. From the wife’s point of view, she knew her

husband better than anyone—certainly better than the doctors—and she

knew what was best for him. For the staff, however, her “interference” caused

concern about thwarting or compromising the patient’s autonomy and right

to know.

Informed consent is closely tied to the quality of communication between

physician and patient. A study designed to assess communication between

physicians and seriously ill patients at the end of life found disturbing short-

comings. 17 (The study, known by its acronym, SUPPORT, was a multicenter

“Study to Understand Prognoses and Preferences for Outcomes and Risks

of Treatment.”) Researchers found that fewer than half (41 percent) of the

patients reported talking to their doctors about prognosis or CPR (cardio-

pulmonary resuscitation); that is, efforts to restart a patient’s heart and

breathing, which range from relatively simple actions, such as external chest

compression, to advanced interventions that involve electric shock, insertion

of a tube to open airways, injection of medication into the heart, and open

chest heart massage. “Physicians misunderstood patient preferences regard-

ing CPR in 80% of cases. When patients wanted CPR withheld, a do-not-

resuscitate order was never written in 50% of cases.” 18 In short, physicians

were oblivious to the reality that some patients near the end of their lives

would not want CPR administered. Furthermore the study revealed that half

of the patients who died had moderate or severe pain during their fi nal three

days of life. Madeline Jacobs says, “The SUPPORT study revealed that people

were suffering terrible deaths in hospitals, in pain, and with no power to con-

trol the last stage of their lives.” 19

Findings from Phase 2 of the study were even more troubling in terms

of informed consent and patient preferences. The SUPPORT investigators

assigned specially trained nurse advocates to help make patients’ wishes

known. Despite this intervention, there was no improvement in physician-

patient communication. One expert stated, “The SUPPORT investigators

underestimated the tenacity of physicians in continuing to care for patients

the way they always have.” 20 A little bit of education for patients and physi-

cians was not enough to overcome the diffi culty of appropriately caring for

the dying.

The fact is, patients may not want disruptive medical technologies at the

end of life, preferring to be allowed to die as peacefully as possible. This pref-

erence can be recognized in the medical setting by designating the patient

as “DNR (meaning, Do Not Resuscitate),” “No Code,” or “CMO” (Comfort

Measures Only)—all of which are intended to inform medical and nursing

staff not to perform CPR. Sharon Kaufman says,

In 1965, CPR was reclassifi ed from an exclusively medical procedure, used

only in certain kinds of cases, to a universal emergency procedure that anyone

could perform. By implication, anyone, anywhere, could benefi t from CPR.

The formal DNR order came into being in 1974. Yet consent for emergency

resuscitation was, and, still is, presumed. 21

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220 c h a p t e r 6 End-of-Life Issues and Decisions

Lack of communication may cause DNR orders to be ignored even when

they exist. Families facing end-of-life decisions frequently want more guid-

ance than they receive. Yet, doctors may be uncertain about the best course

with respect to risks and benefi ts for a patient. There are three categories to

consider in CPR decisions:

1. CPR is a plausible option. For example, a patient who has chronic illness that has not reached end stage.

2. Recommend against CPR. For example, a patient with end-stage advanced illness.

3. Do not offer CPR. For example, a patient who is imminently dying.

Should a decision not to offer CPR be disclosed to patients or their sur-

rogates (persons who serve as substitute decision makers)? Whereas a deci-

sion not to offer treatment for other illnesses—for example, a patient dying

of renal failure from complications of metastatic cancer—is not questioned,

resuscitation is viewed differently from other medical procedures. 22

Patients may not realize that they must speak up if they do not want

emergency attempts at resuscitation. Indeed, most patients and families do

not know what to want when faced with specifi c directives about options

that are generated by institutional routines. 23 Without a DNR order, hospi-

tal policies generally require that CPR be initiated immediately if a patient

is in cardiac arrest or a similar medical emergency. Even when a physician

has entered a DNR order on the patient’s chart, it may not contain specifi c

guidance about which treatments should be initiated and which withheld.

Does the order not to initiate CPR mean that other life-saving medical inter- ventions should be done? Or should all such interventions be withheld? If medical heroics are to be avoided, who decides whether a particular inter-

vention is “heroic” or “ordinary” in a given set of circumstances? When a

When I was a junior physician in a hospital, we were once called urgently to the

bedside of a lady of ninety. The nurse had used the term “cardiac arrest”—the old

lady’s heart had stopped (as hearts are apt to do, around ninety!). But because the

cardiac arrest alarm was raised, I and the other houseman launched into a full-

scale resuscitation. With violent drugs injected directly into the heart, blasts of

electric current through her chest, noise and chaos, she had anything but a peace-

ful death. On refl ection we realized that all this had been inappropriate, but noth-

ing in our medical student training gave us any guide. Indeed once the emergency

is in the air, there is not time to weigh up the pros and cons. The decision is rarely

a doctor’s anyway, because usually the only person on the scene when an emer-

gency occurs is a nurse—probably a relatively junior one if it is nighttime—and she

decides whether or not to resuscitate. Needless to say, it is a very courageous nurse

who decides not to. Once things have started, it is very diffi cult for the doctor when

he arrives to stop everything, particularly if the patient is showing signs of reviving.

Richard Lamerton, Care of the Dying

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Choosing Death 221

patient’s attending physician is not present on the scene to determine the

appropriate level of treatment, it can put other medical and nursing staff in

a quandary about what to do. It is not always straightforward to simply “fol-

low doctor’s orders.”

Many physicians have not been trained to move from aggressive to pal-

liative care, nor are they familiar with the principles of care associated with

palliative medicine. The momentum in medicine naturally moves toward pro-

viding life-sustaining treatment. Thus, a patient’s wish to refuse CPR or other

life-sustaining interventions simply may not be on a doctor’s “radar screen.”

Although forced, coercive treatment is rare, caregivers can—unwittingly

or not—exert undue infl uence on patients by means of subtle or overt

manipulation. Once the patient is admitted to a health care institution,

cooperation with caregivers is expected. The tacit communication may

be that the patient has no choice. Informed consent requires cooperation

between patient and physician in seeking the common goal of optimal and

appropriate health care.

Choosing Death Techniques for cardiopulmonary resuscitation (CPR) and artifi cial respira-

tion allow physicians to intervene in the “normal” dying process. The human

organism can be kept functioning despite the cessation of normal heart,

brain, respiratory, or kidney function. (Note, however, that the portrayal of

CPR on television medical shows generally presents a misleading picture of

the frequency with which such resuscitation results in “miracles.”) 24 When

medical technologies spare patients’ lives and enable them to resume more

or less normal functioning, the results are gratifying. But the same technolo-

gies that prolong life can also prolong dying.

The conventional understanding of the Hippocratic oath, named for the

ancient Greek physician Hippocrates, acknowledges that medical treatment

is sometimes futile; that is, it is ineffective and has no possibility to “cure,

ameliorate, improve, or restore a quality of life that would be satisfactory to

the patient.” 25 Should futile treatment be withheld or withdrawn when doing

so is virtually certain to result in the patient’s death? Alternatively, should

treatment be continued with no reasonable hope of improvement? What is

the proper balance between sustaining life and preventing suffering?

Surrounded by an array of machinery and tubes, the patient may seem

less a human person than an extension of medical technology. Reviewing

the range of modern medical technologies, the President’s Commission for

the Study of Ethical Problems in Medicine concluded, “For almost any life-

threatening condition, some intervention is capable of delaying the moment

of death. Matters that were once the province of fate have now become a mat-

ter of human choice.” 26

Often, the medical slogan seems to be “Keep the patient alive at all costs.”

Patients and their families usually fi nd it diffi cult to make a decision to limit

treatment, to stop “doing everything that can be done.” Yet, striving to keep

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222 c h a p t e r 6 End-of-Life Issues and Decisions

patients alive by all means and at any cost is also questioned. At times, in the

medical arena, “the available choices are between dying sooner and comfort-

ably and living slightly longer by receiving aggressive therapy, which may pro-

long the dying process, increase discomfort and dependence, and decrease

the quality of life.” 27 Does a person have a “right to die” when suffering out-

weighs the benefi ts of continued existence? 28

Ethical debates about this question have become prominent since the

landmark case of Karen Ann Quinlan in 1975. At age twenty-one, after a

party at a local bar, she was found in her bed not breathing. Karen was admit-

ted to the intensive care unit of a New Jersey hospital. She was in a coma. (See

Table 6-1 for a description of disorders of consciousness, including coma and

vegetative state.)

Soon Karen’s breathing was sustained by a mechanical MA-1 respirator

and she received artifi cial nutrition. When she remained unresponsive over

the next several months, her parents asked that the respirator be discon-

nected so that nature could take its course. But hospital offi cials denied their

request. Eventually, the petition reached the New Jersey Supreme Court,

which ruled that artifi cial respiration could be discontinued. 29 Karen was

taken off the respirator. To the surprise of many people, she continued to

breathe unaided. She was transferred to a nursing care facility and lived in a

vegetative state until her death in June 1985 at age thirty-one, having become

a focal point for issues pertaining to “death with dignity.”

After Quinlan, both state and federal courts issued rulings concerned

with removal of life-sustaining treatment, including feeding tubes that supply

nutrition and hydration to patients. Noteworthy was the case of Nancy Beth

Cruzan, heard before the United States Supreme Court in 1990. 30 As a result

of injuries sustained in a car crash in 1983, at age twenty-fi ve Nancy was left

in a vegetative state. Although she was resuscitated by paramedics, her brain

had been deprived of oxygen for so long that she never regained conscious-

ness. For nourishment, Nancy’s physicians implanted a feeding tube in her

stomach, the only form of life support she was receiving, a treatment that

physicians said could prolong her life for as long as thirty years.

After waiting four years for a recovery, Nancy’s parents, granted guard-

ianship by the court, asked that the feeding tube be taken out, basing their

request on Nancy’s right to be free from “unwarranted bodily intrusions.”

The hospital refused, and the Missouri Supreme Court denied the Cruzans’

petition, ruling that, without “clear and convincing evidence” of Nancy’s con-

sent, her parents could not exercise her right to refuse treatment. The state’s

“unqualifi ed” interest in preserving life should prevail.

( Clear and convincing is a legal term, indicating a standard of proof between the heaviest burden of proof, beyond a reasonable doubt, which is used in criminal cases, and a preponderance of the evidence, a “more likely than not” standard, which is used in most civil cases.) 31

The Missouri court’s decision was appealed to the United States Supreme

Court, which ruled that the right to refuse treatment, even if life sustaining,

is constitutionally protected. However, the Court said states are justifi ed in

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Choosing Death 223

requiring that only the patient herself or himself can make such a decision.

Because Nancy apparently had not made a clear expression of her wishes

prior to her injury and ensuing unconscious state, Missouri was not bound to

honor her parents’ request.

A few months later, however, in light of testimony from several of Nancy’s

friends that she had expressed her wish “not to live like a vegetable,” a Mis-

souri state court ruled that the standard of “clear and convincing” evidence

of Nancy’s wishes had been met, and the court granted permission to remove

Coma —A state of profound unconsciousness and unresponsiveness. Usually, after a few days or weeks, patients either regain consciousness, progress to a vegetative state, or die (if the entire brain or brain stem is permanently nonfunctional, then the diagnosis is brain death rather than coma).

Vegetative state —In this state, coma has progressed to a state of wakefulness; eyes may be open and the patient may respond refl exively to painful stimuli, but there is no detectable awareness. There is some functioning of the upper brain stem. A deep coma without detectable awareness, the vegetative state is characterized as “awake but unaware.” Some investigators propose the descrip- tion “unresponsive wakefulness syndrome.” It has also been called “hopelessly conscious.”

Persistent vegetative state —This is a wakeful unconscious state that lasts longer than a few weeks. Recovery depends largely on the extent of injury to the brain. Because persistent suggests irreversibility, the terms post-coma unresponsiveness and vegetative coma have been suggested as substitutes.

Permanent vegetative state —A vegetative state is considered permanent after three or twelve months, depending on the nature of the injury. If from oxygen depriva- tion, as with cardiac arrest or drowning, it is considered permanent after three months. If from traumatic brain injury, such as a motor vehicle accident or a fall, it is designated permanent after twelve months. (A word of caution when reading articles or books that use the abbreviation PVS: Although originally used to designate a “persistent” state, because of inherent ambiguity, it is also used to refer to a “permanent” state.)

Minimally conscious state (MCS)—Unlike the vegetative state, with which the MCS may be confused, this is a state of consciousness. It includes varying degrees of cortical injury. Patients exhibit fl uctuating or intermittent periods of awareness of self and environment. A relatively new category of disorders of consciousness, MCS is a condition of severely altered consciousness in which minimal but defi nite behavioral evidence of self or environmental awareness is demonstrated. For example, MCS patients smile or cry appropriately in response to the content of emotional topics or stimuli, give gestural or verbal yes/no responses (regardless of accuracy) that are directly responsive to lin- guistic content of questions, and reach for objects in ways that demonstrate a clear relationship between object location and direction of reach. Such responses are not merely refl exive.

Locked-in syndrome —Not strictly a disorder of consciousness, this state involves paralysis of most muscles, except ocular muscles of the eyes; the patient is con- scious, has awareness, sleep-wake cycles, and meaningful behavior (e.g., eye movement). The patient is aware and awake, but cannot move or communicate verbally. Total locked-in syndrome is similar, except the eyes are also paralyzed.

t a b l e 6-1 Disorders of Consciousness

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224 c h a p t e r 6 End-of-Life Issues and Decisions

the feeding tube. Thirteen days later and seven years after her car accident,

Nancy Cruzan died. Her family said, “She showed no sign of discomfort or

distress in any way. . . . There remains no question that we made the choice

she would want.”

Following Quinlan and Cruzan, the next name to capture widespread

public attention was Terri Schiavo, who collapsed in her home in February

1990, experiencing a cardiac arrest that led to coma and subsequently a veg-

etative state. 32 Eight years later, Michael Schiavo, her husband and guardian,

petitioned a Florida court to remove her feeding tube, an action opposed by

Terri’s parents, who argued that she was conscious. Over the next fi ve years,

there was a struggle in the courts to determine whether life support should be

withdrawn, a struggle compounded by the fact that Terri had not completed

an advance directive, although the court found evidence that she would not

have wanted to be kept alive on a machine.

Terri’s parents, however, argued that Terri was not in a vegetative state

and, instead, was in a “minimally conscious state,” saying that her actions

showed response to external stimuli, not merely refl ex behavior. This asser-

tion led to more court hearings to determine whether new therapies could

help restore Terri’s cognitive function. By this time, the case was being played

out in the media.

Terri’s feeding tube was removed and, within a week, the Florida legisla-

ture passed “Terri’s Law,” which gave Governor Jeb Bush authority to inter-

vene on behalf of the parents and order reinsertion of the tube. A fl urry

of court hearings ensued and Terri’s Law was overturned by the Florida

Supreme Court.

A time and date for removal of the feeding tube were again set by the

court, a ruling that sparked an upsurge of federal involvement in the case.

The U.S. Congress subpoenaed Terri Schiavo to testify at a “fi eld hearing,”

and President Bush signed a bill that transferred jurisdiction to the federal

courts. (Critics pointed out that never before had Congress used its subpoena

power to obtain testimony from someone in a persistent vegetative state.) 33

Within a matter of days, further appeals were denied and the U.S. Supreme

Court declined to grant judicial review, thus ending the legal options of

Terri’s parents.

As Madeline Jacobs observed, “The involvement of the press and ulti-

mately the political system . . . turned this private tragedy into a public cir-

cus.” 34 “Experts” kept providing Schiavo’s parents with “proof ” that therapies

might work or with testimonies that kept their hopes alive, resulting in a

“tragic misperception about Schiavo’s likelihood of recovery.”

Ultimately, the feeding tube was removed and, on March 31, 2005, Terri

died. The subsequent autopsy revealed extensive brain damage, with Terri’s

brain only half the weight expected for a woman of her age, height, and

weight. The report said the damage was “irreversible.” 35 Perhaps because of

the “culture wars” the Schiavo case generated, discussion of the terms vegeta- tive state, coma, and minimally conscious state became part of widespread public discourse. 36

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Choosing Death 225

Schiavo exposed three modern myths about life and death: 37 First, that

death with dignity is easily attainable so long as people make living wills (a

type of advance directive, discussed later in this chapter). Second, that only

patients themselves are permitted to take quality of life into account when

making life-sustaining decisions. Third, that medical innovations and mir-

acle cures bring a promise of extending life indefi nitely. Kathy Cerminara

said, “The waves kicked up by the Schiavo storm will ebb and fl ow long after

the gavel has struck for the fi nal time in the courtroom.” 38

Withholding or Withdrawing Treatment The right of a competent patient to refuse unwanted treatment is gener-

ally established in both law and medical practice. This can mean either with-

holding (not starting) a treatment or withdrawing (stopping) a treatment

once it has been started. The consensus is that there is no medical or ethi-

cal distinction between withholding and withdrawing treatment. The choice

to forgo life-sustaining treatment involves refusing treatments that would be

expected to extend life. Such treatments include cardiopulmonary resuscita-

tion, advanced cardiac life support, renal dialysis, nutritional support and

hydration, mechanical ventilation, organ transplantation and other surgery,

pacemakers, chemotherapy, and antibiotics. Even when a patient decides not

to receive life-sustaining treatments, he or she ordinarily continues to receive

supportive medical care. The right to refuse treatment remains constitu-

tionally protected even when a patient is unable to communicate. Although

specifi c requirements vary, all of the states authorize some type of written

advance directive to honor decisions of individuals who have previously

recorded their wishes and have become unable to speak for themselves.

When a treatment that could sustain life is withheld or withdrawn, some

people have called this practice passive euthanasia, although this term is con- sidered a misnomer because it tends to confuse the widely accepted practice

of withholding or withdrawing treatment with the generally unacceptable

and unlawful practice of taking active steps to cause death. It can be argued

that “passive euthanasia” is not euthanasia at all but, rather, letting nature

take its course.

The distinction between “allowing to die” (withholding or withdrawing

treatment) and “helping to die” (taking steps to cause a patient’s death) is

important in discussions about a right to die; many ethicists and physicians

Ms. Schiavo died after a long odyssey that polarized her family and sparked inter-

national debate. The collision of faith, medicine, law, and politics jolted many of

us into a discussion of such complex social concerns as to when life-sustaining

treatment may or may not be removed from a patient with a catastrophic illness.

Of the thousands of people who die each day, two-thirds will involve some ele-

ment of a decision that a family will have to make.

Rabbi Earl A. Grollman, “Can We Talk?”

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226 c h a p t e r 6 End-of-Life Issues and Decisions

(as well as the general public) are willing to permit the former but not the

latter (see Figure 6-1 ). As you look at this fi gure, consider your own attitudes

about choices that hasten death.

Physician-Assisted Death Assisted death (also called assisted suicide) refers to providing someone

with the means to kill himself or herself, knowing that the recipient intends

to use them to end his or her life. In physician-assisted death, a physician helps a patient hasten his or her death by providing lethal drugs, offering advice

on methods of suicide, or assisting with other interventions—at the patient’s

explicit request—with the understanding that the patient plans to use them to

end his or her life. 39 The patient, not the doctor, administers the fatal dose. 40

In 1997, the U.S. Supreme Court reviewed two cases relating to physi-

cian-assisted death. 41 The decisions in these cases ( Washington v. Glucksberg and Vacco v. Quill ) are important for several reasons. First, the Court upheld the distinction between, on the one hand, withholding or withdrawing treat-

ment and, on the other hand, physician-assisted death. In doing so, the Court

clarifi ed its ruling in the Cruzan case, noting that the right to refuse treatment is based on the right to maintain one’s bodily integrity, not on a right to

hasten death. When treatment is withheld or withdrawn, the Court said, the intent is to honor the patient’s wishes, not to cause death. Second, the Court

affi rmed the rights of states to craft policy concerning physician-assisted

Most Acceptable

Least Acceptable

Withdraw artificial life support from a patient who cannot live

without such intervention

Withdraw artificial feeding or hydration from a patient who does

not require any other artificial life support

Provide pain relief to a patient, knowing that it may hasten

death (the so-called double effect; that is, treating pain and hastening death)

Provide a terminally ill patient with the means to kill himself or

herself (e.g., write a prescription for pain medication or sleeping

pills that, if taken as an overdose, will result in death)

Administer a lethal injection to a patient who is severely or

terminally ill

Figure 6-1 Public Acceptance of Hastening Death Note: Involuntary euthanasia occurs when someone acts arbitrarily, without the patient’s consent, to end the patient’s life.

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Choosing Death 227

death, prohibiting it, as most states now do, or permitting it under some regu-

latory system. A third fi nding of importance in the Supreme Court’s 1997

rulings about physician-assisted death relates to the concept of double effect (discussed later in this chapter).

Currently, physician-assisted death is permitted by legislation enacted in

the states of Oregon and Washington and by court ruling in the state of Mon-

tana. In May 2013, the Vermont senate passed and the governor signed the

“Patient Choice and Control at End of Life Act,” adding Vermont to the list.

Voters in Washington state passed an initiative in 2008 that is substantially

similar to the Death with Dignity Act passed by Oregon voters in 1994 and,

after surviving judicial challenges, reaffi rmed in 1997. So far, right-to-die

groups working to change laws in other states have been unsuccessful.

The Oregon Death with Dignity Act (DWDA) allows physicians to pre-

scribe lethal medication to terminally ill patients. Doctors who are opposed

to aid-in-dying can refuse to participate, and the provisions of the law are

available only to individuals who are legal residents of Oregon. In March

1998, an elderly woman with breast cancer became the fi rst known person

to die under the law, taking a lethal dose of barbiturates prescribed by her

doctor.

During 2008, 88 prescriptions for lethal medications under the provi-

sions of the DWDA were written; of these, 54 patients took the medications

and died, 22 died of their underlying disease, and 12 were alive at the end

of the year. 42 In addition, 6 patients with earlier prescriptions died from tak-

ing the medications, resulting in a total of 60 deaths during 2008. Since the

law was passed in 1997, a total of 401 patients have died with the assistance

of their physicians. Most patients died at home (97 percent). The decision

to request a prescription for lethal medication was associated mainly with

patients’ concerns about loss of autonomy, decreasing ability to participate in

activities that make life enjoyable, and loss of dignity.

In a summary of the Oregon experiment, palliative care physician Timo-

thy Quill and Jane Greenlaw note that the practice of physician-assisted death

is stable and relatively rare:

Although there were few physician-assisted deaths, there was much conversation

on the topic—one in 50 patients talked with the doctors and one in six talked

with their families about the possibility. We also know that pain management

has improved in Oregon, hospice utilization is among the highest in the

nation, and there is a statewide program to record patients’ wishes about

cardiopulmonary resuscitation. 43

Ira Byock, a hospice and palliative care physician, emphasizes the need

for physicians and other caregivers to become more competent in pain

management and other aspects of palliative medicine. 44 Others—including

John Pridonoff, a former executive director of the Hemlock Society (which

advocates assisted suicide and the “right to die”)—argue that hospice and

aid-in-dying can be complementary aspects of a comprehensive approach to

end-of-life decisions. 45

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228 c h a p t e r 6 End-of-Life Issues and Decisions

Although the trend has been toward greater freedom for individuals to

choose when and how they will die, physician-assisted death continues to

spark debate. In 2001, U.S. Attorney General John Ashcroft issued a directive

stating that “prescribing, dispensing, or administering federally controlled

substances to assist suicide violates the Controlled Substances Act.” This

interpretation authorized the Drug Enforcement Administration (DEA) to

pursue criminal prosecution of Oregon physicians who write prescriptions

under that state’s Death with Dignity Act. Court cases ensued and, in Janu-

ary 2006, the U.S. Supreme Court ruled in Gonzales v. Oregon that the attor- ney general (then Alberto Gonzales) was not empowered to prohibit doctors

from prescribing drugs under Oregon’s laws.

Seen here testifying in a Michigan courtroom, Dr. Jack Kevorkian became a symbol of the public debate about ethical and legal issues surrounding physician-assisted suicide. After reportedly assisting in the deaths of at least 130 people over a period of ten years, Kevorkian was found guilty of giving a man a lethal injection and sentenced to prison.

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Choosing Death 229

The Rule of Double Effect In the medical management of pain, the rule of double effect states that a

harmful effect of treatment, even if it results in death, is permissible if the

harm is not intended and occurs as a side effect of a benefi cial action. Some-

times, the dosages of medication needed to relieve a patient’s pain (especially

at the end stage of some diseases) must be increased to levels that can cause

respiratory depression, resulting in the patient’s death, a practice sometimes

referred to as “terminal sedation.” 46 Thus, the relief of suffering (the intended

good effect) may have a bad effect that is foreseen but not the primary inten-

tion. The Court said that such medication for pain, even if it hastens death, is

not physician-assisted death if the intent is to relieve pain.

A study of patients with advanced disease in the Emilia-Romagna region

of Italy found that overall survival was not statistically different between pal-

liatively sedated and unsedated patients, leading researchers to conclude

that palliative sedation therapy does not hasten the death of patients with

advanced disease even when death occurs fairly rapidly after sedation. 47 Com-

menting on this study, physician Drew Rosielle notes that these were patients

with a median survival of about ten days and only a quarter of the sedated

patients received what is termed “deep” or “terminal” sedation. Says Rosielle,

the important point is, fi rst, that “imminently dying patients are imminently

dying patients” and, second, that questions of life-prolongation are really sec-

ondary to relieving pain and other symptoms in such patients. “A peaceful,

comfortable death should be the preeminent treatment goal when someone

is dying, and we don’t need to twist ourselves into ethical knots about it.” 48

This maxim is echoed in a statement by the American Medical Association:

It is the ethical obligation of a physician to offer palliative sedation to

unconsciousness as an option for the relief of intractable symptoms [at the

end of life] when symptoms cannot be diminished through all other means of

palliation. 49

Euthanasia Illegal in the United States and distinguished from withdrawing or

withholding treatment, euthanasia (from the Greek, “easy death”) involves a deliberate act to end another person’s life. 50 It is generally understood as

the intentional act of killing someone who would otherwise suffer from an

incurable and painful disease. An example is the case of “Debbie,” a twenty-

year-old woman with terminal ovarian cancer whose death was hastened by a

physician called to her bedside in the middle of the night, not having previ-

ously known the patient. Seeing her distressful condition and hearing her

say, “Let’s get this over with,” he decided without further discussion to “give

her rest” by preparing a fatal injection. 51 Were Debbie’s words meant as a

request for the physician’s help in her dying? The circumstances in this case

are ambiguous.

At present, euthanasia has found greatest acceptance in the Netherlands,

where physicians are legally permitted to give lethal injections to patients

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230 c h a p t e r 6 End-of-Life Issues and Decisions

who request death. 52 (Euthanasia has also been legal in Belgium since 2002

and in Luxembourg since 2008; physician-assisted death has been legal in

Switzerland since 1942.) The guidelines for euthanasia include the pres-

ence of a terminal diagnosis, the patient’s voluntary consent and unwavering

desire to die, suffering that the patient fi nds unbearable, a second medical

opinion (recommended but not required), and documentation and report-

ing of the death. In the Benelux countries, there is the view that a physician’s

responsibility to respond to a patient’s suffering is a force majeure (superior or irresistible force) that has precedence over normal laws.

Palliative Care and the Right to Die In thinking about options at the end of life, we need to recognize that

a “one size fi ts all” approach to medical treatment and decision making is

likely to fi t relatively few. Our preferences are infl uenced by both our indi-

vidual beliefs and the cultural or ethnic traditions that help defi ne who we

are as human beings. Decisions about hastening death are usually arrived at

because of the pain and suffering experienced by the patient or perceived by

caregivers and family members. The challenge, ethicists say, is not to legalize

euthanasia but to transform care of the dying.

Objections to euthanasia sometimes take the form of “wedge” or “slip-

pery slope” arguments. This refl ects the view that one should not permit acts

that, even if moral in themselves, would pave the way for subsequent acts that

would be immoral. If euthanasia is permitted for people with incurable ill-

ness, it could become a wedge or slippery slope toward expansion of euthana-

sia to the aged, the mentally incompetent, the severely handicapped, or other

“burdens on society.”

Charles Dougherty argues that questions about taking steps to inten-

tionally hasten death should be considered within the context of society’s

“common good.” 53 Emphasizing individual choice can make us lose sight of

the fact that no aspect of human experience is wholly personal and private.

In fact, says Dougherty, “The way we die—when, under what circumstances,

and from what cause or reason—is shaped in profound ways by relation-

ships with others and by large social and institutional forces.” If dying in the

medical setting involves pain and suffering and costs too much, the com-

mon good of society could be served by taking measures that “add simplic-

ity and dignity to the process of dying and contain unnecessary spending.”

Dougherty suggests practical steps toward realizing this common good,

such as the following:

1. Increasing the use of home hospice care

2. Developing strategies for more aggressive pain management

3. Refi ning protocols for timely diagnosis of terminal illness

4. Making the right to refuse extraordinary care universally available to

patients

5. Expanding the use of DNR orders to avoid prolonged, expensive, and

unnecessary care at the end of life

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Choosing Death 231

6. Providing universal access to an appropriate combination of care options

(home, hospice, and so on)

7. Instituting a health insurance system that ensures adequate and appro-

priate care for everyone

Nutrition and Hydration Because of the symbolic signifi cance of nourishment, removing artifi cial

nutrition and hydration tends to evoke deep-rooted human feelings about

food and drink, as well as the image of “starving” a person to death. This

causes some people to characterize removal of artifi cial nutrition and hydra-

tion as “intentional killing.”

Should an exception to a patient’s right to refuse treatment be made for

artifi cial feeding? Answering this question requires exploring the distinction

between ordinary and extraordinary care. Ordinary care is generally defi ned as the use of conventional, proven therapies. In contrast, extraordinary mea- sures usually involve some kind of life-sustaining intervention. Such measures are usually temporary until the patient is able to resume normal biological

functioning.

Of course, therapies that are usually considered ordinary may be extraor-

dinary or even intrusive, depending on the circumstances. Using antibiotics

to treat pneumonia, a practice that generally fi ts into the category of ordinary

care, may be viewed as extraordinary when such drugs are administered to a

person who is actively dying. The distinction between ordinary and extraor-

dinary therapies also becomes blurred in situations where a series of medical

interventions, each one in itself “ordinary,” combine in such a way that the

net result is an “extraordinary” effort to sustain life. Although some medi-

cal ethicists argue that a clear dividing line is needed between ordinary and

extraordinary treatment, Thomas Attig says it is likely that “a defi nitive rule

dividing ordinary and extraordinary treatment will forever elude us.” 54

Because we tend to think of nourishment as ordinary care, withholding it

brings up images of causing the patient’s death by starvation. But such images

may be inaccurate for several reasons. First, the invasive nature of delivering

such nourishment, and the skills required to administer it, argue against the

perception that it is merely providing simple care. Second, artifi cial nourish-

ment causes discomfort to many patients, especially those who are close to

dying. Feeding tubes and intravenous lines may add to a patient’s suffering at

the end of life.

Accordingly, normal, everyday sentiments about the symbolic meaning

of food and water “cannot be transferred without distortion to the hospi-

tal world” and, indeed, “authentic sentiment may demand discontinuance

of artifi cial feeding.” 55 Acknowledging that issues around nourishment are

highly charged emotionally, Dena Davis says, “We need to be very careful

to sort out the physiological aspects of providing nutrition from the social

phenomenon of ‘feeding.’ ” 56 When a person is actively dying, the removal of

artifi cial nutrition and hydration can be good palliative care.

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232 c h a p t e r 6 End-of-Life Issues and Decisions

Seriously Ill Newborns In hospitals with specialized neonatal intensive care units (NICUs), new-

borns who are born prematurely or with serious medical problems are rou-

tinely treated. Some of these babies, however, will never be capable of living

what most people consider a normal life. Such infants suffer from cardio-

pulmonary ailments, brain damage, or other serious congenital defects or

dysfunction. Whereas in the past such conditions would have quickly resulted

in death, now, because of specialized neonatal care, babies born with life-

threatening conditions often survive. Alan Fleishman says, “Predicting out-

comes in the fi rst days of life is diffi cult in most circumstances and creates

the fundamental dilemma of deciding treatment options in the face of not

knowing the future of the infant’s life.” 57

Is medical intervention the course of action to take in every case? Should

the infant’s projected quality of life be considered? For example, should a

newborn with an intestinal blockage be spared by surgical intervention? Is

the answer always yes, that life should be saved, or does the answer change

according to circumstances? Is the answer the same if the infant with intesti-

nal blockage is also severely brain damaged?

In the past, it was often thought to be part of the job of health care pro-

viders to answer such questions and make life-or-death choices. Today, the

family—indeed, the larger community—has a role in such decisions. How-

ever, “parental refusal of a life-sustaining therapy does not relieve the physi-

cian from an ethical duty to the child.” 58 The principle known as the “best

interest of the child” must be taken into account.

Consider an infant born with his entire left side malformed, with no left

eye and very little of a left ear; some of his vertebrae were not fused. Also

affl icted with a tracheoesophageal fi stula (an abnormality of the windpipe

and the canal that leads to the stomach), he could not be fed by mouth. Air

leaked into his stomach instead of going to the lungs, and fl uid from the

stomach pushed up into the lungs. One doctor commented, “It takes little

imagination to think there were further internal diffi culties as well.” In

the ensuing days, the infant’s condition steadily worsened. Pneumonia set

in; his refl exes became impaired; and, because of poor circulation, severe

brain damage was suspected. Despite the seriousness of all these factors, the

immediate threat to his survival, the tracheoesophageal fi stula, could be cor-

rected by a fairly easy surgical procedure. The debate began when the par-

ents refused to give their consent to surgery. Some doctors treating the child

believed surgery was warranted and took the case to court. The judge ruled

against the parents and ordered the surgery, declaring that “at the moment

of live birth, there exists a human being entitled to the fullest protection of

the law.” 59

In another case, which contrasts with the one just described, the mother

of a premature baby overheard a doctor describing her infant as having Down

syndrome with the added complication that the intestines were blocked. This

kind of blockage can be corrected by ordinary surgery; without correction,

the child could not be fed and would die. One physician argued that the

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Advance Directives 233

degree of mental retardation in children with Down syndrome cannot be

predicted; and, in the physician’s words, “They’re almost always trainable.

They can hold simple jobs, and they’re famous for being happy children.

When further complications do not appear, a long life can be anticipated.”

However, the mother felt that “it would be unfair” to her other children if

a retarded child were brought into the home. Her husband supported this

decision, and they refused consent for surgery. Unlike the case of the fi rst

infant described above, this time the hospital staff did not seek a court order

to override the parents’ decision against surgical intervention. The child was

placed in a side room and, eleven days later, died.

Think about the differences between these two cases. In the fi rst, the

severely malformed infant seemed to have less chance of survival or of living

a normal life than the infant in the second example. Yet, the hospital staff in

the fi rst case chose to seek a court order granting surgery, whereas the staff at

the second hospital chose to abide by the parents’ wishes. In the second case,

did the physicians and the parents adequately explore the child’s right to life?

It could be argued that the withholding of ordinary means of treatment (that

is, surgery) was in fact an extraordinary nonintervention. Whatever our feelings about the decisions described, notice a distinction

between ethical issues involving infants and those involving adults. Gener-

ally, with adults, all procedures that might prolong life have been tried or at

least presented to the patient. In cases involving newborns, the question of

whether to treat or withhold treatment cannot be discussed with the patient;

thus, decisions are made by others, who will, it is hoped, act in the child’s best

interest. The tough part, of course, is determining “the child’s best interest.” 60

Generally speaking, federal regulations state that physicians should

use reasonable medical judgment in making treatment recommendations.

Regulations also state that physicians should involve parents in the decision-

making process. Exceptions to the requirement to provide treatment may be

made only when one of the following conditions applies:

• The infant is irreversibly comatose. • The provision of such treatment would merely prolong dying or not be

effective in ameliorating or correcting all of the infant’s life-threatening

conditions or otherwise would be futile in terms of the survival of the

infant. • The provision of such treatment would be virtually futile in terms of the

survival of the infant and the treatment itself under such circumstances

would be inhumane.

As Alan Fleishman says, “Continued treatment should not be forced

when hope for benefi t is uncertain.” 61

Advance Directives Advance directives have generated considerable controversy; opponents

argue that they are a step toward euthanasia, and proponents counter that

they safeguard patients’ rights to determine the manner of care at the end of

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234 c h a p t e r 6 End-of-Life Issues and Decisions

life (see the letters in Figure 6-2 ). In a general sense, an advance directive is any statement made by a competent person about choices for medical treatment

should he or she become unable to make such decisions or communicate

them at some time in the future. 62 A recent study in California found that,

although an overwhelming majority of the state’s residents said they would

prefer to die at home, fewer than one in four have written instructions about

how and where they would like to die. 63 One type of advance directive is the

living will, which Louis Kutner proposed in 1967. 64 Essentially, a living will allows an individual to refuse life-sustaining treatment in the event he or she

is terminally ill and the administration of life-sustaining procedures would

only prolong the dying process. In 1976, California adopted the Natural

Death Act, thereby becoming the fi rst state to give legal recognition to the

living will. 65 The Act was described as “a piece of legislation that encourages

Figure 6-2 Letters to the Editor

Editor: If the governor signs the bill cur- rently before him, this will become the first state

to legalize suicide.

I believe this measure is immoral, bizarre,

and tainted with Mephistophelian connotations.

Legislators, at all levels, should legislate laws

pertaining only to life, as we know it. Death, in

any manner, is nature’s absolute domain, and no

one should attempt to trespass on that domain.

I trust the governor is wise enough and sane

enough to veto the bill presently lying heavily and

cadaverously on his desk.

Editor: We have explored this bill and its im- plications in death and fully support the right of

an individual, who wishes to do so, to be allowed

to make a legally recognized written directive re-

questing withdrawal of life-support systems when

these procedures would serve no purpose except

to artificially delay the moment of death.

We reiterate our belief in the basic human

right of an individual to control his destiny. We

have communicated our support of this bill to

the legislature and to the governor.

Editor: This bill, and all other natural-death or death-with-dignity bills, is based on a faulty

premise. For when we react to tubes, oxygen and

other paraphernalia, our concern is with dainti-

ness, not dignity.

Dignity is the quality of mind having to do

with worth, nobility, and forbearance. The dying,

with the help of the living, can have dignity—no

matter what functions of control are lost.

Instead of unplugging and abandoning

our dying patients, we should work to achieve

truly compassionate care for them in hospices

like those in London, England, and New Haven,

Connecticut.

Editor: No physician is required by law to use extraordinary means of preserving life, and none

has ever been convicted for failing to do so.

So the real purpose of death-with-dignity or

natural-death bills must be to set the stage for

letting doctors take positive action: giving lethal

injections or denying ordinary means of care to

patients who may be handicapped or burden-

some to society.

We must be suspicious of any trend which of-

fers death as a solution to problems, no matter

how heart-rending those problems may be.

Editor: The bill allowing an adult of sound mind to refuse extraordinary life-preservation

measures reaffirms for me the value of life. Life

is active choosing toward greater fulfillment and

reduced suffering, not the beating of a heart in

a pain-wracked and hopeless body. This bill is a

public and legal recognition of that principle.

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Advance Directives 235

a patient to participate in his or her own terminal care” and as legislation

that “underscores the role of technology as another clinical option, not a

necessity.” 66 By the end of the twentieth century, all states had passed some

form of living will legislation.

Questions have been raised, however, about whether living wills are the

best choice to accomplish their stated goals. Some observers suggest that “liv-

ing wills fail not for want of effort, or education, or intelligence, or good will,

but because of stubborn traits of human psychology and persistent features

of social organization.” 67 Among the concerns are these: 68

1. For living wills to be effective, people must have them. Most Americans do not. 2. Individuals must decide what treatment they would want if incompetent. People

often do not know enough about illnesses and treatments to make future

life-or-death decisions about them. Further, their preferences about life-

sustaining treatment change over time and across contexts.

3. Individuals must accurately and lucidly state that preference. People often have trouble reaching well-considered EOL decisions and may issue inconsis-

tent instructions.

4. A living will must be available to people making decisions for the patient. “It can be a long road from the draftee’s chair to the ICU bed.” The living will may

be signed years before it needs to be used, and its existence and location

may have vanished in the mists of time. One study found that 62 percent

of patients with a living will do not give their living will to their physician.

5. People must understand and heed the living will’s instructions. Living wills are not self-executing. Someone must decide whether a medical situation

described in the living will has arisen and what action the living will directs.

Another concern is that, because living wills are not physician orders,

their directives cannot be followed by emergency medical technicians

(EMTs). Finally, a presidential council on bioethics commented that “living

wills make autonomy and self-determination the primary values at a time of

life when one is no longer autonomous or self-determining, and when what

one needs is loyal and loving care.” 69

An alternative to the living will is the standardized document known as

Physician Orders for Life-Sustaining Treatment (POLST), which can be used

together with other advance directives. POLST transfers a patient’s wishes

into a set of medical orders that must be followed. Developed in Oregon and

fully or partially implemented in an increasing number of states, POLST is

a two-sided form that “spells out directions for resuscitation, medical inter-

ventions, antibiotics, and artifi cial feeding.” 70 It provides both a summary of

an individual’s advance-directive decisions and the physician’s order. It can

inform emergency medical services personnel about a patient’s wishes for life-

sustaining procedures, such as CPR. It is also intended to solve the problem

of respecting DNR orders when a patient is transferred from nursing home to

hospital. POLST is designed for individuals with serious or life-threatening

illness. It governs medical issues considered likely to arise in the near term,

usually within the year. One of the primary purposes of POLST—which in

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236 c h a p t e r 6 End-of-Life Issues and Decisions

People may be uncertain about their preferences regarding future life-or-death decisions. Engaging in open discussion with a knowledgeable and trusted physician can help indi- viduals think about the alternatives. Having a document such as the Physician Orders for Life-Sustaining Treatment (POLST) can help ensure compliance with one’s choices.

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Advance Directives 237

some states is called by other names, such as MOLST, meaning “Medical

Orders for Life-Sustaining Treatment”—is to initiate “rich conversations”

between patients and their medical providers. 71

The second important type of advance directive is the health care proxy (also known as a durable power of attorney for health care ). Some commentators believe that health care proxies have advantages over living wills, in part

because they are simpler and more straightforward. The health care proxy

makes it possible to appoint another person, called a proxy (also known as a surrogate ) to represent you in making decisions about medical treatment if you become unable to do so. He or she may be a relative, friend, or attorney,

someone with whom you have discussed your treatment preferences. As your

representative, the proxy you appoint is expected to act in accordance with

your wishes as stated in an advance directive or as otherwise made known.

When a surrogate makes decisions for an incapacitated or incompetent

patient, it is known as substituted judgment. Ideally, the surrogate will use all available evidence to determine as accu-

rately as possible how the patient would have decided if he or she were capa-

ble. A court may take away the proxy’s power to make decisions if he or she

(1) authorizes any illegal act, (2) acts contrary to the patient’s known desires,

or (3) where those desires are not known, does anything clearly contrary to

the patient’s best interests. Completing a health care proxy can provide an

additional safeguard that preferences about life-sustaining treatment will be

followed. Whether used as an adjunct to a living will or on its own to name a

proxy for health care decisions, it is crucial that one’s preferences and choices

are known and available when the need arises.

The document known as Five Wishes, created by the organization Aging

with Dignity, combines a living will and a health care power of attorney. It

also addresses matters of comfort care and spirituality. Here is a summary of

the fi ve wishes:

• Wish 1: The person I want to make care decisions for me when I can’t. This sec- tion is an assignment of a health care agent, proxy, or surrogate to act on

your behalf. • Wish 2: The kind of medical treatment I want or don’t want. This section is a

living will; it lets you specify what life support treatment means to you

and when you would and would not want it. • Wish 3: How comfortable I want to be. This section address matters of com-

fort care, including pain management, personal grooming, and whether

you want to know about options for hospice care, for example. • Wish 4: How I want people to treat me. This section is concerned with per-

sonal matters, such as whether you want to be at home during the illness,

to have your hand held, to have others praying for you, and to die at

home, among other concerns. • Wish 5: What I want my loved ones to know. This section deals with how

you want to be remembered, your wishes regarding funeral or memorial

plans, as well as body disposition, and other matters that may be impor-

tant to you, such as forgiveness.

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238 c h a p t e r 6 End-of-Life Issues and Decisions

Notice that wishes one and two, once signed, are both legal documents in

states where Five Wishes meets regulatory requirements. 72

In 1990, the United States Congress enacted the Patient Self-Determina-

tion Act (PSDA). 73 It requires providers of services under the Medicare and

Medicaid programs to inform patients of their rights to appoint a health care

proxy and draw up written instructions concerning limits to medical care to

be activated if they become incapacitated. Specifi cally, patients have rights to 74

1. participate in and direct their own health care decisions

2. accept or refuse medical or surgical treatment

3. prepare an advance directive

The PSDA has been described as a “medical Miranda warning” (refer-

ring to the requirement that police offi cers advise arrested suspects of their

legal rights) due to its requirement that patients be advised of their rights

regarding advance directives and life-sustaining treatment. Recalling the

earlier discussion of the SUPPORT study (see the section on “Informed Con-

sent”), which was done just fi ve years after passage of the PSDA, it seems that,

despite its aims of improving planning around goals of care, the Act has been

none too successful in terms of improving communication between patients

and providers.

Using Advance Directives Completing an advance directive is one step toward improving the

chances that your treatment preferences will be honored if you become inca-

pacitated. But physicians and other medical staff cannot follow advance direc-

tives if they don’t know about them or if the instructions are too vague to give

direction about what should be done. In addition, laws governing advance

directives vary for different states, making it important to be sure you have

the forms that apply where you live. 75

After you complete an advance directive, review it occasionally to be sure

the preferences expressed in the directive continue to match your wishes.

Without periodic review and clear conversations with trusted persons who

can see that its provisions are carried out, an advance directive may not

accomplish its intended purpose.

In some cases, an advance directive may be less a directive than a request.

Uncertainty about the course of a disease may cause doctors to be wary of

deciding that a patient is in a terminal condition. Individuals should discuss

issues of end-of-life care with their primary doctor and other physicians from

whom they receive treatment, as well as with family members, before a situa- tion occurs in which the advance directive becomes necessary.

If you are called upon to help someone create his or her advance direc-

tive, it is wise to recall the old saying, “We have two ears and one mouth.” The

message is that we should listen twice as much as we talk. It has been pointed

out, “If you wait at least seven seconds after someone stops speaking, chances

are good that they’ll continue talking, perhaps revealing something they’ve

been hesitant to say.” 76 The drafting of an advance directive should not be

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Advance Directives 239

hurried or ill considered. It warrants a generous intent to listen and accept

what is heard.

Because advance directives become effective when medical intervention

is needed and a patient is unable to communicate his or her wishes, the direc-

tive could be implemented in a situation the patient had not foreseen. Con-

sider the case of a woman in her seventies who entered a hospital for hip

replacement surgery and, along with other admission forms, was given an

advance directive to sign. While recovering from surgery, she had an unex-

pected cardiac arrest. Rather than starting a resuscitation attempt, however,

the medical staff assumed that—because she had signed the directive—she

wanted no resuscitation. The woman died. Although this woman was not ter-

minally ill, by signing a document providing evidence that she did not want

to be kept alive if in a grave medical condition, the power to interpret her

wishes was put into the hands of medical staff. Was the outcome what she

intended?

Nor should one be complacent in thinking that all will necessarily go

smoothly so long as an advance directive has been completed and signed.

Zelda Foster, a social worker and educator, describes the struggle to ensure

that her ninety-three-year-old father’s wishes were respected by medical

A physician works with a patient in the Intensive Care Unit, where time for decision making may be short. The goal of knowing and following an individual’s wishes for life- sustaining treatment is challenging in situations where minutes count.

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240 c h a p t e r 6 End-of-Life Issues and Decisions

personnel after he was brought to an emergency room and attached to life-

support machines. 77 Despite having her father’s health care proxy in hand,

the staff seemed to be unfamiliar with its purpose. The hospital administra-

tors insisted that Foster’s family obtain a court order to enforce the proxy’s

provisions. Ms. Foster noted that “the hospital has created one obstacle after

another to challenge our rightful request that our father be allowed to die

with dignity.” As the Supreme Court made clear in the case of Nancy Beth

Cruzan, advance directives offer a means for providing clear and convincing

evidence of one’s wishes for life-sustaining treatment in critical situations;

however, they do not resolve all the diffi culties that may accompany end-of-

life care.

Advance Directives and Emergency Care Do-not-resuscitate (DNR) orders are another type of advance directive.

Unless given other instructions, hospital staff and emergency personnel will

start CPR to help patients whose hearts have stopped or who have stopped

breathing. As mentioned earlier in the chapter, a DNR is a directive stating

that you don’t want to be resuscitated. (There are proposals to replace DNR

orders with Allow Natural Death orders, which are said to be more compas-

sionate and readily accepted by patients and their families. Whether DNR or

AND, the main challenge is eliminating ambiguity about the intended plan

of treatment and clearly communicating this to caregivers. 78 ) In the hospital,

a DNR order is put in your medical chart by your doctor. But what about out-

side the hospital?

I was in the ready room listening to Netcom calls being transmitted to the

local fi re agencies and EMT fi rst-responders. Mostly routine calls were the order of

the day when one scenario caught my ear.

***

Netcom: Medic 4, respond to 119 Wasatch Blvd. for a woman with faint pulse, not alert, and no responses.

Medic 4: Responding. A couple of minutes passed before the next transmission:

Netcom: Medic 4, additional information, the subject is a 70-year-old woman, unconscious, no pulse.

Medic 4: Copy that. Once again, there was a brief pause between messages. Then:

Netcom: Medic 4, on the Wasatch Blvd. call, subject unconscious, no vital signs. She has a DNR order, but they want transport to hospital.

***

I had heard such calls many times before, but on this day I thought to myself,

“Wow, guess the nursing home didn’t want the patient to die on their watch, so

even though she was already dead, they wanted to get her to the hospital where her

death would be pronounced.”

James Scott, EMT Supervisor

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Inheritance: Wills, Probate, and Living Trusts 241

Emergency care provided by paramedics, EMTs, and other personnel is

considered a boon when it helps save lives, but it may be less welcome when it

results in interventions that save the lives of those who would rather die natu-

rally. Once 911 is dialed, it sets in motion a response intended to save life.

First-responders are generally not in a position to make decisions about who

wants to be saved and who doesn’t. In fact, they are legally required to initiate CPR unless there is clear evidence that the person has a valid DNR order pro-

vided by his or her physician.

Imagine a dying person, at home surrounded by family and close friends,

prepared to let nature take its course. When the person begins to experience

diffi culty breathing, however, someone watching this passage toward death

may have an impulse to do something to relieve the apparent suffering. A spontaneous call to 911 can result in the dying person’s being resuscitated

and being placed on life-support equipment, with the result that the last

hours or days of life are played out as a crisis.

Individuals who do not want CPR or other life-saving interventions must

ensure that their instructions are readily available to emergency personnel who

may be called to the scene. Medic-Alert bracelets or wallet cards may be help-

ful in signaling the fact that a person should not receive CPR. In some states,

instructions can be made known in a Physician Orders for Life-Sustaining

Treatment (POLST), discussed earlier.

Inheritance: Wills, Probate, and Living Trusts Individuals with life-limiting illnesses and their families often turn to coun-

selors and other mental health professionals to help explore their fears,

uncertainties, and confl icts, as well as to devise a plan to meet the prospects

that lie ahead; an attorney can be an important part of that team. Estate plan-

ning not only optimizes survivors’ fi nancial security but also helps ensure

peace of mind, both for the bereaved and for the person who has taken steps

to put his or her affairs in order. In addition, by preparing the legal docu-

ments, an attorney can help ensure that a person’s wishes about organ dona-

tion or advance directives for medical care are carried out.

Barton Bernstein outlines three basic legal stages that apply in cases of

terminal illness when death follows expected medical probabilities. 79 The

The clock wound by Elizabeth still ticked, storing in its spring the pressure of

her hand. Life cannot be cut off quickly. One cannot be dead until the things he

changed are dead. His effect is the only evidence of his life. While there remains

even a plaintive memory a person cannot be cut off, dead. A man’s life dies as a

commotion in a still pool dies, in little waves, spreading and growing back towards

stillness.

John Steinbeck, To a God Unknown

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242 c h a p t e r 6 End-of-Life Issues and Decisions

fi rst stage involves long-range planning, in which the terminally ill person arranges his or her legal and fi nancial affairs for the eventuality of death.

During the second stage, which occurs shortly before death, the survivors gather pertinent legal papers, obtain suffi cient funds to cover immediate

expenses, and notify the attorney and insurance representative so they will

be ready to make a smooth transition of the deceased’s legal and fi nancial

affairs. Also at this time, if the dying person intends to make an organ dona-

tion or other anatomical gift (discussed in Chapter 4), the appropriate medi-

cal personnel are alerted.

In the third stage of legal activity, which follows the death, the will is deliv- ered to an attorney for probate (the process of settling an estate). The effort

that went into planning is now rewarded in the survivors’ certainty that affairs

have not been left to chance. The survivors can confront their loss without

the distraction and worry of complex legal and fi nancial entanglements.

About the process of estate planning and will drafting, Kaja Whitehouse says,

“Every seemingly irritating or daunting concept or procedure offers a way for

you to take away a small bit of the sting and the pain that those you love will

have to go through.” 80

Wills A will is a legal document expressing a person’s intentions and wishes

for the disposition of his or her property after death. It is a declaration of

how a person’s estate —that is, money, property, and other possessions—will be distributed to one’s heirs and benefi ciaries upon that person’s death.

The term devise applies to real property, legacy applies to money, and bequest applies to nonmonetary personal property, although you will often hear

the terms legacy and bequest used more generally, even by attorneys. Jackson Rainer says,

A will is the best way to determine the distribution of personal belongings

and assets, to provide for family needs regarding underage children, to plan

wisely for taxes, and to make charitable contributions. Only by having a will

can the individual be assured that personal wishes will be carried out

after death. 81

Conferring a kind of immortality on the testator (the person making the will), a will can be thought of as the deceased’s last words. During the life of

the testator, a will can be changed, replaced, or revoked. Upon the testator’s

death, it becomes a legal instrument that governs the distribution of his or

her estate. (A glossary of additional terms related to inheritance is provided

in Table 6-2 ).

A will can evoke powerful emotions, embodying as it does the testator’s

feelings and intentions toward his or her survivors, possibly affecting the

intensity or course of grief. 82 People usually think of the will as simply a tool

for estate planning, perhaps overlooking its comforting and possibly thera-

peutic effects for both the testator and his or her survivors.

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Inheritance: Wills, Probate, and Living Trusts 243

The person who makes a will must have the mental capacity to under-

stand the nature of the document and the consequences of signing it. He or

she must understand the nature and extent of the property being distributed

by the will and be able to identify the persons who, by convention, ought

to be considered when making a will, whether or not they actually become

benefi ciaries. Given these conditions and in the absence of any signifi cant

Administrator: A person appointed by the court (in the absence of a will, or if no executor is named in one) to carry out the steps necessary to settling an estate. When an administrator is to be appointed, state law requires the drawing up of a preferential list of candidates. Assuming that the necessary qualifi cations are met, the order of preference typically begins with the spouse of the deceased and continues successively through the deceased’s children, grandchildren, par- ents, siblings, more distant next of kin, and a public administrator.

Attestation clause: A statement signed by the persons who witness the testator’s mak- ing of the will.

Codicil: An amendment to a will. Conditional will: A type of formally executed will that states that certain actions will

take place provided that a specifi ed future event occurs. For example, suppose a testator wishes to bequeath money or property to a potential benefi ciary who is incapable of self-care but who has a reasonable chance of recovery. With a conditional will, the money or property could be held in trust for that person until the conditions specifi ed in the will (e.g., recovery) have been satisfi ed. A problem of conditional wills lies in the diffi culty of stipulating with exactitude the nature of events and circumstances that might occur in the future.

Executor: A person named by the testator in his or her will to see that the provisions in the will are carried out properly.

Holographic will: A will written entirely by the hand of the person signing it. Some states do not recognize holographic wills as valid, and those that do generally have stringent conditions for such a document to be deemed valid. Not consid- ered a substitute for a formally executed will.

Intestate: The condition of having made no valid will. Mutual will: A type of formally executed will that contains reciprocal provisions. May

be used by husbands and wives who wish to leave everything to the other spouse with no restrictions, although it limits the range of choices that are available when a will is executed individually.

Nuncupative will: A will made orally. Many states do not recognize a nuncupative will or do so only under extremely limited circumstances. A few states admit an oral will if the person makes it in fear of imminent death or in the expectation of receiving mortal injuries, and the peril does result in death. A nuncupative will may also be valid when made by a soldier or sailor engaged in military service or by a mariner at sea; in these instances, the individual need not be in immediate peril. Generally, an oral will must be witnessed by at least two persons who attest that the will is indeed a statement of the testator’s wishes.

Probate: The process by which an estate is settled and the property distributed. This process generally occupies an average of nine to twelve months, though it may be longer or shorter, depending on circumstances and the complexity of the estate.

t a b l e 6-2 Terms Related to Wills and Inheritance

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244 c h a p t e r 6 End-of-Life Issues and Decisions

delusions, the testator is said to be of sound mind, capable of executing a

legal will. State laws generally specify a minimum age at which a person can

make a legal will—usually eighteen, though in several states as young as

fourteen—and various other requirements, such as the presence of witnesses

and execution of the document in a proper form.

Besides standard clauses, such as a declaration that the document con-

stitutes the person’s last will and testament (along with a statement revoking

previous wills, if applicable), a will may include information about the prop-

erty to be distributed, the names of children and other heirs, and specifi c

bequests and allocations of property, as well as information concerning the

establishment of trusts, the granting of powers to a trustee and/or guardian,

other provisions for disposition of property, and payment of taxes, debts, and

expenses of administration. Not all these items are necessarily part of every

will, nor is a will limited to the items listed here.

The privilege of determining how one’s property will be distributed after

death is not available in all societies, nor is it without limitations. In some

countries, the government assumes control over the settlement of a person’s

affairs; in other countries, including the United States, a person has consider-

able liberty in determining how property will be distributed. Still, depending

on the laws of a particular state, enforcing and carrying out the provisions of

a will may be constrained by circumstances affecting one’s heirs. For exam-

ple, someone may try to avoid willing anything to his or her spouse, but if the

will is contested, a court may overturn it. State statutes usually stipulate that

a surviving spouse cannot be disinherited. Some statutes require that depen-

dent children be provided for in the will. As a rule of thumb, anything that

confl icts with ordinary standards of social conduct may be invalid if the will

is contested.

In making a will, it is generally advisable to involve close family mem-

bers, or at least one’s spouse, to prevent problems that can arise when actions

are taken without the knowledge of those who will be affected. When survi-

vors discover that things are not as expected or customary, it may add to the

burden of grief. In loving families, usually everyone has some idea of what

is going to happen when the will becomes effective. There may be valid

reasons for not disclosing the details of a will. But the testator can tell his

or her survivors something like, “Call Rick, my attorney; he knows where my

will is and can help you in handling my estate.” Some legal experts suggest

that there ought to be a governmental or administrative program whereby

wills, as well as other important documents such as advance directives,

could be registered ahead of time and be readily available when they are

needed (in fact, some states—for example, Maryland and Virginia—allow

a testator to record his or her will in the courthouse with the county or city

register of wills).

In addition to drafting a will, some advisors recommend completing

what has been termed a “family love letter.” 83 Besides providing basic infor-

mation to family members about assets and liabilities, this document also

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Inheritance: Wills, Probate, and Living Trusts 245

communicates personal desires after death, from choice of pallbearers to

tombstone engravings. One fi nancial services fi rm gives clients a nineteen-

page document that begins, “Dear Loved Ones” and includes a number of

topics that could provide clarity during a time of confusion. Financial advi-

sors say the letter is helpful because it compiles data in one place and facili-

tates working with clients on various EOL issues and strategies. It can also

help prevent family confl icts or disagreements that might arise after death.

Of course, bequeathing nonfi nancial legacies, such as personal values

or family stories, is not new. So-called ethical wills were described three thousand years ago in the Hebrew Bible as a means to pass on wisdom and

love to future generations. Ethical wills can include family history, values,

blessings, expressions of love, summary of life’s lessons, hopes and dreams

for children and grandchildren, pride, and desires for forgiveness. 84 Usu-

ally written when facing challenging life situations, they can be among the

most cherished and meaningful gifts left to family members and commu-

nity of friends.

The Formally Executed Will The formally executed will is the conventional document used for specify-

ing a person’s wishes for the distribution of his or her estate after death (see

Figure 6-3 ). If carefully prepared, it not only has suffi cient clarity of purpose

and expression to withstand a court’s scrutiny but also can help ease the bur-

den and stress on survivors.

In making a formally executed will, most people fi nd it benefi cial to

consult an attorney. A comprehensive review of an estate requires that

legal records and other information be gathered. Several meetings may be

required to carefully determine the nature of the property and the testator’s

wishes for its distribution. Once the will’s content is determined and its pro-

visions set, the attorney has it prepared and an appointment is made for its

formal execution. On that occasion, the will is reviewed, two (or, in some

Inheritance When I was ten years old, my father died. And at that time, of course, I thought

my father was the best and fi nest man there ever was. And some years later when I

was eighteen and I began to mingle in the adult community, I introduced myself

to strangers and they would ask me if John Estrada was my father. When I said

yes, they would say, “Well, let me shake your hand. He was a fi ne man and a good

friend of mine.” And then they would tell me wonderful stories about him. Since

that time, I have hoped that when I am gone, some people might meet my children

and say to them that I was a good man and a good friend. To me that is a fi ner

inheritance than any material possession.

Fred Estrada

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246 c h a p t e r 6 End-of-Life Issues and Decisions

states, three) disinterested persons are brought in to serve as witnesses, and

the testator acknowledges that the document accurately refl ects his or her

wishes and signs it. Although preparation of the will may involve weeks or

even months of thoughtful consideration and planning, the actual signing

can take less than fi ve minutes.

Amending or Revoking a Will A will is not cast in stone; it can be changed as the testator’s situation

changes. A will can be revoked and replaced by an entirely new will, or only

certain parts of it can be amended. Amending a will is a means of adding

Will of Tomás Antonio Yorba

In the name of the Holy Trinity, Father, Son, and the Holy Ghost, three distinct persons and one true

God, Amen.

1st Clause. Know all [men] who may read this my last will and testament: that I—Tomás Antonio

Yorba, native born resident of this department of California, legitimate son of Antonio Yorba and

Josefa Grijalva—being sick, but, by divine mercy, in the full enjoyment of my reason, memory and

understanding, believing, as I firmly do, in all the mysteries of our holy Catholic faith, which faith is

natural to me, since I have lived in it from my infancy and I declare that I want to live in it as a faithful

Christian and true Catholic, trusting that, for this reason, his divine Majesty will have mercy on me

and will pardon all my sins, through the mysteries of our Lord Jesus Christ and the intercession of his

most holy mother, who is my protector and benefactress in these my last moments, so that together

with my guardian angel, with St. Joseph, my own name’s saint, and all the other saints of my devotion

and all the other hosts of heaven, they will assist me before the grand tribunal of God, before which

all mortals must render account of their actions—make and decree this my last will and testament as

follows, in ordinary paper because of lack of stamped paper.

2nd Clause. Firstly, I commend my soul to God who created it, and my body to the earth, from

whence it was fashioned, and it is my wish that I be buried in the church of the Mission of San Gabriel

in the shroud of our father St. Francis, the funeral to be according to what my executors and heirs

consider that I deserve and is befitting.

3rd Clause. Item: In regard to the expense of the funeral and masses, these should be drawn from

the fifth of my estate, according to the disposition of my executors, and I leave the residue of this fifth

to my son Juan.

4th Clause. I declare that with respect to my debts, my heirs and executors should collect and

pay any legal claims that may turn up or be due according to law. Item: I declare to have been mar-

ried to Doña Vicenta Sepúlveda, legitimate daughter of Don Francisco Sepúlveda and Doña Ramona

Sepúlveda, of this neighborhood, by which marriage I had five children named: (1) Juan; (2) Guada-

lupe, deceased; (3) José Antonio; (4) Josefa; (5) Ramona. The first being 10 years old, the second died

Figure 6-3 Historical Will Social custom plays a significant part in the making of a will. The will of Don Tomás Antonio Yorba, dating from the period of Mexican rule in California, presents an illuminating contrast to the modern will with its emphasis on the distribution of the testator’s property. Although Yorba’s estate was among the largest of the time—consisting of a Spanish land grant of 62,000 acres known as the Rancho Santiago de Santa Ana in Southern California—only a small frac- tion of his will relates to matters affecting the distribution of the estate to his heirs.

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Inheritance: Wills, Probate, and Living Trusts 247

new provisions without having to rewrite it entirely. A testator who, after the

will has been executed, acquires valuable property, such as an art collec-

tion, might want to make a specifi c provision for the new property without

disturbing other parts of his or her estate plan. A codicil, which is executed in much the same manner as a will, accomplishes that objective. All wills

should be reviewed periodically to determine whether changed circum-

stances call for revision.

When the addition of codicils makes a will unwieldy or potentially con-

fusing, it is time to review the entire will and make a new one. States vary in

their requirements for legally revoking a will. Generally, the testator’s intent

at the age of three, the third six years old, the fourth four years old, and the fifth two years old. Item:

I declare to have given my wife jewels of some value as a wedding present, but I do not remember how

many nor their value; but they must be in her possession, since I gave them to her. Item: According

to my reckoning I have about 2,000 head of cattle, 900 ewes and their respective males, three herds

of about 100 mares and their stallions, and three donkeys; about 21 tame horses, 7 tame and 12

unbroken mules; and lastly, whatever cattle, horses or mules may turn up with my brand which may

not have been legally sold. Item: I declare to have the right—through inheritance from my father—to

part of Middle Santa Ana and Lower Santana, known to be of the Yorbas. I have in Middle Santa Ana

an adobe house, its roof being part timber and part thatched, consisting of 18 rooms, including the

soap-house. Item: I declare that I have two vineyards with wooden fences which are now planted with

bearing vines and some fruit trees; also a section of enclosed land.

5th Clause. I declare that it is my wish to name as executors and guardians of my estate, first, my

brother, Don Bernardo Yorba, and second, Don Raimundo Yorba, by joint approval, to whom I give all

my vested power, as much as may be necessary, to go in and examine my property for the benefit of my

heirs in carrying out this will, and I grant them the power to procure another associate [executor] to

expedite its due execution, whom I consider appointed as a matter of course, granting him the same

authority as those previously named.

6th Clause. I name as my heirs my children and my wife, in the form and manner indicated by the

law, following the necessary inventory.

7th Clause. In this my last will, I annul and void whatever will or wills, codicil or codicils, I may

have previously made, so that they may stand nullified with or without judicial process, now and for-

ever, since I definitely desire that the present testamentary disposition be my last will, codicil, and final

wish, in the manner and form most legally valid. To this effect I beg Don Vicente Sanchez, Judge of 1st

instancia, to exercise his authority in probating this will.

To which I, the citizen Vicente Sanchez, 1st constitutional Alcalde and Judge of the 1st instancia of the city of Los Angeles, certify; and I affirm that the present testamentary disposition was made in

my presence, and that the testator, Don Tomás Antonio Yorba, although ill, finds himself in the full

command of his faculties and natural understanding, and, to attest it, I do this before the assistant

witnesses—the citizens Ramon Aguilar and Ignacio Coronel—the other instrumental witnesses being

the citizens Bautista Mutriel and Mariano Martinez; on the 28th day of the month of January, 1845.

The testator did not sign because of physical inability, but Don Juan Bandini signed for him.

Figure 6-3 (continued)

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248 c h a p t e r 6 End-of-Life Issues and Decisions

to revoke the will must be demonstrated; the accidental burning of a will, for

instance, does not imply revocation. If someone turns up with an earlier will,

it may be diffi cult to prove that it was revoked if a subsequent will does not

explicitly say so. When in doubt, seek legal advice.

Probate The period of probate allows time for the deceased’s affairs to be resolved,

debts and taxes paid, and arrangements made to receive funds that were

owed to the deceased. During the course of probate, the validity of the will

is proved; an executor or administrator of the estate is appointed; the nec-

essary matters for settling the estate are carried out; and with the probate

court’s approval, the decedent’s property is distributed to benefi ciaries. If

the deceased left a valid will, property is distributed in accordance with its

terms. When a person dies intestate —that is, without having left a valid will— property is distributed according to rules set up by the state.

The Duties of the Executor or Administrator Someone has to be responsible for carrying out all the steps necessary to

settling an estate through probate. This is the role of the executor or admin-

istrator. As the decedent’s personal representative, this person may be an

executor named in the will or an administrator appointed by the court. Whereas an executor named by the testator is permitted to act more or less indepen-

dently in the management of the estate provided that he or she acts pru-

dently, a court-appointed administrator may be required to obtain the court’s

approval before proceeding with necessary decisions. In either case, execu-

tor or administrator, the personal representative generally must meet certain

requirements stipulated by the law of the state in which probate occurs.

Although being named as executor of someone’s will is often seen as an

honor, it can be a time-consuming, complex, emotionally frustrating, and

exhausting experience, even for a modestly sized estate. 85 The initial tasks are to

thoroughly read the will and any other instructions from the deceased, register

the will with the court, determine the estate’s heirs, and inventory all property

and assets to determine what is distributed via the will versus what goes directly

to an heir outside of the will, such as life insurance or a retirement account.

Interested parties must be notifi ed of the death. This is generally accom-

plished in two ways. First, parties who are likely to be interested in the settle-

ment of the estate are notifi ed of the death by mail and, if they request it, are

sent a copy of the will. Second, a legal notifi cation of the death is published in

appropriate newspapers (see Figure  6-4 ). This notice serves three purposes

in the probate process: (1) It announces that someone is ready to prove the

legal validity of the will of the decedent; (2) it acknowledges that someone

is petitioning to be appointed by the court to begin probate; and (3) it gives

notice of the death to creditors so that outstanding claims against the dece-

dent can be submitted for settlement.

When a surviving spouse is the estate’s primary or sole heir, the inventory

of personal and household goods can be less meticulous, though items that

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Inheritance: Wills, Probate, and Living Trusts 249

have signifi cant worth, such as paintings, jewelry, and antiques, are specifi ed.

Important papers are gathered, including insurance policies, Social Security

and pension information, military service records, and other documents that

require review and possibly action.

The executor or administrator is responsible for managing the estate

pending its fi nal disbursement to heirs. This includes determining valid cred-

itor claims and making sure the estate pays off any debts. Tax returns may

need to be fi led on behalf of the decedent and the estate. An allowance may

need to be paid to the deceased’s spouse or to minor children for their sup-

port during probate. If the decedent was in business or was a stockholder in

a corporation, the personal representative must manage a smooth transition

that benefi ts the estate. When a personal representative is not knowledgeable

about the law, he or she usually enlists the aid of an attorney to make certain

that legal requirements are satisfi ed.

Finally, an accounting of the estate’s property and a schedule for distrib-

uting it to the benefi ciaries are prepared and submitted for approval by the

probate court. Once the court’s approval is obtained, the property is distrib-

uted, and receipts are obtained to certify that the distribution has been made

correctly. Assuming that everything has been carried out properly, the court

then discharges the personal representative. The estate is settled.

Figure 6-4 Newspaper Notice to Creditors

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250 c h a p t e r 6 End-of-Life Issues and Decisions

Laws of Intestate Succession Statistics show that most people die without leaving a will. A recent study

showed that only 44 percent of adults have a will. 86 Perhaps the failure to

plan ahead by making a will is attributable to the discomfort many people

feel about their own mortality. Or perhaps, overwhelmed by busyness, we

neglect to plan, with the questionable excuse that we are not yet at an age

when death is statistically probable. Whatever the reason, dying without hav-

ing made a will can lead to unnecessary hardships for our survivors, even

when an estate is modest in size.

Failure to prepare a will may result in a distribution of property that is

not compatible with a person’s wishes nor best suited to the interests and

needs of heirs. In the absence of a will, property is distributed according to

End-of-life decisions touch on many aspects of dying and death, ranging from legal matters relating to wills, living trusts, and the settling of estates to issues such as advance direc- tives. This young couple review the documents they have prepared—including those that cover provisions for care of their minor children—with the help of their attorney.

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Inheritance: Wills, Probate, and Living Trusts 251

guidelines established in state law. The state generally tries to accomplish

what it believes the deceased would have done had he or she actually made

a will. Nevertheless, the laws that dictate the disbursement of property, the

care of minor children, and all the matters that pertain to settling the estate

refl ect society’s ideas of fair play and justice. Thus, the values of society, rather

than the deceased’s personal values, determine the outcome.

Although the laws of intestate succession differ among states, some

general patterns prevail. In community-property states, for example, all

community property goes to the surviving spouse. In separate property

or non-community-property states, when there is only one child, an estate

is generally divided equally between child and surviving spouse. If there

is more than one child, usually one-third of the estate goes to the surviv-

ing spouse, and the remaining two-thirds is divided equally among the

children.

If there is no surviving spouse, property is divided among the lineal

descendants (children and grandchildren who are in the decedent’s “lin-

eage”); if there are no lineal descendants, disbursement is made to the

deceased’s parents; if they are not living, property is likely to be divided

among the deceased’s surviving siblings; if there are none, the estate may

be divided among the deceased’s siblings’ children. In attempting to set-

tle an estate, the court will make a determined effort to locate surviving

heirs. If none can be found, the proceeds go to the state. These are some

typical disbursements; however, when a person dies intestate, everything

depends on the exact wording and interpretation of the statutes in a par-

ticular state.

Living Trusts Living trusts can minimize the costs of passing one’s estate to heirs, and

they can avoid the publicity about an estate that accompanies public proceed-

ings. In fact, they can be a substitute for engaging in the complicated pro-

cess of going through probate. In addition, living trusts may be used to avoid

or minimize inheritance taxes that would otherwise have to be paid on the

value of an estate.

There are four main categories of trusts, based on when the trusts

become effective and who owns the assets in the trust. Depending on when a

trust goes into effect, it is either a living or a testamentary trust. A living trust becomes effective immediately, whereas a testamentary trust becomes effective only at the death of the grantor. Sometimes, testamentary trusts are created

within wills. The second distinction about a trust is whether it is revocable or

When it comes to divide an estate, the politest men quarrel.

Ralph Waldo Emerson, Journals (1863)

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252 c h a p t e r 6 End-of-Life Issues and Decisions

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Insurance and Death Benefi ts 253

irrevocable. With a revocable trust, the grantor retains ownership and control of the property in the trust and can change the terms of the trust, including

changing the individuals designated trustees and benefi ciaries. With an irre- vocable trust, ownership and control of property is given to others (trustees) and the grantor no longer owns or controls the property; thus, it is not pos-

sible for the grantor to enact changes to the trust.

The trustees of a trust can be the grantor who is making the trust, family

members, friends, professionals (accountants or attorneys, for example), a

bank or trust company, or a combination of these. A person who establishes a

revocable, living trust will likely name himself or herself as sole trustee. The

benefi ciaries of a trust can be anyone the grantor designates, although ben-

efi ciary distributions are generally to family members or charities.

All decisions about wills, probate, and living trusts should be carefully

considered and, in most cases, it is prudent to have the advice of an attorney

who is well versed in such matters.

Insurance and Death Benefi ts In the United States, the fi rst life insurance company was established in 1759

by the Presbyterian Synod of Philadelphia for its ministers. Although life

insurance did not become common until the middle of the nineteenth cen-

tury, it is now a huge industry. Most American households include at least one

member who owns some form of life insurance. 87

Depending on a person’s age and health, life insurance can be a conve-

nient way of leaving a basic estate for our benefi ciaries after we die. It may

represent a small portion of a large estate or the major portion of a smaller

estate. Insurance plans can be designed in a number of ways and to suit many

purposes. Some policies are part of a total investment portfolio that can be

drawn upon during the insured’s lifetime. Other policies provide benefi t pay-

ments only after the death of the insured.

Life insurance offers some advantages not available with other invest-

ments. For example, life insurance benefi ts payable to a named benefi ciary

(not the decedent’s estate) are not subject to attachment by creditors. Also,

unlike assets that must be processed through probate, insurance benefi ts

usually become available immediately following death. These benefi ts can

have important psychological and emotional value, possibly providing relief

and a sense of security to a surviving spouse or other dependents in the

period soon after death. Knowing that money is available to cover anticipated

expenses may help to reduce stress.

In estate planning, people sometimes focus solely on the breadwinner

of the family and fail to consider the economic value that would be lost with

the death of a nonworking spouse. Following the death of his wife, one man

described the fi nancial burdens he incurred with the added expenses of

child care. The nonworking spouse, as well as the working spouse, should be

considered as part of a comprehensive estate plan.

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254 c h a p t e r 6 End-of-Life Issues and Decisions

A recent development allows terminally ill patients to sell their life insur-

ance policies to “viatical settlement companies” so that they can pay medical

bills, travel, or purchase things they want to enjoy before dying. A viatical settlement allows a person with terminal illness to sell his or her life insurance policy before death and receive payment for a percentage of its face value.

Viatical settlement companies typically pay about 70 percent of the face value

of the policy, and the policy is cashed in for its full value after the policyhold-

er’s death. For example, on a policy with a face value of $100,000,  the   settle-

ment   company   might   pay  $70,000 to the policyholder. Patients with less than

a year to live usually receive a higher percentage of face value than those

expected to live longer. When the patient dies and the policy is cashed in,

the settlement company pockets the difference between what was paid to the

policyholder and the face amount of the policy, less its operating expenses.

Some mainstream insurers offer similar options. As with any area of fi nancial

planning, it is wise to compare choices. Many survivors qualify for benefi ts from programs like Social Security

and the Veterans Administration. To obtain current information about such

death-benefi t programs, call or write the appropriate government agency. A

person entitled to benefi ts under one or more of these programs may not

receive them unless a claim is fi led. Moreover, delays in fi ling may result in

a loss of benefi ts. A comprehensive estate plan includes consideration of

benefi ts that accrue from government programs, as well as those related to

employee or union pension programs.

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Burial in a national cemetery, such as the Black Hills National Cemetery in South Dakota, is a benefi t made available to veterans who have served in American military forces during wartime. Such cemeteries have been established across the United States. Other death benefi ts for veterans include a lump-sum payment to help defray burial expenses and, under certain circumstances, direct payments to survivors.

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Considering End-of-Life Issues and Decisions 255

When a death results from negligence, other death benefi ts may be

payable to survivors. Such benefi ts sometimes result from court cases that

attempt to place a value on the deceased’s life and what the loss represents to

his or her survivors. Although settlements of this kind may indeed be helpful

to survivors, the monetary amount of a settlement, no matter how large, is

poor compensation for the loss of a loved one (see Figure 6-5 ).

Dealing with legal and fi nancial matters surrounding dying and death

can be a burden when a person is grieving the death of a loved one or coping

with the impending death of a family member. Yet, crucial and even irre-

vocable decisions often must be made at times like these. Preparation can

help ease the burden. Although one cannot plan for every contingency, it is

possible to become aware of the range of legalities that may impinge on our

experiences of death and dying and, acting out of that recognition, to take

appropriate steps to prepare ourselves for the inevitable eventualities.

Considering End-of-Life Issues and Decisions Studies of the factors that patients, family members, physicians, and care

providers consider important at the end of life include pain and symptom

management, communication with one’s physician, preparation for death,

and the opportunity to achieve a sense of completion. “Whereas physicians

tend to focus on physical aspects, patients and families tend to view the end

of life with broader psychosocial and spiritual meaning, shaped by a lifetime

of experiences.” 88 The challenge to medicine, then, say researchers, is to

“design fl exible care systems that permit a variety of expressions of a good

death.” In her study, And a Time to Die: How American Hospitals Shape the End of Life, Sharon Kaufman observes,

Waiting for death—without an institutionally imposed concern for how long it

takes—was necessary and time-consuming in the 1960s. Death today is mostly

decided, not waited for. “The deathwatch has given way,” said one thoughtful ICU nurse, “to saving

a life or offering the best palliative care possible, to heading full bore into

strategies and techniques for mastering death by staving it off or by choosing

the time for it.” 89

Figure 6-5 Death of a Son

Death of a Son

“I’m not happy because I no more my son already. . . . I miss him. Even if I get my money,

I no more my loved one, my son. I’m not interested in money. Every day, after work, even

if I feel tired, I no miss to go visit my boy. Sometimes I cry. Sometimes I give food [for

his grave]. Soda. His favorite—Kentucky Fried Chicken. Sometimes fried saimin. Then

I give an orange. Ice cream. . . . One day after the crash, my boy, he come my house in

spirit. He tell me, ‘Daddy, I miss you. I no more hands. I no more eyes.’ Ho, I cry.”

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256 c h a p t e r 6 End-of-Life Issues and Decisions

In reviewing the rapidity with which issues and decisions involving the

end of life have come to public interest during the past few decades, bioethi-

cist Leon Kass observes that “today the ethics business is booming”; medical

schools now offer courses in medical ethics, hospitals establish ethics commit-

tees, courts adjudicate ethical confl icts, and blue-ribbon commissions analyze

and pronounce on ethical issues. 90 Yet, Kass argues, much of this “action” is

really just talk—philosophical theorizing and rational analysis—with com-

paratively little time devoted to “what genuinely moves people to act—their

motives and passions.” This is not to say that analysis and theorizing are irrel-

evant, but the “morality of ordinary practice” is where the rubber meets the

road. Kass points out that every human encounter is an ethical encounter, an

occasion for the practice and cultivation of virtue and respect. Jitaro Mizuno

says, “The place where ethical problems occur is not in an isolated individual

consciousness, but rather in the relationship of person to person.” 91

Writing about care of individuals at the end of life, one scholar asks: “Are

we not getting better at managing death? Or is it that death itself cannot be

controlled, cannot be managed?” 92

Our choices about end-of-life issues result not only from our personal

values but also from values present within our particular ethnic or cultural

group. Different value systems produce different attitudes about the end of

life. Richard Gilbert says,

End-of-life care requires us to at least be available to the dying and their loved

ones around the issues of meaning, beliefs, rituals, and their longing for peace

as they face whatever may be ahead for them. . . . It requires us to stand fi rmly

in their presence as guest, nonjudgmentally, while also tracking our own

spiritual/religious issues, challenges, and shortcomings. 93

Concerns about issues pertaining to the end of life do not affect merely

the realm of public policy but also bear directly, often poignantly, on the lives

of individuals and families.

Further Readings Jeffrey Paul Bishop. The Anticipatory Corpse: Medicine, Power, and the Care of the Dying.

Notre Dame, Ind.: University of Notre Dame Press, 2011.

Michael C. Brannigan and Judith A. Boss. Healthcare Ethics in a Diverse Society. Boston: McGraw-Hill, 2001.

Denis Clifford and Cora Jordan. Plan Your Estate, 8th ed. Berkeley, Calif.: Nolo Press, 2006.

Susan Dolan and Audrey Vizzard. The End of Life Advisor: Personal, Legal, and Medical Considerations for a Peaceful, Dignifi ed Death. New York: Kaplan, 2009.

Donald E. Gelfand and others. End-of-Life Stories: Crossing Disciplinary Boundaries. New York: Springer, 2005.

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Further Readings 257

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

John Griffi ths, Heleen Weyers, and Maurice Adams. Euthanasia and Law in Europe. Portland, Ore: Hart, 2008.

Matt Weinberg, ed. Medical Ethics: Applying Theories and Principles to the Patient Encoun- ter. Buffalo, N.Y.: Prometheus, 2001.

James L. Werth, Jr., and Dean Blevins, eds. Decision Making Near the End of Life: Issues, Developments, and Future Directions. New York: Routledge, 2008.

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te

Total care for the patient with a life-threatening illness includes warm, intimate contact with caring persons who are able to listen and share the patient’s concerns.

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259

C H A P T E R 7

Facing Death: Living with

Life-Threatening Illness

O ne day, you wake up and notice symptoms in your body that you associate with a serious illness. What goes through your mind? Perhaps you just barely admit to yourself the

possibility that you’re “really sick,” then quickly push away such thoughts and go on with

your day’s activities. “After all,” you say, “there’s no reason to suspect it’s anything serious; it’s

probably nothing.” You don’t want to tempt fate by looking too closely.

You forget about it for a while. But, more and more persistently, the symptoms demand

your attention. “This better not be anything serious,” you tell yourself, “I’ve got too much to

do.” Yet, in some part of your mind, you recognize that it could be serious. You begin to admit

your concern, feeling a bit anxious about what the symptoms might mean, how they might

affect your life.

You make an appointment with your doctor, describe your symptoms, submit to an

examination, and wait for the results. Perhaps right away, or maybe only after additional tests

are completed, you learn the diagnosis. Your doctor informs you that you have a tumor, a

malignancy. Cancer.

Now your thoughts and emotions really become agitated: “What can be done? How are

the doctors going to treat this illness? What kind of changes will I have to make in my life?

Should I postpone the trip I’ve been planning? What course of treatment should be fol-

lowed? Are there side effects? Can this kind of cancer be cured? Will it be painful? Will

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260 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

I die?” As the drama unfolds, you fi nd ways to cope with the crisis. Earlier

fears about symptoms are transformed into concerns about diagnosis, treat-

ment, and outcome.

As time passes, you experience a remission: The tumor appears to have

stopped growing. The doctors are optimistic. Still, you wonder whether the

cancer is really gone for good. Cancer used to mean a terminal prognosis;

now, because of early detection and treatment advances, it is not always a

fatal disease. Despite good reports from your doctors, you wonder whether

you will be a “cancer victim” or a “cancer survivor.” Your health status is up

in the air. You are in limbo. You’re happy that things seem to be going well,

but optimism is mixed with uncertainty and fear. Perhaps after a while you

begin to relax and feel less anxious about the cancer returning. It seems your

cancer was curable.

However, sooner or later you may notice the recurrence of symptoms,

signaling the cancer’s return. You fear the spreading of the cancer to other

areas of your body. Cancer symbolizes the worst fears of our age: pain, wast-

ing away, suffering, and death.

Thoughts of dying may become more predominant. Attention is focused

on enacting the role of patient with a life-threatening illness. When noth-

ing more can be done to stop the progression of the disease, fear or anxi-

ety about the prospect of dying is diffi cult to avoid. Still, fear is balanced by

hope. We hope for a remission, a change for the better that doctors haven’t

foreseen. We may fi ght to the end with the attitude, “I’ve always outwitted the

percentages. Why not now?” Or we may take a different approach, coping

with the end of life by making the most of the time we have left, surrounding

ourselves with those closest to us, and accepting our fate. As a physician who

had been diagnosed with a life-threatening illness said, “The attitude, ‘I’m

going to beat this thing’ makes everyone who dies a loser. Death is a fi ght that

no one can win.” 1

Life-threatening diseases confront us with our mortality, exposing our

anxiety about being separated from all that we love, our fear of pain, and the

imagined horror of dying.

Of course, cancer—the focus of the preceding scenario—is only one cat-

egory of life-threatening illness. For example, heart disease and stroke are

also killers. 2 The main forms of heart and circulatory disease are atheroscle-

rosis (thickening and hardening of the arteries), coronary and peripheral

artery disease, congestive heart failure, congenital heart disease, rheumatic

heart disease, and heart valve problems. Stroke—also called a cerebrovascu-

lar accident (CVA)—refers to an impeded blood supply to some part of the

brain, resulting in destruction of brain cells. Although people think of heart

disease as a malady of modern life, CT scans of mummies from three conti-

nents show hardened arteries, evidence suggesting that humans may have a

predisposition to cardiovascular disease as they age. 3

Sometimes serious heart or cerebrovascular disorders have no symptoms

until they reach a late stage. Sudden cardiac death refers to unexpected

death from cardiac arrest, usually due to arrhythmia (disruption of the

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Personal and Social Meanings of Life-Threatening Illness 261

heart’s electrical conduction system in which it beats too quickly, too slowly,

or irregularly). This category of disease does not always cause sudden, unex-

pected death. For example, damage to heart muscle can result in a heart

attack, or myocardial infarction, that becomes a threat that must be dealt

with over time.

In addition to cancer, heart disease, and stroke, other leading causes of

death in the United States include accidents, Alzheimer’s disease, and suicide.

These ways of “facing death” are discussed in later chapters. However, except

for some parts of the discussion of treatment options, which focus particu-

larly on cancer, the material in this chapter is pertinent to life-threatening

illnesses generally. In our discussion of treatment options, we focus particu-

larly on cancer for two reasons: First, it symbolizes for many people the nature

of life-threatening or terminal illness; second, many of the medical and pal-

liative care options now available to patients with life-threatening diseases

were initially developed as a result of efforts to improve cancer care.

Personal and Social Meanings of Life-Threatening Illness

Life-threatening diseases are sometimes treated as taboo (from the Polyne-

sian word tapu, meaning “marked off ”), as if fraught with mystical danger. 4

With her seriously ill daughter, this mother waits for the test results that will help determine the next step in care and treatment.

© B

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te e le

, T

im es

-P ic

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262 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

This can lead to avoidance of people, places, and objects associated with the

forbidden condition. Kay Toombs says,

Diagnoses are permeated with personal and cultural meanings. The dread

diseases—cancer, heart disease, AIDS—carry with them a particularly powerful

symbolic signifi cance. In living an illness, one is forced not only to deal with the

physical symptoms of disease but also to confront the meanings associated with

the diagnosis—particularly with respect to the response of others. 5

A pattern of taboo and avoidance can cause friends and relatives as

well as caregivers to abandon the patient, creating a kind of “social death”;

the patient feels walled off from the rest of society as somehow “in-valid.”

(Researchers note that, although cancer still carries a stigma, it is nothing

like it was before celebrities started “coming out” about the disease.) 6

A person who fails to achieve or retain good health may feel guilty: “Am I

responsible for bringing this illness on myself?” Magical thinking—assuming

oneself responsible though it’s not clear just how—can place an additional

burden on a patient with life-threatening illness: “If I had done this or not

done that, maybe I wouldn’t be in this predicament.” The pursuit of wellness

becomes a kind of moral virtue.

In addition, serious and life-threatening diseases are expensive, incur-

ring costs related to hospitalization, outpatient therapy, offi ce visits, and

medications. Besides medical care, there are incidental costs associated

with transportation, support services, child care, and temporary housing for

patients who travel long distances to receive specialized care. Time off from

work results in lost earnings. Looking at the family as a system, as the illness

affects the patient, it also affects family life; and this pattern is reciprocal.

When all these things are considered, in addition to the stress and problems

inherent in the care of a life-limiting illness, we begin to agree with the sum-

mary expressed by Ira Byock, “We make dying a lot harder than it has to be.” 7

Education, counseling, and support groups can help individuals cope

with life-threatening illness. Acquiring information about the disease and

its treatment, sharing experiences with others in an environment of mutual

support, using counseling services to clarify issues, and fi nding ways of com-

municating more effectively with caregivers as well as family and friends—all

of these are examples of positive approaches to dealing with life-threatening

I sat in our yard, a peaceful wooded place in the hills fi lled with the sound of birds,

and just breathed in the scent of bay trees and pine. I knew that my life would

never be the same—my work life, my family life, and the way I felt physically every

day would all be different. I also knew that I couldn’t imagine what this would feel

like: chemotherapy, radiation, pain, daily nausea, and eventual fading away into

death. I had watched many patients experience this but never asked them what it

felt like. I was about to fi nd out. I was embarking on a very challenging journey,

to say the least. I sat there enjoying the last thirty minutes of my existence before

cancer would become the life focus for both my family and me.

Lee Lipsenthal, Enjoy Every Sandwich

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Coping with Life-Threatening Illness 263

illness, restoring some sense of personal control over one’s life. Nevertheless,

there may be overwhelming feelings of loss on all levels. Byock says, “The

fundamental nature of illness is not medical; it is personal. . . . Illness is the

interaction of a person with a disease.” 8

Coping with Life-Threatening Illness Every disease has its own set of problems and challenges, and each person

copes in his or her own way. 9 How people respond to illness is shaped by

personality, psychological makeup, family patterns, and social environment.

Arthur Frank says, “Critical illness teaches us that to be alive is to be con-

stantly at risk, but the risk greater than dying is living less than well.” 10

Religious faith and spiritual beliefs can be important allies in coping with

life-threatening illness. Patients and their families may be comforted by faith

that helps them face the abyss of death and somehow make sense of existence. 11

Faith can promote a sense of self-confi dence, peacefulness, and purpose.

Charles Corr identifi es four primary dimensions in coping with dying:

physical, psychological, social, and spiritual (see Table 7-1 ). 12 This highlights

the fact that coping involves more than just body or mind. The spiritual

dimension, it should be noted, is not exclusively religious; rather, it encom-

passes a person’s basic values and sources of meaning about life and death.

This model shifts our perspective from a narrow or limited view of coping

with the threat of dying to one that is holistic.

Awareness of Dying Observing family interactions in response to life-threatening illness, soci-

ologists Barney Glaser and Anselm Strauss noted four distinctive ways in which

a context of awareness about dying shapes communication styles. 13 In the closed awareness context, the dying person is not aware of his or her impending death, although others may know. This context is characterized by a lack of communi-

cation about the person’s illness or the prospect of his or her death.

In the suspected awareness context, a person suspects his or her progno- sis, but this suspicion is not verifi ed by those who know. The dying person

may try to confi rm or deny his or her suspicions by testing family members,

friends, and medical staff in an effort to elicit information known by oth-

ers but not openly shared. Despite this secrecy, the patient observes the dis-

ruptions in family communication patterns caused by the illness and senses

1. Physical. Involves satisfying bodily needs and minimizing physical distress in ways consistent with other values.

2. Psychological. Involves maximizing psychological security, autonomy, and rich- ness in living.

3. Social. Involves sustaining and enhancing signifi cant interpersonal relationships and addressing the social implications of dying.

4. Spiritual. Involves identifying, developing, or reaffi rming sources of spiritual energy or meaning and, in so doing, fostering hope.

t a b l e 7-1 Four Primary Dimensions in Coping with Dying

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264 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

others’ anxiety about the illness, thus tending to confi rm suspicions. Ken-

neth Doka tells a story that illustrates this: One patient said his fi rst inkling of

impending dying occurred when he told his wife that he wanted to plant an

herb garden next spring. Grasping his hand tightly, his wife said, with tears

in her eyes, “Of course you will, dear.” The man said wryly, “She never before

showed so much emotion about my gardening.” 14

The mutual pretense context is like a dance in which participants sidestep direct communication about the patient’s condition. This can lead to compli-

cated though usually unspoken rules of behavior intended to sustain the illu-

sion that the patient is getting well. Participants exchange subtle signals that

the style of communication used to cope with the crisis is to pretend that things

are normal. Everyone, the patient included, recognizes that death will be the

outcome, but all act as if the patient will recover. In the short term, mutual pre-

tense can be a useful strategy for coping with a diffi cult and painful situation.

Underlying mutual pretense is the notion that everyone should avoid

“dangerous” or “threatening” topics, such as facts about the disease, its prog-

nosis, medical procedures, the deaths of other patients with the same disease,

and future plans and events that will likely occur after the patient dies. When

something happens that threatens to break the fi ction and disclose the real-

ity, the parties to mutual pretense act as if the threatening event had not

occurred. People may respond to the risk of disclosure by becoming angry or

withdrawn, or they may avoid further communication by saying they need to

go out for a walk or make a phone call. Mutual pretense may be carried on

right to the end, even when unspoken rules are occasionally violated in ways

that could have revealed the patient’s condition.

Glaser and Strauss’s fourth designation, the context of open awareness, is one in which death is acknowledged and discussed. Open awareness does not

necessarily make death easier to accept, but it does allow for the possibility

of sharing support in ways that are not readily available with the other aware-

ness contexts.

As new information about the disease comes to light or the course of the

disease changes, the context of awareness may change. For example, mutual

pretense may dominate through a succession of medical procedures; then,

with receipt of new test results, participants may begin to openly acknowl-

edge the illness as life threatening. As circumstances change, the awareness

context may shift.

Adapting to “Living-Dying” Living with a life-threatening illness can be described as a “living-dying”

experience, during which patients and families fl uctuate between denial and

acceptance. 15 Avery Weisman described this coping process as involving mid- dle knowledge; that is, individuals seek a balance between sustaining hope and acknowledging the reality. 16

Based on her work with dying patients, more than forty years ago, Elisabeth

Kübler-Ross developed a description of common emotional and psychologi-

cal responses to life-threatening illness. 17 “At the heart of Kübler-Ross’s work

was her concern for the patient and her wish that every physician be able to

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Coping with Life-Threatening Illness 265

fully imagine the patient’s suffering and act accordingly.” 18 She reminded her

students and readers of how important it is to pay attention to dying people,

who have much to teach us about our shared humanity and the fi nal stages of

life with all its anxieties, fears, and hopes. 19

Perhaps you have heard or read about the fi ve stages associated with

Kübler-Ross’s model: denial, anger, bargaining, depression, and acceptance.

Receiving the diagnosis of a life-threatening illness, a person may respond

with avoidance or denial. Bargaining, or attempting to strike a deal with fate or

with God, occurs as a patient tries to fi nd a way to avoid the inevitable. Expres-

sions of anger can mask anxiety about the encounter with serious illness and

its meaning. It may be manifest as displaced hostility, perhaps directed toward

a caregiver, as displayed in complaints about food or other aspects of care:

“Why can’t you fi x me a good cup of tea? You know I can’t do it for myself!”

As the illness progresses, weakening the body, an individual’s attempts to

be stoic may be replaced by depression, a profound sense of loss. Kübler-Ross

distinguished two kinds of depression: reactive depression, which is a response to disruptions caused by the disease, and preparatory depression, which is related to the awareness that one is dying and must prepare for death.

In coping with a life-threatening illness and its accompanying losses, an

individual may ultimately fi nd some acceptance or resolution. Rather than

But You Look So Good It’s with me each day.

I wake, thinking

Today it will go away.

But the pain seems to stay . . .

Persistent, resistant, consistent.

People say,

But you look so good.

If only I could

Feel like I look.

Or, should

I look bad?

So they’ll know

How I feel

is real.

Do they doubt?

I wish the pain

Was on the outside—

something you see.

Not only the pain

Do I need to survive,

But also my

Paranoid imaginings

Of others’ disbelief.

Judy Ellsworth

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266 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

giving up or losing hope, “acceptance” implies facing one’s mortality in a

manner that is essentially positive. Consider the words of writer Harold Brod-

key as he faced the prospect of dying from AIDS:

I have liked my life. I like my life at present, being ill. I like the people I deal

with. I don’t feel I am being whisked off the stage or murdered and stuffed in a

laundry hamper while my life is incomplete. It’s my turn to die—I can see that

is interesting to some people but not that it is tragic. Yes, I was left out of some

things and was cheated over a lifetime in a bad way but who isn’t and so what?

I had a lot of privileges as well. Sometimes I’m sad about its being over but I’m

that way about books and sunsets and conversations. 20

The “Kübler-Ross” model has been portrayed in cartoons and on television

shows, such as The Simpsons. The acronym DABDA is used by medical students preparing for their exams. The idea that these fi ve stages occur in a linear

progression—and that a person is supposed to move through them sequentially

and eventually wind up at acceptance—became a prescription for how people

should cope with the process of living-dying. In reality, each person’s pathway is unique, determined by such factors as the specifi c nature of the illness, his or

her personality, and the helping resources available in his or her environment.

Kübler-Ross stimulated a better understanding of how people experience

the prospect of dying. However, this model became, for a time, the way to cope, despite the fact that Kübler-Ross herself said that patients tend to go

back and forth among the various “stages” during the course of an illness and

may experience different stages at the same time. People sometimes interpret

denial as a bad thing, something the dying person should “get over” or move

beyond. But this interpretation ignores the fact that denial can be healthy

and an effective way of coping. Whether denial is adaptive or maladaptive

depends on its timing and duration, as well as the nature of the perceived

threat. Facing reality is not always the healthiest choice; there are times when

game-playing or acting as if circumstances were otherwise is appropriate.

Moving beyond Kübler-Ross, in focusing on the tasks that individuals

manage at different phases of a life-threatening illness, Kenneth Doka pro-

vides a useful model of the chronology of living-dying (see Table 7-2 ). 21 This

model describes an acute phase, initiated by the diagnosis; a chronic phase, living with the disease; and a terminal phase, coping with impending death. Doka points out that, in some cases, two additional phases may occur: fi rst, a

prediagnostic phase, during which a person suspects the illness and may seek medical attention; and, second, a recovery phase, which follows the cure or remission of a previously life-threatening disease. As you think about the tasks

that pertain to each of these phases, keep in mind that serious illness doesn’t

automatically liberate a person from the ordinary challenges of life. Doka

says, “Life-threatening illness is only part of life.” 22 All the previous issues and

problems of life remain part of the larger struggle of life and living.

Patterns of Coping Herman Feifel points out that patterns of coping with a life-threatening

illness vary in signifi cant fashion. 23 Thus, we need to keep in mind both the

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Coping with Life-Threatening Illness 267

highly individual nature of coping styles and the fact that a person can have

various ways of coping with life-threatening illness. It is not feasible to rely

solely on some “standard” model of the dying process to tell us how a given

individual is likely to behave or what he or she is likely to feel or think. We

must pay attention to the dying person’s own life story (see Figure 7-1 ). Avery Weisman observed that coping effectively with life-threatening

illness involves three interrelated tasks: fi rst, confronting the problem and

revising one’s plans as necessary; second, keeping communication open

and wisely using the help offered by others; and third, maintaining a sense

of optimism and hope. 24 Weisman suggested that the process of coping

with terminal illness consists of three phases: (1) from the time symptoms

are noticed until the diagnosis is confi rmed, (2) the time between diag-

nosis and the fi nal decline, and (3) from decline to death. 25 Among the

“landmarks” that characterize the journey through terminal illness are the

following:

1. Existential plight. A crisis of self-identity begins with the initial shock of diagnosis as the person attempts to come to terms with the life-

altering news.

2. Mitigation and accommodation. When treatment begins, the reality of the illness becomes part of the person’s life as adjustments and accommoda-

tions are made.

Acute Phase Chronic Phase Terminal Phase

Understand the disease. Manage symptoms and

side effects.

Manage discomfort, pain,

incapacitation, other

symptoms.

Maximize health and

lifestyle.

Carry out health

regimens.

Cope with health proce-

dures and institutional

stress.

Optimize coping

strengths.

Manage stress and

examine coping

behaviors.

Manage stress and examine

coping behaviors.

Develop strategies to

deal with issues

created by disease.

Normalize life to extent

possible in face

of disease.

Prepare for death and say

goodbye.

Explore effect of

diagnosis on self

and others.

Maximize social sup-

port and preserve

self-concept.

Sustain self-concept and

appropriate relation-

ships with others.

Express feelings and

fears.

Express feelings and

fears.

Express feelings and fears.

Integrate present reality

into sense of past

and future.

Find meaning in uncer-

tainty and suffering.

Find meaning in life and

death.

t a b l e 7-2 Tasks in Coping with Life-Threatening Illness

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268 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

3. Preterminality and terminality. When no cure or extension of life is in the offi ng, the individual confronts progressive decline and deterioration as

the limits of life become increasingly clear. As the end draws near, pallia-

tive care replaces curative therapy as the dying person prepares for death.

Although life-threatening illness disrupts virtually all aspects of a person’s

life, it has been known for a long time that there is a vital link between fi nd-

ing meaning and achieving a sense of mastery. 26 The threat of a potentially

fatal illness evokes a variety of responses to make the threat manageable.

Psychologically, these responses can be divided into two categories: defense

mechanisms and coping strategies. 27 Defense mechanisms occur unintentionally and without conscious effort or awareness; they function to change a person’s

internal psychological states, not the external reality. Coping strategies involve conscious, purposeful effort; they are employed with the intention of solving a

problem situation. Although coping strategies are generally viewed more posi-

tively than defense mechanisms, both involve psychological processes that can

help ease a distressful situation. Denial, for example, is a defense mechanism

that is sometimes adaptive and sometimes not, depending on the person and

the situation. In the short term, denial can give a person “breathing room” in

living with a distressing situation; over the longer term, however, defenses may

hinder a positive outcome if they prevent a person from mobilizing needed

resources and taking appropriate action. Consider the example of a person

who uses denial to delay seeking medical attention because of his or her fear

about illness. 28 Edwin Shneidman says, “Intermittent denial is the ubiquitous

psychological feature of the dying process.” 29

Therese Rando identifi es three major psychological and behavioral

patterns that individuals use in coping with the threat of death: (1) retreat

and conservation of energy, (2) exclusion from the threat of death, and

(3) attempting to master or control the threat of death. 30 The main aim of

the mental processes and behaviors involved in coping is to establish control

over a stressful situation. This generally requires different coping strategies

working in concert. As with an orchestra, wherein particular instruments

Figure 7-1 Life Change with Life-Threatening Illness: Real Estate Want Ad The confrontation with a life-threatening illness may activate desires to accom- plish in the present plans that previously had been visualized as occurring in the future.

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Coping with Life-Threatening Illness 269

come to the fore at a given time while other instruments await their turn,

the various coping strategies may be employed at different times to achieve

different purposes. One way of distinguishing different strategies is to

examine their purpose and focus. Emotion-focused coping, for example, helps regulate the level of distress. It allows a person to escape the impact of the

stressful situation by reframing it or distancing himself or herself from it.

Reframing a situation to put it in a positive light can reduce the sense of

threat. Another strategy, problem-focused coping, deals with managing the problem that is causing distress. An individual who seeks out information

about a diagnosis and takes an active role in determining options is engag-

ing in problem-focused coping. A hallmark of this style of coping is the pur-

suit of personally meaningful goals. Recalling that the main aim of coping

is to establish a sense of control, it is noteworthy that a greater sense of con-

trol is associated with problem-focused coping. A third strategy, meaning- based coping, helps maintain a person’s sense of positive well-being. Examples include giving up goals that are no longer achievable and formulating new

ones, making some sense of what is happening, and, where possible, fi nding

benefi t in the distressing situation. In searching for meaning, people often

turn to spiritual beliefs for insight in making the best of a bad situation.

Finding some redeeming value in loss can make the burden easier to bear

(see Figure 7-2 ).

People vary their styles of coping depending on opportunities for prob-

lem solving, the intensity of their emotional responses and their ability to

regulate them, and the changes in their environment as the distressing situa-

tion unfolds. Thus, coping strategies are dynamic rather than static. They are

also interdependent, each supplementing the others. 31 Thus, the overall pat-

tern of coping resembles a more or less continual fl ow or oscillation among

various styles.

How individuals respond to stressful circumstances is largely determined

by who they are—by their enduring dispositions and personalities. 32 People

who apparently cope best with life-threatening illness often exhibit a “fi ght-

ing spirit” that views the illness not only as a threat but also as a challenge. 33

Such people strive to inform themselves about their illness and take an active

part in treatment decisions. They are optimistic and try to discover positive

meaning in ordinary events. Holding to a positive outlook despite distressing

circumstances involves creating a sense of meaning bigger than the threat. In

the context of life-threatening illness, this encompasses a person’s ability to

comprehend the implications an illness has for the future as well as for his or

her ability to accomplish goals, maintain relationships, and sustain a sense of

personal vitality, competence, and power.

Maintaining Coping Potency From the moment one notices unusual symptoms, through the ups and

downs of treatment, and on to the fi nal moments of life, hope and honesty

are often delicately balanced—honesty to face reality as it is, hope that the

outcome is positive. The capacity to maintain a sense of self-worth, to set

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270 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

Figure 7-2 Invitation to a Going-Away Party Ritual and companionship can assist in dealing with impending death. This celebration was attended by close friends and family, who said the occasion was an extremely moving experience. Knowing that she would soon die from cancer, Joan created a ritual that involved drawing a line on the fl oor and, in her weak- ened condition, she was helped across it by her ex-husband and her children while members of the gathering played music and sang. Although such an event would not be appropriate for everyone, Joan’s farewell party aptly refl ected her lifestyle and values. She died seven months later.

Dear Friends,

In company with our dear Mother Earth, I have arrived at the

time of autumn in my worldly life, that time of transition between

life and death. Before long, just as the leaves drop from the trees to

continue Life’s cycle of generation and regeneration, so will my body

be shed and become part of the muttering earth. Like the tree

gathering in energy to prepare itself for winter, I feel a need to

gather energy for the process of dying. Also, I want to share a last

celebration with you dear friends. To do this, I have planned a ritual

of transition to take place on Sunday, November 3, at 2:30 p.m. here

at my home.

I would love it if you can participate with your presence; and if

you cannot, I would appreciate your joining us in spirit with loving

energy via the ethers that afternoon.

If you can come, please bring a pillow to sit on and a symbolic

gift of your energy and blessing for me in this process I am going

through—something from nature (rock, shell, feather, etc.); a poem,

picture or song; something written or drawn; or whatever you are

inspired to bring. Please also bring a casserole, salad or dessert or

beverage to contribute to our potluck supper following the ritual.

There is a new joy that is beginning to be realized in me as I

acknowledge the prospect of having a spirit fl oat free of my tired

body. I look forward to sharing this with you too.

Love and blessings,

Joan Conn

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Coping with Life-Threatening Illness 271

goals and strive to meet them, to exercise choice out of an awareness of

one’s power to meet challenges, to engage in active interactions with one’s

environment—all of these refl ect a “coping potency” that sustains the will to

live in the face of death. It has long been a truism in medicine that hope plays

a key role in a patient’s ability to live with illness.

Reportedly, both John Adams and Thomas Jefferson, although gravely

ill, managed to live until July 4, 1826, the fi ftieth anniversary of the signing of

the Declaration of Independence. According to his physician, Jefferson’s last

words were, “Is it the Fourth?” This story raises the question, Do individuals

have the ability to delay or defer death so they can observe an anniversary or

other important event? 34

The object of hope changes over time. Hope that the symptoms mean

nothing gives way to hope that there will be a cure. When hope for a cure is

no longer possible, one may hope for more time. When time runs out, one

hopes for a pain-free death. Hope is sustained by focusing on meaningful

aspects of life. 35

Doctors often attempt to instill hope in patients by the manner in which

they discuss a disease and its treatment. They talk about taking things one step

at a time, fi rst controlling pain or other symptoms. Or they may use analogies,

likening the process of coping with a serious illness to climbing a mountain,

which can be hard but potentially successful as long as one keeps advancing

to the top. This metaphor suggests that the doctor can help “pull the patient

to safer, higher ground.” One oncologist explains, “You have to give people

something to wake up for in the morning, otherwise they might as well take

some cyanide.” 36 In putting the best face on bad news, doctors see themselves

in the role of “the patient’s cheerleader.” Yet it is also the case that “sometimes

the only real hope you can offer a dying person is that you will accompany

them to their death and respect their wishes to the best of your ability.” 37

I got the news that I was sick on the afternoon of my thirty-ninth birthday. It took

a bit of time, travel, and a series of wretched tests to get the specifi c diagnosis, but

by then the main blow had been delivered, and that main blow is what matters.

I have an incurable cancer in my blood. The disease is as rare as it is mysterious,

killing some people quickly and sparing others for decades, affl icting some with

all manner of miseries and disabilities and leaving others relatively healthy until

the end. Of all the doctors I have seen, not one has been willing to venture even a

vague prognosis.

Conventional wisdom says that tragedy will cause either extreme closeness

or estrangement in a couple. We’d been married less than a year when we got the

news of the cancer.

In those early days after the diagnosis, when we mostly just sat on the couch

and cried, I alone was dying, but we were mourning very much together. And what

we were mourning was not my death, exactly, but the death of the life we had

imagined with each other.

Christian Wiman, “Love Bade Me Welcome”

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272 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

Treatment Options and Issues The options for treating life-threatening illness vary with the nature of the

disease and the patient’s particular situation. Some diseases that are life-

threatening can be cured by relatively simple treatment. Others diminish

or become stabilized with treatment. With yet others, there is little hope of

survival. People who are seriously ill have reasonable expectations of the

following: 38

• To have one’s pain and other symptoms regularly assessed and compe-

tently treated. • To have adequate information about one’s condition and treatments, in

clear and simple terms. • To have care coordinated between visits and among physicians and

health programs involved in one’s care. • To have crises prevented when possible and have clear plans in place for

managing emergencies. • To have enough nurses and aides on staff to provide safe and high- quality

care. • To have one’s family supported in giving care and, eventually, in their

grief.

The range of available choices for treating disease depends to an extent

on circumstances in society at large. Disparities in access to health care are

obvious. Individuals who fi t the category of the urban poor tell “indignity

stories” that occur in treatment experiences, causing them to ask, “Can you

give me respect?” 39 Conversely, patients at the high end of the socioeconomic

scale may encounter problems as a result of a greater access to care. A New York Times article observed, “You end up with the phenomenon of special- ists referring to other specialists, with nobody coordinating, which results in

confused messages, more referrals, more hospitalizations, deterioration in

health care and a more anxious patient.” 40

Dignity is important for all human beings, perhaps especially so in the

dramas and circumstances that accompany the end of life. Harvey Max

Chochinov points out that dignity is defi ned as “the quality or state of being

worthy, honored, or esteemed.” 41 He adds: “Dignity provides an overarching

framework that may guide the physician, patient, and family in defi ning the

objectives and therapeutic considerations fundamental at the end of life.” In

studies conducted in Hong Kong, Andy Ho and his colleagues concluded:

As dignity is a value- and cultural-laden concept that encompasses a wide

spectrum of physical, psychosocial, spiritual, familial, and cultural issues,

greater awareness of ethnic diversity is required for all palliative care workers.

Yet, most end-of-life interventions still focus prominently on pain and symptoms

control, while holistic care and familial support are limited. 42

Another example of how social choices affect treatment options is dem-

onstrated in the medical emergency of heart attack, which typically occurs

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Treatment Options and Issues 273

when a blockage in a coronary artery cuts off the blood supply to a region of

the heart. Half of the deaths from heart attack occur in the fi rst three to four

hours after the onset of symptoms. The sooner treatment begins, the better

the chances of survival. Victims who receive early treatment have a survival

rate of about 90 percent. The key to life-saving help is a rapid emergency

response. Some communities, recognizing that sudden cardiac death is a

pressing public health problem, have funded sophisticated mobile cardiac

care units; other communities consider these units too costly.

As mentioned earlier, our focus in this section is primarily treatment

options for cancer. Nevertheless, much of what is presented—especially con-

cerning alternative therapies and pain management—applies generally to

life-threatening illness.

As a general term, cancer encompasses many types of malignant, or potentially lethal, growths that occur in the body. Essentially, cancer is the

abnormal, uncontrolled multiplication of cells. 43 The most common types of

cancer in the United States are prostate, breast, lung, colorectal, urinary and

bladder, kidney, oral cavity and pharynx, and pancreas cancers; melanoma;

non-Hodgkin’s lymphoma; leukemia; and cancers of the female reproductive

tract (cervical, uterine, and ovarian cancer). Cancer cells can develop in any

tissue within any organ.

Because there are many categories and types of cancer, some experts

propose that cancer is best understood as a process, of which time is a critical dimension. 44 Cancer growth may be fast or slow; it may take weeks or years.

Cancer is classifi ed according to how it has spread in the body. This process is

called staging. It denotes the extent of disease and helps determine treatment decisions as well as prognosis (see Table 7-3 ). Tumors are typically assessed in

three ways: (1) extent of the primary tumor, (2) absence or presence of lymph

node involvement, and (3) absence or presence of distant metastases. First

affecting tissues in one part of the body, cancer may spread, either by invad-

ing adjacent tissues or by metastasis, a process whereby diseased cells travel in the blood or lymphatic system or through body tracts to more distant parts of

the body. The speed at which cancer progresses affects how the patient and

his or her family cope with the illness.

Stage Description

0 “Carcinoma in situ”: An early cancer that is present only in cells

where it originated; that is, it has not spread into surrounding

tissue.

I–IV More extensive cancer, with higher numbers indicating greater

tumor size or degree to which cancer has spread to nearby lymph

nodes or organs adjacent to primary tumor. For descriptive

and statistical analysis, invasive cancers are categorized as local, regional, or distant based on the extent of spread.

t a b l e 7-3 Cancer Staging

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274 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

Alkylating agents: A family of chemotherapeutic drugs that combine with DNA (genetic substance) to prevent normal cell division.

Analgesic: A drug used for reducing pain. Antimetabolites: A family of chemotherapeutic drugs that interfere with the processes

of DNA production and thus prevent normal cell division.

Benign: Not malignant. [See malignant. ] Biopsy: The surgical removal of a small portion of tissue for diagnosis. Blood count: A laboratory study to evaluate the number of white cells, red cells, and

platelets.

Bone marrow: A soft substance found within bone cavities, ordinarily composed of fat and developing red cells, white cells, and platelets.

Cancer: A condition involving the proliferation of malignant cells that are capable of invading normal tissues.

Chemotherapy: The treatment of disease by chemicals (drugs) introduced into the bloodstream by injection or taken by mouth as tablets.

Cobalt treatment: A form of radiotherapy that uses gamma rays generated from the breakdown of radioactive cobalt-60.

Colostomy: The surgical formation of an artifi cial anus in the abdominal wall so the colon can drain feces into a bag.

Coma: A condition of decreased mental function in which the individual is incapable of responding to any stimulus, including painful stimuli.

Cyanotic: A blue appearance of the skin, lips, or fi ngernails as the result of low oxy- gen content of the circulating blood.

Diagnosis: The process by which a disease is identifi ed. DNA: The abbreviation for deoxyribonucleic acid, the building block of the genes,

responsible for the passing of hereditary characteristics from cell to cell.

Hodgkin’s disease: A form of tumor that arises in a single lymph node and may spread, fi rst to local lymph nodes, then to distant ones, and fi nally to other tissues, com-

monly the spleen, liver, and bone marrow.

Immunotherapy: A method of cancer therapy that stimulates the body defenses (the immune system) to attack cancer cells or modify a specifi c disease state.

Intravenous (IV): Pertaining to the administration of a drug or of fl uid directly into a vein. Leukemia: A malignant proliferation of white blood cells in the bone marrow; cancer

of the blood cells.

Lymph nodes: Organized clusters of lymphocytes through which the tissue fl uids drain upon returning to the blood circulation; they act as the fi rst line of

defense, fi ltering out and destroying infective organisms or cancer cells and ini-

tiating the generalized immune response.

t a b l e 7-4 Medical Treatment Word List

Successful treatment of cancer requires that all cancerous tissue be

destroyed or removed; otherwise, the disease recurs. In treating cancer, atten-

tion is focused on the primary tumor and its metastases. No single therapy

is effective for all types of cancer. A therapy that has a high success rate with

one type of cancer may be ineffective with another. Some cancers require a

combination of therapies. There also may be a need for an adjuvant therapy (an auxiliary remedy which aids or assists another; other key terms used in

cancer care are defi ned in Table 7-4 ). When a cure is not possible, palliation

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Treatment Options and Issues 275

Malignant: Having the potential to be lethal if not successfully treated. All cancers are malignant by defi nition.

Melanoma: A cancer of the pigment cells of the skin, usually arising in a preexisting pigmented area (mole).

Metastasis: The establishment of a secondary site or multiple sites of cancer separate from the primary or original site.

Multimodality therapy: The use of more than one modality for cure or palliation (abatement) of cancer.

Myelogram: The introduction of radiopaque dye into the sac surrounding the spinal cord, a process that makes it possible to see tumor involvement of the spinal

cord or nerve roots on X-ray.

Oncologist: An internist (specialist in internal medicine dealing with nonsurgical treatment of disease) who has further specialized in cancer therapy and has

expertise in both chemotherapy and the handling of problems that arise during

the course of the disease.

Parkinson’s disease: A degenerative disease of the brain resulting in tremor and rigid muscles.

Prognosis: An estimate of the outcome of a disease based on the status of the patient and accumulated information about the disease and its treatment.

Prosthesis: An artifi cial structure designed to replace or approximate a normal one. Regression: The diminution of cancerous involvement, usually as the result of therapy; it is manifested by decreased size of the tumor (or tumors) or its clini-

cal evidence in fewer locations.

Relapse: The reappearance of cancer following a period of remission. Remission: The temporary disappearance of evident active cancer, occurring either

spontaneously or as the result of therapy.

Sarcoma: A cancer of connective tissue, bone, cartilage, fat, muscle, nerve sheath, blood vessels, or lymphoid system.

Subcutaneous cyst: A cyst located beneath the skin; usually benign. Symptom: A manifestation or complaint of disease as described by the patient, as

opposed to one found by the doctor’s examination; the latter is referred to as

a sign. Terminal: Pertaining to the condition of decline toward death, from which not even a

brief reversal can be expected.

Therapeutic procedure: A procedure intended to offer palliation (abatement) or cure of a condition or disease.

Toxicity: The state of being poisonous; that is, injurious to health or dangerous to life. Tumor: A mass or swelling. A tumor can be either benign or malignant.

t a b l e 7-4 (continued)

of symptoms using some or all of the following therapies may improve the

quality and duration of life. Patients need enough information to clearly

understand the risks and benefi ts of each therapy, as well as to assess the con-

sequences of pursuing a different course of action.

Surgery Surgery is the oldest and most common form of cancer therapy, and

some cancers are curable in early stages with surgery alone. 45 Surgery is com-

monly used in treating many other diseases as well. Although surgery is a

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276 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

routine medical practice, it can also be seen as a “violation of the body” the

side effects of which may include disfi gurement, disability, or loss of bodily

function.

The diagnosis of cancer is usually established by a biopsy, a tissue sample

surgically removed and examined for the presence of cancerous cells. To stop

the growth of cancer and prevent it from spreading, surgery usually involves

removing not only the malignant organ or tissue but also adjacent healthy

tissue. In addition to its role as a primary treatment for many types of cancer,

surgery is used as a therapeutic option in treating pain. 46

Radiation Therapy Soon after the discovery of radium in 1898, it was recognized that radia-

tion could be used to treat cancer. Radiation therapy uses ionizing radiation

to preferentially destroy cells that divide rapidly. 47 Although radiation affects

both normal and cancerous tissues, cancer cells are damaged more seriously

because they usually grow more rapidly than normal cells. Radiation plays a

key role in the treatment of some cancers, and it is used as an adjunct to che-

motherapy in others. Even when radiation does not provide a cure, it may be

used as a palliative therapy to relieve symptoms and thus improve quality of life.

Surgery is a commonly used therapy in treating cancers. Advances in surgical technology and in surgeons’ skills have resulted in notable successes in treatment. Palliative surgery may be done to relieve symptoms and restore quality of life when a cure is unlikely or an attempt at cure produces adverse effects that are unacceptable to the patient.

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Treatment Options and Issues 277

Patients who receive radiation therapy are usually scheduled for frequent

treatments over a period of several months. The radiation dose is prescribed

on the basis of the stage of the disease and the patient’s ability to withstand

side effects, which can include nausea, vomiting, tiredness, and general

weakness.

Chemotherapy Chemotherapy has been called the leading weapon for increasing the

number of patients who can be cured of cancer. It involves the use of toxic

drugs to kill cancer cells. 48 Some cancers are cured by chemotherapy; others

respond but aren’t cured; and still others are resistant.

This form of therapy developed from the observation that toxic effects of

mustard gases during World War I included damage to bone marrow. Clini-

cal trials began after World War II. The ideal chemotherapeutic agent would

attack cancerous cells in the body without affecting healthy tissue. The dose

must be strong enough to kill the cancer or slow its growth but not so potent

that it seriously harms the patient. Although chemotherapy may provide

some palliation, it is also associated with substantial toxic effects. 49

All chemotherapeutic agents basically work by blocking metabolic pro-

cesses involved in cellular division. As a result, they damage healthy as well as

diseased tissue. However, because cancer cells divide more rapidly than most

normal cells, chemotherapy preferentially affects cancerous cells. Whether

a particular drug prevents cells from making genetic material (DNA),

blocks nucleic acid synthesis, or stops cell division and induces other cellu-

lar changes, chemotherapeutic agents owe their effectiveness to the fact that

they are poisonous.

Chemotherapy is an important treatment in many types of cancers

despite the fact that it usually causes distressing side effects, including hair

loss, nausea, sleeplessness, problems with eating and digestion, mouth sores,

ulceration and bleeding in the gastrointestinal tract, and other toxic effects.

Alternative Therapies Paul Insel and Walton Roth observe, “One of the important character-

istics of Western medicine is the belief that disease is caused by identifi able

physical factors.” They add: “Another feature that distinguishes Western bio-

medicine from other medical systems is the concept that almost every disease

The oncology bargain is that, in return for at least the chance of a few more useful

years, you agree to submit to chemotherapy and then, if you are lucky with that,

to radiation or even surgery. So here’s the wager: You stick around for a bit, but

in return we are going to need some things from you. These things may include

your taste buds, your ability to concentrate, your ability to digest, and the hair on

your head.

Christopher Hitchens, Mortality

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278 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

is defi ned by a certain set of signs (physical manifestations) and symptoms

(the effects on an individual), and that they are similar in most patients suf-

fering from the disease.” 50

The conventional medical system is based, therefore, on describing

health-related phenomena by using scientifi c explanations, which is to say

explanations that are 51

• Empirical (based on evidence of the senses and objective observation) • Rational (follow rules of logic and are consistent with known facts) • Parsimonious (explain phenomena by use of fewest causes) • Rigorously evaluated (capable of verifi cation) • Tentative (open to new or better evidence)

Patients are often willing to try unproven treatments when standard

therapies fail. For instance, they try to gain entrance into clinical trials of

therapies that are being investigated for possible effi cacy. Doctors point out,

however, that experimental drugs are not therapies; they are research com-

pounds that may end up causing more harm than good. 52 Physicians warn

that patients, “often grasping at straws, need to be informed and wary of

those who falsely promise cure.” 53

However, people sometimes fi nd mainstream medicine lacking in its

ability to address the patient as a whole person, not just the recipient of a

“doctor-centered” treatment regimen. The result is growing interest in so-

called complementary and alternative medicine (CAM) —sometimes referred to as “integrative medicine”—which comprises a diverse set of healing philos-

ophies, therapies, and products (see Table  7-5 ). 54 While some of these are

t a b l e 7-5 Complementary and Alternative Therapies

Mind-Body Interventions Systems-Oriented Approaches Manual Healing Methods

Psychotherapy and sup-

port groups

Meditation

Imagery

Hypnosis and

biofeedback

Yoga, dance therapy,

other movement

therapies

Music therapy and art

therapy

Prayer and mental

healing

Traditional Chinese

medicine

Acupuncture and

acupressure

Herbal medicine and diet/

nutritional approaches

Community-based practices

(for example, Native

American sweat lodges

and Latin American

curanderismo)

Ayurveda (India)

Homeopathic medicine

Naturopathic medicine

Osteopathic medicine

Chiropractic treatment

Massage therapy

Biofield therapeutics

(that is, laying on of

hands)

Reflexology

“Body work” (for exam-

ple, Rolfing, Trager,

Feldenkrais method,

Alexander technique,

shiatsu)

Bioenergetics

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Treatment Options and Issues 279

unorthodox techniques considered harmful by the medical establishment,

others are compatible with conventional medicine. 55

In managing pain, for example, adjuvant methods may include psycho-

therapy and other mind-body interventions (meditation, imagery, biofeed-

back, and so on), as well as physical therapy and other forms of manual healing.

In conjunction with chemotherapy, patients may use visualization to imagine the therapeutic agent inside the body as it helps to restore well-being. Such

techniques help patients mobilize their inner healing resources by imagining

the diseased parts of the body becoming well again (see Figure 7-3 ).

At Shibata Hospital in Japan, conventional treatment is accompanied by

a psychotherapeutic technique called ikigai ryoho, or meaningful-life ther- apy. 56 The idea behind this therapy is that, even when we are terminally ill,

we can “take responsibility for what to do in the time remaining to us.” Thus,

patients begin by acknowledging their own suffering and gradually proceed

to the recognition that others also suffer, then to an acceptance of the real-

ity of the illness, and fi nally to “an ability to live fully and deeply within the

realistic limits posed by the illness.”

Figure 7-3 Good Cells and Bad Cells: A Child’s Drawing In this drawing by a child with cancer, the health-giving good cells are depicted as being victorious over the diseased bad cells. Such imaginative techniques can be ways of enlisting the patient’s internal resources as an adjunct to conven- tional therapies.

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280 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

Cross-cultural issues are becoming more important in conventional

medicine as well. 57 Instead of viewing such beliefs as irrational or wrong,

physicians are increasingly recognizing that optimal care is often achieved

by judiciously combining conventional biomedicine and folk beliefs, or ethno- medicine. This means physicians must entertain the possibility that practices other than the “culture of biomedicine” may be effective. Arthur Kleinman

says, “If you can’t see that your own culture has its own set of interests, emo-

tions, and biases, how can you expect to deal successfully with someone else’s

culture?” 58

Traditional tribal beliefs are integrated into conventional medicine

to present a holistic approach that Lori Arviso Alvord offers to her Navajo

patients. 59 In this way, Alvord “bridges two worlds of medicine—traditional

Navajo healing and conventional Western medicine—to treat the whole

patient.” 60 When Alvord, a graduate of Stanford University School of Medi-

cine, returned to her Navajo community, she discovered that, although she

was a good doctor, she “was not always a good healer.”

I went back to the healers of my tribe to learn what a surgical residency could

not teach me. From them I have heard a resounding message: Everything in

life is connected. Learn to understand the bonds between humans, spirit, and

nature. Realize that our illness and our healing alike come from maintaining

strong and healthy relationships in every aspect of our lives. 61

Gerry Cox points out that “the basis of care of the dying in Indian cul-

ture lies in nature and healing rituals.” 62

Among some Mexican Americans, traditional practices of curanderismo (from the Spanish verb curar, “to heal”) are an important part of total health care. 63 A study comparing folk healing and biomedicine concluded, “In the

search for the alleviation of pain, pragmatism prevails; people judge the

treatments they are given by their effects.” 64

A standard medical text states, “If the goal is the maintenance of or a

return to health, all available mechanisms should be used.” 65 Many physi-

cians caution, however, that “respect for multiculturalism should not be used

as a sentimental excuse to abandon one’s professional obligation to serve the

patient’s best interest.” 66

The Placebo Effect As the defi nition of medical treatment is changing, so too are attitudes

about placebos. In 2008, Harvard created an institute dedicated to their study,

the Program in Placebo Studies and the Therapeutic Encounter. 67 What

is a placebo? Steven Perlmutter, a doctor and attorney, defi nes it as “a sub-

stance with no known specifi c pharmacologic activity for the condition being

treated.” 68 Placebos may be not only sugar tablets, an isotonic saline solu-

tion, and other non-drug interventions, but also so-called impure placebos—

substances that have known therapeutic actions but not for the disease in

question. A common example is an antibiotic for a non-bacterial infection. In

the case of procedures such as surgery, a sham procedure is used. 69

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Treatment Options and Issues 281

An interesting historical note: The word placebo comes from the Latin for “I will please.” In medieval times, hired mourners participated in Vespers for

the Dead. Because they were hired, the mourners’ emotions were considered

insincere. People called them ‘placebos.’” 70

The “placebo effect” is the positive response to a treatment that a per-

son believes to be an effective therapy. Researchers have found that “simply

believing in a treatment can be as effective as the treatment itself.” 71 In other

words, our expectations have a profound impact on healing, even if “it’s all in

your head.” Perlmutter says, “In general, injections are more potent than oral

medication, capsules work better than tablets, brightly colored remedies are

more effi cacious than muted colors, and two pills work better than one.” 72

A placebo may be justifi ed when physicians think a patient may go “doctor-

shopping” and receive inappropriate or overly aggressive treatment from a

less skilled or more self-serving provider, or when there is a risk of dangerous

“Google self-treatment.” Studies show that common indications for placebo

use include pain and the desire to avoid informing patients that treatment

possibilities are exhausted. Perlmutter points out, “When the disease is incur-

able and the situation is hopeless, the placebo offers a ‘treatment’ option.” 73

Unorthodox Treatment What comes to mind when you hear the word unorthodox? Ineffective?

Outside the establishment? Unorthodox therapies are methods of treatment

that the medical establishment considers unproved or potentially harmful.

The advocates of such remedies may be branded as quacks, charlatans, or

frauds and their methods characterized as updated editions of Dr. Feelgood’s

Medicine Show, a form of snake oil medicine that, even if intrinsically harm-

less, diverts individuals from conventional medicine, which could help them.

Even in the best circumstances, alternative approaches typically make

use of unproved therapies—that is, therapies that have not been subjected to

rigorous scientifi c testing. Such unproved therapies may be launched in the

mass media or via the Internet, a primary source of information on health

issues for many people. A study in Italy found that patients are willing to

try therapies of unknown effi cacy in the hope of being cured: “Ignorance

about the benefi ts of a treatment is what keeps hope alive, whereas knowledge

requires coming to terms with uncertainty especially when the benefi t of a

treatment (such as palliative chemotherapy) is limited.” 74

That a cure could be found in the pits of apricots or shark cartilage

stretches credibility; indeed, such “cures” may be not only controversial

but also dangerous. Yet, many common medications derive from seemingly

unlikely sources. Digitalis, in continuous use for more than two hundred years

and prescribed for heart ailments, comes from the plant foxglove. Penicillin

is naturally produced from molds. The active ingredient of aspirin is close

kin to a substance found in the bark and leaves of the white willow. Perhaps

the source of a proposed medicinal substance should concern us less than

the question, Does it work? In China, about 1700 plants are commonly used

as medicines, and in India that number is about 2500. As scientists seek out

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282 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

“undiscovered” drugs used by healers around the world, the study of medici-

nal plants is increasingly important to pharmacology. 75 Indeed, “Much of the

pharmacopoeia of present-day scientifi c medicine originated in the folk medi-

cine of native people, and many drugs used today are derived from plants.” 76

The debate over the medical use of marijuana has involved confl icts

between law and medicine because the substance in question is not only an

unproved therapy but also a generally illegal one. 77 A review by the Insti-

tute of Medicine concluded that marijuana appears to have a natural role

in modulating and easing pain as well as in treating wasting syndrome, nau-

sea, appetite loss, and anxiety. It noted that studies show that marijuana and

other cannabinoids “may provide useful adjuncts to existing medications.” 78

However, a statement from the federal Food and Drug Administration (FDA)

said there were no sound scientifi c studies to support the medical use of mar-

ijuana. 79 Many physicians, as well as patients, believe further clinical trials

could resolve the question. However, the federal Drug Enforcement Admin-

istration (DEA) routinely refuses to grant universities and pharmaceutical

companies permission to research marijuana use. 80 The outcome of this

ongoing debate remains to be seen.

Anson Shupe and Jeffrey Hadden use the term symbolic healing to identify the varied therapies known under such names as “faith healing,” “supernatu-

ral healing,” and “folk healing.” 81 What we take to be meaningful—what we

believe—potentially affects the functioning of our bodies. As human beings, we

live within a series of overlapping environments: biological, social, and cultural.

Cross-culturally, most healing systems describe illness as “an imbalance among

different realms of a patient’s life.” When alternative therapies help restore this

balance, they are an adjunct to conventional medical treatment. Adjunctive

therapies of this kind are characterized as “complementary therapies.”

Shortly before his death, Norman Cousins said, “The great tragedy of life

is not death but what dies inside us while we live.” 82 The reality of living with

serious or terminal illness can wreak damage on the human spirit, damage

that conventional medical therapies alone may not repair. It may be a mis-

take to confront patients with an either-or situation, forcing them to choose

between conventional and alternative treatments. There are times when rig-

idly defending standard practices can do more harm than good.

Pain Management Pain is the most common symptom in terminally ill patients. “Physical,

often unbearable, suffering is part of everyday life in the world of palliative

care.” 83 A recent review of studies conducted between 1987 and 2007 found

that nearly one of two patients with cancer pain is undertreated, a condition

usually attributed to the inappropriate use of opioids. 84 Pain is now viewed

as a “fi fth vital sign,” one that should be added to the four vital signs (tem-

perature, pulse, respiration, and blood pressure) recorded and assessed as a

standard part of patient care. 85

Pain is a complex, multidimensional phenomenon; the type and sever-

ity of pain can be important diagnostic tools. 86 Acute pain is “an essential

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Treatment Options and Issues 283

biological signal of the potential for or the extent of injury.” 87 It is a protec-

tive mechanism that prompts the sufferer to remove or withdraw from the

source of the pain. 88 Chronic pain, in contrast, is usually defi ned as pain that persists longer than three to six months. When pain lasts this long, it loses

its adaptive role. Chronic pain may be accompanied by sleep disturbances,

loss of appetite, weight loss, and depression. It may also result in diminished

sexual interest and corresponding changes in closeness and intimacy. 89 It can

result from physical mechanisms (somatogenic pain), psychological mecha-

nisms (psychogenic pain), the activation of pain-sensitive nerve fi bers (noci-

ceptive pain), or nerve-tissue damage (neuropathic pain).

The Language of Pain People often speak of pain as if it were a well-defi ned entity, but, in fact, as

Linda Garro points out, pain is “subjective in nature and ultimately unshare-

able.” 90 Garro says, “Pain cannot be directly measured or observed; it is a

perceptual experience that can only be communicated through verbal means

and/or by behavior interpreted as indicating pain.” Culturally related belief

systems have a dramatic impact on how patients “represent” their illness, as

well as on their coping responses.

Languages differ in their lexicon for talking about pain. When describ-

ing pain, English speakers use such terms as pain, hurt, sore, and ache. Quali- fi ers are added to make the description match the experience. We talk about

having a “burning” or “stabbing” pain or about “unbearable ache” or “sore-

ness in the shoulder.” Notice the tendency to treat pain as an object: “I have a

pain.” For Thai speakers, the basic terms for describing pain are verbs, refer-

ring to the active perception of sensations and often conveying the location

of the pain as well; for example, “suffering focused abdominal pain” or “feel-

ing irritated by an abrasion.” Pain is described not as an object but as a per-

ceptual process. Our response to pain, at least in part, is culturally shaped.

Treating Pain Yvette Colón of the American Pain Foundation points out that “the belief

that pain is real is a critical fi rst step in assessing and managing that pain.” 91

Effective treatment of pain requires attention to, among other factors, its

The family of an elderly terminal cancer patient sued a nursing home that uni-

laterally reduced his pain medication without seeking approval from his doctor,

a decision that caused the 75-year-old patient increased suffering. Deciding that

the patient was “addicted to morphine,” the nursing home staff substituted a “mild

tranquilizer,” which failed to control his pain. In response to the lawsuit, the nurs-

ing director at the facility said: “I have never heard of giving such high doses, at

such frequent intervals. .  .  . The staff and I did not think he needed that much

morphine.”

Maureen Cushing, “Pain Management on Trial”

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284 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

severity, location, quality, duration, and course, as well as the “meaning” of

pain to the patient. Patients may experience different mechanisms of pain

operating simultaneously. 92 It is important to distinguish between pain and

suffering, especially with patients, “whose suffering may be due as much to loss of function and fear of impending death as to pain.” 93

Pain is generally managed in a stepwise approach, beginning with basic

non-opioid pain relievers such as aspirin, acetaminophen, and nonsteroidal

anti-infl ammatories (NSAIDs); then, if necessary, moving to opioid deriva-

tives like codeine or tramadol; and, if pain is not relieved, using strong opi-

oids such as morphine and fentanyl. 94 A combination of treatments is usually

most effective. Numerous studies have shown that when these guidelines are

followed, 90 percent of patients are pain free. 95 Colón says, “Something can

always be done to manage pain.”

The most useful agents for the treatment of pain associated with advanced

disease are opioid analgesics. Yet, 80 percent of the world’s population lacks

adequate access to opiod medications for pain control. 96 Morphine is the

gold standard of analgesics and a cornerstone for management of serious

pain, although the development of new drugs and formulations of different

opioids has enlarged the therapeutic arsenal. 97 Morphine works effectively to

manage pain because it taps into the body’s own pain relief system, the neu-

rotransmitters, one class of which is chemically similar to morphine.

The good news is that (1) it is not diffi cult to assess and treat pain and

that (2) physicians and other medical personnel are paying more attention to

pain. 98 The not-so-good news is that there are doctors, nurses, and pharma-

cists whose misunderstandings about opioid analgesics, such as morphine,

prevent patients from receiving adequate pain control. 99

Pain specialists say that medicine has the means to alleviate the pain and

suffering of almost all dying patients; it is the will to treat pain effectively that

is lacking (see Table 7-6 ). There is a distinction between addiction (in which

drug-seeking behavior occurs in an effort to reproduce the high) and physi-

cal dependence (which simply results in an abstinence syndrome after the

• Medical personnel have concerns that patients may become addicted, so they either don’t prescribe appropriate drugs or prescribe only low, insuffi cient doses of medications that would be helpful in adequate dosages.

• Physicians are afraid to prescribe powerful narcotics due to concern about prosecution by overzealous law enforcers.

• Patients feel they should silently live with pain as a sign of moral strength or stoicism.

• Patients worry that, if they use strong painkillers now, nothing will be available later when pain may become worse; in fact, however, for most people there is no upper limit to the ability of narcotics like morphine to control pain.

• Many doctors really don’t know much about how to control pain. There is a severe lack of training and information about the principles of pain management and palliative medicine.

t a b l e 7-6 Factors That Inhibit Adequate Pain Control

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Treatment Options and Issues 285

patient stops taking the drug). A common misconception is that patients with

severe pain obtain pleasant, euphoric sensations from drugs.

Governmental regulation can adversely affect pain management as an

unintended side effect of fi ghting abuse. A Medscape poll of physicians found

that 86 percent said there was little or no cooperation between clinicians and

the DEA. Thus, the “politics of pain management” is a factor in determining

whether pain is treated adequately.

Advances in pain management are occurring as the pathways of pain and

its mechanisms become better understood. Pain can be treated with a vari-

ety of medical techniques, including nerve blocks, electrical stimulation of

nerves, and neurosurgery. Patient-controlled analgesia (PCA), a mechanism

that allows patients to determine for themselves the best timing of pain relief,

is often more effective than relying on caregivers for an injection or a tablet

after pain has worsened. Epidural and intraspinal drug delivery—placement

of a slow, steady stream of morphine directly into the spinal column—is used

effectively with some dying patients. In addition, antidepressants and other

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286 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

drugs are prescribed to relieve anxiety, confusion, and depression. Finally,

drugs can be given to minimize the distressing effects of constipation, nau-

sea, respiratory depression, and other physical symptoms.

Controlling pain in patients near the end of life presents a formidable chal-

lenge requiring specialized attention by skilled professionals. However, effective

techniques for pain control are known and accessible. Hospice and palliative

care practitioners have been at the forefront in calling attention to adequate

pain management, especially in terms of responding to a patient’s “total pain,”

which includes physical, psychological, social, and spiritual components. 100

The Dying Trajectory Our expectations about dying may be quite different from what most people

actually experience. Young adults tend to imagine themselves living into old

age and then quickly dying at home, alert and lucid until the end. 101 Pain and

discomforts of dying tend to be absent from these imagined deathbed scenes.

Our pictures of dying may be infl uenced more by images from movies and

other media than by what is likely to actually occur.

The concept of a trajectory of dying is useful for understanding patients’ experiences as they near death. Although sudden death from an unexpected

cause—a massive heart attack or an accident, for example—is one type of

dying trajectory, our focus here is on deaths that occur when there is fore-

warning. Among these, some trajectories involve a steady and fairly pre-

dictable decline. This is the case with many cancers, which tend to follow

the course of a progressive disease with a terminal phase. Other kinds of

advanced chronic illness involve a long period of slow decline marked by epi-

sodes of crisis, the last of which proves to be “suddenly” fatal.

We can also distinguish between different stages in a dying trajectory:

namely, a period in which a person is known to be terminally ill but is liv-

ing with a life expectancy of perhaps weeks or months, possibly years; and

a later period in which death is imminent and the person is described as

“actively dying.” The way such trajectories are estimated—their duration and

expected course—can affect both patients and caregivers and can infl uence

their actions. Deaths that occur “out of time” (too quickly or too slowly) may

pose special diffi culties.

In addition to the expected quick trajectory, in which an individual makes a sudden exit, as in accidents or other emergency situations when life or

death hangs in the balance, researchers have described the lingering trajec- tory, in which a patient’s life fades away slowly and inevitably. 102 This second

trajectory, which applies to people with progressive chronic illnesses who are

receiving palliative care, can be further subdivided into three distinct trajec-

tories for different diseases (see Figure 7-4 ). 103

• Trajectory 1: Short period of evident decline. There is a reasonably pre- dictable decline over a period of weeks, months, or, in some cases, years.

This is a trajectory with steady progression and usually a clear terminal

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The Dying Trajectory 287

phase. There is usually time to anticipate palliative needs and plan for

end-of-life care. This is typically the case with cancer. • Trajectory 2: Long-term limitations with intermittent serious episodes.

This is a trajectory with gradual decline, punctuated by periods of acute

deterioration and some recovery, with seemingly unexpected “sudden”

death. Heart failure and respiratory illnesses are examples. • Trajectory 3: Prolonged gradual decline or “dwindling.” This is a trajectory

of progressive disability from an already low level of cognitive or physi-

cal functioning, with patients dying from minor physical events that may

seem trivial, but, occurring in combination with declining reserves, prove

fatal. Examples include death in old age from such illnesses as Alzheimer’s

or other dementia, or from generalized frailty of multiple body systems.

An acute stroke, for instance, could result in a swift decline, as in trajec-

tory 1; a series of smaller strokes and recovery could mimic trajectory 2; and

gradual decline due to stroke sequelae could parallel trajectory 3. A central

point is that different models of care will be appropriate for people with dif-

ferent illness trajectories. “The key to caring well for people who will die in

the (relatively) near future is to understand how they may die, and then plan

appropriately.” 104

Death

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Death

Mostly frailty and dementia

High

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Figure 7-4 (c) Trajectory 3

The three trajectories of decline shown here are typical of chronic illness, especially in the elderly. Trajectory 1, typical of cancer, depicts a steady progression of disease followed by a relatively rapid period of decline preceding death. Trajec- tory 2, typical of organ failure, shows long-term limitations with occasional serious episodes requiring emergency hospital admissions, fol- lowed by a fi nal episode leading to a “sudden” death. Trajectory 3, typical of frailty, dementia, and disabling stroke, presents prolonged decline with gradual disability and generalized failure of multiple systems.

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288 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

Common Symptoms During Last Days or Hours . . . • Body systems slow down. • Breathing pattern changes and becomes irregular (for example, shallow breaths

followed by deep breath; periods of panting). • Diffi culty breathing (dyspnea). • Congestion (noisy and moist breathing; gurgling sounds). • Decrease in appetite and thirst. • Nausea and vomiting. • Incontinence. • Sweating. • Restlessness and agitation (for example, jerking, twitching, pulling at bed linen or

clothing). • Disorientation and confusion (for example, about time, place, identity of people). • Decreased socialization; progressive detachment. • Changes in skin color as circulation decreases (limbs may become cool and

perhaps bluish or mottled). • Increased sleeping. • Decrease in consciousness.

At Time of Death . . . • Relaxing of the throat muscles or secretions in the throat may cause noisy

breathing (the “death rattle”). • Breathing ceases. • Muscle contractions may occur, and the chest may heave as if to breathe. • Heart may beat a few minutes after breathing stops, and a brief seizure may occur. • Heartbeat ceases. • Person cannot be aroused. • Eyelids may be partly open with the eyes in a fi xed stare. • Mouth may fall open as the jaw relaxes. • Bowel and bladder contents may be released.

t a b l e 7-7 Signs of “Active Dying”

The end of life is characterized by what is termed active dying (see Table  7-7 ). Among the signs that death is near are loss of appetite, exces-

sive fatigue and sleep, increased physical weakness, and social withdrawal.

The end stage is expected to last only hours or at most a few days. Pain should

be treated aggressively as part of a comprehensive approach to comfort care.

Some patients, even near death, still have concerns about addiction or want

to delay pain medication “until it is really needed” or want to maintain con-

trol by “using the pain as a reminder that they are still living.” 105

During this phase, a dying person may exhibit irregular breathing or

shortness of breath, nausea and vomiting, incontinence, and decreased appe-

tite and thirst. People near the end of life are often more comfortable with-

out food or liquids.

Dying patients may also experience confusion, delirium, disorientation,

and diminished consciousness, as well as anxiety, agitation, and restlessness.

A distinction is made between restlessness as a general symptom and the med-

ical emergency referred to as terminal restlessness (also referred to as terminal delirium and agitation delirium ). 106 Symptoms can include inability to maintain

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The Social Role of the Dying Patient 289

attention or relax, disturbances in sleep or rest patterns, mumbling speech,

twitching, trying to climb out of bed, picking at clothes, and other agitated

motor activity. Such symptoms can be disturbing and even overwhelming for

families who are unfamiliar with behaviors near the end of life.

As death becomes imminent, relaxation of the throat muscles or secre-

tions in the throat may cause the person’s breathing to become noisy, result-

ing in a sound called the “death rattle.” Dying persons usually are not aware

of this noisy breathing. If the sound unnerves family or caregivers, medica-

tion or repositioning the person can help. Just before death, the dying per-

son may take a breath and sigh or shudder. After death, unless the person

had a rare infectious disease, family and friends may stay with the body for a

time as they make their farewells.

The Social Role of the Dying Patient Eric Cassell writes, “There are two distinct things happening to the terminally

ill: the death of the body and the passing of the person.” 107 The death of the

body is a physical phenomenon, whereas the passing of the person is non-

physical (social, emotional, psychological, spiritual). When we focus on the

former and neglect the latter, biological death may be preceded by social death. “Being healthy” is a vital characteristic of our social world. Sociologist

Talcott Parsons tells us that illness is accompanied by a particular social

role. 108 A sick person is obligated to engage in a supervised attempt to get

well. Like all social roles—parent, child, student, employee, spouse—the role

of the “person who is sick” includes rights and responsibilities. Illness tends

to excuse a person from his or her usual tasks. Other people make allowances

for our behavior. We are granted the right to be sick. Whereas taking off

from work just to enjoy a day in the sun is frowned upon, absence due to ill-

ness elicits sympathy rather than reprimands. The sick person not only enjoys

exemptions from usual social obligations but also is given special care. Such

care is part of the role of being sick, of being a patient. But these “rights” are

balanced by responsibilities. The sick person must cooperate with his or her

caregivers. You’ve got to take your medicine.

In coping with life-threatening illness, individuals often fi nd ways to

redefi ne their situation so that they still feel “healthy.” A woman with meta-

static cancer said, “I am really very healthy. I just have this problem, but I am

still me.” Her statement shows a sense of self-integrity that demonstrates an

ability to go on with life despite the disease. 109

When life-threatening illness becomes terminal illness, the parameters of

the “sick role” described by Parsons do not apply. Now, illness is no longer a

temporary condition expected to be followed by a return to wellness. However,

society has not clearly defi ned a social role for the dying person. 110 Even when

circumstances are contrary, the dying person may be urged to deny the real-

ity of his or her experience, to hope for recovery. This can result in actions

that are incongruous. Consider, for example, the image of an end-stage, ter-

minally ill person being rushed to the ICU (intensive care unit) and subjected

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290 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

to heroic attempts to sustain his or her life. This image is real more often than

we wish to admit.

What would an appropriate social role for the dying look like? First, the

dying person would not be expected to maintain the appearance of expecting

to live forever, of getting well again, of sustaining false hope. Instead, he or she

would be encouraged to mobilize the resources necessary for attending to the

prospect of death. Relatives and friends, accepting this changed perspective

as natural, would allow the patient to set his or her own agenda about activi-

ties and relationships as the end of life draws closer. 111 In a study of “farewells

by the dying,” most people wanted to express their farewells through giving

gifts, writing letters, and informal conversations with those closest to them. 112

Valued relationships are important for most people right to the end of life. Ira

Byock suggests that persons who are dying—and, indeed, this suggestion is for

everyone—make a point of expressing the “four things that matter”: Please

forgive me. I forgive you. Thank you. I love you. 113

As a person begins to recognize his or her impending death, this

acknowledgment may stimulate a period of life review, an assessment of one’s

After being diagnosed with a recurrence of cancer, Vernon Nantz chose to be cared for at home by family and friends, with the support of hospice. In his last days, Vernon’s family united in tears and prayers, sharing a vigil around his bedside, as he drifted away to the peaceful end he sought.

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The Social Role of the Dying Patient 291

accomplishments in life: What have I achieved or failed to achieve? How have

I contributed to others’ well-being or to the betterment of humankind? Have

I met my expectations for a life well lived? How will my reputation fare after

I’m gone? Has life been “fair”? Has “good luck” outweighed the bad? In short,

what is the “balance sheet” of my life?

Reviewing the course of a life can empower that person to make the

choices he or she values in completing the last chapter of life. Reviewing

relationships and events, the person gains an opportunity to complete unfi n-

ished business. However, as Stephen Connor says:

Hospice and palliative care workers cannot impose their ideas of how one

should react or respond. They may have the idea that dying people should

always say goodbye to their families. This is laudable, but in each life there are

many different relationships, and not all of them can be resolved. All people die

with some unfi nished business. 114

As a person realizes that he or she is nearing the end of life, the most

important thing may be “to believe that life has, if not a purpose, at least a

singularity that makes it memorable.” 115

In his work as a volunteer with Capital Hospice (now Capital Caring) in

Arlington, Virginia, Thomas Lyons describes how a patient’s review of his or

her life can result in a precious legacy for family and friends:

These patients tell me their personal story while I fi lm them. I edit the result and

add text, titles, and music to produce a personalized DVD, which contains the

image of the person, their voice, their expressions and gestures, and the stories

they cherish enough to tell at the end of their life. They, of course, do this to be

remembered, and I do my best to provide this service for them. 116

Lyons says his experience is that hospice patients who want to make a

Legacy Movie fall into three categories: (1) They want to leave their life story

for their family, (2) They want to leave a personal message for a spouse, young

children, or grandchildren, or (3) They want to recollect and review the

worthwhile memories of a lifetime, which distracts them from their present

circumstances and helps them validate themselves. “It is my honor to help

them fulfi ll any of these goals,” says Lyons.

Allan Kellehear reminds us that experiences of courage, love, and posi-

tive transformation are an under-described phenomenon in the literature of

dying. 117 These are qualities that make facing death bearable. Living with life-

threatening illness is not all suffering, sadness, anger, and fear. Ira Byock says,

“In assisting people with the diffi cult tasks of life completion, palliative care

extends beyond management of symptoms to focus on the priorities of the indi-

vidual and family.” 118 We see, then, that a social role of the dying encompasses

spiritual needs as well as physical and emotional ones. Spiritual needs include: 119

1. The need for meaning and purpose. This involves reviewing one’s life (includ- ing relationships, work, other achievements, and religious concerns) and

attempting to make sense of it, to place it within a larger perspective that

has meaning.

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292 c h a p t e r 7 Facing Death: Living with Life-Threatening Illness

2. The need for hope and creativity. Whereas the fi rst item involves looking back over one’s life to discover meaning and purpose, this one is oriented toward

the future. It may involve the aspiration for improved well-being, for being

free of pain; the desire to accomplish a personal goal or to achieve recon-

ciliation with others; or the hope of an afterlife. This need may also center

on the hope “that that which has been of meaning and purpose to the

individual may be affi rmed by those who are important to him or her.”

3. The need to give and receive love. “We all need to be reassured that we are loved and that others need our love.” 120 Reconciliation is a key element in

satisfying this human spiritual need.

Being with Someone Who is Dying People often feel uncomfortable in the presence of someone diagnosed with

a life-threatening illness. What can we say? How should we act? Perhaps it

seems that anything we might think of to express our thoughts or feelings

would come out as nothing more than a stale platitude. Discomfort may be

exhibited through either excessive sympathy or obsessive avoidance while we

shy away from real communication. As an antidote to such responses, it is

helpful to keep in mind that the essence of caregiving is to leave your own

agenda at the door and to be present to whatever the person needs. Keep in

mind, too, the crucial difference between dying (still alive) and death.

Often, the only task that matters in being with someone who is dying is to

sit still and listen to the stories. In a talk to volunteers at San Francisco’s Zen

Hospice Project, Tenshin Reb Anderson expressed it this way: “Stay close and

do nothing.” 121 Near the end of life, an individual may attend to a variety of

interrelated concerns and activities, such as these: 122

• Re-examining beliefs • Reconciling life choices • Exploring lifetime contributions • Examining loving relationships • Exploring ideas and beliefs about an afterlife • Discovering meaning

“How are you doing?” Every day millions of people ask that question to millions

of other people who respond “Fine,” even though both may be suffering greatly.

The ending of a life can offer precious opportunities for authentic connections

between people who care deeply for each other but may withhold their feelings to

maintain a façade of strength and protect a loved one from overwhelming emo-

tions. The admission of fears and anxieties does not indicate weakness. Listening

to one another exchange honest expressions of sadness and loss as well as words of

love can be both gratifying and consoling.

Susan Dolan and Audrey Vizzard, The End of Life Advisor

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Further Readings 293

By staying close and doing nothing special, we can accompany the person

we love along the passage to death’s door.

In an essay titled “The Eyes of a Dying Man,” Japanese author Yasunari

Kawabata suggests that the human longing for beauty is realized in a special

way by people who are dying. This theme is echoed in his stories as well. For

example, in “The Moon in the Water,” a dying man fi nds an enhanced appre-

ciation of the beauty of nature. In The Sound of the Mountain, an aged man, approaching death, enjoys an intensifi ed awareness of the beauty of the hero-

ine Kikuko. Finally, in “House of the Sleeping Beauties,” the “beauties” are

all the more beautiful because they are seen through the eyes of old Eguchi,

who knows his days are numbered. 123

Being with someone who is seriously ill or dying, we confront our own

mortality. We come to appreciate how precious life is and how uncertain. Few

occasions in life present us with the chance to be so vulnerable to aspects

of ourselves that are usually kept hidden. Jitaro Mizuno says, “It is through

the act of caring for another person that the existence of what we call ‘the

self’ becomes clear.” 124 Being with someone who is dying can surprise us with

moments of grace and beauty. In describing the end of her mother’s life and

her death, Janmarie Silvera describes how the blossoming of a “huge, lumi-

nous full moon” through a hospital window became an occasion of “wonder-

ment,” a moment of intimacy acknowledging both life and death. 125

Further Readings Joan Berzoff and Phyllis R. Silverman. Living with Dying: A Handbook for End-of-Life

Healthcare Practitioners. New York: Columbia University Press, 2004. Pauline W. Chen. Final Exam: A Surgeon’s Refl ections on Mortality. New York: Knopf,

2007.

Kenneth J. Doka and Amy S. Tucci, eds. Beyond Kübler-Ross: New Perspectives on Death, Dying, and Grief. Washington, D.C.: Hospice Foundation of America, 2011.

Christopher Hitchens. Mortality. New York: Twelve, 2012. Allan Kellehear. The Inner Life of the Dying Person. New York: Columbia University

Press, 2014.

Joanne Lynn, Joan Harrold, and Janice Lynch Schuster. Handbook for Mortals: Guid- ance for People Facing Serious Illness, 2nd ed. New York: Oxford University Press, 2011.

Ernest H. Rosenbaum and Isadora Rosenbaum. Supportive Cancer Care: The Complete Guide for Patients and Their Families. Naperville, Ill.: Sourcebooks, 2001.

L. Eugene Thomas. “Personal Refl ections on Terminal Illness After Twenty Years of

Teaching a Death and Dying Course,” Omega: Journal of Death and Dying 43, no. 2 (2001): 119–127.

Jonathan S. Watts and Tomatsu Yoshiharu, eds. Buddhist Care for the Dying and Bereaved. Boston: Wisdom, 2012.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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Familiarity with the choices available in funeral services can help us appreciate our many options, perhaps alleviating some of the stress of making such choices in the midst of crisis. The roles of the funeral director and others who can provide assistance in coping with the practical matters of death may also be better understood.

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295

C H A P T E R 8

Last Rites: Funerals and Body

Disposition

F uneral rites have been characterized as “the most signifi cant of the rites of passage in our progress from womb to tomb.” 1 As you begin to think about the signifi cance of funer-

als, consider these questions: Who does the funeral serve, the living or the dead? What is the

purpose, socially and psychologically, of last rites? How do the ceremonies that a community

enacts to mark the passing of one of its members express, through symbol and metaphor,

how death is perceived within a particular social group? 2 Consider the following description

of the royal funeral for Alexander the Great.

The hearse itself took two years to build and took the form of an Ionic temple, roofed with gold,

inside which Alexander’s mummy was enclosed in a golden sarcophagus over which was draped

his purple cloak. Golden nets prevented the profane gaze from falling on it and no fewer than

64 mules were needed to drag the hearse on its lengthy processional route. 3

What messages did this funeral communicate to the onlookers? In what ways was this a

fi tting ceremony within Alexander’s social group? Did these actions fulfi ll the purposes of

last rites?

Funeral ritual “permits meaningful action at a chaotic time” and “offers cues as to what

we are supposed to feel and models how we are to mourn.” 4 Thus, funerals can have an effect

on how we grieve. Learning the technique of ritual is likened to learning to play a musical

instrument: “Once we master the scales and chords and gain suffi cient dexterity in the use of

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296 c h a p t e r 8 Last Rites: Funerals and Body Disposition

our fi ngers, we can play the piano in such a manner as to release our aes-

thetic feelings. This inner ecstasy of performance is open to those who prac-

tice ritual as well.” 5

In contrast to cultures that view the funeral as a means to prepare the

dead for a successful migration to the afterworld, funerals in the United

States are focused mainly on the welfare of survivors. Funerals provide a set-

ting wherein the bereaved family makes a public statement that one of its

members has died. The wider community uses the occasion to respond with

sympathy and support for the bereaved. Vanderlyn Pine points out that the

funeral historically has addressed four major social functions: 6

1. It serves to acknowledge and commemorate a person’s death.

2. It provides a setting for the disposition of the dead body.

3. It assists in reorienting the bereaved to their lives, which have been rup-

tured by the death.

4. It demonstrates reciprocal economic and social obligations between the

bereaved and their social world.

Traditionally, funeral rites begin with the gathering of family and friends

for a “deathwatch” to accompany the dying person in his or her last hours,

and they formally end with the disposition of the corpse (see Table 8-1 ). His-

torically, in African American culture, it was customary, immediately after a

death, to have a “settin’ up,” at which friends and family would stay with the

body as the soul or spirit began its journey to the next world. 7

In other contexts, “settin’ up” is referred to as a wake. A wake is a vigil (usu- ally) held prior to burial at which those close to the deceased keep watch over

the body. Wakes are said to “have a transforming effect on friends and family,

not only helping them adjust to life without the departed, but also re-creating

their bonds.” 8 Another funeral tradition is the “funeral meal.” 9 It sometimes

takes place during the wake; in other instances, it takes place after the cer-

emony and disposition. In the South, for example, people gather and bring

foods that were favored by the deceased as well as other regional favorites—

fried chicken, greens, baked beans, ham, molasses pie, macaroni and cheese,

iced tea—and share a meal as well as memories. There can be a sense of “sacred

space and time” as the bereaved enjoy food and fellowship. Depending on indi-

vidual and cultural preferences, funerals today do not always include all of the

traditional elements shown in Table 8-1 , and some of them may be abbreviated.

Music may be employed to evoke the emotions of the bereaved or mem-

ories of the deceased. 10 Selection of music is often very important. Consid-

erations include the role of music in shaping and managing the ceremony,

providing comfort to survivors, and creating meaning relative to the life of

the deceased and his or her relationships with the bereaved. Sue Adamson

and Margaret Holloway say, “Music is not just an important feature of contem- porary funerals, it offers an interpretive lens through which we may under-

stand the complex interweaving of personalized, customized meanings with

social and cultural purposes and traditional frames of reference.” 11

Samuel Barber’s Adagio for Strings was played at the funerals of Franklin Delano Roosevelt and John F. Kennedy. This piece of music is often used

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Last Rites: Funerals and Body Disposition 297

1. Deathwatch (also known as the “death vigil” or “sitting up”). As death nears, rela- tives and friends gather to say farewells and show respect for the dying person, as well as to give support and care to his or her family. Historically, a deathwatch might continue for hours, days, or even weeks or months.

2. Preparation of the deceased. Involves various tasks associated with preparing the corpse for ultimate disposition, usually burial or cremation.

3. Wake (also known as “visitation” or “calling hours”). Traditionally held on the night after death occurs, this practice involves laying out the corpse and keep- ing a watch or “wake” over it. Historically, wakes were observed as a safeguard against premature burial, as an opportunity to pay respects to the deceased, and, in some cultures, as an occasion for lively festivities focused on allaying fears by “rousing the ghost.”

With changes in the social patterns of mourning, the traditional wake has been transformed into the practice of setting aside time for viewing of the body prior to the funeral service. As with traditional wakes, the modern visitation offers opportunities for social interactions that can be healing in the aftermath of loss.

4. Funeral. As the centerpiece of the ritual surrounding death, the funeral is a rite of passage for both the deceased and his or her survivors. Services are usually held in a mortuary chapel or church, although they may be held in the home or at the gravesite. The body may or may not be present; if it is present, the casket may be open or closed. Funeral services typically include music, prayers, read- ings from scripture or other poetry or prose, a eulogy honoring the life of the deceased, and, less frequently, a funeral sermon focusing on the role of death in human life in general. In modern times, funerals are usually held within a few days after death, and they are increasingly scheduled in the evening or on week- ends so mourners who work during the week can attend the service.

5. Procession. Traditionally, funerals include a procession conveying the corpse from the site of the funeral to the place of burial. It is considered an honor to be among the friends and relatives chosen to carry the deceased’s body to its fi nal resting place. Funerals for national leaders and other notables may include a lengthy pro- cession, or cortege, in which the corpse is attended by honorary pallbearers.

6. Committal. A ceremony held at the grave or crematorium, the committal service is held after, or sometimes in lieu of, the funeral service. When it follows a funeral service, it usually consists of a brief ceremony focusing on disposition of the deceased’s remains.

7. Disposal of the corpse. In modern societies, disposition usually means burial or cremation.

t a b l e 8-1 Elements of Funeral Ritual

as background for solemn refl ections. Chopin’s Funeral March and George Frederick Handel’s Dead March are also favored by many funeral planners. 12

The “second line” march (or jazz funeral) of New Orleans brass bands

are processions that typically occur alongside a conventional funeral at a

church or mortuary.

The tradition of funerals with brass bands is rooted in the many benevolent

associations that sprang up among African Americans in New Orleans and

offered, among other things, burial insurance to members. Another benefi t

was the option of having a brass band (or bands) play for your funeral, both as

a celebration of life and as a throwback to the ancient Christian and African

traditions of rejoicing when you die. 13

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298 c h a p t e r 8 Last Rites: Funerals and Body Disposition

On the walk to the cemetery, the music is slow, dirgelike, and solemn.

Returning, it is fast, joyful, and uplifting. This New Orleans tradition, which

has elements of both African and Afro-Caribbean traditions, has been called

“a celebration of the soul’s entrance into heaven.” 14

On the value of learning about death rituals in other cultures, William

Hoy says, “Through the exploration of rituals, new insights develop about

the way the world’s people face death in their families and communities.” 15

Review the descriptions given in Table 8-1 and consider which of the ele-

ments you believe would have value in planning a funeral for a loved one or

which you would want to have included as part of your own last rites.

Psychosocial Aspects of Last Rites Just as people gather to commemorate other major transitions in a person’s

life, such as birth and marriage, funerals and memorial services are rites of

passage that honor a person’s life in a community and acknowledge his or

her passing from that community. Funerals and memorial services provide

a framework that allows survivors to support one another as they cope with

their loss and express their grief. The presence of death rites in every human

culture suggests that they serve innate human needs. Thomas Lynch, author

of The Undertaking: Life Studies from the Dismal Trade, makes the observation that “funerals are the way we close the gap between the death that happens

and the death that matters.” 16

Announcement of Death When a person dies, fi rst to learn of it, besides those present at the time

of death, are usually members of the person’s immediate family. Then, in a

widening circle of relatives, friends, and acquaintances, others affected by

the death are notifi ed. In his classic study Passing On: The Social Organiza- tion of Dying, David Sudnow observed that announcements of death usually occur in a consistent pattern from the immediate family to the wider com-

munity (see Figure  8-1 ). 17 Those with closest relationships to the deceased

are told fi rst, followed by those with less intimate relationships. Futhermore,

announcements generally take place between people in a peer relationship.

For example, a bereaved mother might fi rst call the child who had been clos-

est to the deceased, and that person then calls other brothers and sisters.

They in turn notify more distant kin. A similar pattern occurs among people

not directly related to the deceased. For instance, a coworker or neighbor

who learns of the death tells others who had a similar relationship with the

deceased. Ideally, this process—taking in a gradually widening circle of rela-

tives, friends, and acquaintances—continues until everyone affected by the

death is notifi ed.

Human beings have an inherent need to respond to the death of some-

one who has been signifi cant to them. Thus, it is important for this notifi ca-

tion process to occur in a timely fashion so that those affected by the death

are able to come together in a spirit of mutual support to grieve their loss.

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Psychosocial Aspects of Last Rites 299

Figure 8-1 Widening Circles of Death Announcement

Relatives Friends Immediate family

Acquaintances and community

NEWS OF DEATH

Hospital personnel

Police

Coroner

Figure 8-2 Newspaper Obituary

Announcements of death also take place by means of notices and obituar-

ies that appear in newspapers (see Figure  8-2 ). When an announcement

does not appear in a timely fashion, it can be upsetting. The following com-

plaint is typical: “The obituary did not appear in the newspaper until the

morning of the funeral. We had a number of calls and letters from people

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300 c h a p t e r 8 Last Rites: Funerals and Body Disposition

who didn’t know about the funeral until it was too late to attend.” The

belatedly notifi ed person may feel that he or she is alone in dealing with

grief. The value placed on timely notifi cation within the African American

community is underscored by Ronald Barrett: “The immediacy of notifi ca-

tion is equated with importance and respect. To not be informed of the

death in a timely manner is considered insensitive, lacking respect, and an

insult.” 18

When the deceased is well known, news of the death is broadcast more

widely. The death of President John F. Kennedy, for example, was known by

about 90 percent of the American people within an hour of its offi cial pro-

nouncement at Parkland Hospital in Dallas. 19

Death notifi cation also helps set apart the bereaved during the period

of mourning. Traditionally, the black armband, mourning colors and cloth-

ing, and other signs and symbols distinguished the bereaved person. Such

signs of mourning have all but vanished in North America. Still, people feel

that the bereaved deserve special consideration, especially during the initial

period of mourning.

A woman who became involved in a minor automobile accident several

days after the death of her child said later that she wished she could have had

a banner proclaiming her status as a “mother whose child has just died.” With

no outward symbol of her bereavement, she was subjected, as any of us would

be, to the strain of waiting around and fi lling in seemingly endless accident

report forms. Had she lived in a small town, the process of death notifi cation

itself might have set her apart in such a way that the task of completing the

paperwork would have been made easier.

The Internet, with its worlds of online gamers and social networks, has

created a need for a new kind of death announcement. 20 When one man died

after an argument in the middle of a multiplayer game, his friends thought

that he had just logged off the site and needed some time to cool off. When

he didn’t return after several weeks, they fi gured he must have been angrier

than they thought. Only when the man’s daughter searched online for the

guild he belonged to did his fellow gamers fi nd out that he had died from an

abdominal aneurysm.

Because of situations like this, and because online social networks are

becoming ever more important in our lives, Web sites have been set up to

notify online friends of a death. One site, Deathswitch, allows people to set

up e-mail death notifi cations that will be sent automatically if the person

doesn’t check in at specifi ed intervals. Another site, Slightly Morbid, requires

customers to give a trusted friend or family member a password to start the

announcement process. One gamer commented, “People die all the time, but

you never really think about how people online are real people and could die

and you’d never know about it.” 21

The Internet sometimes brings announcement of death that outruns the

coroner’s notifi cation. A mother whose son died in an automobile accident

learned of his death through a Facebook posting while the coroner was on

her way to notify the family.

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Psychosocial Aspects of Last Rites 301

Mutual Support When people learn about the death of a person who is signifi cant to

them, they tend to gather together, closing ranks to provide support and

comfort in their mutual bereavement. This emotional and social support

is directed primarily toward the bereaved family. When a small child asked

her mother why they were going to visit a bereaved family, the mother

replied, “It’s important for people to know that you care.” What we think

we can or cannot do for the bereaved family matters little; what counts is

that we show our care and concern. J. Z. Young says, “Probably the very act

of coming together symbolizes communication.” 22 Assembling as a commu-

nity reassures us that we are part of a larger whole, thereby strengthening

our individual lives.

Gathering at the home of the bereaved is a unique social occasion. Some

people stay only a short time, express condolences, and leave. Others, usually

relatives or close friends, stay for a longer time, perhaps assisting with the

The funeral has traditionally been a time when family and friends come together to pay respects and to say farewells. It is a time of mutual support for the bereaved and of tribute to the deceased. The display of fl owers surrounding this coffi n bespeaks the affection felt for the deceased while she was alive and the sense of loss at her absence from the community.

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302 c h a p t e r 8 Last Rites: Funerals and Body Disposition

preparation of food, caring for children, helping with funeral arrangements,

greeting visitors, and doing whatever else needs doing.

Funeral rituals embody the rhythms of separation and integration. Death

is a change of status both for the person who dies and for his or her survivors.

This change of status is refl ected in language when we refer to someone as a

“widow” or “widower.” This special designation for a bereaved spouse affi rms

the social and psychological impact associated with the death of a mate.

Based on a cross-cultural investigation of funeral rites, Vernon Reynolds and

Ralph Tanner conclude,

The importance of the rituals of death is that they are socioreligious

requirements which have to be carried out by the bereaved within the social

context of friends, relatives, and neighbors who are less bereaved. The bereaved

are not left alone to generate and multiply the psychosomatic symptoms of

their grief, but are required to be active, and in many cultures there is a special

role for bereaved persons over quite a long period . . . at the end of which their

recovery from bereavement is well advanced. 23

Impetus for Coping with Loss Announcements, visiting the bereaved, and other after-death rituals

are forms of social interaction that provide a potent psychological impetus

for realizing a loss. While these social interactions are crucial, it is impor-

tant to remember that the death of a person is experienced not only within

a social setting but also within the psyche of the bereaved individual. When

death occurs, an immediate concern of survivors is the disposition of the

corpse. This process involves both a mental activity (deciding what is to be

done) and a physical activity (carrying out the action decided upon). Mak-

ing arrangements for the disposition of the body engages survivors in a

process that reinforces the recognition that the deceased person is really

dead. This acknowledgment occurs whether the survivor actively constructs

the coffi n and digs the grave or simply talks with someone about funeral

arrangements.

The funeral itself offers a range of opportunities for the bereaved to

engage in activities that promote expression of grief. Survivors may place

items that are signifi cant to the deceased in the casket. The practice of bury-

ing grave goods, or funerary artifacts, with the dead is found in many cultures. 24 Jewelry, photographs, rosaries, Bibles or other special books, favorite hats,

military medals, stuffed animals, and organizational emblems are among the

items commonly placed in caskets. Tobacco, alcohol, and articles related to

a favorite activity such as golf or fi shing are other examples of grave goods.

The placing of such grave goods is a mourning practice that is meaningful to

survivors. When a widely known and beloved German funeral director died,

family and friends placed various items in his casket, arranging cookies his

grandchildren had baked on his stomach to commemorate the fact that he

enjoyed eating well. The fi nal disposition of a dead body is surrounded by a

web of social, cultural, religious, psychological, and personal considerations

that determine how this task is accomplished.

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Funerals in the United States 303

Funerals in the United States Few people personally care for their own dead in modern societies. Most hire

professionals—funeral directors or morticians—to provide services and mer-

chandise for conducting a funeral service and handling various tasks involved

in caring for the dead. Because we are unfamiliar with these tasks and

choices, the funeral business tends to be viewed as a “mystery business.” Crit-

ics claim that mortuaries, by their very nature, are in a position to take advan-

tage of their customers. This claim is made despite the fact that most people

give funeral directors high marks for the services they provide at a distressing

time. Beyond this, it has been noted that, in African American communities,

black funeral directors not only are seen as important members of their com-

munities, but often have had key roles in civil rights struggles as well.

To counteract the potential for abuses, the U.S. Federal Trade Commis-

sion (FTC) implemented the Trade Regulation Rule on Funeral Industry

Practices in 1984. 25 The Funeral Rule, as it is called, stipulates that funeral

service providers must give detailed information about prices and legal

requirements to people who are arranging funerals. It requires the disclosure

of itemized prices both over the telephone and in writing. Misrepresentations

about the disposition of human remains are prohibited, as are certain prac-

tices, such as embalming for a fee without prior permission, requiring cus-

tomers to purchase caskets for a direct cremation, or making the purchase of

any funeral good or service conditional on the purchase of any other funeral

If you have an uncomfortable feeling about funerals, which are the accepted social

pattern for confronting death in our culture, if you try to avoid or eliminate them,

that might be a sign that you’re dealing with major residual death anxiety. That’s

one of the things that shows up in our culture: the way people delude themselves

and retreat from the major therapeutic resources that are provided culturally.

There’s a notion that if we have a mini-funeral, we’ll have mini-grief. But we know

that the exact opposite is true.

The more you reduce your emotional acting out at the time of the event,

the more you prolong the pain of grief and postpone the therapeutic work of

mourning.

That’s why in a culture such as ours, where you have an unwise management

of grief, you have a very large proportion of illness responses after the death expe-

rience. People act it out physically rather than doing it psychologically or socially.

That’s a very heavy weight.

But in primitive cultures, such as the aboriginals in Australia, where you have

almost a two-week funeral process, where there are all kinds of acting out of deep

feelings, you come to the end of that two weeks, and a major portion of the grief

work has been done, and the survivor is ready to move into the period of resolu-

tion through the mourning process, which takes quite a bit longer, usually.

Edgar N. Jackson, from an interview with the authors

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304 c h a p t e r 8 Last Rites: Funerals and Body Disposition

good or service. The FTC Funeral Rule is the outcome of a historical process

that has removed death from the purview of family and friends and placed it

in the hands of professionals.

The Rise of Professional Funeral Services When families themselves took care of the disposition of their dead, criti-

cisms would have been irrelevant. And, of course, there was no profi t motive.

Disposition of the dead was simply a human task to be carried out by the

family and community. At a time when the family’s ceremonial occasions

involving death were held within the home, the “undertaker,” when he came

upon the scene during the Colonial era, mainly functioned as a merchant

who supplied materials and funeral paraphernalia—such items as the casket

and carriage, door badges and scarves, special clothing, memorial cards and

announcements, robes, pillows, gauze, candles, ornaments, and so on—for

mourning rituals (see Figure 8-3 ).

During the later decades of the nineteenth century, the undertaker

assumed a larger role in caring for the dead. 26 No longer merely a trades-

man who furnished goods to bereaved families, the undertaker became a

provider of services. He began to actually take part in the disposition of the

dead: laying out the body for the wake, transporting it to the church for the

funeral, and, fi nally, taking it to the cemetery for burial. With the coming

of smaller houses and urbanization, the place for viewing the body moved

from the parlor of the family home to a room reserved for such use by the

tradesman-undertaker. The funeral “parlor” in town became a substitute for

the ceremonial room that people no longer had in their own homes. This

one-room funeral parlor was the forerunner of the present-day funeral home

or mortuary.

Also around this time, undertakers were becoming “morticians” and

were starting to view themselves as “funeral directors. ” 27 For instance, the Funeral Directors National Association, established in the 1880s—now

the National Funeral Directors Association (NFDA)—was among the fi rst

Figure 8-3 City Directory Listing for a Cabinet Maker and Supplier of Funeral Furnishings, circa 1850

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Funerals in the United States 305

of the new trade organizations designed to promote funeral service busi-

nesses as well as establish standards. Early trade publications, such as The Casket and Sunnyside, helped to facilitate communication among funeral directors.

What is the job of a funeral director like? Gary Benito says, “Our entire

client load is comprised of people on the worst day of their life. We’re con-

fronted every day with our mortality.” His partner, Vince Azzaro, says, “A lot

of the job is simply guiding people through the red tape and bureacracy that

have grown up around the disposition of a body.” 28

The stress of getting every detail right, from the choice of fl owers to how

a pastor pronounces the deceased’s name is intense, leaving undertakers

emotionally exhausted by the end of the day. They’re charged with cramming

into two days the same amount of organizing wedding planners take a year to

pull off. At the same time, they have to treat each family as if they’re the only

people walking through the door. 29

Although some funeral homes handle fewer than fi fty calls per year and

are often run by husband and wife, others handle hundreds of calls and may

be owned by small companies or large corporations. The average funeral

home handles 112 calls per year. 30

Many mortuaries have expanded their services to include “aftercare” pro-

grams, which can range from simply telephoning a bereaved spouse to see how

he or she is doing to offering counseling or support groups for bereaved cus-

tomers. Mortuary staff may attend training programs to prepare themselves for

this kind of aftercare or, in some cases, the funeral home hires a psychologist

or grief counselor to manage such services. Many funeral directors view this

offering of aftercare service—this extension of their professional services—

as a contemporary expression of “old-fashioned neighborly concern.” 31

The clergy has traditionally played a major role in assisting bereaved fam-

ilies in making funeral arrangements. Whereas funerals were once commonly

held in churches, they are now likely to be held in funeral chapels. The move

from church to mortuary (along with the more dominant role of mortuary

personnel) has sometimes put a strain on relationships between clergy and

funeral directors. Some clergy are bringing funeral services back into church

and taking a greater role in funeral arrangements. Some churches have even

started operating their own “funeral businesses” or have contracted with

fi rms that agree to provide funerals for parishioners.

During the past several decades, conglomeration in the funeral industry

has become a major trend and a much-debated topic. Large multinational

corporations that own hundreds of funeral homes are purchasing neighbor-

hood “mom-and-pop” funeral homes, many of which have been family owned

and operated for generations. Many observers wonder whether the personal

touch provided by locally owned funeral homes will be lost with corporate

ownership. In some communities, customers of funeral homes that were once

family owned but now are owned by corporations “vote with their feet” as

they switch to mortuary establishments that are devoted to local ownership

and personal service.

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306 c h a p t e r 8 Last Rites: Funerals and Body Disposition

Even though we are accustomed to turning over care of our dead to pro-

fessionals, the fact that someone is profi ting from such services may seem

somehow macabre. When a corpse belongs to someone we loved, the com-

mon aversion to touching a dead body may be mixed with guilt. Unconscious

resentment may be felt toward the funeral director or mortician who prepares

the body of our loved one for fi nal disposition. Pulled in opposing directions,

we experience a confusing range of emotions regarding our dead: aversion,

guilt, resentment, anxiety, and affection. Lack of familiarity with the dead

can result in funeral directors and funeral establishments becoming a light-

ning rod for criticisms.

Criticisms of Funeral Practices Funerals have attracted criticism of various kinds since ancient times.

The Greek philosopher Herodotus, in the fourth century BCE, spoke criti-

cally about what he called “lavish displays for the dead.” Funeral practices

in the United States have received their share of criticism as well. One of the

earliest criticisms was directed not just at funeral practices but at the funeral

itself. Published in 1926, Bertram Puckle’s Funeral Customs: Their Origin and Development argued that the modern funeral was merely the vestige of a “pagan” superstitious fear of the dead. Like Herodotus, Puckle was especially

critical of elaborate ceremonies for the dead.

In 1959, the commercialism and conspicuous display connected with

funerals were documented by LeRoy Bowman in The American Funeral: A Study in Guilt, Extravagance, and Sublimity. 32 Bowman was especially interested in the social and psychological value of funerals. He was concerned that modern

funerals were overlaid with such ostentation that the essential meaning and

dignity of funeral rites had all but disappeared. The funeral, Bowman said,

Visiting with a family in a funeral home one night, we witnessed a woman enter

the visiting room. She approached the casket and burst into convulsive tears. Two

men stood up and supported her on either side as she sobbed loudly. The mother

of the deceased man leaned over to me and said, “Brother Wayne, do you know

that woman?” I had never seen her before. Everyone in the room was whispering

and looking. “Who is that?” they were asking.

After this loud display, the men escorted the woman to a folding chair, where

she gradually calmed herself. Finally, one of the men asked her how she was

acquainted with his brother, Bill.

She raised her head and asked, “Bill?”

“Yes, that’s my brother Bill.”

The mystery lady stood, looked in the casket, and said, “Oh, I’m sorry . . . I’m

in the wrong room,” and quickly exited.

As we all doubled over with laughter, Bill’s widow said, “I was fi xin’ to get up

there and fi nd out WHO she was and WHY she was so upset that Bill was dead!”

Wayne Delk, U.S. Gospel News

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Funerals in the United States 307

“appears to be an anachronism, an elaboration of early customs rather than

the adaptation to modern needs that it should be.” To Bowman, the funeral

director was a tradesman, selling wares that were unnecessary and unwanted.

Bowman believed that consumers could avoid the potential for exploita-

tion associated with the materialistic features of contemporary practices by

becoming aware of the essential social, psychological, and spiritual functions

of funeral rituals. The function of the funeral director, said Bowman, should

be to help the family fulfi ll its own wishes. He also argued for greater fl exibil-

ity in funeral service: “The uniformity of present usage,” he said, “should give

way to individually adapted procedures, whatever they may be.”

In 1963, two books appeared that brought widespread public attention to

funeral practices in the United States: Jessica Mitford’s The American Way of Death and Ruth M. Harmer’s The High Cost of Dying. Both Mitford and Harmer were critical of what they viewed as excessive materialism in funeral practices.

These books, especially Mitford’s The American Way of Death, stimulated lobby- ing by advocates for greater governmental regulation of funeral businesses.

Mitford employed a heavy dose of satire in making the case that conven-

tional funeral practices were bizarre and morbid; efforts to disguise and pret-

tify death made it more grotesque. The language used by funeral industry

personnel became a special target of Mitford’s wit. She took issue with the

euphemisms employed to soften the reality of death: the metamorphosis of

coffi ns into “caskets,” hearses into “coaches,” fl owers into “fl oral tributes,” and

cremated ashes into “cremains.” The corpse, she said, now lies in state in the

“slumber room.” The undertaker, now a “funeral director,” displays a solid-

copper “Colonial Classic Beauty” casket, replete with “Perfect-Posture” adjust-

able mattress, in a choice of “60 color-matched shades.” The deceased wears

“handmade original fashions” from a “gravewear couturiere” and “Nature-

Glo, the ultimate in cosmetic grooming.” 33 Mitford’s use of wry humor in her

critical examination of funeral practices was reminiscent of Evelyn Waugh’s

earlier novel, The Loved One (1948), in which Waugh employed satire to poke fun at what he believed were hypocritical and death-avoiding attitudes about

funerals.

Despite these criticisms of funeral practices, most people appear to be sat-

isfi ed with the quality of service provided by their local mortuaries. Funeral

directors often receive expressions of gratitude from the people they serve

for their help in sorting out the events that immediately follow the death of a

loved one. A willingness to “go the extra mile” is typical of funeral directors.

Most funeral directors are committed to meeting the needs and wishes of

bereaved families, even when they vary from standard practices, as the follow-

ing story illustrates.

When a Dutch couple died unexpectedly while traveling in South Amer-

ica, their relatives felt that the couple’s intimacy and sharing in life should

be carried through to their death rites. They wanted the couple buried

together in one coffi n and in one grave. Although this request had never

been made before, the funeral establishment checked applicable laws and

found that they did not prohibit the family’s wishes being carried out. There

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308 c h a p t e r 8 Last Rites: Funerals and Body Disposition

Thousands of American citizens joined in the funeral observance honoring the Unknown Serviceman of the Vietnam Era. Here the procession is crossing Memorial Bridge between a Marine honor cordon, on its way to Arlington National Cemetery. Replete with full mili- tary honors, the funeral was an occasion for expressing national gratitude and grief in response to the ultimate sacrifi ce of those who died in the wartime service of their country.

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Funerals in the United States 309

were practical problems, however. No company made a double casket. Acting

quickly, the funeral home found a craftsman who was able to make a special

casket by working overtime, and with a few adjustments all went smoothly.

The funeral director said, “We are proud that we have been able to arrange

this committal for the couple in which, for the children, the love between

their parents was confi rmed.” 34

New and Rediscovered Memorial Choices The Internet has ushered in a variety of innovative services related to

funerals and memorials. Individuals can make online purchases of funeral

goods, including caskets. The Internet has become the site of cyber tributes

and even webcasts of funeral services, or cyberfunerals. Carla Sofka says, “A cyberfuneral, also known as funeral-casting or memorial webcasting, is the

broadcasting via the World Wide Web of a ritual to commemorate an indi-

vidual’s life and death.” 35 Cameras placed in the mortuary or chapel can

transmit video of the funeral to “cybermourners” via the Internet. 36 Such

funeral-casts may be viewed live or “on demand,” on an individual monitor or

projected onto a large screen for an audience. According to Sofka, the bar-

riers overcome by funeral-casting include limitations created by geographic

distance, work obligations, or the requirements of a religious or spiritual rit-

ual (for example, burial within twenty-four hours according to some religious

practices), as well as by an inability to travel due to physical or health matters,

the cost of airfare, or the need to remain at home to care for young children.

Memorial pages on the Internet allow mourners to post condolences and

share grief online. For example, Legacy.com is a media company that collabo-

rates with more than 800 newspapers to provide ways for the bereaved to express

condolences and shape remembrances through online obituaries and memo-

rials. It draws more than 18 million visitors each month. 37 Web sites known

as “virtual cemeteries” or “memorial gardens” provide space for photographs

and biographical information about the dead, and visitors have opportunities

to sign guest books and leave “digital fl owers.” 38 According to Pamela Roberts,

Analysis suggests that rather than serving as a poor substitute for traditional

bereavement activities, Web memorialization is a valued addition, allowing

the bereaved to enhance their relationship with the dead and to increase and

deepen their connections with others who have suffered a loss. 39

High-tech innovations are also resulting in new styles of electronic

gravesite memorials. One such offering allows survivors to compile a “visual

eulogy” of a deceased loved one, whereby photographs, the deceased’s life

story and family history, and other such gleanings of a life well lived are

electronically stored and can be displayed on a small video monitor that is

installed into a traditional grave marker. Containing up to 250 pages of infor-

mation, this personalized memorial “allows a person’s life story to be remem-

bered for generations to come.” 40

Memorialization opportunities abound in the world of the twenty-

fi rst century. For example, with the growing popularity of cremation,

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310 c h a p t e r 8 Last Rites: Funerals and Body Disposition

entrepreneurs have developed, or rediscovered, innovative ways of memori-

alizing a deceased loved one. Several fi rms offer “cremation jewelry,” locket-

style pendants, which can be worn around the neck or displayed in special

holders, that hold a small bit of cremated remains.

In some parts of the United States, T-shirts are worn as a way of memo-

rializing victims of violence as well as persons who died in accidents or from

illnesses. The custom apparently began in New Orleans and has since been

adopted elsewhere. As “wearable tombstones,” these shirts are characterized

as “a uniquely modern twist on the ancient ritual of honoring the dead.” One

woman in her early twenties has memorial T-shirts for eight family members

and friends murdered in and around her neighborhood. A man in his early

thirties says, “Now I got more T-shirts than friends.” The shirts are worn to

wakes and funerals, on the anniversaries of the deaths, on the victim’s birth-

day, when visiting the gravesite, or just when someone is missed. 41 Memorials

are also found in the form of “memorial wall art” painted on buildings. 42

Roadside memorials, also called descansos (literally, “resting places”), have spread from a regional southwestern Hispanic usage to appear throughout

Epitaphs and messages written by friends and relatives are displayed on a photograph of a hip-hop musician at his funeral. Such spontaneous sentiments are characteristic of the innovative personalized or “life-centered” rituals that are increasingly becoming the norm for rituals today.

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Selecting Funeral Services 311

the United States. 43 They range from a simple cross to a more elaborate

memorial. Typically, great pains are taken to place the memorial with pre-

cision at the site where death occurred. They are not farewells as much as

efforts to maintain a sense of continuity with the deceased who “knows what

is taking place at the scene of his or her death.” As such memorials have

become more mainstream, they are sometimes erected by state road crews to

memorialize coworkers killed while working on highways.

Although roadside memorials seem to be a new phenomenon, such

“marking of travel-related deaths” has a long history. Prehistoric traders bur-

ied their dead beside the trails of Europe. Roadside memorials, as it happens,

are “far older than roadways and nearly as old as travel itself.” 44

Memorial wall art, roadside crosses, sidewalk memorials, fl oral offer-

ings, and cyber memorials are all examples of what are called “spontane-

ous shrines.” Such shrines were seen following deaths from the Newtown

school shootings, the Boston marathon bombings, and the death of Princess

Diana, when resources of cut fl owers throughout Europe were almost totally

depleted by the demand, and they were seen in the aftermath of 9/11 in the

photocopied snapshots and portraits that, Sylvia Grider says, “reinforced the

function of spontaneous shrines as sites for communication between the liv-

ing and the dead.” 45 Grider points out that some mourners spend a great deal

of time preparing their tributes and make special pilgrimages to place their

offerings at the shrines. She says, “Part of our shared humanity is feeling a

sense of loss from the deaths of our fellow humans.” 46

Selecting Funeral Services In commemorating a person’s life and death, the choice of last rites may

involve a traditional funeral ceremony or a simple memorial service. Whereas

the casketed body is typically present at a funeral, it is not at a memorial

service. In some cases, both a funeral and a memorial service are held, the

former within a few days after death and the latter sometime later (perhaps

in a different town, where the deceased had a large social network). Although

individuals and families sometimes express a preference that no funeral ser-

vices be held, bereaved relatives and friends usually want to honor and pay

respect to the deceased and express their grief through ceremony.

After a death occurs, survivors are confronted by a number of tasks that

demand attention in preparing for last rites (see Table 8-2 ). Some tasks can

be dealt with before a person’s death, and preparations can be made for com-

pleting others. It can be helpful to have done some of this homework before

death occurs. In making choices, it can be worthwhile to remember that a

meaningful funeral or memorial service can be designed in many different

ways. Decisions about one’s own last rites are ideally made with a view to the

needs and wishes of one’s survivors. In making plans or arrangements, you

may want to review the various elements that are traditionally part of after-

death rituals (discussed earlier in this chapter).

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312 c h a p t e r 8 Last Rites: Funerals and Body Disposition

• Make a list of relatives, friends, and colleagues who should be made aware that the death has occurred, and inform them as soon as possible.

• Find out if the deceased left instructions regarding a funeral or memorial service, or for disposition of his or her body, whether burial, cremation, or some form of “green” disposition.

• If no prior plan is in place, consider what type of funeral arrangement and body disposition would be appropriate.

• If professional help is needed, contact a funeral home, mortuary, or memorial society.

• Consider relevant cultural or religious factors • Gather information and write the obituary. Consider including such items as the

deceased’s age, birthplace, cause of death, occupation or life’s work, academic degrees, memberships, military service, and religious affi liation; the names and relationships of the nearest survivors; and the time and place of the funeral or memorial service you are planning.

• Ask friends to help coordinate meals for the fi rst days following the death and to assist with other tasks and child care, if necessary.

• If relatives or friends will be coming from out of the area, ask a friend or family member to help with travel arrangements, such as transportation and lodging.

• If a funeral service is planned, choose and notify the individuals who will be pall- bearers and who will assume other roles in the ceremony, such as offi ciator or clergy, ushers, and persons who will present the eulogy/eulogies.

• Gather photographs and other mementos for a memory book, memory board, or memorial Web site.

• If you want to have a memorial brochure with photos and information about the deceased, enlist the aid of friends and family to create it and have it printed.

• Don’t let too many cooks into the kitchen; that is, rely on your close-knit support system when it’s time to make decisions.

• Did I do what my loved one wanted? Did I do the right thing? If you feel assured in answering these questions, be confi dent that you have served the memory of your loved one honorably.

t a b l e 8-2 Funeral Tasks for Survivors

The purchase of funeral services is a transaction unique in commerce.

Most people give it little thought until they fi nd themselves in the midst of an

emotional crisis. As with other purchases, the customer who winds up with

the fewest regrets is likely to be the one who has taken time beforehand to

investigate his or her options. When arrangements for funeral services are

made during a crisis, the customer must make an on-the-spot decision. Cas-

kets do not bear a notice saying, “Return in thirty days if not completely satis-

fi ed.” Once made, the decision is fi nal.

Selecting funeral services differs from the way we make most other pur-

chases. When purchasing a new car, for example, you can shop around and

test-drive various makes and models. If you encounter a salesperson who

uses high-pressure tactics, you can either submit or walk away; you have a

clear choice. Yet, the circumstances surrounding the purchase of funeral

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Selecting Funeral Services 313

services rarely allow for objectivity or coolheadedness. The bereaved is usu-

ally not in a position to simply walk away and compare prices elsewhere.

Once a death has occurred, it may be too late to investigate options. (How-

ever, there is no law that prohibits moving a body from one funeral home

to another.)

It is unfortunate when an expensive casket or lavish display becomes the

focal point of a funeral merely because survivors are attempting to assuage

guilt or compensate for unresolved confl ict with the deceased. Spending a

huge sum of money on a funeral may, in some circumstances, thwart the real

purpose of last rites—namely, to effect a kind of closure on the deceased’s

life and comfort the bereaved. As Thomas Lynch, a funeral director and

poet-essayist, says, “In even the best of caskets, it never all fi ts—all that we’d

like to bury in them: the hurt and forgiveness, the anger and pain, the praise

and thanksgiving, the emptiness and exaltations, the untidy feelings when

someone dies.” 47

The funeral is a setting for private sorrow and public loss whereby the

burden of grief is reduced by sharing with others. Last rites effect the disposi-

tion of the corpse while acknowledging that a life has been lived. Funeral ritu-

als are a statement from survivors to the community: “We have lost someone,

and we are grieving.” The purpose of the funeral can be realized whether it is

garnished with diamonds and rubies or with poetry and a song.

Funeral Service Charges The National Funeral Directors Association distinguishes four catego-

ries of costs in a conventional funeral. The fi rst category includes services

provided by the funeral director and mortuary staff, the use of mortuary

facilities and equipment, and the casket and any other funeral merchandise

selected by the customer.

The second category pertains to the disposition of the body. This can

include the purchase of a gravesite and costs for opening and closing the

grave; or, if aboveground entombment is chosen, the cost of a mausoleum

crypt; or, if the body is cremated, the cost of cremation and subsequent inter-

ment, entombment, or scattering of the cremated remains, as well as the cost

of an urn to hold the ashes, if desired.

The third category involves costs related to memorialization. For burials,

this can include a monument or marker for the grave; for cremated remains,

it can include an inscription or plaque for the niche (recessed compartment)

in a columbarium, an aboveground structure with a series of niches for urns. The fourth category involves miscellaneous expenses. These may include

a clergy member’s honorarium, the use of limousines and additional vehi-

cles (if not included in the funeral services category), fl owers, death notices

in newspapers, and transportation of the body outside the local area, if

necessary.

It has become an FTC requirement for all funeral businesses to provide

itemized price information on a general price list so that customers can

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314 c h a p t e r 8 Last Rites: Funerals and Body Disposition

compare prices or choose only those elements of a funeral they want. It is

important to note that FTC requirements do not prohibit funeral directors

from also offering “package” funerals for a single price.

Funeral costs vary among regions of the country as well as between rural

and metropolitan areas. As with other goods and services, costs have risen

over recent decades. According to surveys conducted periodically by the

NFDA, average cost of an adult funeral, including casket but excluding burial

vault and cemetery costs, was about $1,800 in 1980, $3,700 in 1990, $5,200

in 2000, and $6,600 in 2009. 48 With about 2.5 million people in the United

States dying each year, expenditures for funeral, cemetery, and other such

“death care” services total about $15.2 billion. 49 As of 2012, there were about

19,700 funeral homes in the United States. Eighty-six percent of these funeral

homes were owned by individuals, families, or closely held companies and

14 percent were owned by publicly traded stock corporations. 50 Although

most funeral service fi rms are small businesses, considered in the aggregate,

disposition of the dead is big business.

Comparing the Costs Even when itemized, costs quoted by different funeral homes may be

diffi cult to compare. Funeral providers do not always offer exactly the same

goods and services, and they may have different ways of presenting prices.

Nevertheless, it is useful to distinguish the usual charges (see Table 8-3 ). You

may fi nd it interesting to compare prices in your own area with these national

ranges by obtaining information from local funeral homes.

Professional Services Funeral costs include a basic charge for services provided by mortuary

staff, such as arranging the funeral, consulting with family members and

clergy, directing the visitation and funeral ceremony, and preparing and

Services

Professional service fee $1,817

Transfer of remains to funeral home $250

Embalming $628

Other body preparation $200

Use of staff/facilities for viewing $395

Use of staff/facilities for funeral ceremony $450

Use of hearse $275

Use of service car/van $125

Merchandise Casket (metal) $2,295

Memorial cards $125

Burial vault $1,195

t a b l e 8-3 Funeral Costs

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Selecting Funeral Services 315

fi ling necessary notices and authorizations related to body disposition. The

latter may include fi ling the death certifi cate and certain claims for death

benefi ts.

The fee for professional services also covers a share of the overhead and

business expenses required to maintain facilities and staff. Mortuary facili-

ties usually require a large capital investment because of their specialized

design. The typical funeral business is located in a large, possibly colonial

style, building. The fl oor plan may be designed especially to function as a

funeral home. Funerals have been compared to theatrical presentations, with

certain activities taking place “off stage.” 51 The backstage area, hidden from

the public’s gaze, is where the body is embalmed and cosmetized for its even-

tual role in the funeral.

Besides the fee for professional services, mortuaries usually charge an

“intake fee” for transferring remains from the place of death to the mortu-

ary, and there may be a surcharge for after-hours (night or weekend) pickup.

Cemetery or crematory services, fl owers, placement of newspaper notices,

and other incidental costs are usually billed separately.

(As an alternative pricing method, the FTC rule allows funeral providers

to include the professional service fee as part of the cost of caskets. When this

is done, however, a description of such services must appear on the casket

price list.)

The FTC Funeral Rule also specifi es that, with direct cremation or imme-

diate burial, the fee for professional services must be included in the price

quoted for those methods of disposition. Similarly, the fee for professional

services must be included in prices quoted for forwarding remains to another

funeral home or receiving remains from another funeral home.

Embalming Embalming methods have differed among cultures, and preservation

of the corpse has varied correspondingly. The mummifi cation of royalty

and members of the upper class practiced in classical antiquity by the Egyp-

tians is a notable example of embalming. Other noteworthy examples from

more modern times include the body of the Soviet Union’s founder, Vladi-

mir Lenin, displayed in a mausoleum in Red Square. Lenin’s embalmment

became a model for other leaders whose bodies have been put on display,

Ho Chi Minh in Hanoi and Mao Zedong in Tiananmen Square, for example.

A body destined for burial or cremation may or may not be embalmed. If

the body will be viewed during a wake or will be present at the funeral, how-

ever, embalming is generally done (although facilities with “cold rooms” may

substitute for embalming).

In Death to Dust, Kenneth Iserson says, “Originally, embalming meant placing balm, essentially natural sap and aromatic substances, on a corpse.” 52

In modern usage, embalming involves removing the blood and other fl uids

in the body and replacing them with chemicals to disinfect and temporarily

retard deterioration of the corpse.

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316 c h a p t e r 8 Last Rites: Funerals and Body Disposition

In the United States, embalming was adopted around the time of the

Civil War, as funeral homes like Brown & Alexander in Washington, D.C.,

began to make embalming available to their clientele. Brown was a medical

doctor whose interest in embalming grew out of his training in anatomy

and his marriage to the daughter of the man who founded Kirk & Nice in

Philadelphia, the oldest funeral home in the United States, which began

operation in 1761. After witnessing embalming demonstrations by a French

doctor in New York City, Brown decided to offer this service at no charge for

“soldiers who may be so unfortunate as to die or be killed while at the seat

of war and away from their families and friends.” 53 The funeral procession

for President Abraham Lincoln, which traveled by train from Washington,

D.C., to Springfi eld, Illinois, was a public event that signifi cantly increased

awareness of embalming. 54 During this period, however, other means of

temporarily retarding decomposition of the corpse remained in use (see

Figure 8-4 ).

In the United States, embalming is usually considered a practical neces-

sity by most mortuary establishments when a body will be viewed. With few

exceptions, however, the FTC Funeral Rule requires that mortuaries obtain

Figure 8-4 Refrigerated Casket Advertisement, 1881 Undertakers of the 1880s could keep a body for viewing over a longer period of time by using an ice casket, such as the one shown in this advertisement. When embalming became widespread, these cold-air preservation devices became obsolete.

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Selecting Funeral Services 317

express permission to embalm from the family in order to charge a fee for

the procedure. 55 Furthermore, the mortuary’s price list must include the fol-

lowing disclosure next to the price for embalming:

Except in certain special cases, embalming is not required by law. Embalming

may be necessary, however, if you select certain funeral arrangements, such

as a funeral with viewing. If you do not want embalming, you usually have the

right to choose an arrangement which does not require you to pay for it, such as

direct cremation or immediate burial.

Some mortuaries have a combined fee for both embalming and body

preparation; others itemize the procedures separately. In addition to basic

antiseptic hygiene procedures, body preparation may include cosmetology,

hair styling, and manicuring, as well as dressing the body, placing it in the

casket, and composing it for viewing.

If refrigeration or a “cold room” is available, a mortuary may offer the

alternative of storing a body for a short time without embalming. Refrigera-

tion usually costs a little less than embalming. A refrigerated, unembalmed

body will remain relatively preserved for about three days, although some

mortuaries may have a policy of not holding an unembalmed body longer

than forty-eight hours.

Caskets Most people feel that the casket is the centerpiece of a traditional funeral

because of its symbolic and emotional value in honoring the deceased. The

average amount spent on a casket is about $2,300. When it comes to buying

a casket, however, customers have a wide range of choices, and prices are

highly variable. Choices range from inexpensive cardboard containers all the

way to solid mahogany, copper, or bronze caskets that cost thousands of dol-

lars. Most funeral homes offer caskets in a range of prices.

Caskets at the lower end of the price range are typically made of cloth-

covered plywood or pressboard and contain a mattress that is likely to be

made of straw covered with an acetate sheet. At the next pricing level, refi ne-

ments appear. The casket may be covered with copper or bronze sheathing

and the mattress constructed with springs and topped by a layer of foam rub-

ber with a covering of acetate material. In this middle range, gasketed steel

caskets are available with devices intended to ensure an airtight environment

within the casket. (Although this may provide solace for some people, any

added protection is debatable.) The gasketed steel casket is the most popular

choice in the United States.

The price of a top-of-the-line casket ranges from about $7,000 upward to

$50,000 or more. For this sum, there are caskets constructed of mahogany,

copper, or bronze and fi tted out with all the embellishments of the casket

manufacturer’s art.

The FTC rule requires funeral providers to supply customers with a list of

the prices and descriptions of available caskets. This may be done either on

the general price list or on a separate casket price list. In addition, the FTC

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318 c h a p t e r 8 Last Rites: Funerals and Body Disposition

rule stipulates that customers have the right to buy a casket from a supplier

different from the funeral home contracted to handle all the other aspects of

the funeral service and burial. In addition, mortuaries may not charge han-

dling fees on caskets purchased elsewhere.

The FTC rule led to an increase in the number of casket discounters,

some of which are operated as small chains. Although many discounters are

storefront businesses or are even located in shopping malls, some are set up

so that customers can order caskets via a toll-free number or on the Internet.

In 2009, Walmart announced that it had added caskets and urns to its retail

Web site. The warehouse club Costco had been selling these items online

even earlier. Traditional, handmade wooden caskets are also available from

some monastic communities, such as those made by Trappist monks at New

Melleray Abbey in Iowa. Mortuaries are joining this trend by opening their

own “funeral shops,” where caskets and funeral accessories are sold at dis-

counted prices.

Despite the opportunity to avoid part of the markup on caskets, individu-

als may not feel comfortable buying funeral merchandise at discount. Not

only do funeral homes provide “one-stop shopping” for merchandise and ser-

vices, but the notion of “skimping” on a loved one’s funeral may be troubling.

Nevertheless, for some people, casket retailers appear to be an idea whose

time has come. The Regale Funeral Store in London, England, a “funeral

supermarket,” offers fl owers, memorials, caskets, urns, and other funeral par-

aphernalia in a supermarket-style shopping hall, with the prices of all prod-

ucts and services clearly itemized and priced. 56

People are usually surprised to learn that there is no law requiring that

a body destined for cremation must be placed in a casket. Most crematoria

require only that the body be delivered in a rigid container. Mortuaries sell

a body-sized cardboard box that suffi ces for this purpose. The FTC rule pro-

hibits funeral providers from telling consumers that state or local law requires

them to purchase a casket when they want to arrange a direct cremation (that

is, a cremation that occurs without formal viewing of the remains or any visi-

tation or ceremony with the body present). The FTC rule stipulates that fi rms

offering direct cremation provide the following disclosure:

If you want to arrange a direct cremation, you can use an unfi nished wood box

or an alternative container. Alternative containers can be made of materials

like heavy cardboard or composition materials (with or without an outside

covering), or pouches of canvas.

Outer Burial Containers If outer burial containers (vaults or grave liners) are offered for sale by a

funeral home, prices must be listed, either separately or on the general price

list, and the following disclosure must be made:

In most areas of the country, no state or local law makes you buy a container to

surround the casket in the grave. However, many cemeteries require that you

have such a container so that the grave will not sink in. Either a burial vault or a

grave liner will satisfy these requirements.

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Selecting Funeral Services 319

Because many funeral businesses do not sell burial vaults or grave liners,

this item may not appear on the price lists of mortuaries in your area.

Facilities and Vehicles The use of a visitation or viewing room is a common component of most

funerals. In the itemized listing of prices, the funeral establishment may use

whatever method of pricing it prefers or follow common practice in its area.

For example, various settings in the funeral home might be listed, along with

the charges for each by day, half day, or hour. Similarly, if funeral ceremonies

can be held in a chapel at the funeral home, a charge for the chapel’s use

will be specifi ed. When other facilities are made available to customers (for

example, tent and chairs for graveside services), the charges must be stated

on the price list.

According to the FTC rule, charges for the use of a hearse, limousine,

or other automotive equipment provided by the mortuary must be itemized

separately on the general price list. Family members, pallbearers, or other

participants (such as clergy) often use vehicles provided by a funeral home.

A “fl ower car” (or van) may be engaged to transport fl oral arrangements

from the place where the funeral is held to the cemetery or crematorium. A

fee will also be assessed when a motorcycle escort is hired to be part of the

procession.

Miscellaneous Charges In the miscellaneous category are charges for goods or services provided

directly by the funeral home, as well as charges incurred on behalf of the cus-

tomer from outside sources. The latter include cash-advance items, such as

fl oral arrangements and newspaper notices. The customer may be billed for

the actual amounts of the items, or the funeral provider may add a surcharge

for arranging these cash-advance items. If an additional charge is made, a

notice to that effect must be shown on the general price list.

The FTC rule specifi cally mentions that memorial cards must be item-

ized if the funeral provider sells those items or performs the service of fi lling

out and sending them for customers.

The miscellaneous charges category may also include the cost of burial

garments purchased from the mortuary, any fees or honoraria for pallbear-

ers, or an honorarium for the clergyperson who conducts the funeral service.

Direct Cremations and Immediate Burials Most mortuaries offer direct cremations and immediate burials to cus-

tomers. These methods of body disposition generally do not involve any

formal viewing of the remains or any visitation or ceremony with the body

present. (Some mortuaries respond to requests for viewing or informal cer-

emonies by placing the body on a cloth-covered gurney.)

If direct cremation or immediate burial is offered by a funeral home,

the cost—which includes the fee for professional services—is shown on the

general price list. When direct cremation is selected, the customer must be

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320 c h a p t e r 8 Last Rites: Funerals and Body Disposition

given the option of providing the container or of purchasing an unfi nished

pine box or alternative container (such as a box made of cardboard, plywood,

or composition material). Similarly, for immediate burials, the customer can

provide a container or purchase a simple casket, such as one made of wood

A papier-mâché bull symbolizing the deceased’s caste is a focal point of this cremation cer- emony in a Balinese village. According to local custom, corpses are buried until families accumulate the necessary funds to pay for the cremation ritual; at that time, the body is disinterred, wrapped in cloth, and placed, along with various offerings, in ritual objects such as the bull shown here at the cremation site.

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Body Disposition 321

and covered with cloth. (If a funeral home offers immediate burials but does

not offer direct cremations, the FTC rule does not require the fi rm to make

available an alternative container or unfi nished wood box, although a funeral

director might choose to do so.)

Funeral and Memorial Societies Funeral and memorial societies are nonprofi t, cooperative organizations

that offer body disposition to members at a reduced cost by providing sim-

plicity and economy in after-death arrangements. They are generally mini-

malist with respect to disposition of the corpse—either immediate cremation

or immediate burial—although some offer other options at a higher cost.

Such societies represent a response to consumers’ wishes for low-cost, simple

methods of body disposition.

Body Disposition Speaking of the need for appropriate disposal of the dead, Stephen Prothero

says, “Death rites remind us that corpses are feared as well as feted. Though

the dead arrive at funerals as honored guests, at the party’s climax they are

summarily shown the door.” 57

Think for a moment about what you would choose to be done with your

body after you die. When people in the United States are asked their prefer-

ences, responses usually fall into one of the following categories: earth burial,

entombment in a mausoleum crypt, cremation, or donation to science. In

ancient Greece, from the sixth century BCE, it was considered criminal not

to give the dead body a tomb, condemning it to roam the banks of the Styx,

the dreaded river of the underworld.

Some recent innovations in body disposition—green or woodland buri-

als, space burials, and cryonics, for example—are mentioned in a later sec-

tion titled “New Directions in Funerals and Body Disposition.” Here, we focus

on conventional choices available to individuals and families.

Assume that we are confronted with the dead body of a man. What disposition

shall we make of it? Shall we lay it in a boat that is set adrift? Shall we take the

heart from it and bury it in one place and the rest of the body in another? Shall

we expose it to wild animals? Burn it on a pyre? Push it into a pit to rot with other

bodies? Boil it until the fl esh falls off the bones, and throw the fl esh away and

treasure the bones? Such questions provoke others which may not be consciously

articulated, such as: “What do men generally think this body is?” And, “What do

they think is a proper way of dealing with it?”

Robert W. Habenstein and William M. Lamers, The History of American Funeral Directing

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322 c h a p t e r 8 Last Rites: Funerals and Body Disposition

Corpses must be disposed of for sanitary reasons, though it is unlikely

that a person’s choice of how to accomplish disposition is infl uenced by that fact. The method chosen is more likely to involve social, cultural, religious,

psychological, and personal considerations. Reynolds and Tanner point out

that “dead bodies have to be disposed of and religions often provide the

rules and personnel for this, even when the dead and their survivors are not

specifi cally religious.” 58 For example, Judaism, Christianity, and Islam typi-

cally practice ground burial, whereas Hindus and Buddhists prefer crema-

tion. Each method of disposing of the corpse has symbolic meanings that

are important to followers of the respective religions. For example, among

Hindus, cremation is seen as a gesture of purifi cation and symbol of the

transitory nature of human life. Orthodox Judaism, in contrast, views crema-

tion as a form of idolatry; burial returns the body to the “dust” from whence

it was created by God. Other branches of Judaism have less strict views about

the ban on cremation. In Christianity, prohibition against cremation is no

longer universal, having been replaced by a diversity of viewpoints; some

churches support or tolerate cremation, whereas others require or strongly

prefer ground burial.

In Death to Dust, Kenneth Iserson reports that “an unembalmed adult body buried six feet deep in ordinary soil without a coffi n normally takes

ten to twelve years to decompose down to the bony skeleton; a child’s body

takes about half that time.” 59 Environmental conditions can delay or hasten

decomposition; for example, corpses buried in coffi ns or caskets take longer

to decompose than those buried without such containers, and bodies directly

exposed to the environment will generally be reduced to skeletons rather

quickly.

The decomposition of the body is hastened in some societies by washing

the fl esh from the bones when the corpse is partially decomposed; parts of

the body are then retained as a memorial. In other societies, open-air dis-

posal is practiced; the body is left to the elements, where it generally decom-

poses quite rapidly (except in very dry, desert climates, where heat removes

the moisture from the body, acting thereby to preserve it). Some Indian

tribes of the plains constructed platforms on which the corpse was exposed

to the effects of the sun, wind, and rain. In some societies, vultures or other

animals consume the remains of the dead. In India, for example, one can

see scaffolds known as high dakhmas (towers of silence) on Bombay’s fashion- able Marabar Hill, where the Parsi community disposes of its dead by leaving

corpses to be devoured by birds of prey. As followers of Zoroaster, they regard

earth, fi re, and water as sacred and therefore not to be defi led by the dead.

A method of body disposal practiced by mariners since ancient times is

water burial, or burial at sea. Depending on circumstances and cultural prac-

tices, this form of body disposition might involve either ceremonially sliding

the corpse off the side of a ship or placing the corpse inside a boat that is set

afl ame and then set adrift. The Norwegian ship burials of the Viking Age

present an interesting twist on this method of body disposal by combining the

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Body Disposition 323

“burial at sea” theme with ground burial. 60 The dead were laid in a wooden

grave chamber and placed in a ship along with grave goods, and the whole

was covered by an earthen mound.

Donation to medical science is another method of body disposition. The

person who chooses this may gain satisfaction from the notion that he or

she is making a contribution to the advancement of knowledge: “My body

will serve a useful function even after I’m gone.” This is a somewhat limited

option, however, because medical schools and other such institutions require

relatively few cadavers. When a body has been donated to science, the fi nal

disposition of the remains may be left to the discretion of the institution that

received the donation. Usually, however, the next of kin is usually given a say

in determining the fi nal disposition once the medical or scientifi c purposes

of the donation have been achieved. Most medical schools and research insti-

tutions have policies to ensure that cadavers are treated ethically and dis-

posed of properly. In some cases, a memorial service is held to acknowledge

the gift represented by the donation of the body to science. 61

From the burials of prehistory to space-age cryonics, human beings have

chosen from a variety of alternatives for disposing of the dead. Although few

Burial at sea is a naval tradition the world over, particularly during times of war. Here the body of a seaman is committed to the deep during burial services aboard the USS Ranger.

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324 c h a p t e r 8 Last Rites: Funerals and Body Disposition

people give much thought to the subject of body disposition, it is nonetheless

fraught with emotional and psychological importance, as the following story

illustrates: When Major Edward Strombeck was killed in a plane crash while

on duty in Vietnam, the military cremated his body and forwarded the ashes

by mail to his home in Hawaii. 62 Shocked at the lack of proper ceremony, his

mother and other family members expressed their dismay and gained the

attention of U.S. Senator Daniel Inouye. The result was a change in policy,

which ordered that the ashes of military personnel must be escorted home

with dignity and honor. Proper disposition of human remains is a matter of

considerable signifi cance not only to the immediate survivors but also to the

larger community. What do your own preferences regarding body disposition

tell you about your attitudes toward and beliefs about death?

Burial It’s been said that no land in the United States is more sacred than the

square mile of Arlington National Cemetery. It is a place “where the living

meet the dead and where national history is intertwined with personal loss.” 63

This poignant sentiment bespeaks the value that historically has been con-

ferred on a “place” for the dead. Cemetery comes from the Greek, meaning “sleeping chamber.” Related words include necropolis, or city of the dead, refer- ring especially to the large cemeteries with elaborate monuments that were

outside ancient cities, and graveyard, which, in Western European history, was usually located near a church. Sir Raymond Firth says, “Cemeteries offer a

rich fi eld for anthropological study because they illustrate the emotional and

symbolic meaning attached to material objects in human culture, including

even the bodies of the dead.” 64 Other writers point out that the cemetery is

not only a place, but also a process. “In it the thoughts and feelings of the

bereaved are evoked and constrained in their culturally appropriate behav-

ioural expression.” 65 Commenting on passage of the Native American Grave

Protection and Repatriation Act by Congress in 1990, Michael Kammen says,

“Returning bodies to their rightful places becomes a symbolic way of reorder-

ing a disruptive and confusing world.” 66

The term burial encompasses a wide range of practices. It may involve digging a single grave in the soil, or it may refer to entombment in a mau-

soleum (of which the Taj Mahal and the pyramids in Egypt are examples).

The whole body can be buried, just the bones, or even cremated remains. In

parts of the world, cemetery plots are purchased outright; elsewhere, a burial

plot is merely rented for a number of years. 67 In some cemeteries, everyone is

equal in death; in others, the social distinctions that held sway in life are per-

petuated by dividing burial space into classes, with better placement of graves

for those who occupy fi rst-class ranks. 68

In addition to the cost of a cemetery plot, cemeteries usually require a

grave liner or vault to support the earth around and above the casket. This

adds about $1,000 to the cost of ground burial, although vaults that are

designed (but not guaranteed) to seal out moisture cost considerably more.

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Body Disposition 325

The cost of entombment in a mausoleum or crypt averages about $2,000,

although, as always, prices vary. At the mausoleum recently completed beneath

the Cathedral of Our Lady of the Angels in Los Angeles, the 1300 invitation-

only crypts start at about $50,000 each and are available to individuals who

made substantial contributions to the building of the cathedral (space in one

of the six semiprivate chapels or a crypt near one of the stained-glass win-

dows will cost much more). 69 Historically, the term crypt denotes a subterra- nean burial vault or chamber often situated beneath the fl oor of a church. In

modern usage, the term also refers to space in a mausoleum, an aboveground structure of concrete, marble, or other stone in which one or more bodies

are entombed. The most expensive crypt spaces are usually those at eye level,

with less expensive spaces at the top and bottom. (The Queen of Heaven

mausoleum complex in Chicago, the world’s largest Catholic mausoleum, has

space for 33,000 bodies.) 70 The opening and closing of a grave or crypt nor-

mally involves additional charges.

Simple bronze or stone grave markers generally cost several hundred dol-

lars; nameplates for mausoleum crypts cost a bit less. More elaborate memori-

als, if they are permitted by a cemetery (some permit only fl at-on-the-ground

markers), cost from several hundred to many thousands of dollars.

Mausoleum crypts, such as those seen here in Oaxaca, Mexico, are an alternative to underground burial that is found in many parts of the world. When space is at a pre- mium, bodies may be removed from the chambers after a period of time and given under- ground burial or other disposition.

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326 c h a p t e r 8 Last Rites: Funerals and Body Disposition

Finally, some cemeteries assess an endowment or “perpetual care”

cost that subsidizes upkeep of the cemetery, although this fee is sometimes

included in the basic cost for burial or entombment.

With a growing number of cremations, traditional cemetery burial is

becoming more of a lifestyle choice. 71

Cremation Using intense heat, approximately 2000 to 2500 degrees Fahrenheit, cre-

mation reduces the organic components of a body to a mineralized skeleton through a process of dehydration and oxidation. In the United States, the

practice of cremation as a method of body disposal dates from the nineteenth

century (although it had been customary for some Native American cultural

groups for centuries). In Europe, the practice is considerably older, going

back at least to the Bronze Age. Cremation is the most common method of

body disposal in many countries, including India and Japan, and it has found

growing acceptance in the United States in recent decades. Currently, crema-

tion is the method of body disposition chosen in slightly over 40 percent of

fi nal dispositions in the United States. 72

Cremation has been accomplished by various methods, from a simple

wood fi re to sophisticated electric or gas retorts. In the United States, natural

gas is the most commonly used fuel. An average-size body takes about one

and one-half hours to be reduced to a mineralized skeleton, which is put

through a “cremulator” that reduces the bone fragments to a granular state,

often referred to as “ashes.” (The term ashes leads some people to believe that the cremated remains will look and feel like wood or paper ashes. Actually,

they are very small pieces of bone, which look and feel like coarse coral sands

whose shell-like components are worn by the wind and waves.)

Environmental concerns have led to “green” techniques that can substi-

tute for the conventional cremation process. Resomation (alkaline hydrolysis), for example, is a chemical process that reduces a human cadaver to a few

pounds of bone fragments in a timeframe approximately equal to fi re crema-

tion. Bones are then dried and ground into ash. The process of cryomation is the virtual opposite of fi re cremation and alkaline hydrolysis. Akin to the

freeze-drying used to dehydrate food for space travel and long-term preser-

vation, cryomation involves immersing the body into a liquid nitrogen bath,

freezing the cadaver into brittle particles that can be pulverized into fi ne

powder. William Hoy says, “Like cremation, their older ‘cousin,’ technologies

such as resomation and cryomation neither interfere with funeral rituals nor

take their place.” 73

Cremated remains can be buried, placed in a columbarium niche, put

into an urn kept by the family or interred in an urn garden, or scattered at

sea or on land. State and local laws may restrict how some of these options are

carried out. Although scattering cremated remains is a popular method of

fi nal disposition and usually the least costly, some people who have decided to

scatter “ashes” later regret it because, as one woman said about her husband,

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Body Disposition 327

“I have no place to take him a fl ower.” When remains are scattered at sea,

over a forest, or in some similar locale, people may fi nd that they miss the

emotional power of a specifi c place where one can visit the deceased loved one. (The provision of GPS coordinates of longitude and latitude might relieve

this concern for some.) In Japanese cemeteries, haka —small, private family mausolea that fi t on a standard cemetery plot—hold a dozen crematory urns.

This setting has been called “the Asian equivalent of a European family plot

with a hedge growing around it.” 74 As land for burials becomes more expen-

sive, mainstream cemeteries may respond to the increasing popularity of

cremation by offering landscaped “garden” plots that have space for several

urns, thereby allowing several generations to be buried and memorialized in

a family plot.

Survivors may choose to memorialize the deceased in conjunction with

cremation, just as with traditional burials. Urns to hold cremated remains can

be purchased at prices from about $50 to $400, though more expensive urns

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328 c h a p t e r 8 Last Rites: Funerals and Body Disposition

are available. If cremated remains are to be entombed, columbarium niches

(small vaults in which the urns are placed) are available; the cost depends on

the size and location of the niche. Among some families and ethnic groups,

a family tomb is the resting place for the ashes of several generations of the

dead. For cremated remains, memorialization may include an inscription or

plaque on a columbarium niche or a special urn to hold the ashes.

Memorialization Grave markers and monuments are examples of how people have tradi-

tionally chosen to honor and remember their dead. Memorials can be struc-

tures as large as the Taj Mahal or as tall as the obelisk in Washington, D.C.,

honoring the fi rst president of the United States. Or they can be as small

as a postal stamp. The faces of presidents and prime ministers, kings and

queens, writers and painters, and all manner of personalities are printed

on postage stamps as a way to honor and remember those whom a nation

fi nds worthy. When wartime British prime minister Winston Churchill died

in 1965, some 287 stamps were issued by 73 countries within a year of his

death. The runner-up was John F. Kennedy, for whom 183 stamps were

issued by 44 countries. 75

The U.S. Department of Veterans Affairs offers at least thirty-nine differ-

ent emblems to designate a veteran’s belief, from the expected Christian (the

cross), Buddhist (the wheel of dharma), Muslim (the crescent and star), and

Jewish (the Star of David), to more recently adopted symbols representing

Wicca (the pentacle), humanist, and atheist.

In some African American communities, obituaries have been turned

into memorials celebrating and honoring the life of the deceased. Colorful

funeral booklets with testimonial prose and photos describe the highlights of

a person’s life in magazine format. Printing technologies make it possible to

quickly produce as many copies as needed of the memorial magazines, which

are seen as simply another step in the progression of African American style.

One writer comments, “Some people rate an obituary. And then some people

rate an entire magazine.” 76

Marion Pinsdorf notes that widows have been “image makers” for dead

husbands both in history and in modern times. 77 She cites Mrs. George Arm-

strong Custer’s example of stage-managing the general’s funeral to gain the

greatest impact visually and historically. Yoko Ono is a modern example who

“organized and sanitized” John Lennon’s life. Other widows who acted to

enhance the memorialization of their husbands include Jacqueline Kennedy,

Coretta Scott King, and Susan Eakins (widow of painter Thomas Eakins).

In some cases, image triumphs over deeds as widows strive to make “dead

heroes” of their husbands.

Conventional forms of memorialization are not the only options for

achieving the purpose of a memorial: namely, to commemorate (remind)

and to celebrate (honor and give public notice). A memorial may be a keep-

sake, memento, or memoir, as well as a sculpture or structure made of con-

crete or bricks. A memorial functions to “keep interest alive” and “preserve

remembrance.”

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Body Disposition 329

Laws Regulating Body Disposition As a general rule, the deceased’s next of kin is responsible for arranging

for the fi nal disposition of the body. State laws and local ordinances, however,

may govern the manner in which disposition can be effected. For example,

some communities have ordinances prohibiting burial within city limits.

When the deceased has left no money to cover the cost of body disposi-

tion, and his or her relatives are unwilling or unable to pay, the state may be

forced to step in and handle the details. Counties generally have an “indigent

burial fund” for such cases. The public administrator’s offi ce may distinguish

between “inconvenient to pay” and “unable to pay.” When funds are not avail-

able from private sources, the county picks up the cost. The county may have

a contract with a local mortuary that provides direct cremation and burial of

the cremated remains. If the next of kin opposes cremation, the corpse may

be placed in a casket and buried in a plot donated by a cemetery (or, again,

paid for out of community funds).

Located in a setting of great natural beauty on the Hawaiian island of Oahu, this Chi- nese cemetery is situated on a hillside that gently slopes down toward the city of Honolulu and the ocean beyond. Following Chinese custom and in accord with the principles of fêng-shui, care is taken to ensure proper siting of the grave to facilitate the journey of the deceased’s spirit to the afterlife. As with this cemetery located above a bustling, metropoli- tan city, certain aspects of traditional practices retain importance even in modern social settings.

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330 c h a p t e r 8 Last Rites: Funerals and Body Disposition

New Directions in Funerals and Body Disposition Whereas grieving families used to be faced with two basic choices—how

much to spend on a casket and where to bury their deceased loved one—now

they encounter dozens of options for care and disposal of the deceased, rang-

ing from presenting video biographies of the deceased at the funeral to wear-

ing jewelry made from cremated remains.

Even the selection of a casket is changing. In place of the conventional

“selection” room, typically a fairly large space fi lled with caskets of various

styles and costs, mortuaries are installing high-tech, touchscreen monitors

and software that allow families to choose from a larger range of caskets than

could be housed in a selection room, and that also serve as an information

center about products and services available for both burials and cremations.

One funeral director says, “Many families tell us they dread the thought of

walking into a showroom surrounded by caskets and having to choose.” The

new technology, which goes by names like “Family Advisor,” eases some of

that mental anguish while allowing the mortuary to provide a wider selection

of merchandise, even allowing families to design their own casket through

the touchscreen interface.

Kathleen Garces-Foley says, “The choices available to the modern fam-

ily may feel like a burden, but they also present an opportunity to create a

funeral experience that is personally meaningful.” 78 Funeral directors have

had to stay abreast of these changes as people seek new options and choices

in funerals and memorials. A new generation of funeral directors is emerging

and beginning to see themselves less as morticians and more as event plan-

ners. 79 (Some people are calling them “hipster undertakers.”) Garces-Foley

says, “Inventive energy is being put into the creation of death rites that are

personally meaningful.” 80

The San Francisco Columbarium recently held a gala party for its “future

residents.” While music played and food and beverages were served, the mor-

tuary helped people share ideas for decorating their vaults. Marilyn Yalom

says that, although such an event “may appear bizarre to many Americans

who generally think of death in less entertaining terms,” this was not just a

San Francisco phenomenon but “part of a larger trend to make resting places

more user friendly.” 81

Personalized funerals, which adapt many elements of conventional funer-

als, are increasingly preferred as more “authentic” rituals. 82 For example,

eulogies in honor of the deceased usually remain part of the ritual, but they

are likely to be spoken not just by clergy but also by family and friends. Such

“shared eulogies” may even expand into open, spontaneous sharing by those

present, causing some clergy to complain that such eulogies neglect “the

comfort religion offers the grieving” and “can become a space for telling sto-

ries about the good ’ole times.” 83

Personalized funerals are also called “life-centered” funerals, because

the focus is placed on the life and the relationships of the deceased, not on

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New Directions in Funerals and Body Disposition 331

religious teachings about death or the afterlife. Favorite music is played,

and favorite poems may be read. Douglas Davies says that such ceremonies

“refl ect life rather than confront the bereaved with beliefs they may not

hold.” 84

Movement toward personalization is also seen in the growing popular-

ity of a “do-it-yourself ” orientation toward last rites. This development has

been described variously as a “natural funeral,” “home funeral,” and “family-

directed funeral” (as distinguished from a funeral directed by a licensed

mortician). A guidebook for such funerals states:

A home funeral is a noncommercial, family-centered response to death that

involves the family and social community in the care and preparation of the

body for burial or cremation and/or in planning and carrying out related

rituals or ceremonies and/or in the burial or cremation itself. It is differentiated

from the institutional funeral by its emphasis on minimal, noninvasive care

and preparation of the body, on its reliance on the family’s own social networks

for assistance and support, and on the relative or total absence of commercial

funeral providers in its proceedings. 85

Survivors may be guided through their choices by a “death midwife,” a

person who is familiar with the options and knows how to negotiate the some-

times complex bureacracy of conventional funeral rules. 86

For body disposition, conventional choices in burial and cremation

have been joined by new-age options. “Natural,” “woodland,” or “green”

burials increasingly have come to public attention and are becoming an

option for some people, although one that is not yet widely available. 87

Green burials fi rst became institutionalized in England in the 1990s before

being introduced in the United States. 88 A green burial connotes body dis-

posal in a natural setting, with no embalming. The body is wrapped in a

shroud or placed in a biodegradable coffi n (see Figure 8-5 ). 89 The empha-

sis is on materials that naturally return to the earth. Toxic materials are

forbidden (see Table 8-4 ). In Sweden, an organization named Promessa,

led by an ecologist, is pioneering a method of burial that does not involve

embalming fl uid; rather it uses liquid nitrogen to remove water from the

body, transforming it to dust. The recycled body is then used as fertilizer.

As a testament to changing times, funeral-cremation providers must be reminded

that valuables on bodies might no longer only include ordinary items such as rings,

watches, earrings, necklaces, bracelets, anklets, and toe rings nor be confi ned to

ears, toes, fi ngers, necks or wrists. Body piercing is common. Diligence now re-

quires thoroughly inspecting other parts of the body that may contain valuables.

The tongue, chest, navel, pubic areas and nasal cavity must be inspected.

Michael Kubasak and William M. Lamers, Jr., Traversing the Minefi eld—Best Practice: Reducing Risk in Funeral-Cremation Service

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332 c h a p t e r 8 Last Rites: Funerals and Body Disposition

In green cemeteries, a natural marker, such as a tree or special rock, may

be permitted, but the setting is free of tombstones or mausoleums. The

goal is a “sustainable” cemetery.

Individuals are also choosing a form of ocean burial called an “eternal

reef,” in which cremated remains are integrated into a small, constructed

“reef ” that is lowered into the ocean and that soon becomes a habitat for sea

animals. 90 Green burials, whether on land or in the ocean, appeal especially

to those who live by the “reduce, reuse, recycle” lifestyle.

The “gonzo” journalist Hunter S. Thompson chose a unique send-off as

a method of disposition when his ashes were blasted into the sky carried by

red, white, and blue fi reworks. Six months to the day after he shot himself

to death at his home, guests watched “as his ashes exploded with fi reworks,

lingered in great puffs of milky smoke, then vanished.” 91

Another option is a “space burial.” In this form of disposition, cremated

remains are loaded onto a rocket and launched into space, where they orbit

Earth and after a few weeks descend into the atmosphere and are totally

incinerated. A more costly variation provides rocket transport of the cre-

mated remains to the Moon or beyond.

Figure 8-5 The Ecopod The Ecopod, made in England, is a recyclable casket made from post-consumer newspapers churned with water and a natural plant hardener to make paper clay, which is then laid by hand into molds for the lids and base. The outer sur- face is covered with a design printed on a sheet of paper made from mulberry pulp. Cotton webbing and removable bamboo handles complete the Ecopod.

Burial inters more than a body. What else goes under the ground each year in the

United States? • 30 million board feet of casket wood, including tropical hardwoods • 90,000 tons of steel, more than enough to build the Golden Gate Bridge • 1.6 million tons of concrete in burial vaults • Over 800,000 gallons of embalming fl uid, more than enough to fi ll an Olympic-

size pool

t a b l e 8-4 Environmental Impact of Burial C

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Remembrance Rituals and Linking Objects 333

Strictly speaking, cryonics, or cryogenic suspension, is not a method of body disposal but rather an experimental technology. It has nevertheless

attracted attention as a unique way to deal with a body after death. Cryo-

genic suspension involves preserving a corpse (or only the head) by freez-

ing it in liquid nitrogen and keeping it frozen until some future time when

medical science is sophisticated enough to allow for resuscitation and con-

tinued life.

Remembrance Rituals and Linking Objects Bereaved people may fi nd solace through remembrance or leave-taking rit-

uals that differ from, or become an adjunct to, conventional funeral rites

and services. Such rituals of remembrance or continuity typically use linking objects; that is, any physical object or image that serves to connect a mourner in a comforting or constructive way with a deceased loved one. Lou LaGrand,

a longtime grief counselor, says,

Linking objects are in effect transitional objects that assist the mourner in

maintaining a healthy bond of remembrance and thanksgiving as one begins

the journey to fi nd new ways to reinvest emotional energy into life. . . . These

objects are one type of learning tool to bring empathy, understanding, and

awareness that love never dies into the experience of massive change. 92

Some writers express the view that linking objects are a “chain” that

should be broken. Although it is true that holding onto possessions of the

deceased may be done in a manner that is not helpful in adjusting to a

loss and moving forward, it is also true that discarding every reminder of

the deceased can be equally unhelpful. Indeed, the use of linking objects

in remembrance ritual can help individuals move from a maladaptive to

an adaptive style of grieving. 93 In effect, it is a form of “directive mourn-

ing therapy” that allows grieving survivors to take symbolic leave of the

deceased. 94

Memorial garden This is her fi rst garden. It’s a memorial garden. It is a place to visit her still and

have a chat. The garden is another way of keeping in touch. I come every week on

Thursday since she died. To tidy up, trim, cut the grass, put fresh water in, change

the fl owers that others bring. I feel she’s still with me. I used to see her every day

when she was living. I worked where she lived and I would see her and have a cup

of tea and a chat. Although Mum’s no longer alive, I still have a chat—for fi ve min-

utes after I tidy up; I tell her what’s going on.

East End resident whose mother was buried at the City of London Cemetery

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334 c h a p t e r 8 Last Rites: Funerals and Body Disposition

Examples of using linking objects to create a ritual of remembrance or

continuity include writing a farewell letter to the deceased and subsequently

burying or burning it. An activity like this can be followed by a “reunion”

ritual, perhaps in the form of a ceremonial dinner with family and friends.

In this way, the rhythms of separation and joining found in traditional ritu-

als can be adapted to the circumstances of a particular person. It is usually

appropriate to strike a balance between the linking activities that maintain the survivor’s ties to the past and the bridging activities that lead the survivor to a future without the deceased. The following story is illustrative.

Sometimes you get what you need.

A woman whose older brother died in a plane crash over the ocean (where

his body was never found) decided she needed to honor his memory some

thirty-three years after his death. Until then, she had lived in a seaside town, in

a house facing the ocean with her drapes closed so that she didn’t have to look

at her brother’s “killer.”

With encouragement from her counselor, the woman chose long-stemmed

red roses, one for each year her brother had been dead. She took the fl owers,

some music, and a few poems to a cliff overlooking the ocean. Her plan was to

have a simple ceremony by herself. She would cast the roses, one by one, into

the ocean—something peaceful as well as forgiving of the ocean for keeping

her brother’s body.

Being unfamiliar with the waves in the chosen spot, she began her

ceremony. She threw a rose off the cliff. The ocean current and waves hurled

and smashed it back to the cliff. With each rose, the ocean seemingly refused to

take her offering. By the time the last rose was gone, she was down on her hands

and knees, at the cliff’s edge, crying and swearing.

Her peaceful ritual had become a catharsis for years of pain and grief at

the sudden loss of an adored sibling. When she again became aware of her

surroundings, she checked to see if anyone had observed her loud temper

tantrum, remarking later that the ritual turned out to be exactly what she

needed but hadn’t planned.

Making Meaningful Choices Willliam Lamers, Sr., defi ned the funeral as “an organized, purposeful, time-

limited, fl exible, group-centered response to death.” 95 In light of the varied

and diverse styles of funeral service now available, does this defi nition apply

to our current approaches to caring for the dead? What values guide our

actions in memorializing the dead and meeting the emotional needs of survi-

vors? The choices we make concerning funerals and body disposition increas-

ingly refl ect personal rather than community judgments.

If the monolithic and perhaps stereotypical “American funeral” is dis-

appearing, it is being replaced by a broader range of options. Refl ecting

cultural diversity, funeral directors generally have at least some familiarity

not only with the rituals practiced in Judaism and Christianity but also

with Buddhist, Hindu, and Muslim services as well as nonreligious human-

istic and fraternal rites. Rather than being locked into a “conventional

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Making Meaningful Choices 335

Figure 8-6 Three Views of a Child’s Coffi n Top View: When the wooden coffi n constructed by the family and friends had been completed, the surviving child ran his hand over the surface and voiced his approval but said that it “needs something more.” He gathered his marking pens and began to ornament the coffi n with drawings. The inscriptions on the outer surface of the lid show the child’s interest in identifying by name and by picture the fact that this coffi n was built for his brother. His own participation in the making of the coffi n is also connoted by the inclusion of his name and by the demonstration of his newly developed skills with the use of numerals and letters.

funeral,” people can now choose from a wide range of resources that allow

them to create or adapt funeral customs from both religious and secular

traditions. There are many ways to deal meaningfully and appropriately

with death. Becoming aware of the alternatives enables us to make mean-

ingful choices.

Some people prefer a minimal role in caring for their dead; others

seek to participate actively. The experience of a family following the death

of a young son is illustrative. There were no plans for a formal funeral

ceremony. The body would be cremated and the ashes scattered. Before

the body was to be cremated, the family found themselves experiencing

the acute grief that comes with a sudden and intimate loss. As they tried

to come to terms with their emotions and the loss of their son, someone

in their circle of friends suggested that they put their energy into building

a coffi n. Soon, friends and members of the family, including the fi ve-year-

old older brother of the child who was killed, were busily engaged in the

task of constructing a coffi n. Later, they said they were relieved to have had

the opportunity to “do something.” Building the coffi n became a meaning-

ful way to honor the dead child as well as a means of working through their

feelings (see Figure 8-6 ).

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336 c h a p t e r 8 Last Rites: Funerals and Body Disposition

Figure 8-6 (continued) Detail of Lid Interior: In this close-up of a portion of the interior lid, viewed from left to right, one can see a chrysalis—indicating a transition from caterpillar to butterfl y—along with some of the younger brother’s favorite television charac- ters: Big Bird, Oscar the Grouch, and Cookie Monster. Interior of Lid: In contrast to the matter-of-fact inscriptions placed on the outer surface, the inside of the coffi n lid is fi lled with representations of experiences, events, and objects that brought joy into the life of the child’s younger brother. Many of the dead child’s favorite activities, such as listening to the stereo with headphones and sitting on a horse at grandma’s house, are depicted. The surviving child depicts himself as sad because of his brother’s death, yet also as happy because of the shared experiences he enjoyed with his brother. It is interesting to notice the degree of detail and the variety of images placed on the interior of the coffi n lid.

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Making Meaningful Choices 337

Traditional practices are being altered by the fast pace of modern life.

Attendance at funerals is down; fewer people “have the time” to take off

from work or other activities for a mourning ceremony that seems some-

how optional. Yet the desire to participate in such ceremonies persists, as

evidenced by the advent of technologies—cyberfunerals and memorial web-

casting, for instance—that allow distant mourners to feel they are included

in funerals and memorials when they can’t be physically present. These new

options attest to the strength of the bonds between the living and the dead

and the desire to connect with others in bereavement.

Whether these are adequate substitutes for intimate, face-to-face social

support provided by conventional services is questioned. What does it say

about how we manage our lives when we are too busy to join together with

other mourners to acknowledge the passing of a person who was loved and

respected as part of our community of friends and family?

There are those who believe that substituting a memorial service for a

traditional funeral is lacking in several respects: First, it usually does not take

place when feelings about a loss are most intense. Second, members of the

family are not as exposed to the fact that death has occurred, nor do they

participate as fully as they would in making funeral arrangements and going

through the funeralization process. Third, the body is not present at a memo-

rial service, thus removing the therapeutic benefi t that comes with fi xing the

fact of death in the minds of mourners. 96 Alan Wolfelt, director of the Center

for Loss and Life Transition, says, “Opponents of viewing [the body] often

describe it as unseemly, expensive, undignifi ed, and unnecessary. Yet, seeing

and spending time with the body allows for last good-byes and visual confi r-

mation that someone loved is indeed dead.” 97

At Pütz-Roth, an innovative funeral establishment in Bergisch Gladbach,

Germany, mourners are encouraged to give themselves suffi cient time to

grieve after a loved one’s death. In a homelike environment, the bereaved

family and friends are offered opportunities to spend time with the body

over a period of several days before fi nal disposition of the remains (see

Figure 8-7 ). The bodies of the dead are not embalmed but instead are kept

in a “cool room.” When family and friends come, the body is moved to a sit-

ting room, where the bereaved have access to a kitchen facility for keeping

beverages or making snacks. In addition to comfortable seating and soothing

artworks, each room has windows that look out on natural surroundings and

that also let in the sounds of running water and birdsong. Amid this natural

setting, as the body begins to show signs of deterioration, the mourners are

subtly encouraged to recognize that all things have a beginning and an end-

ing and that grief involves letting go of the physical aspects of the deceased

while fi nding a “place in the heart for grief.” 98

The social support that accompanies meaningful ritual need not be lim-

ited to the period immediately following a death. In traditional Hawaiian

culture, for example, the bereaved community holds a memorial feast on the

fi rst-year anniversary of the day of death for any person—man, woman, child,

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338 c h a p t e r 8 Last Rites: Funerals and Body Disposition

even a newborn baby. 99 For the extended family, this is considered “one of the

three greatest occasions, the others being the feasts of rejoicing for the fi rst-

born and the marriage festival.” Although this memorial occasion is called

the ’aha’aina waimaka, or “feast of tears,” because it embraces everyone who had shed tears out of respect and love for the deceased, it is in fact “a happy

occasion, a joyful reunion of all who had previously shed tears together.” One

participant said: “There was drinking, eating, singing and dancing. We had a

lu’au when all the grief was done.”

Figure 8-7 Mourners at Pütz-Roth in Bergisch Gladbach, Germany, are given opportunities to sit with their deceased loved ones in a serene, homelike environment that aids their coming to terms with the death. This innovative funeral establishment is a model for helping the bereaved fi nd a place in the heart for grief.

© P

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Further Readings 339

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

Further Readings Lisa Takeuchi Cullen. Remember Me: A Lively Tour of the New American Way of Death. New

York: HarperCollins, 2006.

Douglas J. Davies. Death, Ritual, and Belief: The Rhetoric of Funeral Rites, 2nd ed. Lon- don: Continuum, 2002.

Keith Eggener. Cemeteries: Library of Congress Visual Sourcebooks in Architecture, Design & Engineering. New York: Norton, 2010.

Mark Harris. Grave Matters: A Journey Through the Modern Funeral Industry to a Natural Way of Burial. New York: Scribner, 2007.

William G. Hoy. Do Funerals Matter? The Purposes and Practices of Death Rituals in Global Perspective. New York: Routledge, 2013.

Kenneth V. Iserson. Death to Dust: What Happens to Dead Bodies? 2nd ed. Tucson: Galen Press, 2001.

Thomas Lynch. The Undertaking: Life Studies from the Dismal Trade. New York: Norton, 1997.

Marilyn Yalom. The American Resting Place: Four Hundred Years of History Through Our Cemeteries and Burial Grounds. Boston: Houghton Miffl in, 2008.

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The profound effect of loss on survivors is starkly depicted in this woodcut by German artist Käthe Kollwitz.

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341

C H A P T E R 9

Survivors: Understanding

the Experience of Loss

W e are all survivors. Even if we have not experienced the death of someone close, we are survivors of losses that occur in our lives because of changes and endings. The loss of a

job, the ending of a relationship, transitions from one school or neighborhood to another—

such losses are sometimes called “little deaths,” and, in varying degrees, all can involve grief.

Recall some of the little deaths in your own life. Remember the responses they evoked in

you? Georges Bataille writes,

It is a naive opinion that links death closely to sorrow. The tears of the living, which respond to its

coming, are themselves far from having a meaning opposite to joy. Far from being sorrowful, the

tears are the expression of a keen awareness of shared life grasped in its intimacy. 1

Grief can be a unifying rather than an alienating human experience. Bereaved individ-

uals often describe themselves as stronger, more competent, more mature, more indepen-

dent, better able to face other crises of life. “Bereavement challenges people to fi nd a way

to continue their lives following loss while dealing with the thoughts, feelings, and imagery

that accompany adjustment to the reality that a loved one has died.” 2 One bereaved father

said, “Living without my son has meant adding another room onto the house in my mind;

not so I can shut the door on his death, but so I can move in and out of the experience of

my loss.” 3

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342 c h a p t e r 9 Survivors: Understanding the Experience of Loss

When the Chicago White Sox played their last game at Old Comiskey

Park, many fans experienced grief that was a response to losses associated

with their memories of attending games at “the world’s greatest baseball pal-

ace.” 4 One fan recalled attending a game at the park with six of his friends

before leaving for combat. He said, “Three of those guys eventually were

killed in the war, and I guess I’m sayin’ goodbye to them. This park was my

bond with them and now I’m gonna lose that tie.” Another fan said that his

fondest memories of his father were associated with ball games they attended

together at the stadium. He said, “As a son, I went back to recapture the

warmth and contentment I always had felt sitting in those ‘special’ seats—

I went back to visit my father. .  .  . When Old Comiskey closed that autumn

day . . . I lost something. I lost a very real connection to the feelings a six-year-

old boy has for his father.”

While you are reading about the experiences of loss due to death, it is

important to remember that there are many other occasions for loss in life.

These losses occur in the “death” of a relationship, a job, a family bond,

a home, as well as many other endings. Throughout our life we amass col-

lections of friends and treasured possessions. When we lose something

precious to us, we are left with feelings. Whether it is a friend or a trea-

sured object, the loss can be diffi cult. Some say that it’s as if a part of you

has gone missing. Having close relationships helps us feel less alone in the

world. When we lose someone or something that is valuable to us, we are

survivors. 5

Loss occurs when something is left behind—something we no longer

have, whether by choice or circumstances. For example, even the initiator

of the end of a relationship is not immune to experiences of grief. One

student who had survived both the loss of a marriage because of death

and another relationship to a welcomed divorce said, “The death was eas-

ier in that it was the end of the relationship and I had great support for my

loss. The divorce was much worse as the relationship, changed as it was,

the kids, custody arrangements, and running into my ex-partner around

town with a new mate remained ‘alive.’” As you read about being a survi-

vor, think about the losses you’ve experienced. You will fi nd that many of

the issues discussed apply to other losses in your life as well as to losses

from death.

Working through our endings allows us to redefi ne

our relationships, to surrender what is dead

and to accept what is alive,

and to be in the world more fully to face the

new situation.

Stanley Keleman, Living Your Dying

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Bereavement, Grief, and Mourning 343

Bereavement, Grief, and Mourning Knowing the defi nitions of bereavement, grief, and mourning can broaden our understanding of what it means to be a survivor. Each of these terms refers to

a distinct aspect of the encounter with loss. 6

Bereavement is defi ned as the objective event of loss. It comes from a root word meaning “shorn off or torn up”—as if something precious had been sud-

denly yanked away by a disruptive force. Thus, bereavement conveys a sense of deprivation, that some part of ourselves has been stripped away against our

will, that we have been robbed. Although bereavement can disrupt our lives, it

is appropriate to understand it as an event that is normal in human experience.

Grief is the reaction to loss. There is no one right or universal way to expe- rience and respond to loss. 7 Grief is highly variable. It encompasses thoughts

and feelings as well as physical, behavioral, and spiritual responses. These

reactions may appear immediately after the bereaved learns of the death,

or they may be delayed; they may even be absent. No particular survivor will

necessarily experience all of them, nor must all be present.

Mental or cognitive distress in grief may manifest as disbelief, confusion,

anxiety, tension, pain, a pervasive sense of disorganization, and depression.

Things and events may seem unreal, sensory responses undependable and

erratic. Or the bereaved may have heightened perceptual and emotional

The passionate nature of grief is vividly portrayed by the “stone screams” in this detail from the Lamentation by the fi fteenth-century artist Niccolò dell’Arca. The artist, who took his name from arca , the Italian word for “tomb,” created this powerful work for the church of Santa Maria della Vita in Bologna, Italy. Mary Magdalene, on the right, is shown in horrifi ed dis- belief as she looks down at the dead Christ. On the left, Mary of Cleofe (St. Mary Cleophas) gestures, “I cannot look,” as she backs away, shrieking.

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344 c h a p t e r 9 Survivors: Understanding the Experience of Loss

sensitivity to people and events. Especially in the early period after a loss,

survivors may appear depressed. They may also experience periods of eupho-

ria. The bereaved person may be preoccupied with images of the deceased,

experienced in dreams, or may feel a sense of the deceased’s presence. Para-

normal or psychic experiences in which the dead appear or communicate

with the living are not unusual.

Emotions in grief may include sadness, longing, loneliness, sorrow, self-

pity, anguish, guilt, and anger, as well as relief. The bereaved may express

outrage at the apparent injustice of the loss. Inability to control events may

leave the bereaved person feeling frustrated and impotent. If the world could

be arranged more to his or her liking, it would not have included this loss. By

recognizing that grief can involve a very wide range of feelings, even confl ict-

ing ones, we become better able to cope.

Physically, grief may be exhibited in frequent sighing, shortness of breath,

tightness of the throat, a feeling of emptiness in the abdomen, muscle weak-

ness, chills, tremors, nervous system hyperactivity, insomnia or other sleep

disruptions, and changes in appetite. It may also be manifested physically as

“wandering about” or aimless wandering, a condition psychologists refer to as

psychomotor agitation. Behaviors associated with grief include crying and “searching” for the

deceased. Bereaved people may talk incessantly about the deceased and the

circumstances of the death. Or they may talk about everything but the loss. At times, survivors may be highly irritable or even hostile. They may withdraw

from social interactions, or they may exhibit a kind of frenetic overactivity

and general restlessness, as if they didn’t know what to do with themselves.

Religious or spiritual beliefs may be reexamined as a person tries to fi nd

meaning in a loss. Bereaved people may also turn to such beliefs as a source

of consolation and comfort in coping with loss. A signifi cant loss can cause us

to question our fundamental assumptions about the world and our place in it,

undermining beliefs we had taken for granted. When loss shatters our “assump-

tive world,” a world we expect to be stable and reliable, healing the rifts may

require us to relearn how to live in all the dimensions affected by the loss. 8

Thus, grief involves the whole person and is manifest in a variety of ways:

mentally, emotionally, physically, behaviorally, and spiritually. When we limit

Grief Is Its Own Size The interesting thing about grief, I think, is that it is its own size. It is not the size

of you. It is its own size. And grief comes to you. You know what I mean? I’ve always

liked that phrase “He was visited by grief,” because that’s really what it is. Grief is

its own thing. It’s not like it’s in me and I’m going to deal with it. It’s a thing, and

you have to be okay with its presence. If you try to ignore it, it will be like a wolf at

your door.

Stephen Colbert, talking about deaths of family members 40 years later

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Bereavement, Grief, and Mourning 345

the defi nition of grief, it reduces our chances of accepting all of the reactions

to loss we may experience. Many kinds of thoughts, feelings, behaviors, and

so on are a normal part of grief.

Mourning is closely related to grief and is often used as a synonym for it. However, the term mourning refers not so much to the reaction to loss but rather to the process by which a bereaved person integrates the loss into his or her ongoing life. This process is determined at least partly by social and cul-

tural norms for expressing grief. Grief and mourning are the natural path-

ways toward coping with loss.

Typical mourning behaviors include wearing black armbands or

clothes of subdued colors and, if the deceased was a public fi gure, fl ying

the national fl ag at half-mast. In earlier times, the mater dolorosa, a veiled woman in black clothing, represented the socially prescribed way of mourn-

ing. In some cultures widows wear black for years following the death of a

spouse as a public way of acknowledging their loss, their changed status,

and their grief. Altering one’s appearance as a sign of mourning occurs in

many societies. Among some Native Americans, a person’s hair is shorn as a

way of signifying that he or she is mourning. “To cut the hair short is a sym-

bolic and actual sacrifi ce in memory and respect of the one lost. It is also

an immediate sign to visitors that such a loss has taken place. It is a strong

visual symbol of grief.” 9

A theme common to mourning behaviors cross-culturally is that the

bereaved are different and that this difference diminishes with time. This is

seen in customs that involve seclusion of the bereaved. Seclusion forces the

survivor to abstain from social relationships. You may have heard someone

say, “That family experienced a death and is in mourning; they aren’t going

out socially.” Seclusion serves two purposes during the period of mourning:

First, it allows survivors to shelter their grief from the world; second, it pre-

vents survivors from forgetting the deceased too quickly. 10

In the United States, mourning customs are not as formal or as socially

regulated as they once were. Lacking well-defi ned rules, bereaved people

sometimes experience confl ict about what constitutes appropriate mourn-

ing behavior, as illustrated by the following story: A young girl wrote to an

advice columnist about a “sweet sixteen” party that her dying father asked

the family to celebrate for her, even if the party should occur on the day of

his funeral. The girl said that, although she did not feel like having a party,

family members decided to honor the promise to her father. So the party

was held two days after her father’s death, and it turned out to be a good

experience for all who attended. The problem, she wrote, arose when sev-

eral relatives became horrifi ed because, in their view, enjoying a party was

not appropriate during a time of mourning. What advice would you have

given to this girl?

“Appropriate” mourning behavior is diffi cult to defi ne in culturally

diverse societies. It is wise to suspend judgments or preconceptions about

what is “correct,” recognizing instead that many different kinds of mourning

behaviors can be appropriate for different people and circumstances.

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346 c h a p t e r 9 Survivors: Understanding the Experience of Loss

Tasks of Mourning This description of the tasks of grief, or tasks of mourning, is associated with

J. William Worden. Before going on to discuss several different perspectives

on the process of grieving, Worden’s description provides a useful overview.

The fi rst task is to accept the reality of the loss. 11 “Denying the facts of the loss,” says Worden, “can vary in degree from a slight distortion to a full-blown

delusion.” One signpost in the journey is the survivor’s choice of words when

talking about the deceased person. Most signifi cant is the transition from

present to past tense, from is to was, as, for example, from “Randy is a won- derful carpenter” to “Randy was a wonderful carpenter.”

The second task is to process the pain of grief. This includes physical as well as emotional and behavioral pain. As Worden says, “Not everyone experi-

ences the same intensity of pain or feels it in the same way, but it is impossible

to lose someone you have been deeply attached to without experiencing some

level of pain.” In accomplishing this task, humor can lighten the weight of

grief, providing respite as survivors cope with loss.

The third task is to adjust to a world without the deceased. It takes time to make this adjustment, especially when a relationship was of long duration

and exceptional closeness. The many roles fulfi lled by the deceased in the

bereaved’s life may not be fully recognized until after the loss. The changed

environment of a “world without the deceased” encompasses physical, emo-

tional, mental, behavioral, and spiritual dimensions of life. This change is

symbolized by actions such as rearranging the furniture or changing the

place settings at the dining table.

The fourth task is to fi nd an enduring connection with the deceased in the midst of embarking on a new life. Accomplishing this task involves the recognition that, although one does not forget or stop loving the deceased person, there

are other people one can love.

Therese Rando offers yet another perspective on the tasks of grief, or

mourning. 12 She calls these tasks the “Six R’s”:

1. Recognize the loss (acknowledge and understand the death).

2. React to the separation (experience the pain; feel, identify, accept, and

express the reaction to loss; and identify and mourn secondary losses).

3. Recollect and reexperience the deceased and the relationship (review

and remember realistically; revive and reexperience the feelings).

4. Relinquish the old attachments to the deceased and the old assumptive

world.

5. Readjust to move adaptively into the new world without forgetting the old

(develop a new relationship with the deceased, adopt new ways of being

in the world, form a new identity).

6. Reinvest (the emotional energy that was invested in the relationship with

the deceased needs to be reinvested where it can return some of the emo-

tional gratifi cation that was lost with the death).

Notice that healthy grief involves recognizing the reality of the loss,

adjusting to a world without the deceased without forgetting the old, and

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Models of Grief 347

fi nding a connection with the deceased that allows one to discover new

ways of being in the world and a new life.

Models of Grief The notion that there is a consistent pattern to grief and mourning may

bring us solace when we are bereaved. Human beings appear to have an

affi nity for patterns and models that help them make sense of complex

phenomena. 13 However, although models may provide a “snapshot” of a

dynamic process, they tend to oversimplify and distort reality. With this

caveat in mind, it is still worthwhile to examine some of the major efforts

to create models for understanding how individuals grieve and mourn. We

begin with the perspective of “grief work,” associated with Sigmund Freud,

and then discuss several models that have been proposed to more accurately

or thoroughly capture the nature of grief and how it is experienced, and

complete the discussion of models with a review of efforts to arrive at an

integrated model of grief.

Working Through Grief The concept of “working through grief ” received major emphasis in

Freud’s 1917 paper, “Mourning and Melancholia.” 14 The central message of

the grief work perspective is usually understood as the idea that it is neces- sary for the bereaved to “let go”of the affectional bonds of attachment to

the deceased by gradually “working through” these attachments and relin-

quishing them. John Bowlby’s publication of a three-part work in 1969, 1973,

and 1982 contributed signifi cantly to the understanding of the nature of our

attachments and the process by which they are relinquished. 15

According to attachment theory, when a person recognizes that an object (someone loved) to which he or she is attached no longer exists, grief arises,

along with a defensive psychological demand to withdraw libido (energy)

from the object. This demand to withdraw energy is likely to meet with

resistance, causing the survivor to temporarily turn away from reality in an

attempt to cling to the lost object. As the grief work continues, the energy

previously invested eventually becomes detached from the object, and the

ego (personality) is freed of its attachment so that new relationships can be

formed. As Therese Rando points out, according to this model,

Mourning is initiated by the need to detach from the lost object, and the reason

mourning is such a struggle is that the human being never willingly abandons

an emotional attachment, and only does so when he or she learns that it is

better to relinquish the object than to try to hold on to it now that it is lost. 16

All that day I walked alone. In the afternoon I looked for a church, went into a

café, and fi nally left on the bus, carrying with me more grief and sorrow than I

had ever borne before, my body in tatters and my whole life a moan.

Oscar Lewis, A Death in the Sanchez Family

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348 c h a p t e r 9 Survivors: Understanding the Experience of Loss

In “The Symptomatology and Management of Acute Grief ” (1944), a

landmark article based on the author’s involvement as a psychiatrist treating

the survivors of a nightclub fi re in which 492 people died, Erich Lindemann

observed,

The duration of a grief reaction seems to depend upon the success with which

a person does the grief work, namely, emancipation from the bondage to the deceased, readjustment to the environment in which the deceased is missing,

and the formation of new relationships. 17

Lindemann added that the main obstacle to successful grief work was

the fact that many people “try to avoid the intense distress connected with

the grief experience and to avoid the expression of emotion necessary for it.”

The grief-work model has been widely accepted as the standard formula-

tion for understanding and helping people accommodate to loss. However, its

apparent emphasis on the need for bereaved individuals to break their rela-

tional bonds with the deceased has been questioned. Colin Murray Parkes

points out, “Each love relationship is unique, and theoretical models which

assume that libido can be withdrawn from one object in order to become

invested in another similar object, fail to recognize this uniqueness.” 18 Parkes

says, “The emotion that is the sine qua non [essential quality] of grief is pining or yearning for the lost person who is intensely missed.” 19

The conventional formulation of the grief-work model seems to imply

that everyone must work through grief in a similar fashion to recover from a

loss. In reality, however, there may be no universal way of coping with grief.

Cross-cultural studies reveal diversity in grief and mourning. 20 Grief is highly

individualistic. Furthermore, it is infl uenced by a variety of situational fac-

tors, such as type of death, circumstances of the loss, and so on.

Margaret Stroebe asks a number of pertinent questions about this model:

Is it really necessary to work through grief in order to adapt to a loss? Are

there occasions when, or persons for whom, grief work is not adaptive? Where does one draw the line between healthy and unhealthy grief work? Stroebe

points out that, within the range of normal grief reactions, suppression or

avoidance of confrontation with memories related to the deceased can be as

effective a strategy as “working through” grief. 21

Nonetheless, the model of “working through grief ” advances several

worthwhile points to consider in thinking about grief and mourning: First, it

describes grief as an adaptive response to loss. Second, it states that the reality of the loss must be confronted and accepted. Third, it acknowledges that griev- ing is an active process that occurs over time. Let’s look at how these points are dealt with in other models of grief.

Continuing Bonds with the Deceased The idea that healthy grief means relinquishing affectional ties with the

deceased is giving way to a perspective that more accurately describes the range

of behaviors and emotions that human beings experience when experiencing

loss. In this view, rather than severing ties, the bereaved person acknowledges

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Models of Grief 349

the loss and yet maintains an enduring connection with the deceased. In other

words, the deceased loved one is integrated into the bereaved person’s ongoing

life so the relationship is sustained beyond death. This is called “continuing

bonds,” and it occurs in various ways. Some cultures create continuing bonds

in the context of rituals that locate the deceased in the realm of beloved ances-

tors. Recall, for example, African traditions that celebrate relationships with

the “living-dead” or the Japanese custom of maintaining a household shrine

for ancestors. Other cultures and individuals defi ne such bonds as keeping a

special place for the deceased in one’s heart and mind. 22 Whatever the cultural

context, “an adaptive response to loss will generally balance attention to the

challenges of life with a fl exible but ongoing connection to the deceased.” 23

Dennis Klass observes that bereaved parents often fi nd solace by main-

taining bonds with their children who died. 24 “Memory,” Klass says, “binds

family and communities together.” Through religious beliefs and objects that

link the parents with memories of the child, a kind of immortality is granted

to the child in the lives of surviving family members. Klass points out that the

death of a child challenges parents’ worldviews—that is, their basic assump-

tions about how the universe functions and their place in the world. Making

sense of such a loss is facilitated by maintaining an “inner representation” of

the dead child that allows for continuing interactions so that the signifi cance

Contemporary memorial stories often refl ect a similar emphasis on the unending love felt by survivors for the deceased and on the faith that bonds forged during a per- son’s lifetime can remain strong despite death.

The nineteenth-century Romantic view of death is refl ected in the Lawson memorial, which characterizes both the devotion of the bereaved to the deceased and the belief that loving relationships continue beyond the mortal framework of the human life span.

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350 c h a p t e r 9 Survivors: Understanding the Experience of Loss

of the child’s life is not forgotten or diminished. 25 Work done by Phyllis

Silverman, Steven Nickman, and J. William Worden supports the notion that

children likewise maintain connections with deceased parents through mem-

ories and linking objects (discussed in Chapter 8). 26

Therese Rando says, “The development of a healthy new relationship

with the deceased is a crucial part of the mourning process when the person

lost has been integral to the mourner’s life.” 27 Whether maintaining continu-

ing bonds with the deceased refl ects a healthy adjustment to loss depends on

two criteria: First, does the mourner truly recognize that the person is dead

and understand the implications of the death? Second, is the mourner mov-

ing adaptively into his or her new life? 28

Klass states that continuing bonds are collectively held. We see this when

people visit cemeteries. “The bonds with the individual dead person are thus

interwoven with the bonds to the other dead buried there, as well as to the

other living people.” 29 In comments about the social bond between human

beings, Lyn Lofl and suggests the following are among the “threads of con-

nectedness” or “ties that bind” us to one another:

We are linked to others by the roles we play, by the help we receive, by the wider network of others made available to us, by the selves others create and sustain, by the comforting myths they allow us, by the reality they validate for us, and by the futures they make possible. 30

Telling the “Story”: Narrative Reconstruction When someone we love dies, we face the prospect of revising and re-form-

ing our life story. John Kelly suggests that by contemplating grieving in terms

of a narrative, or story, we cope with loss by re-forming our story so that we

integrate the deceased into our lives in a new way and adjust our relationships

in ways that restore wholeness. 31 In the context of grief, narrative reconstruc-

tion has to do with how an individual weaves a story about transitions and life

events into an interpretation of meaning and possibility. Jerome Bruner says

stories, or narratives, are “a version of reality” that refl ect how we organize

our experience and our memory of human happenings. 32

Through narrative, the story of grief can be told without the constraint

of having to conform to a particular model of how it should be or what it

should feel like or what should be thought. In a sense, it is the “real” story. In

telling and retelling it, the story gradually reveals the dimensions of grief in

ways that allow survivors to carry on despite loss. Carolyn Ellis describes how

telling the story of her brother’s death in an airplane crash not only gives

meaning to the loss but also helps in “reconstructing” her life:

Each writing and reading of my text has permitted me to relive my brother’s

death from an aesthetic distance, a place that allows me to experience the

experience but with an awareness that I am not actually again in this situation, and thus I muster the courage to continue grieving. 33

In telling the story of loss, Ellis says, “We can make true a plot in which

we play the part of, and become in the playing, actual ‘survivors.’”

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Models of Grief 351

Mary Anne Sedney and her colleagues note that “every death creates a

story, or a set of stories, to tell.” 34 Coping with grief involves telling the story.

Conversing with others, we not only gain appreciation of the deceased’s life

but also come to a revised assessment of our own life. “Through storytell-

ing, the diverse meanings of life experience and existence are woven into a

whole.” 35

One way we “keep” those we have lost to death is to talk about them with

family, friends, and neighbors who knew them. Describing how this process

occurred with the death of a former girlfriend, Tony Walter says, “This was

not social support for an intrinsically personal grief process, but an intrin-

sically social process in which we negotiated and re-negotiated who Corina was, how she had died, and what she had meant to us.” 36 Sharing the story

of a loss provides emotional relief, promotes the search for meaning, and

brings people together in support of one another. Kathleen Gilbert says,

“We need to create stories to make order of disorder and to fi nd meaning in

the meaningless.” 37 This is all part of the “reworking of the life narrative.” 38

“Giving grief voice” by telling our stories about the dead and listening to the

stories others tell helps us move on with our lives without leaving our loved

ones behind. 39

The Dual Process Model of Coping One of the most important recent contributions to understanding grief

is the dual process model of coping with bereavement proposed by Marga-

ret Stroebe and Henk Schut. 40 According to the dual process model, the

bereaved person experiences and expresses both loss-oriented and restoration- oriented coping behaviors. Depending on individual as well as cultural char- acteristics, each of these behaviors occurs in varying proportions. There is

“oscillation,” movement back and forth, between these aspects of coping.

Examples of loss-oriented coping include yearning for the deceased,

looking at old photographs, crying about the death, and so on. Restoration-

oriented coping includes mastering tasks that had been taken care of by the

deceased (such as cooking or handling the fi nances), dealing with arrange-

ments for reorganizing one’s life (such as selling the house or moving to

another area), developing a new identity (such as changing status from spouse

to widower or from parent to parent of deceased child), and so on.

Thus, on the one hand, loss-oriented coping involves “concentrating on,

dealing with, [or] processing some aspect of the loss experience.” Restoration-

oriented coping, on the other hand, involves making the changes that are

required to cope with the “secondary consequences” of loss—all those aspects

of the bereaved’s life that require rearrangement in the wake of the loss.

Central to this model is the understanding that grief is a dynamic pro-

cess. It involves movement—oscillation or alternation—between loss-oriented

and restoration-oriented coping. It avoids getting stuck in an either-or frame-

work whereby the bereaved must either “let go” of the deceased or “hold on”

to memories. In coping with loss, the bereaved at times will be actively con-

fronting the loss; at other times, he or she will avoid troubling memories,

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352 c h a p t e r 9 Survivors: Understanding the Experience of Loss

be distracted, or seek relief by turning attention to other things. Over time,

movement between these ways of coping leads to adjustment to the loss.

The Two-Track Model of Bereavement In this model, developed by Simon Shimshon Rubin, the loss process is

conceptualized along two distinct but interactive tracks that attend to aspects

of the loss (see Table 9-1 ). 41 Track I is concerned with biopsychosocial func-

tioning in the wake of the loss. Track II focuses on the bereaved’s ongoing or

continuing relationship to the deceased.

From this perspective, in the fi rst track loss is examined along a range of

dimensions of functioning, where the terms recovery, growth, continuing diffi cul- ties, or inadequate adaptation may apply. The second track, the continuing rela- tionship to the deceased, considers the nature of transforming that relationship, which typically involves both an acceptance of the death and a transformed

connection with the deceased. As time passes, bereaved individuals are likely

to experience changes in their perspective on themselves and on the nature

of their relational bond to the deceased. For example, a widow’s relationship

to her young husband who died at twenty-fi ve will probably have different

meanings across her life trajectory of possibly an additional sixty years.

Rubin and his colleagues point out that, while relationship to another

person is what initiates grief and the loss response, professionals as well as

lay people tend to respond as if the relationship with the deceased is neither

central or of particular signifi cance. 42 However, an unbalanced emphasis on

Track I, the biopsychosocial elements of bereavement, can miss an important

aspect of adaptation to loss. The two-track model calls for a coordinated, bal-

anced view of bereavement.

Track I: General Biopsychosocial Functioning

Track II: Ongoing Relationship to the Deceased

• Anxiety • Depressive affect and cognitions • Somatic (physical) and health

concerns • Behaviors and symptoms associ-

ated with psychiatric problems • Posttraumatic stress and other

emotional diffi culties • Quality of family relationships • Quality of other interpersonal

relationships • Self-esteem and self-worth • Meaning structure in life • Investment in work • Investment in life tasks

• Narrative construction of the relationship

• Imagery and memory • Emotional distance • Positive affect vis-à-vis deceased • Negative affect vis-à-vis deceased • Preoccupation with the loss and the lost • Idealization • Confl ict and problems with the deceased • Presence of various elements of loss

process (shock, searching, disorganiza- tion and reorganization)

• Impact of memories on self-perception • Memorialization and transformation of

the loss experience and the relationship with the deceased

t a b l e 9-1 The Two-Track Model of Bereavement: A Multidimensional View

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Models of Grief 353

Rubin explains that four main points serve to orient the observer to the

process of grief: First, the loss of a close relationship usually has a major

impact on the bereaved. Fixed patterns of functioning undergo change in

intrapersonal, behavioral, biological, and interpersonal areas. When the

initial response to loss has subsided, we would expect a return to adaptive

functioning, although not necessarily identical to the states prior to the

loss. Second, the initial challenge of response to loss requires the bereaved

to accept the reality that death has occurred. Rubin says, “As the loss process

unfolds, the narrowing of the lived relationship to the deceased is charac-

terized by its opposite, an intensive psychological focus on the relationship

and the deceased.” Third, as time passes, the acuteness of the response to

loss subsides. “Some of the changes that buffeted the bereaved will have

disappeared and others will recede with time.” Fourth, after a lapse of a

signifi cant amount of time (for some persons and for some losses, mea-

sured in weeks; for others, measured in years), the bereaved will achieve a

new level of organization in his or her life. With this new organization, “It

is now possible to look for a balance along the dimension of functioning as

well as along that of relationship to the deceased.” Rubin and colleagues

say, “The management of one’s life following the loss of a loved one is inti-

mately associated with how the ongoing relationship with the complex of

memories, thoughts, emotions, and needs [is] associated with the person

who has died.” 43

Toward an Integrated Model of Grief Colin Murray Parkes points to three main infl uences on a person’s course

of grieving: 44

1. The urge to look back, cry, and search for what is lost

2. The urge to look forward, explore the world that emerges out of the loss,

and discover what can be carried forward from the past into the future

3. The social and cultural pressures that infl uence how the fi rst two urges

are inhibited or expressed

It has been suggested that the major theorists should compare their theo-

ries to identify commonalities and differences with the aim of reaching some

agreement on a professional vocabulary of grief. Hannelore Wass points out,

“An integrated theory of grief is a pipe dream,” but adds, “We all have to

dream, don’t we?” 45

We know that an integrated understanding of grief must look beyond

the individual and encompass the family system as well as the wider culture.

Janice Nadeau says, “Individual grief is profoundly shaped by the family con-

text in which it occurs, and the grief of an individual has profound effects on

the family.” 46 Nancy Moos says, “Families and family grief processes are inex-

tricably linked to individual grief and recovery.” 47 The family and its patterns

of interaction are often crucial determinants of whether grief is dealt with in

a healthy or a dysfunctional manner.

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354 c h a p t e r 9 Survivors: Understanding the Experience of Loss

Although there is no standard way of coping with loss, all of the models

discussed here represent contributions to a more complex and refi ned under-

standing of grief and mourning. 48 In thinking about the personal meaning of a loss, Stephen Fleming and Paul Robinson observe,

You do not fi nd meaning in death, you fi nd meaning in the life that was lived. Central to the struggle to fi nd meaning in the life that was lived is the notion of

the deceased’s legacy. The legacy is the appreciation of how knowing and loving

the deceased has irrevocably changed the survivor, thus realizing the transition

from losing what one has to having what one has lost. 49

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The Experience of Grief 355

The Experience of Grief People often ask, What is normal grief? How long should a person actively

be grieving? If the bereaved is not “over” the loss by a certain time, does

it mean he or she is grieving or mourning inappropriately? Such questions

require us to consider the circumstances of a death as well as other factors

that infl uence a person’s experience. Individuals who are newly bereaved may

be alarmed by the fl ood of reactions they experience. “Grief, at times, may be

experienced as frightening, overwhelming, even ‘crazy-making.’” 50 It can be

helpful to have an understanding about how grief is likely to be expressed

over time.

Mental Versus Emotional Responses When there is a substantial difference between a survivor’s emotional

and mental responses to death, and the survivor believes only one response

can be right, the result is confl ict. To expect the head and the heart to react

exactly the same to loss is unrealistic; disparity between thoughts and feelings

is likely. In grief, many different emotions will be felt, and many different

thoughts will arise. By allowing them all and not judging the rightness and

wrongness of particular emotions or thoughts, a bereaved person is more

likely to experience grief as healing.

Survivors may have rigid rules about emotions that can be expressed in

grief—such as where and when it is acceptable to be angry or to be open to

the pain and release an intense outburst of sadness. Permission to experience

and express feelings is of key importance. “How can I be mad at someone for

dying?” Yet, anger may indeed be present in grief. Consider the example of

someone who died by suicide or as a result of driving while intoxicated. Of

course, survivors may be angry even if the death was seemingly unavoidable

and beyond the victim’s control. One young mother told of walking past a

photograph of her recently deceased child and noticing, amid her grief and

pain, a small voice within blurting out, “Brat! How could you die and leave

me as you did!” How could she be angry at her child for dying? We might be

tempted to think this mother’s behavior inappropriate. Yet, survivors need to

give themselves permission to experience their feelings, perhaps to feel anger

at the person for having died and anger at themselves for not having been

able to prevent the death. As Ira Byock observes, “Anger is a way of holding

sadness at bay.” 51

The Course of Grief To describe the course of grief as a series of phases seems to suggest a lin-

ear progression from the fi rst stage through the second and so on, until the

process has been completed. Such a scenario might be comforting to some-

one who would like to have a ready-made outline for evaluating the journey

after loss. We need to be cautious about applying such schemata to the expe-

rience of a particular survivor. The different phases of grief “may overlap,

may be of varying and unpredictable duration, occur in any order, may be

present simultaneously, and may disappear or reappear at random.” 52

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356 c h a p t e r 9 Survivors: Understanding the Experience of Loss

In the fi rst hours or days following a death, grief usually manifests in

shock and numbness, feelings of being stunned as well as of feelings of dis-

belief. There may be an expression of denial—“No! This can’t be true!”—

especially if the death was sudden and unexpected. Even when a death is

anticipated, grief is not necessarily diminished when the loss becomes real.

During the initial period of grief, the sense of confusion and disorganiza-

tion can be overwhelming, as if the bereaved person, motionless and helpless,

is stranded in the middle of a fast-fl owing stream while water and debris rush

about him or her. Bewildered by the shock of the loss, a bereaved individual

may be vulnerable and seek protection by withdrawing. Another survivor

might process the death differently, wading into the water. The early period

of grief is set against the requirement for survivors to attend to decisions and

activities related to disposition of the deceased’s body. This is normally a time

when the bereaved are occupied with arranging for funeral services, as well

as starting to sort out the deceased’s personal and family affairs. Engaging in

Tears stream down the face of accordion player Graham Jackson as the body of President Franklin Delano Roosevelt is carried to the train at Warm Springs, Georgia, the day after his death—a poignant example of how bereaved persons express their loss in public as well as private.

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The Experience of Grief 357

such activities within the context of community can help promote acceptance

of the reality of the death and allow survivors to begin moving beyond the

acute period of grief. As relatives and friends gather to support one another,

the funeral can be a focal point that helps reintegrate distraught and disori-

ented grievers after the disruption caused by death. 53

In its middle period, grief is characterized by anxiety, apathy, and pining

for the deceased. Despair is likely to be felt, as “feelings of disbelief give way to

the realization that there will be no reprieve and that the reality is neither a hor-

rible hoax nor a bad dream.” 54 Bereaved individuals may repeatedly go over the

events surrounding the loss, wishing to undo the calamity and make everything

as it was before. Pangs of grief are felt as the bereaved person deeply experi-

ences the pain of separation and the intense yearning for the one who died.

During this phase, which can last some time, survivors often experience

volatile emotions, which suggests the image of a volcano that at times gives

off steam and at other times appears relatively dormant. Rage and resent-

ment may be felt and expressed toward persons or institutions that might

have somehow prevented the death “if only things had been different.” Anger

may be directed toward the deceased loved one whose “abandonment” causes

such pain, as well as toward God (“How could you let this happen?”) or about

the situation itself (“How could this happen to me?”). Hostile or negative feel-

ings may in turn give rise to guilt.

The predominant emotion during the middle period of grief is likely

to be sadness accompanied by longing and loneliness as various needs and

dependencies that had been satisfi ed by the deceased become painfully

apparent. Time is fi lled with if-onlys and what-ifs as the bereaved comes to

terms with the reality: The loved one is dead. Starting to accept the unwel-

come fact that the loss is real and cannot be changed, the bereaved person

is likely to review and sort through all the bits of interaction that created his

or her relationship with the deceased. This can involve an intense reexperi-

encing of the history of the relationship. Over a period of weeks or months,

the process goes on, as the bonds of the relationship that was are gradually undone and a new relationship with the deceased is created as part of the

survivor’s ongoing life.

This is usually a painful time. Yet, it is a time when the bereaved may not

have much social support from relatives and friends, who were more pres-

ent during the earlier period. After the funeral, the bereaved may be left

alone with his or her grief. When acting to comfort a grieving person, it’s

helpful to remember that social support after the acute phase can facilitate

opportunities for the bereaved to talk about the loss and express grief. A

counselor offers the advice that a supportive person should not ask, “How

are you doing?” unless there is at least forty-fi ve minutes to listen to the

answer. Be prepared to hear, “I’m okay,” as a preface to a lengthy description

of painful issues.

There is no predetermined timetable in grief. In restoring one’s well-

being, however, the last phase of “active” grief is marked by a sense of reso-

lution, recovery, reintegration, and transformation as the bereaved person

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358 c h a p t e r 9 Survivors: Understanding the Experience of Loss

moves forward with a life that is irrevocably changed but worth living. Physi-

cal and mental balance is reestablished. The turmoil of grief subsides; it no

longer dominates every waking hour. This is not to say that sadness goes away

completely; rather, it gradually recedes into the background. Grief is no lon-

ger “heavy”; a weight has been lifted. At times, adapting to loss may feel like a

betrayal of the deceased loved one, but it is healthy to once again engage life

and become oriented toward the future.

The impact of change on recently bereaved people may affect virtually

every detail of life: The family unit is different; social realities are no lon-

ger the same; legal and fi nancial matters require attention. Bereaved people

face the question, How can I make the necessary adjustment in each of these

areas? Survivors are sometimes urged to take a hand in the practical manage-

ment of their everyday affairs soon after bereavement, but it can be useful to

limit, insofar as possible, the number of changes made, especially in the fi rst

few months after loss.

Anniversaries, birthdays, and other reminders are likely to stimulate

active grieving from time to time. New losses may reactivate grief for an

earlier loss. Adjusting to loss doesn’t mean forgetting or minimizing the sig-

nifi cance of the lost relationship. It is not “getting over the grief ” in some

absolute or fi nal sense but rather a process of “living with the loss.”

When you recall a loss in your life, you may remember the emotions,

thoughts, physical reactions, and behaviors associated with grief. Perhaps all

these reactions were happening at once. Part of you may have been in shock

while another part was calm. Distinguishing the waypoints of grief can help

us better comprehend “how grief works.” Even so, the experience itself resem-

bles a series of dance steps more than it does a cross-country walk.

The Duration of Grief How long does grief last? Six months? A year? People sometimes assume

that normal grief lasts only a short time. This assumption can place unreal-

istic expectations on a bereaved person. What happens when grief appears

to continue beyond some arbitrarily defi ned limit? Counselors, psychothera-

pists, and other professionals who work with people who are grieving usually

endorse the axiom that grief has no absolute end point or timetable.

When signs of painful and deeply felt grief persist, along with other dis-

turbances, this could be an indication of unhealthy and dysfunctional grief.

This may be the case, for example, when an individual exhibits symptoms

of depression, especially if compounded by other emotional problems, sub-

stance abuse, or suicidal thoughts. Help is warranted when unhealthy griev-

ing puts bereaved individuals at risk. In general, however, a cautious approach

is preferred before labeling certain manifestations of grief “prolonged” or

“abnormal.” 55

The onset of intense grief years after a loss may be mistaken as abnormal

when it is actually a normal response to a new loss and, therefore, a time-

appropriate response rather than a delayed one. 56 This is illustrated in the

experience of a young woman who reported intense grief over the death of

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The Experience of Grief 359

her husband, though he had died nearly four years earlier. Bewildered, she

said, “I don’t understand myself; it feels almost like the day he died.” In con-

versation with a counselor, she discovered the event that triggered her pain:

Within a few days, the couple’s seven-year-old daughter would be celebrating

her fi rst communion. Although happily remarried, successfully back to work,

and obviously adjusting to her loss, this devoutly religious woman grieved the

absence of her child’s father from a celebration that had been discussed and

anticipated since the child’s birth.

Individuals may also experience a resurfacing of grief stimulated by a

public death. Researchers call this a “ripple effect.” For example, in the week

following the highly publicized death of Diana, Princess of Wales, South

Australia’s largest cemetery reported having more visitors than on Mother’s

Day, traditionally the busiest visitation day of the year. 57 Individual grief was

called forth by the death of a public fi gure.

Survivors may experience a recurrence of grief for a signifi cant loss at

various times throughout their lives when something brings freshly to mind

the recognition that what once was is no more. For example, a person who

was bereaved as a child by a parent’s death may grieve that death anew many

years later when his or her own child is born. A study of bereaved spouses

found that the effects of loss are often sustained over an extended period of

time that is more appropriately termed a “life transition” than a “life crisis,”

with survivors grieving in some fashion for the rest of their lives. 58

Perhaps in your own life you recognize a recurrence of grief for earlier

losses. For example, people often grieve the loss of childhood and its spe-

cial experiences. A woman mentioned visiting her parents after some years

of living on her own; one day, while poking around in the attic, her mother

opened a trunk and pulled out a collection of dolls that had belonged to the

daughter when she was a child. Seeing the dolls evoked grief for the child-

hood that had ended years earlier. She said, “I looked at those dolls and their

tiny clothes, and I got in touch with the loss of that time in my life when

my mother had made clothes for my dolls and taken care of me. There I

was, sitting in the attic, just bawling.” Perhaps you have experienced a similar

situation? Some event, picture, place, song, or other stimulus provokes grief

related to something or someone no longer present. Stephen Fleming and

Paul Robinson point out that the meaning of loss is negotiated and renegoti-

ated over time; in effect, moving from a “going on” to an “ongoing” perspec-

tive of the loss. 59

Complications of Grief Therese Rando lists the following as examples of situations that heighten

the risk of what she termed complicated mourning: 60

1. Sudden and unanticipated death, especially when it is traumatic, violent,

mutilating, or random

2. Death from an overly lengthy illness

3. Death of a child

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360 c h a p t e r 9 Survivors: Understanding the Experience of Loss

4. The bereaved’s perception that the death was somehow preventable

5. A relationship between the bereaved and the deceased that was markedly

angry or ambivalent, or markedly dependent

6. The bereaved’s prior or concurrent mental health problems or unaccom-

modated losses and stresses

7. The bereaved’s perceived lack of social support

These are examples of situations that might hamper the bereaved’s ability

to adapt to life without the deceased. They affect the journey through grief.

Robert Hansson and Margaret Stroebe write, “It is important to remem-

ber that bereavement is a normal, emotional reaction to the loss of a loved

person, not a psychiatric disorder, even though in some cases it is associated

with higher risks of intense symptomatology.” 61 Determining whether grief

is complicated is not as simple as picking up a checklist and marking off the

appropriate items. Rando says, “What may be an appropriate response in

one circumstance for an individual mourner may be a highly pathological

response for a different mourner in other circumstances.” In reviewing the

circumstances that may complicate grief, notice that complicating circum-

stances alone do not justify labeling a person’s grief “abnormal” or “patho-

logical.” For example, a parent who experiences the death of his or her child

due to random violence may be confronted by a mode of bereavement that

is inherently complicated, but this fact alone does not lead us to conclude that the parent’s grief will be dysfunctional.

Rando says that all forms of complicated grief involve attempts to do

two things: (1) to deny, repress, or avoid aspects of the loss, its pain, and

the full realization of its implications for the mourner; and (2) to hold onto,

and avoid relinquishing, the lost loved one. When grief is suppressed, and

emotional engagement with the loss is absent or diminished, or when grief

is so boundless that it becomes totally overwhelming, it sets the stage for a

poor adjustment. According to Rando, the prevalence of complicated grief is

increasing due to a variety of social processes, including urbanization, secu-

larization, and deritualization, as well as violence, availability of guns, social

alienation, substance abuse, and a general sense of hopelessness. 62

Attachment has a role in complicated grief. According to John Bowlby

and Mary Ainsworth, during the early years of life, children develop what

is called an internal working model of primary attachment relationships. This model, or attachment style, can be of various types, such as avoidant attach-

ment, secure attachment, and anxious-ambivalent attachment. The working

model developed by the child functions as a basic pattern for viewing the

world and guides future relationships. The quality of a person’s attachment

style has signifi cant implications for how he or she grieves. Having a history

of insecure or anxious attachment styles, especially when replicated in the

mourner-decedent relationship, puts grievers at risk for complicated bereave-

ment reactions. 63

In their article “Mourning and Meaning,” Robert Neimeyer, Holly Priger-

son, and Betty Davies say that complicated grief can be viewed as “the inabil-

ity to reconstruct a meaningful personal reality” and is “an outcome to which

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The Experience of Grief 361

individuals with insecure working models of self and relationships are espe-

cially vulnerable” (see Figure 9-1 ). 64

Recently, a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a reference used by mental health professionals, was pub- lished in the United States. In it, a change was made from the previous edi-

tion ( DSM-4 ). That edition included a so-called bereavement exclusion, which instructed that a diagnosis of depression or adjustment disorder should not be made in the immediate aftermath of a signifi cant death. This “exclusion”

was deleted from the new DSM-5. The argument for removal was “that it does not make sense to exclude bereavement if the symptoms fi t the criteria for depres- sion while other stressors, such as divorce or job loss, are not excluded.” 65

Figure 9-1 Pathways to Complicated Grief and Uncomplicated Grief

Given the non-threatening meaning of the loss, survivors experience sadness and upset over the loss, but are able to

Accept the loss Believe that life holds meaning Sustain coherent sense of self (feel complete) Feel efficacious Maintain health and daily routine Feel trusting of, and connected to, others Reinvest in interpersonal relationships Find meaning and pleasure in pursuits

Uncomplicated Grief Given the threatening meaning of the loss, survivors experience symptoms of

Separation Distress: Yearning, searching, loneliness, preoccupation with thoughts of deceased and Traumatic Distress: Sense of futility, numbness/detachment, disbelief, anger, shattered worldview (loss of security, trust, control), emptiness, and loss of meaning

Complicated Grief

Non-Threatening to Self Happiness Survival

Meaning of the Death

Threatening to Self Happiness Survival

Secure Attachment Style Death of

Significant Other Insecure Attachment Styles: Compulsive caregiving Defensive separation Excessive dependency Unstable attachment styles (disorganized)

Childhood Security Experiences fostering secure attachment to parental figures

Childhood Insecurity Experiences fostering insecure attachment to parental figures

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362 c h a p t e r 9 Survivors: Understanding the Experience of Loss

Among the concerns expressed about this change is that individuals who

are experiencing grief will have a greater likelihood of being prescribed anti-

depressants even though their grief is “normal,” not dysfunctional. Sadness

and “feeling down” is part of grieving. Pharmaceutical companies may try to

capitalize on this change in the DSM-5 by “medicalizing” or “pathologizing” grief, promoting the idea that bereaved people should consult a physician

when they are coping with a loss. The lesson in this is that people need to

be careful of treating loss and its accompanying emotions as if medication is

necessary.

In response to the change in the DSM-5, a group of internationally

renowned thanatologists wrote a statement, When Does A Broken Heart Become A Mental Disorder?, and provided the answer, “Rarely, if ever.” The statement pointed out:

Grief is not the same experience as major depressive disorder. It is not an

illness to be treated or cured. It is a healthy response to a painful reality

that one’s world is forever altered and will never be the same. Absorbing

this loss, and adapting to all the changes it unleashes, has its own unique

course for every person and will not be stilled or stopped by quick fi xes or

simple solutions. Death is a life-altering event, but grief is not a pathological

condition.

There is a strong likelihood that newly bereaved people will qualify for

a diagnosis of Major Depressive Disorder just two weeks after a death even

though their reactions are normal. Antidepressants have not been shown to

be helpful with grief-related depressive symptoms, and there is accumulating

evidence of long-term negative effects of being on antidepressants. We need to

ask why psychiatry is pathologizing grief and therefore making inappropriate

pharmacological treatment easier. And we should not overlook the self-interest

of pharmaceutical companies who see a new and substantial market for

antidepressants, currently a multi-billion dollar industry.

The caution here? Be wary of physicians or other medical professionals

who rush to prescribe anti depressants to address your grief. 66

Phyllis Silverman points out that there can be tension “between those

who focus on grieving behavior as symptoms of psychiatric problems and

those who see mourning as an expected life-cycle transition, the pain that

is to be expected under the circumstances.” 67 It appears to be the case

that normal and complicated (or prolonged) grief fall along different

ends of the same continuum. 68 As Margaret Stroebe and Henk Schut com-

ment, “bereavement is a normal life event with—sometimes—complicated

reactions.” 69

The Mortality of Bereavement During the fi fteenth century, grief was a legal cause of death that could

be listed on death certifi cates. The death of a loved one involves many con-

current changes, or secondary losses, that add to the bereaved’s vulnerability. Can a grieving person really die of a “broken heart”? 70 What determines

the outcome is not so much stress itself as the person’s ability to cope with

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The Experience of Grief 363

it. Stephen Oppenheimer, a neurologist, says, “It’s an old wives’ tale that a

person can die of a broken heart. . . . But, many old wives’ tales are true.” 71

Stress can throw the heart into an irregular and fatal heartbeat. Oppen-

heimer studies the brain’s insular cortex, an area of the nervous system that

controls breathing and heartbeat and that links up with the limbic system,

which deals with anger, fear, sadness, and other emotions. He says that

damage to the insular cortex may render a person susceptible to a chaotic

heartbeat called ventricular fi brillation, leading to cardiac arrest and, thus,

a “broken heart.”

In reviewing the “broken heart” phenomenon, Margaret Stroebe con-

cludes that “both the direct consequences of loss of a loved one, or a broken

heart, and secondary effects, or the stress of bereavement, are responsible for

the bereavement-mortality relationship.” 72 She adds, “When extreme grief

coincides with severe life stresses during bereavement, the risk to life is likely

to be greatest of all.”

The stress of bereavement appears to aggravate physical conditions that

may have been inactive, causing symptoms to appear or develop more rap-

idly. An early study of a small community in Wales found that the death rate

among bereaved individuals during the fi rst year of bereavement was nearly

seven times that of the general population. 73 Another study found a dimin-

ished immune response among widowers during the fi rst months following

bereavement. 74 Other studies have shown signifi cant depression of lympho-

cyte (T-cell) function following bereavement. 75

George Engel investigated the possible relationship between stress and

sudden death. 76 After compiling a number of case reports, Engel classifi ed

stressful situations into eight categories, four of which can be considered

as either a direct or an indirect component of grief and mourning: (1) the

impact of the death of a close person, (2) the stress of acute grief, (3) the

stress that occurs with mourning, and (4) the loss of status or self-esteem fol-

lowing bereavement.

At fi rst glance, loss of self-esteem may not seem especially relevant. How-

ever, guilt tends to lower self-esteem, and guilt is a common experience in

grief. Consider the bereaved person who says, “If only I had tried harder or

done something differently, my loved one might not have died.” The changed

circumstances of daily life may also tend to diminish a survivor’s self-esteem.

A widower who used to attend social functions with his spouse may now be

left off the guest list; a widow may decline social events that she believes are

for “couples only.” Tighter fi nances may lower self-esteem. Loss of status that

had been enjoyed due to a deceased mate’s professional or community stand-

ing can have a similar effect.

There is intriguing evidence that hints of the possibility that the reac-

tion to loss can contribute to illness and even death. But no direct cause-

and-effect link has been established between bereavement and onset of

disease. Colin Murray Parkes says, “The fact that bereavement may be fol-

lowed by death from heart disease does not prove that grief itself is a cause

of death.” 77

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364 c h a p t e r 9 Survivors: Understanding the Experience of Loss

Variables Infl uencing Grief Just as no two individuals are exactly alike, no two experiences of grief are

exactly alike. There may be similarities, but the circumstances of death,

the personality and social roles of the bereaved, the relationship with the

deceased—these are among the factors that infl uence grief and mourning

and make each experience of grief unique. These factors offer clues about

why some deaths are especially devastating to survivors. In thinking about

some of the variables that infl uence a survivor’s grief, the following are some

fundamental questions: Who died? How did the death occur? What was the

quality of the survivor’s relationship to the deceased? Is there any “unfi n-

ished business”? What prior losses has the survivor experienced? Were there

complicating factors about the death? Was the loss socially sanctioned? (See

“Social Support and Disenfranchised Grief ” later in this chapter.) Are there

fi nancial and legal matters that remain to be dealt with in the wake of the

death? Each of these questions provokes further investigation.

Survivor’s Model of the World A survivor’s response to loss is conditioned by his or her model of the

world—that is, by his or her perception of reality and assumptions about

how the world works. How a person copes with loss—the death of a mate,

another family member, or a close friend—tends to be consistent with how

that individual copes with everyday stresses and small losses of daily living.

In considering how a person’s model of the world applies to bereavement,

Edgar Jackson identifi ed four factors that are especially important: personal-

ity, social roles, perception of the deceased’s importance, and values. 78

Personality Self-concept is an important determinant of how a person responds to

death. The person with an immature or dependent personality is vulnerable

to the loss of someone in whom much emotional capital has been invested.

The upper middles would probably drink themselves silly at the funeral. Although

a few years ago this would have been frowned on. When my husband in the six-

ties announced that he intended to leave £200 in his will for a booze-up for his

friends, his lawyer talked him out of it, saying it was in bad taste and would upset

people. The same year his grandmother died, and after the funeral, recovering

from the innate vulgarity of the cremation service when the gramophone record

stuck on ‘Abi-abi-abi-abi-de with me’, the whole family trooped home and discov-

ered some crates of Australian burgundy under the stairs. A rip-roaring party

ensued and soon a lower middle busybody who lived next door came bustling over

to see if anything was wrong. Whereupon my father-in-law, holding a glass and

seeing her coming up the path, uttered the immortal line: ‘Who is this intruding

on our grief?’

Jilly Cooper, Class

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Variables Infl uencing Grief 365

Perhaps in an attempt to compensate for feelings of inadequacy, the depen-

dent personality has projected part of his or her identity onto another person.

With the death of that person, more of the survivor’s projected self is involved

in the loss. In contrast, the person with greater self-esteem and stronger self-

concept is not as prone to such overcompensation. Thus, grief is quite likely

to be less devastating. Similarly, people who report a high degree of purpose

in life tend to cope more effectively with bereavement than do people who

report a low purpose in life. 79

Cultural Context and Social Roles Grief is shaped by social context. 80 It is infl uenced by norms prescrib-

ing the emotions appropriate within a culture for a given situation. To some

extent, the human response to loss is culturally learned. This is apparent in

differences sometimes observed between bereaved males and females in vari-

ous cultural settings. Wolfgang and Margaret Stroebe point out:

Grief is channeled in all cultures along specifi ed lines [and] there are

substantial differences in the rules laid down by cultures as to how long the

deceased should be grieved over and how long mourning should last. . . . What

is sanctioned or prohibited in one culture may differ dramatically from what is

or is not permitted in another. 81

Daniel Callahan says, “Every great culture has had a characteristic view

of death, ordinarily accompanied by public rituals, customary practices, and

time-honored patterns of communal grief.” 82

In examining bereavement and loss in two Muslim communities—one

in Egypt, the other in Bali—Unni Wikan describes how culture is a potent

shaper and organizer of the way people respond to loss. 83 Although both

societies share a common religious heritage, one encourages mourners to

express their sorrow in wails and lamentations, whereas the other encourages

mourners to contain their sorrow and maintain a quiet and essentially cheer-

ful countenance. Grief is embedded in a web of complex relationships. 84

The question is sometimes asked, Are there “universals” in grief—that is,

do people in all cultures have essentially the same response to loss in terms of

their grief? Although this question is not completely resolved, it is clear that

the cultural environment is an important factor in shaping a person’s grief

and mourning. It may be that people do not “naturally” grieve any more than

they “naturally” laugh or cry. 85 Stephen Connor says, “Grief is not a universal

process with typical symptoms. There are a wide range of individual and cul-

tural differences in the way people grieve. What is normal in one culture may

be quite aberrant in another.” 86

Perceived Relationship with the Deceased The survivor’s perception of the relative importance of the deceased also

shapes the experience of grief. Was the deceased an important person in

the bereaved’s life? Is the bereaved’s life likely to be signifi cantly changed

by the death? Think for a moment about the various relationships in your

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366 c h a p t e r 9 Survivors: Understanding the Experience of Loss

life—parents, children, neighbors, coworkers, teachers, friends, lovers, and

so on. Generally speaking, the death of a family member or other close rela-

tive is perceived as more important than the death of a coworker or neigh-

bor. But the outward form of the relationship is not the only determinant

of the deceased’s importance to a survivor. The death of a close friend may

parallel the mourning patterns associated with surviving a death within the

family. 87 Reports of death in the media may even prompt “vicarious grief ”

experiences, especially if they involve events or circumstances that have spe-

cial poignancy to the griever. 88

Whatever the outward form—kin, friend, neighbor, or mate—relation-

ships vary according to degree of intimacy, perception of each other’s roles,

expectations of the other person, and the quality of the relationship itself.

In some instances, a person’s relationship with his or her parents may refl ect

socially defi ned roles of “parent” and “child” more than feelings of friend-

ship or personal intimacy. For others, a parent may occupy additional roles of

business associate, neighbor, and friend. These differing roles and expecta-

tions result in different perceptions that are likely to shape the experience of

grief when a parent dies.

This portrait of the Saltonstall family, painted in 1611 by David Des Granges, provides a record of living family members and their relational links with the deceased, whose infl u- ence is still felt. The husband and father, Sir Richard, is portrayed as if standing at the bedside of his dead wife, whose arm reaches toward their two children. Seated in the chair and holding her baby, the newest member of the family, is Sir Richard’s second wife, whom he married three years after the death of his fi rst wife.

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Variables Infl uencing Grief 367

In his paper “Human Grief: A Model for Prediction and Intervention,”

Larry Bugen observed that a death involving someone central to the survi-

vor’s life generally will be more affecting than the death of someone who

is perceived to be on the periphery. 89 Bugen added that grief can also be

predicted to some extent by a survivor’s belief about the circumstances of

the death—that is, whether the death was preventable or not. For instance,

given a central relationship between the survivor and the deceased and the belief that the death was preventable, mourning would be expected to be both intense and prolonged. However, if a survivor had a peripheral relationship with the deceased and believed that the death was not preventable, mourning could be expected to be less intense as well as of shorter duration.

It is also important to mention the effect of ambivalence on the course of grief. Ambivalence involves a push-pull struggle between love and hate, and it

may be subtle or dramatic. Perhaps no relationship is entirely free of ambiva-

lence, but when it is intense and ongoing, ambivalence complicates grieving.

Relationship with the deceased may also be considered in terms of a sur-

vivor’s perceived similarity to the deceased. This hypothesis suggests that the more similar to the deceased a survivor believes he or she is, the greater the

grief reaction is likely to be. 90 (Perceived similarity is also a factor in the for-

mation of support groups that are composed of people who have experienced

similar losses.)

Values and Beliefs We sometimes hear people say things like, “Of course, his wife misses him

terribly, but she is relieved that he is no longer enduring such pain and suf-

fering.” Knowing the husband’s suffering is over lessens the wife’s grief at his

death. More generally, a person’s value structure—that is, the relative worth

he or she assigns to different experiences and outcomes—is yet another infl u-

ence on grief. Values that include a place for death in a person’s philosophy

of life can be a factor in how that person experiences loss and grief.

Religious and spiritual beliefs infl uence how individuals relate to values

and the meaning of death; thus, they play a role in shaping the experience of

loss and grief. Even with hope of an eventual reunion with the deceased loved

one, the immediate reality must be recognized. Although religious faith may

be consoling and comforting, the path of grief still must be trod. Richard

Leliaert says, “To suggest that faith itself can drive out the pain of bereave-

ment is to counsel badly.” 91

Coping Patterns and Gender People sometimes believe that “men don’t cry, women do,” thus associat-

ing with only one gender a behavior that applies to human beings generally.

Gender stereotypes portray women as more emotional than men, a notion

that is sometimes interpreted as a sign that women are better able to cope

with grief. It is important to understand that, although gender infl uences pat-

terns of grief and mourning, it does not determine them. Terry Martin and Kenneth Doka point out that there are many effec-

tive ways of expressing and adapting to loss and that women as well as men

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368 c h a p t e r 9 Survivors: Understanding the Experience of Loss

make use of various coping strategies. 92 They identify two patterns of griev-

ing: intuitive and instrumental. In the fi rst, individuals experience and express grief in an affective way (feelings or emotions as distinguished from thought

or action); in the second, grief is experienced physically, such as in restless-

ness or mental activity. Although the fi rst pattern tends to be associated with

women and the second with men, Martin and Doka reject the notion that one

pattern is inherently better than the other, along with the bias that correlates

these patterns with gender. In fact, both patterns can be effective ways of cop-

ing, and both men and women make use of them.

Another model that goes beyond gender stereotypes and allows an under-

standing of individual patterns involves a distinction between two styles, lin-

ear and systemic. 93

In the linear style of thinking and communicating, processes continue one after another: step one, step two, step three, and so on. Thus, people who use

a linear style have thought processes that move from one point to the next and

involve “doing” something. Advice is for problem solving, and intimacy is usu-

ally doing something together. Language is for giving information, protection,

or gaining advantage. A symbol of the linear style could be a straight line.

In contrast, the systemic mode could easily be symbolized by a spider’s web. In this style of thinking and communicating, processes move from one

A Letter from the Canadian Prairie Heather Brae, Alberta

January 12, 1906

Miss Jennie Magee

Dear Sister:

You will be surprised to hear from me after so many years. Well I have bad

news for you. My Dear little wife is Dead and I am the lonelyist Man in all the

world. She gave Birth to little Daughter on the 27th of December three Days after

she went out of her mind and on the 7th of January she took Pnumonia and Died

about half past three in the afternoon. We buried her tuesday afternoon in a little

cemetary on the Prarry about 15 miles from here. I am writing to you to see if

you will come and keep house for me and raise my little Baby. I would not like

to infl uence you in any way as I am afraid you would be lonely when I have to go

from home as I will now and again. You are used to so much stir in the city. I have

400 acres of Land and I have 9 or ten cows and some hens. If you come you can

make all you can out of the Butter and eggs and I might be able to Pay you a small

wage .  .  .  . Write and let me know as soon as Possible what you think about the

Proposition. I am writing to the rest tonight to let them know the bad news. I think

this is all at Present from your affectionate Brother.

William Magee

Linda Rasmussen, Lorna Rasmussen, Candace Savage, and Anne Wheeler, A Harvest Yet to Reap: A History of Prairie Women

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Variables Infl uencing Grief 369

point on the web to another, leading linear thinkers to ask, “How did you get

there?” Systemic thinkers have thought processes that move quickly through

connections and involve “being.” The emphasis is on feelings. Listening, not

problem solving, is expected. Intimacy is shared feelings. Language is for

bonding and building connections. If you compare these two polarities, you

can easily see the differences between these two styles.

An example of the linear coping approach is starting an organiza-

tion devoted to assisting survivors, such as Mothers Against Drunk Drivers

(MADD), which was begun by a woman whose child was killed by a drunk

driver. A person using a linear mode seeks to provide solutions to problems

expressed by another, rather than merely listening and extending sympathy.

For example, in the linear style someone might offer Internet resources that

explain treatment options, provide books to read, and the like. Writing about

loss experiences intended to help inform others in similar circumstances is

characteristic of a linear style. Other examples of this style include preparing

for death by planning a funeral, updating a will, and organizing important

papers that will be needed after death.

Systemic patterns revolve around “being.” Operating in a systemic coping

mode, an individual might attend a survivor’s support group in order to make

connections with people whose losses are similar. Providing a listening ear

for problems expressed by another without offering solutions is a hallmark of

the systemic mode. When writing, someone operating in a systemic mode will

likely write about his or her loss experiences as a means to sort out feelings

and understand reactions. Offering suggestions for funeral options whereby

the survivors can choose what is best for them is an indication of someone

acting systemically.

With respect to grief, someone operating systemically will likely experi-

ence and express grief emotionally, whereas a linear expression involves phys-

ical or mental activity. As with instrumental versus intuitional differences,

notice that the linear mode tends to be associated with men and the systemic

mode with women. However, keep in mind that the phrase “Men don’t cry,

women do” is a gender stereotype, and stereotypes do not explain the vast

richness of diversity within a given population. Both patterns are effective

ways of coping with loss, and both men and women use them.

Mode of Death How a person dies affects a survivor’s grief. Consider the ways in which

people die: the grandmother who dies quietly in her sleep, the child who is

pronounced DOA after a bicycle crash, the bystander caught in the cross-

fi re of violence, a despondent person who dies by suicide, the chronically ill

patient who dies a lingering death. The mode of death—accidental, homi-

cidal, suicidal, or natural—has an impact on the nature of grief, as does the

survivor’s previous experience with that type of death. 94

The circumstances of a death infl uence whether it is likely to involve high grief or low grief. 95 A high-grief death is characterized by intense reactions; a

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370 c h a p t e r 9 Survivors: Understanding the Experience of Loss

low-grief death is perceived as less devastating, and thus grief is likely to be

less intense. The death of a child is often cited as the classic example of a

high-grief death.

Some losses are characterized as “ambiguous” because they are in some

way incomplete or uncertain. Examples include losses where the body is pres-

ent but the mind is absent (such as Alzheimer’s, chronic mental illness, head

trauma, addictions), as well as those where the body is absent but the person

is psychologically present in the lives of family members and friends (such

as military personnel missing in action, missing children, hostages). 96 Such

ambiguity can make adjusting to loss more diffi cult.

Anticipated Death The phenomenon of anticipatory grief, or anticipatory mourning, can be

understood as a reaction to the awareness of an impending loss. This aware-

ness may be accompanied by a recognition of associated losses. 97 Some

Many people believe the death of a young child to be the most heartrending of all bereave- ment experiences—what researchers term a high-grief death because it tends to elicit a tremendous sense of loss.

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Variables Infl uencing Grief 371

people believe that an expected or anticipated death, as is often the case with

chronic or long-term illnesses, is easier to cope with than a death that occurs

suddenly, without warning. 98 Others believe that grief experienced before a

death occurs does not diminish the grief experienced when the anticipated

loss becomes an objective fact.

Sudden Death Yvonne Ameche described her experience on the night two policemen

came to her door with news of her son’s unexpected death. Despite hav-

ing experienced the deaths of her grandparents during her childhood and,

later, the deaths of both her parents, Ameche said, “I don’t know if anything

prepared me for the knock on the door the night Paul died. . . . I remember

reeling back [and feeling] like I had been physically assaulted.” 99 The sense

of overwhelming shock caused by the unexpected nature of her son’s death

was accompanied by feelings that her own familiar sense of self had been

“lost” as well. The journey of survivorship from head to heart, as Ameche

describes it, “where I started to internalize what I had so carefully intellectu-

alized,” took a long time and, she adds, “it was a long time before I felt like

myself.”

Survivors who are bereft because of a sudden death usually want infor-

mation, often in considerable detail, to help them begin to make sense of

the loss. Hospital staff, emergency personnel, and others who deal with trau-

matic deaths need to offer this information in a sensitive, compassionate

manner. (See “Death Notifi cation” in Chapter 5.) The abrupt breaking of

ties between the deceased and his or her survivors makes sudden death a cat-

egory of bereavement that many people consider especially diffi cult.

Suicide People who survive a loved one’s death by suicide are often left feeling

bewildered: “Oh, my God, he did it to himself!” The impact of suicide can

intensify survivors’ feelings of blame and guilt. If someone close to us was in

such pain that he or she died by suicide, we may be burdened by guilty ques-

tions: “Why didn’t I see the predicament and do more to help? What could

have been done to respond to the cry for help?” In a series of interviews with

individuals bereaved by suicide, Carol Van Dongen concluded,

A consistent theme throughout survivors’ experiences was an intense need to

understand why the suicide had occurred and what were the implications of the

death for themselves and their family. Survivors agonized over possible reasons

for the suicide, as well as how the death was affecting them now and what it

might mean in the future. 100

Besides guilt and self-questioning, survivors may direct feelings of anger

and blame toward the person who died by suicide. Suicide is seen as the ulti-

mate affront, the fi nal insult—one that, because it cannot be answered, com-

pounds survivors’ frustration and anger. When a suicide is actually witnessed

by family or friends, it is likely to add to the trauma of the loss. 101

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372 c h a p t e r 9 Survivors: Understanding the Experience of Loss

Feelings of guilt and blame may be made more diffi cult to cope with

because of societal attitudes. Survivors may be “held responsible” for a death

by suicide, as if somehow complicit. This kind of negativity may be even

directed toward the parents of a child who died by suicide. 102 Such attitudes

can result in a lack of social support. Because suicide is usually unexpected,

the shock of suddenness magnifi es the bereaved’s sense that the death

occurred “out of time” or was inappropriate.

Homicide When a loved one dies as a victim of homicide, the survivor may experi-

ence the world as dangerous and cruel, unsafe and unfair. Furthermore, as

Lula Redmond points out, “The raw wound of the grieving homicide survi-

vor is overtly and covertly affected by the performance of law enforcement

offi cials, criminal justice practitioners, media personnel, and others after a

murder.” 103 Dealing with the criminal justice system extends the active griev-

ing period as the case drags on, with no assurance that the result will give

the survivor a sense of justice being done. Among the “trigger events” that

Redmond cites as restimulating grief are these:

1. Identifi cation of the assailant

2. Sensing (hearing, smelling, and so on) something that elicits recollection

of an experience acutely associated with the traumatic event

3. Anniversaries of the event

4. Holidays and other signifi cant events in the life of the family (such as

birthdays)

5. Hearings, trials, appeals, and other criminal justice proceedings

6. Media reports about the event or about similar events

Survivors of murder victims face a number of obstacles in adjusting to

the loss. The survivor may have to give depositions to attorneys and possibly

testify in court. He or she may be surprised to learn that the charge of mur-

der is a crime against the state, not against the loved one for whom the survivor grieves. Prosecutors may decide to plea-bargain or reduce the charge to a

lesser offense, and they may do so without consulting the bereaved family. As

the case proceeds through the judicial system, survivors can fi nd themselves

facing the defendant in the courtroom or in the courthouse corridor. Char-

acter witnesses may describe the defendant as a good and honorable person.

Survivors may have to contend with the defendant’s receiving a light sentence

or even being released. In other cases, the crime may never be solved, or it

may not be prosecuted because of insuffi cient evidence to bring the case to

trial. These are special circumstances that make grieving a homicide death

especially diffi cult.

Disaster People who survive a disaster in which others died become survivors

twice over—survivors of a catastrophic event that could have ended their own

lives and survivors of the deaths of others, often friends or relatives. Because

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Variables Infl uencing Grief 373

such survivors may feel that they did not deserve to live when others did not

survive, a sense of profound guilt can accompany the anguish and sorrow of

grief. Relief at having survived catastrophic and threatening circumstances—

a natural human response—may be accompanied by intense questioning:

Why did I survive while others very much like me perished? Such feelings are

often intensifi ed by catastrophic events involving untimely or unwarranted

deaths of others. Survivor guilt at being alive while others died can be hard to cope with. 104 Survivors of the Nazi Holocaust typically express a deep sense

of guilt about having survived the camps and torture while others did not

survive. 105 Veterans whose comrades were killed in combat often feel much

the same way. (Other aspects of coping with the aftermath of disaster are

discussed in Chapter 13.)

Multiple Losses and Bereavement Burnout Experiencing multiple losses can intensify grief. Catastrophe, whether

natural or human caused, can cause survivors to become overwhelmed by

loss, so devastated that they become emotionally numb and disoriented, pre-

venting the expression of normal grief.

In the wake of multiple losses, survivors may feel that they have “run out

of tears,” that they are bereft of emotional resources to express further feel-

ings of grief. 106 The experience of multiple losses can result in what has been

termed bereavement burnout. It’s as if the normal expression of grief is short- circuited by an unending experience of loss.

Social Support and Disenfranchised Grief The experience of grief and mourning also varies according to the

kind of social support available to the bereaved. In some communities and

religious traditions, social support is provided within an organized frame-

work that ensures caring concern for the bereaved. Among religious Jewish

families, for example, there are specifi c customs associated with aninut, the period between death and interment; keriah, the rending of the garment by the bereaved, which allows expression of deep anger in response to grief in

a controlled, religiously sanctioned manner; the hesped, or eulogy, in which the virtues of the deceased are recounted in a way that elicits the natural

expression of grief; seudat havraah, the meal of condolence, which recognizes that the fi rst meal after the interment should be provided by the mourner’s

friends or neighbors as a way of offering consolation; the kaddish prayer, which subliminally transfers the focus from the deceased to the living; and

shivah, the seven days of mourning that give structure to the early period of grief. 107 Social support of this kind can be immensely helpful to mourners.

Conversely, when social support is lacking, mourners may experience

an added burden in dealing with a loss. For example, after the death of an

unborn child, whether through miscarriage or abortion, bereaved persons

may receive little or no social support of the kind that comforts survivors of

other types of bereavement. In most cases, there is no funeral or other formal

observance of the death; the loss may not be acknowledged at all by the larger

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374 c h a p t e r 9 Survivors: Understanding the Experience of Loss

community. Occurrences of this kind can involve what Ken Doka has termed

disenfranchised grief —that is, grief experienced in connection with a loss that is not socially supported or acknowledged through the usual rituals. 108

When grief is disenfranchised, either because the signifi cance of the

loss is not recognized or because the relationship between the deceased and

the bereaved is not socially sanctioned, the bereaved person has little or no

opportunity to mourn publicly. Bereaved same-sex mates of persons who die

Family members leave the church after attending the funeral of a son and brother. Providing community support for the bereaved, such social rituals exhibit a blending of private grief and public mourning that offers solace during the early days of grief.

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Variables Infl uencing Grief 375

may face this situation. Survivors may receive comparatively little support

from the broader community as they cope with their loss. How many com-

munity resources, such as spousal support groups, are welcoming of persons

with a different sexual orientation? Obviously, the answer to this question

varies depending on the community and the mind-set of a particular sup-

port group. For example, in one community, a support group for parents who

experience neonatal loss integrated lesbian couples whose babies had died,

thus providing a measure of community support. When a death is treated by

society as if it were not a signifi cant loss, the process of adjustment is unneces-

sarily made diffi cult for survivors.

Grief may also be disenfranchised not because of the circumstances of

the loss but because of certain qualities that others may wittingly or unwit-

tingly associate with the bereaved. Darlene Kloeppel and Sheila Hollins point

out that complications may occur when a death in the family is combined

with a grieving family member’s having a mental handicap. 109 These com-

plications may affect both the family’s functioning and the handicapped

person’s mourning. Kloeppel and Hollins add that “death and mental retar-

dation are both taboo subjects in our society” and that “taboos elicit fear and

avoidance.”

Family support can be central to determining whether the survivor

is encouraged to cope not only with grief but also with the many practi-

cal issues that accompany bereavement. An illustration of this is the situa-

tion in western Nigeria, where a widow has no rights of inheritance to her

deceased husband’s estate; all possessions revert to the husband’s family.

Kemi Adamolekun points out that the social support provided by in-laws, or

the lack of it, is an important factor in how these widows mourn their loss. 110

Complicated grieving was especially noted when in-laws held the widow

somehow responsible for her husband’s death and when in-laws took steps to

dispossess the widow and her children of property. One observer at an Afri-

can funeral said, “When a widow cries uncontrollably at her husband’s burial,

she is not crying only for the loss, but for herself, because of the ordeal ahead

of her.” Indeed, a common saying is that widowhood should not be wished

even for an enemy.

Language can also disenfranchise. What expectations do we communi-

cate when we talk about “working through” or “getting over” a loss? When it

turns out that grief is not so readily “resolved” and “closure” is not realized,

the bereaved may feel somehow defi cient, as if something must be wrong with

them. Phyllis Silverman observes that our way of talking about grief infl u-

ences both how we understand it and how we cope with it. 111

Unfi nished Business Unfi nished business can be aptly termed “business that goes on after

death.” Something is incomplete. The content of unfi nished business, how

it is handled, and how the survivor is affected by it all have an impact on

mourning. Unfi nished business can be thought of in one or both of two ways

relative to its effect on survivors: fi rst is the fact of death itself; second is the

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376 c h a p t e r 9 Survivors: Understanding the Experience of Loss

relationship between deceased and survivor. As to the fi rst, perhaps an ear-

lier death of a parent, child, sibling, or someone else close continues to be a

vivid reminder of the survivor’s uncertainty and fears about death. Regard-

less of an individual’s particular beliefs or values, the more “fi nished” the

business of death is—that is, the more a survivor feels resolved within himself

or herself—the easier it will be to accept death and to cope with it. If a person

rails against death, refusing to make a place for it, grief is likely to be more

diffi cult to accept. Accepting death, giving it a place in our lives, allows us to

be fi nished with otherwise unresolved issues about death itself.

Second, and perhaps more crucial, is the unfi nished business between the

deceased and the survivor. Something in the relationship was left incomplete—

perhaps some long-standing confl ict was never resolved while the deceased

was alive, and now it’s too late. Unfi nished business can include things that

were and were not said, things done or not done. Bereaved people often say

that the things left unsaid or undone seem to come back to haunt them and

make mourning more painful. The sense of never being able to resolve con-

fl icts left by unfi nished business amplifi es the suffering. Consider the image of

a son standing over his father’s grave saying, “If only we had been closer, Dad.

We ought to have taken more time to visit each other.” It may be possible to

resolve unfi nished business by dealing with issues through the help of creative

or therapeutic interventions, but it is generally better to resolve unfi nished

business daily, in all our relationships and especially our intimate ones.

Unfi nished business can also relate to the plans and dreams that the

bereaved person had shared with the deceased. Perhaps there were places

they had talked about going together at some time in the future; now, these

travel plans will never be fulfi lled. Perhaps the survivor and the deceased

shared dreams related to family matters—plans about their children or

retirement years, for example. Such plans and dreams can touch on a num-

ber of areas in a survivor’s life. Death brings an end to all that had involved

the presence of the deceased.

Deathbed promises constitute a particular kind of unfi nished business.

Picture the classic scene in which the person who is dying elicits some prom-

ise from the survivor to perform a particular action after the person dies.

Most survivors agree to enact the promise, whether or not they really want to

comply with the deathbed request. Thus, a deathbed promise can later cre-

ate confl ict for the survivor, who may be torn between fulfi lling the promise

and taking another course of action. Whereas some people carry through

a deathbed promise and fi nd it to be a gratifying choice, others fi nd that

deathbed promises need to be reevaluated in the light of their own wishes

and circumstances.

Grief Counseling and Grief Therapy Because society is increasingly diverse, we cannot always easily determine

what may or may not be “healthy grieving.” Howard Winokuer and Darcy

Harris state, “One of the most important aspects of grief that differentiates

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Grief Counseling and Grief Therapy 377

it from other issues that clients bring into the counseling relationship is that

the grieving process itself is an adaptive response and not a form of pathol-

ogy.” 112 The task is to develop new concepts and approaches that can aid in

understanding the differentiated experiences of bereaved people. 113 In some circumstances, survivors may seek professional help to cope with their grief.

J. William Worden differentiates grief counseling, which involves helping people facilitate normal or uncomplicated grief, from grief therapy, which involves specialized techniques to help people with abnormal or compli-

cated grief reactions. 114 Worden also says that counselors and therapists are

challenged to work with issues of trauma and to know how to perform triage

among those needing traumatic intervention and those who need bereave-

ment intervention. 115 It seems that the more complicated the grief appears

to be or to become, the better the chances of interventions leading to posi-

tive results. 116

In recent years, articles have been published both in scholarly journals

and in the popular press suggesting that grief counseling may be more harm-

ful than helpful. One article states, “Grief counseling may sometimes make

matters worse.” 117 Another states, “Grief counseling does not appear to be

very effective, most probably because many of the people who receive it would

do just as well (and perhaps in some cases better) without it.” 118

In a recent study, Dale Larson and William Hoyt conclude that this pes-

simistic view of grief counseling was initiated by an unpublished dissertation

that did not have the benefi t of peer review. They say, “There is no empirical

or statistical foundation for these claims.” 119 According to Larson and Hoyt,

there is no reason to believe that grief counseling is less effective than other

forms of counseling or psychotherapy, which have positive outcomes for vari-

ous forms of psychological distress. A study of treatments for traumatized

children found that, whereas cognitive-behavioral therapy shows benefi ts,

the results are not as clear for psychodynamic therapy, art therapy, drug ther-

apy, play therapy, or psychological debriefi ng. 120 With limited data available

at present, additional research is needed to clarify whether or not grief coun-

seling—with its various techniques—is an effective treatment for normally

bereaved people.

Grief counseling on the Internet raises additional questions. Cyberther-

apy, e-therapy, teletherapy, Web-based counseling—a variety of names are

used to describe mental health services delivered via the Internet. Perhaps

this should not be surprising when it is considered that the history of indirect

treatment can be traced back to Freud’s practice of providing psychoanalysis

by letter when necessary because of geographic distance. 121 Are such cyber

services appropriate or effective?

In discussing the effi cacy of grief counseling, several questions pre-

sent themselves, the fi rst of which is, Do grievers need counseling? Phyllis

Silverman reminds us that the bereaved “need comfort, support, and help

as they deal with their grief and fi nd a new direction for their lives. Who

should that helping person be in our postmodern society—grief counselor,

family, and/or friend?” 122 David Crenshaw says, “Throughout the life span

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378 c h a p t e r 9 Survivors: Understanding the Experience of Loss

the primary intervention for most bereaved children, adults, and families

is some form of bereavement support. The majority will receive this sup-

port from their families, church, synagogue, or mosque, their school, or the

larger community.” 123

When additional intervention or professional help is needed, the

bereaved may turn to counseling or therapy. Here the question becomes, Is

the counselor death competent? What is death competence? In their book titled Ethical Practice in Grief Counseling, Louis Gamino and Hal Ritter defi ne the term to mean the counselor’s specialized skill in tolerating and managing

clients’ problems related to dying, death, and bereavement. 124 They liken it

to a three-layer cake in which death competence rests on a solid stratum of

emotional competence that itself rests on a bedrock of cognitive competence.

Dennis Klass offers an additional caveat when he advises, “If we want to hold

ourselves out as experts in helping the bereaved, we need to have a rather

good grasp of the symbols by which people fi nd meaning or lose meaning,

and the religious traditions (even the secular religion that believes in “spiritu-

ality”) that supply those symbols.” 125

In contrast to the death-competent counselor or therapist, Gamino and

Ritter remark that “individuals who deliberately try to solve their own prob-

lems in grieving through the professional role of grief counselor are really

clients masquerading as counselors.” 126

Bereaved people who experience traumatic death, who have dys-

functional attachment styles, or who, because of other factors (such as

those mentioned earlier in this chapter), are susceptible to complications

may benefit from help in coping with grief. More research is needed to

Grief Counseling on the Internet Picture the following scene: a client enters a coffee shop on the entry level of a

large offi ce building in a major U.S. city on the eastern seaboard and selects a

comfortable, overstuffed chair in a secluded corner. With the technological assis-

tance of a very smart phone and local wireless access to the Internet, the client par-

ticipates in a real-time, video-conference grief-counseling session with an expert

provider located on the West Coast, who was recommended as the best counselor

available for the client’s particular loss. The client wears a wireless headset to hear

the counselor’s comments and responds into a sensitive microphone that trans-

mits clearly what the client says when speaking no louder than a library voice. On

the telephone screen, the client can see the grief counselor, who is seated at a desk-

top computer with Webcam in an offi ce at the counselor’s home 3,000 miles away.

When the client’s cup of coffee is fi nished, and the 50-minute therapy “hour” is

over, both parties sign off, and the bill is paid over the Internet by credit card.

Does this sound futuristic?

Louis A. Gamino and R. Hal Ritter, Jr., Ethical Practice in Grief Counseling

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Support for the Bereaved 379

answer the question whether grief counseling is efficacious for normally

bereaved people.

Margaret Stroebe and her colleagues suggest that we “search for an appre-

ciative understanding of grief in all its varieties.” In part, “this would mean

curtailing the search for ideal therapeutic practices and focusing instead on

tailor-made treatments.” 127

Support for the Bereaved When a person experiences a signifi cant loss, he or she may initially feel and

behave much like a frightened child. A hug may be more comforting than

words. Having someone who can simply listen is helpful. The key to being a

good listener is to refrain from making judgments about whether the feelings

expressed by a bereaved person are “right” or “wrong,” “good” or “bad.” Talk-

ing and crying, even yelling in rage, are ways of coping with intense emotions.

In offering support to the bereaved, a basic guideline is not to expect them

to be “strong” and “brave” or to hold back their feelings. The emotions and

thoughts evoked by loss may not be expected, but they can be valid within a

survivor’s experience.

The role of the wake in Hawaiian culture illustrates how social support

can provide opportunities for the bereaved to engage in a controlled expres-

sion of anger and hostility that leads to a lessening of guilt and anxiety. Every-

one in the ‘ohana, or extended family, attends the wake, including children. With each new arrival, a relative might say—as if telling the dead person—

“Here comes Keone, your old fi shing companion,” or “Tutu is coming in now;

remember how she used to massage you when you were sick?” The assembled

mourners address the dead, recalling their memories and sometimes describ-

ing their feelings of abandonment or even scolding the deceased. A fi shing

companion might exclaim, “Why you mean, go off when we gon’ go fi shing!

Now who I go fi sh with?” Or a wife might say, “You had no business to go.

You should be ashamed. We need you.” 128 Scolding the corpse gives survivors

an opportunity to vent hostility toward the dead who had abandoned them.

What a contrast to the idea that one should “not speak ill of the dead,” which

encourages suppressing feelings of anger at the deceased.

As a culturally condoned vehicle for expressing grief, funerals and other

death-related community gatherings facilitate mourning by providing a social

framework for coping with the fact of death. Funerals and other rituals can

help survivors begin to integrate a loss into their lives. Donna Schuurman

offers insight in this regard: “I look at rituals not as closure; I don’t think the

word closure goes with death. I look at them as punctuation. Ritual gives the

mourner the opportunity to mark that something special has happened.” 129

(Or, as Robert Neimeyer has said, “Closure is for bank accounts, not for love

accounts.”) 130

For some, funerals are occasions of weeping and wailing; for others, stoic

and subdued emotions are the rule. Different styles of mourning behavior

can be equally valid and appropriate. Whereas dense social networks—small

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380 c h a p t e r 9 Survivors: Understanding the Experience of Loss

or medium-sized Israeli kibbutzim, for example—have social structures that

allow mourning to take place within an intimate circle of family, friends,

neighbors, and coworkers, looser social networks may need funerals and

other rituals to provide a structure wherein support can be offered to the

bereaved. 131

Social support is critical during the later course of grief, just as it is dur-

ing the fi rst days and weeks after a loss. Bereaved people should be able to

rely on receiving support from those they trust. They need to be reassured

that it is appropriate to express grief. They may also need permission to

occasionally give themselves a break from grieving. As they move forward

with life, bereaved individuals may be helped by encouragement from oth-

ers to face the world confi dently. The anniversary following a signifi cant loss

is usually a time of renewed grieving, when the support of others is impor-

tant and appreciated. Knowing that others remember and acknowledge the

loss, and that they take time to “touch base,” is usually perceived as very

supportive.

Besides receiving social support from individuals who form their net-

work of friends and relations, bereaved people may want to share their sto-

ries and concerns through organized support groups. Most such groups are

based on perceived similarity. Having experienced similar losses, members

of support groups come together to talk with each other as they integrate

those losses into their lives. Widow-to-widow groups, for example, provide

opportunities for women to share experiences of being a woman alone and

encourage one another in the task of coping with the death of a spouse.

Military families receive bereavement support through the Tragedy Assis-

tance Program for Survivors (T.A.P.S.), which offers peer-to-peer support,

counseling referrals, survivor seminars, and other types of help. 132 Other

organizations, such as The Compassionate Friends (TCF) and Bereaved

Families of Ontario (BFO), assist families who are coping with the death of

a child. In describing the aims of BFO, Stephen Fleming and Leslie Balmer

note that it is “designed to facilitate the grieving process, emancipate the

bereaved from crippling attachments to the deceased, assuage fears that

one is ‘going crazy,’ educate the survivors about the nature and dynamics of

grief to normalize their experience, and promote the usual curative quali-

ties found in groups (the installation of hope, altruism, group cohesiveness,

catharsis, and insight).” 133 Some support groups are composed entirely of

peers; others are led by a trained professional or lay counselor. Hospice and

palliative care programs usually have trained volunteers to help families

cope with grief.

Bereavement as an Opportunity for Growth When life’s events bring loss into our lives, we might wish there was some

potion we could access that would induce forgetfulness of pain and sorrow,

what the Greeks called nepenthe, something capable of causing the end of

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Bereavement as an Opportunity for Growth 381

suffering and grief. Viewing bereavement as an opportunity for growth can be

diffi cult at fi rst, but this perspective can promote gradual movement toward

accommodating the loss. As the bereaved person begins to reformulate the

loss, it frees up energy that had been bound to the past. As John Schneider

says, “There is a change in perceptual set from focusing on limits to focusing

on potential; from coping to growth; and from problems to challenges.” 134

The tragic event of a death is reformulated in a way that doesn’t shut out new

possibilities. Loss can be transformed in ways that place it within a context

of growth. This reframing can carry over into other areas of the person’s life

so that beliefs and assumptions that were once limiting are reassessed with

greater self-confi dence and self-awareness, making possible signifi cant and

rewarding life changes.

Turning to inner sources of creativity can give form to the experience of

grief. Creatively responding to loss can bring forth remarkable results. Those

who work with the bereaved can spark a grieving person’s creative response,

as in the case of a young woman who had experienced the sudden, unex-

pected death of her son at birth. Overwhelmed by feelings of sadness, depres-

sion, and an inability to do anything other than grieve, she was despairing

of words to communicate her feelings. In a counseling session six months

after her son’s death, she remarked, “I haven’t touched a lump of clay since

Justin died.” The obvious question was, What had she done with clay before

his death? She said that her sculptures of whales and seals had sold at a local

seaside crafts shop. The counselor pointed out that the reason for her inabil-

ity to return to her art might lie in the products of her creative energies.

Although whales and seals might one day reemerge from the lumps of clay,

her creativity at present might take a different form. The client agreed to

fi nd a quiet moment when she would put her hands to the lump of clay as an

experiment to see what might emerge.

Both the bereaved mother and the counselor were amazed at the results

(see Figures 9-2 a , b , c ). Over the course of twelve months, a series of some

twenty-two fi gures emerged. The earliest were naked; later works were

draped with a blanket; and, with the fi nal pieces, the fabric of the blanket

had been turned into clothing. The mother’s creativity not only gave form to

her loss but also manifested an unconscious understanding of the process of

recovery and the integration of her loss. Subsequently, the sculptures were

photographed and published along with her prose, giving comfort to other

survivors. 135

People maintain connections with deceased loved ones through memo-

ries, as well as through personal and social rituals that provide a “space” in

their ongoing lives for acknowledging affection and love for the deceased.

The journey of grief has benefi ted from theory, research, and clinical expe-

rience, which have deepened our appreciation of the lifelong impact of

bereavement on survivors. 136 Bereavement, grief, and mourning are com-

plementary threads in the fabric of life, part of the warp and weft of human

experience.

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382 c h a p t e r 9 Survivors: Understanding the Experience of Loss

Figure 9-2 (b) Sharing the Grief Figure 9-2 (a) Anguish of Loss

Figure 9-2 (c) Collapsing

Further Readings Thomas Attig. How We Grieve: Relearning the World, 2nd ed. New York: Oxford Univer-

sity Press, 2010.

Sandra M. Gilbert. Death’s Door: Modern Dying and the Ways We Grieve. New York: Norton, 2006.

Robert E. Goss and Dennis Klass. Dead but Not Lost: Grief Narratives in Religious Tradi- tions. Walnut Creek, Calif.: AltaMira Press, 2005.

“The anguish of loss is overpowering and vast,” begins the prose accompanying the sculpture by Julie Fritsch pictured here, part of the series created following the death of her son. “Sharing the grief ” states the theme of the second sculpture, acknowledging that “together we must comfort and be comforted.” The third sculpture portrays the bereaved artist “collapsing from the weight of emotions I cannot control.” The prose accompany- ing this sculpture continues: “Drained of any ability to cope or carry on, I must collapse now. And feel myself overcome by absolute grief.”

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Further Readings 383

Nancy R. Hooyman and Betty J. Kramer. Living Through Loss: Interventions Across the Life Span. New York: Columbia University Press, 2006.

Robert A. Neimeyer, Darcy L. Harris, Howard R. Winokuer, and Gordon F. Thornton,

eds. Grief and Bereavement in Contemporary Society: Bridging Research and Practice. New York: Routledge, 2011.

Colin Murray Parkes and Holly G. Prigerson. Bereavement: Studies of Grief in Adult Life, 4th ed. New York: Routledge, 2010.

Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolfgang Stroebe, eds.

Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, D.C.: American Psychological Association, 2008.

Christine Valentine. Bereavement Narratives: Continuing Bonds in the Twenty-First Cen- tury. New York: Routledge, 2008 .

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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© M

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A child feels the death of a parent or other close family member or friend as deeply as do adult survivors. This young Chinese girl holds a picture of her mother, who died in an earthquake. The girl’s hat and white clothes, known as Pi Ma Dai Xiao, make up the traditional garments worn in Chinese funerals to signify mourning the death of a parent.

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385

C H A P T E R 1 0

Death in the Lives of Children

and Adolescents

P arents and other adults have natural concerns about what to tell children about death. How can we help a child cope with death? How should we start the discussion? What

is the child able to understand? Deaths that are sudden and unexpected or that result from

suicide or homicide complicate issues the child faces in coping with loss. 1 Although chil-

dren tend to be resilient in coping with tragedies in their lives, adults can play a crucial role

in guiding a child through grief by listening to the child’s concerns and communicating

support for the child’s well-being. Family patterns and styles of communication infl uence a

child’s or adolescent’s ability to understand and cope with loss.

According to the International Work Group on Death, Dying, and Bereavement, “All

too often, the needs of children and adolescents who encounter issues related to death are

not properly acknowledged or appreciated by adults.” 2 Loss due to death is part of life for

children as well as adults. Yet, it is a topic that society as a whole tries to shield from chil-

dren. 3 When a loss occurs in a child’s life, attempts are often made to minimize its effects.

The death of a pet, for example, may be swiftly followed by its replacement with another

animal. However, this strategy for comfort may be of limited benefi t. Severing an attachment

to someone special is a signifi cant loss. A more constructive approach is to help children

explore their feelings about death. Despite our wish to spare children the pain of bereave-

ment, death is a fact of life that eventually cannot be ignored.

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386 c h a p t e r 10 Death in the Lives of Children and Adolescents

Whether or not they receive instruction, children develop their own

concepts about death, even when the topic is considered taboo. How a child

experiences and copes with death is likely to correspond to his or her develop-

mental phase. 4 (The process of learning about death is discussed in Chapter 2.)

Children who have had death experience appear to have a more complete

understanding of death than their inexperienced age-mates. 5

One six-year-old who witnessed the accidental death of her sibling

expressed a clear understanding that death is fi nal, that people die, and that

Children experience the impact of war on their lives in a variety of ways. For the German child seen here, war brought a stark encounter with death. This child was one of many German citizens who, at the end of World War II, were ordered by the provisional military government of the U.S. Third Army to view the exhumed bodies of Russians, Poles, and Czechs killed while imprisoned in the concentration camp at Flossenberg. For Amanda Wille (facing page), the impact of war was felt in terms of the anticipated loss of her father, a Navy computer technician, as he prepared to board the USS John F. Kennedy for service during the Persian Gulf War. Understanding only that her father was going away, the three-year-old seemed anxious and bewildered until she found a piece of string on the Nor- folk, Virginia, dock. After her father broke the string and tied one piece around his wrist and the other around hers, Amanda cried and hugged him goodbye.

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387

she herself could die. She was concerned about how she could protect her-

self and her friends from the dangerous circumstances that had led to her

brother’s death. Her attitude was displayed in admonitions to schoolmates

that they should try to prevent accidents.

Besides being survivors of tragedy or a close death, children and adoles-

cents sometimes encounter death in the context of being challenged to cope

with serious and possibly life-limiting illness. An Institute of Medicine report

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388 c h a p t e r 10 Death in the Lives of Children and Adolescents

states: “We can and should do more than we are currently doing to prevent

the physical and emotional suffering of dying children and . . . to respect the

personal dignity of the dying child.” 6 This is discussed later in this chapter.

Children want to know about death, just as they want to learn about all

the things they encounter in their lives. One child wrote, “Dear God, what’s

it like when you die? Nobody will tell me. I just want to know. I don’t want to

do it.”

Experiences with Death Children who experience fi rsthand the reality of death through war or vio-

lence, or in connection with other forms of catastrophic death, often exhibit

a fatalistic attitude that contrasts with the attitude of children whose expe-

riences of death occur in more benign circumstances. A diary written by a

young girl in war-torn Sarajevo highlights the effects of violence on children.

Zlata Filipovic’s diary displays an evolution from the ordinary concerns of

teenage life to a shattering preoccupation with destruction and death as

warfare disrupts normal life. In one entry, Zlata writes, “War has crossed out

the day and replaced it with horror, and now horrors are unfolding instead

of days.” 7

A study of the psychosocial effects of war among displaced children in

Southern Darfur found that increased exposure to war experiences led to

higher levels of traumatic reactions, depression, and grief symptoms. 8 War

experiences included abduction, hiding to protect oneself, being raped, being

forced to fi ght and to kill or hurt family members, and death of a parent. A

separate study in Uganda found children who said they had to keep quiet

about such deaths, not only because it was too painful to talk about but also

because they were afraid of retaliation by those who had a hand in the kill-

ings. 9 James Garbarino says, “Few issues challenge our moral, intellectual, and

political resources as does the topic of children and community violence—

war, violent crime on the streets, and other forms of armed confl ict.” 10

Many children and teenagers growing up in America’s cities experience

warlike disruptions due to drug-related violence and gang warfare, a situation

that writer, actor, and musician Ice-T characterizes as “the killing fi elds” of

America (see Figures 10-1 and 10-2).11 When children in an urban school in

Germany were asked about the ways people die, violent deaths were described

as being caused by “weapons” and “sharp knives.” Conspicuously absent was

any use of the word gun. 12 In Germany, fi rearms are strictly regulated and not readily available to the populace.

Children who have witnessed violence or experienced it indirectly,

such as losing a parent to murder, may develop posttraumatic stress disor-

der (PTSD) or other harmful disorders. A task force on traumatic events

among children and adolescents found that individual and group cognitive-

behavioral therapy is helpful in relieving symptoms of PTSD, depression,

anxiety, and related problems by addressing distortions of perception regard-

ing self-blame, safety, and the trustworthiness of others. 13

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Experiences with Death 389

Figure 10-1 Ways People Die: Children’s Images Above: A seven-year-old African American boy in a large midwestern city draws a picture of murder by decapitation. (In separate incidents, two young girls in his city had recently been killed in this manner.) Below: In contrast, the drawing created by a seven-year-old Caucasian boy attend- ing Catholic school in a small California town portrays the child’s concept that people die when “God calls you home.” Notice the child’s depiction of the voice of God and heavenly “pearly gates.”

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390 c h a p t e r 10 Death in the Lives of Children and Adolescents

Figure 10-2 Ways People Die: Children’s Explanations Environment, including both time and place, infl uences a child’s understand- ing of death. The impact of environment on children’s views of death can be evoked by asking them to make a list or draw a picture in response to the question, What are the ways people die? The list shown above was written by a seven-year-old Caucasian girl living in a small coastal California town. It stands in sharp contrast to the thirteen-item response (facing page) written by a seven- year-old African American boy living in a major midwestern city. Although both lists were created by children of the same age, the second list refl ects the circumstances of life in an inner-city metropolitan environment. Whereas the fi rst child’s list focuses on diseases and accidents, the second child’s explana- tion shows familiarity with a broad range of causes of death, few of which relate to “natural” events. His illustration of item number 11, “cut your head off,” is shown in Figure 10-1.

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Children as Survivors of a Close Death 391

Chance encounters or fortuitous happenings may be benefi cial or detri-

mental, depending on the nature and interplay of personal and social forces.

Some detrimental confrontations occur in which the affected person simply

happened to be in the wrong place at the wrong time.

They may get injured, maimed, or deeply enmeshed in nightmarish events

that leave debilitating effects. In tragic cases, as when an innocent victim

is unexpectedly caught in a cross fi re and killed by a drive-by shooting, the

unfortunate victim is no longer around to provide narratives. 14

When questioned about the ways people die, children in violent or death-

saturated environments tend to answer quite differently from children whose

lives are comparatively sheltered from such experiences.

Children as Survivors of a Close Death A particular child’s response to loss refl ects the infl uence of such factors as

age, stage of mental and emotional development, patterns of interaction and

communication within his or her family, relationship with the person who

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392 c h a p t e r 10 Death in the Lives of Children and Adolescents

has died, and previous experiences with death. Generally speaking, bereaved

children experience grief reactions similar to those experienced by adults.

However, children differ from adults in cognitive abilities, need for identifi ca-

tion fi gures, and dependence on adults for support.

The Bereaved Child’s Experience of Grief A story about Monica, a three-year-old who nearly drowned when her

house collapsed into the raging water of Hurricane Katrina, can add to our

understanding of children’s grief. 15 After the disaster waned, each time she got

into the tub, Monica reacted as if she were going to drown. At fi rst whimpering,

then sobbing softly, and fi nally wailing as the tub began to fi ll. She learned in

the storm that those she loves and who love her can’t always protect her. Faith

in her parents’ ability to protect her was shattered. As a result of the hurricane,

school-age children struggled with intrusive thoughts and their anxiety mani-

fested in physical symptoms like stomachaches. For adolescents, depression set

in as they realized it could be years before they could be back in their homes.

Certain expressions of grief are prevalent during early childhood. 16

These include regression, magical thinking, guilt over “causing” a death,

helplessness, and wishful thoughts about the return of the deceased. Older

children typically exhibit anger, concerns about health, or school problems.

Coping strategies change as one matures. For example, children often try to

derive comfort by seeking comfort from others, denying at times the impact of

the loss, adhering to familiar activities and routines, using fantasy to ameliorate

aspects of the loss. As they enter adolescence, young persons begin to engage in

more effective behavioral coping strategies (for example, help seeking, problem

solving, expressing feelings). 17

Adolescents begin to engage in cognitive coping strategies, such as

search for meaning, positive reappraisal, and acceptance of the loss. In doing

so, they are likely to make use of the Internet and social networking sites.

Adolescents’ developmental tasks of feeling in control, attaining a sense

of mastery, and being able to predict events are compromised by death. 18 In

a study of adolescents’ responses to the terror attacks of September 11, 2001,

researchers found that adolescents (especially girls) were frightened and

reported concerns about dying from other disasters, such as tornadoes or

earthquakes. These anxiety reactions are consistent with adolescents’ devel-

opmental issues related to vulnerability to death. Resilience, too, was seen

in their efforts to make a coherent narrative of the events and to refocus on

their daily living. 19 Indeed, some researchers and clinicians suggest that resil-

ience can be a key protective factor. 20 In a study of African American teen

girls who had experienced the homicidal death of a friend, Celeste Johnson

found that they demonstrated resilience in their ability to “move on” with

their lives by calling upon reserves of motivation and meaning-making in

their lives. 21

If a child believes he or she may have played a role in the events that

led to a death, guilt may predominate among emotions experienced. It is

important to openly discuss the circumstances surrounding the death and

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Children as Survivors of a Close Death 393

give the child opportunities to explore the troubling aspects of his or her

grief. When children are left on their own to fi gure out how to cope with

confused feelings of guilt and blame, traumatic effects may persist into adult-

hood. To illustrate, in one situation, which involved three brothers playing

with a loaded gun, the youngest pushed the oldest, who held the gun as a

bullet was discharged, killing the third sibling. “I have always struggled with

myself about whether my brother would have died if I hadn’t tried to push

my other brother away,” said a thirty-year-old man, recalling events that had

taken place more than a quarter of a century earlier. “I always thought I did

the right thing in trying to prevent the accident, but no one ever talked with me about my feelings. For years, I cried myself to sleep alone in my bed at

night.” Even when it is obvious to others in the environment that a child bears

no responsibility for a death, he or she should be encouraged to share his or

her perceptions and beliefs about how the death occurred. The child’s expe-

rience can be different from that of the adults.

In coping with loss, children sometimes selectively forget or try to recon-

struct reality in a more desirable and comfortable way. A child may not recall

how frightened she was by the sight of a sibling lying ill in a hospital bed sur-

rounded by awesome medical paraphernalia; or the child may remember a

protracted illness with long stays in the hospital as if the sibling had been away

from home only briefl y for a few tests. The forgotten details or reconstructed

images provide a way to cope without being overwhelmed by painful memories.

Despite signifi cant advances in the understanding of grief, some pediat-

ric medical journals continue to rely on the Kübler-Ross model as a descrip-

tion of the “stages of grief ” children experience with loss. 22 The wise parent

or counselor will expand this framework by making use of other strategies for

understanding grief (such as those discussed in Chapter 9).

The Death of a Parent Of all the deaths that may be experienced in childhood, the most affect-

ing is likely to be the death of a parent. 23 A parent’s death is perceived as

a loss of security, nurture, and affection—a loss of the emotional and psy-

chological support upon which the child could formerly rely. Coping may

be complicated when the death results from suicide or homicide. 24 In the

United States, it is reported that more than 2 million children and adoles-

cents younger than eighteen (roughly 3.5 percent) have experienced the

death of a parent. 25

Death leaves a gap not only from the lack of the physical presence, but also from

the part the parent played in defi ning and directing the family life. Parents are

role models, teachers, nurturers, and framers of family traditions. Each child

loses someone different, depending on their parent’s role in the family and also

on the child’s relationship to that parent. 26

Based on data obtained from the Child Bereavement Study, Phyllis Silver-

man and her colleagues conclude that children who have lost a parent typi-

cally establish a set of memories, feelings, and actions that the child draws on

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394 c h a p t e r 10 Death in the Lives of Children and Adolescents

in “reconstructing” an image of the dead parent. 27 This involves building an

“inner representation” that allows the child to sustain his or her relationship

with the deceased parent, and “this relationship changes as the child matures

and as the intensity of grief lessens.” The child negotiates and renegotiates

the meaning of the loss over time. The loss is permanent; the process of cop-

ing with it changes.

When the death of a parent occurs when a child is very young, grief may

involve mourning the years of relationship that were lost due to the parent’s

premature death. There can be a lingering sense of “never having known”

the deceased parent. Consider, for example, the situation of a parent who

dies as a result of war. Powerful emotions may lie buried for years until some

stimulus—perhaps the discovery of the parent’s military papers or a visit to

a war memorial—brings the loss to the surface. Sharing the loss with others

can aid healing. Ways of forming an understanding of the loss may include

talking to other veterans, allowing the child to fi ll in the picture of a deceased

parent whom he or she had not been able to fully know.

Children sometimes take responsibility as they struggle to understand a

close death. For example, a child whose parent died of cancer might remem-

ber times when she was noisy and her parent needed to rest. “Maybe if I had

been quiet,” the child thinks, “Mom would have gotten well.” The very fact

that the parent is dead while the child is alive may cause children to experi-

ence “survivor’s guilt.” A drawing made by a four-year-old whose father had

died of leukemia illustrates this (see Figure 10-3 ). Some time after his father’s

death, as the child was playing with pencils and drawing paper, he asked

his mother how to spell various words. Attracted by the child’s activity, his

mother noticed that he had drawn a picture of his father. In the drawing, the

father was saying to the child, “I am mad at you!” Surprised at this depiction

of her husband’s anger toward her son, the mother asked, “Why would your

father have been mad at you?” The child explained, “Because you and I can

still play together and Dad can’t.” Amid the confusing feelings resulting from

his father’s death, the child was attempting to come to terms with the fact of

his survivorship.

Even young children sense that they are different from other kids after a parent

dies. During one of The Dougy Center’s “Littles” groups for three to fi ve year olds,

Luke got a splinter in his fi nger while climbing on the playhouse outside. He went

inside with an adult facilitator for a Band-Aid, trailed by his buddy, Mario. Both of

these preschoolers’ fathers had died in car accidents. As Luke’s fi nger was washed

and the Band-Aid applied, Mario said that he too had a “boo-boo” and needed a

Band-Aid. When the facilitator asked him where his boo-boo was, he replied, “It’s

invis’ble. All of us kids at The Dougy Center have invis’ble boo-boos, ’cause we all

had someone die.” He knew, even at four, that he was different from other kids.

Donna Schuurman, Never the Same: Coming to Terms with the Death of a Parent

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Children as Survivors of a Close Death 395

Now, in working with this child as a survivor, his mother did a very wise

thing. She said, “Tell me about this picture.” She asked open-ended ques-

tions, which allowed her to elicit information about the child’s feelings and

respond directly to the child’s concerns. Using art with bereaved children

helps them work through grief by providing a safe, focused environment for

expressing their concerns and feelings.

The Death of a Sibling One effect of a sibling’s death may be to increase the surviving child’s

sense of vulnerability to death, especially when siblings are close in age. When

Figure 10-3 A Four-Year-Old’s “I Am Mad at You” Drawing Following the death of his father, a four-year-old has depicted his father saying, “Donovan, I am mad at you.” Notice that the father is portrayed as being bald due to chemotherapy treatments. Whereas baldness is an accurate representation of the father’s appearance, the absence of arms refl ects the child’s emotional per- ception of the situation. Arms reach out; they hug and enfold; they are a common means by which human beings express affection for one another. In the later stages of the father’s illness, the pain was so great that he was unable to gather the child into his arms. The child’s experience of this has been depicted in his drawing. Also notice that the drawing shows the father’s body facing the viewer, yet his feet are drawn at an angle as if they are walking off the page. Again, the drawing refl ects the child’s experience, this time showing the father’s movement out of his life. Impor- tantly, the child’s mother used the occasion of this drawing as an opportunity to talk with the child about his present feelings regarding his father’s death.

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396 c h a p t e r 10 Death in the Lives of Children and Adolescents

Siblings enjoy a special relationship, one conjoining both rivalries and mutual affection and love. The death of a brother or sister thus severs a unique human relationship. The surviving child may feel the loss more intensely because of identifi cation with the deceased brother or sister. The surviving child recognizes that he or she is also not immune to dying at an early age.

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Children as Survivors of a Close Death 397

a child dies, most of the attention is focused on the parents rather than on

the dead child’s surviving siblings. As Betty Davies points out, relatively little

attention has been devoted to sibling bereavement. 28 Yet, in countries like the

United States, where families tend to be small, the death of a sibling can make

the surviving child an only child. Losing a brother or sister can be a lonely experience. As one child said, “It was like my mom and dad had each other,

and I had no one.” With the parents grieving their own loss, the surviving

child may also experience losing his or her parents as they were once known.

The brother or sister may have been a protector or caregiver as well as a play-

mate. The surviving child may grieve the loss of this unique relationship, wor-

ried that the protection and care given by the sibling are no longer available and

yet relieved or even pleased that, with the sibling’s absence, he or she can now be

closer to the center of attention in the family. Such a mixture of emotions can

produce guilt and confusion as a child comes to terms with the sibling’s death.

Children typically look to their parents for help in understanding and

coping with a sibling’s death and its effects on the family. In studies of ado-

lescent sibling bereavement, the support considered most helpful by the

bereaved teenagers was perceived as “people being there for me.” 29 Dys-

functional family patterns impair the surviving child’s ability to cope. Such

responses range from overt resentment of the surviving child to attempts to

re-create in that child the qualities of the deceased child. As parents come to

terms with a child’s death, they may unintentionally minimize contact with

the surviving child. The living child can be a painful reminder of the child

now lost. Conversely, parents may become overprotective of the surviving

child. Parental responses like these may be present to a lesser extent even in

families that appear to be coping successfully.

The bereaved child must be given opportunities to acknowledge and

express his or her grief. If a child talks about feeling guilty, one can ask,

“What would it take to forgive yourself?” Feelings of guilt are often related to

normal sibling rivalry. The sister at whom one angrily yells, “I hate you!” in

the morning may be lying dead at the morgue in the afternoon, the victim of

a bicycle accident. To a young child, anger directed toward a person and that

person’s subsequent death might be viewed as a cause-and-effect relationship.

This assumption of responsibility is sometimes displayed as a preoccupa-

tion with the “should haves.” One fi ve-year-old whose younger brother was

run over by a truck while they were outside playing told his mother later,

“I should have .  .  . I should have.” He saw himself as his younger brother’s

protector, responsible for his safety. His mother asked him, “You should have

what?” He replied, “I just should have!”

His mother then asked, “What do you mean, you ‘should have’?” The boy

answered, “I should have looked, I should have known, I should have . . . ”—

a fl ood of “should haves” about being his brother’s guardian and protector.

Taking the child into her arms, his mother said, “I understand, honey. Dad-

dy’s got the ‘should haves.’ Mommy’s got the ‘should haves.’ We all have them.

It’s okay to have them. And it’s okay to know that everybody could have done

something differently, and that they would have if they’d had a choice.”

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398 c h a p t e r 10 Death in the Lives of Children and Adolescents

Figure 10-4 A Five-Year-Old’s “Crooked Day” Drawing In this drawing of “The Crooked Day,” a fi ve-year-old boy depicts his experience of the events that transpired on the day his brother received fatal injuries in an accident. Contrary to what might be assumed about this drawing, the places on the line where the greatest stress is indicated occurred after the accident itself. The sharp dip in the line at the left-hand side of the drawing represents the accident; the point at which the line crosses back on itself denotes the time when the surviving child was left with a neighbor while his parents were at the hospital with his brother. This was a period of uncertainty and confusion, and the child was angry about not being with the other members of his family. The point at which his parents returned and informed him of his brother’s death is indicated by the vertical slash marks, which were literally stabbed onto the paper. The jagged line connoting the remainder of the day represents the emo- tional upheaval that occurred as the child and his parents together focused their attention on coping with the initial shock of their loss. Importantly, the drawing ends with an upward slanting line that is indicative of an essentially positive attitude—the child’s ability to deal constructively with his experience of loss. This drawing demonstrates that even a simple artistic expression, such as a line depicting the chronology of events, can reveal a wealth of detail about a child’s experience of a traumatic event such as death.

Allowing a child to be a participant in the family’s experience helps the

child cope with crisis, as we see exemplifi ed in a drawing by the fi ve-year-old

who saw his younger brother killed (see Figure 10-4 ). The drawing represents

“the day my brother was killed”; the point of greatest stress is shown to be the

period of time when he was left at a neighbor’s house while his parents were

at the hospital. Even more frightening than seeing the wheel of the truck roll

over his brother’s head was the feeling of being left alone, separated from the

rest of his family, not knowing what was happening with his parents and his

younger brother.

This child’s parents not only encouraged the child to express his feel-

ings but also sought out resources as additional support for coping with the

tragedy. Just as the child’s work with spontaneous drawings helped bring to

light his anger at being left out, the parents received support by sharing their

experience with others who had survived similar experiences and by calling

on therapeutic resources in their community.

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Children with Life-Threatening Illnesses 399

For adolescents bereaved by a sibling’s death, efforts to cope with the loss

may be intertwined with the developmental task of formulating a personal

sense of the meaning of life, a task that usually includes intense questioning

about the value of religious beliefs and the existence of God. David Balk points

out that the death of a sibling shatters “trust in a benign, innocent universe”

and various “questions about the nature of life and death, about good and

evil, and about the meaning of life become personal.” 30 Coping with a sibling’s

death can bring about a greater maturity in cognitive development, social

reasoning, moral judgment, identity formation, and religious understanding.

Indeed, bereaved young people often cite religion as an important resource

for coping with loss, reporting that it offers a source of meaning that provides

solace as they search for signifi cance in the aftermath of tragedy. A sense of

the “ongoing presence” of the sibling bond is also reported by bereaved ado-

lescents, as they continue the “conversation” with a deceased brother or sister

and take time to “catch up” on things that have been going on in their lives. 31

Children with Life-Threatening Illnesses “Mental fi rst aid” may be needed by children with life-threatening illness to

help them cope with disturbing thoughts and feelings. Such assistance may

mean simply comforting the child and being supportive through a diffi cult

or painful procedure, or it may require more substantive intervention to deal

with anxiety, guilt, anger, or other confl icting or unresolved emotions. Car-

ing for children requires a fl exible approach. A child who feels unsure about

what is happening may have fantasies that are more frightening than the

truth. A supportive atmosphere in which the child feels free to express his

or her fears diminishes feelings of separation and loneliness. Care of chil-

dren who are seriously ill goes beyond physical care. As an Institute of Medi-

cine panel stated, “We can and must reduce the number of those who fail to

receive consistent, competent care that meets not only their physical needs,

but their emotional, spiritual, and cultural ones as well.” 32

Some suggestions for communication with seriously ill children are given

in Table 10-1 . In early childhood, the experience of serious illness is likely to

be characterized by possibly frightening periods of hospitalization, painful

and incomprehensible procedures, periods of separation from familiar adults,

limitations caused by the disease and treatment, and communication issues

(especially when parents are reluctant to inform the child). For a school-age

child, major issues may include a sense of stigma and impaired self-concept,

interactions with peers, managing the illness within the school environment

(such as intermittent absences and poor academic performance), side effects

of treatment, and issues with parents concerning autonomy. For an adoles-

cent, concerns may focus on being forced into a dependent role when trying

to achieve independence, impaired body image and impaired self-concept,

limited ability to establish ties with peers, questioning of beliefs, and ambiva-

lence or open confl ict with parents.

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400 c h a p t e r 10 Death in the Lives of Children and Adolescents

Parents and other adults often fi nd it diffi cult to respond to a seriously ill

child’s or teen’s questions. Such questions can evoke uncertainty and may be

met with silence or other forms of avoidance. Is it ethical, or even possible, to

withhold information about a serious or life-threatening illness from a child

or adolescent? This poses a dilemma for those who might wish to keep trou-

bling news from them. William Bartholome observes that “the most daunt-

ing problem facing parents and caregivers who are caring for a terminally ill

child is that the person they are caring for lives in a different reality.” 33

The Child’s Perception of Serious Illness Younger children’s perception of their illnesses can be remarkable.

Marie-Bénédicte Dembour writes movingly about the “conscious death” of a

two-year-old, describing how the child behaved with obvious awareness and

curiosity as her parents and doctors discussed her prognosis and her treat-

ment was carried out. 34

Studying children in a leukemia ward, Myra Bluebond-Langner observed

that seriously ill children were usually able to guess their condition by inter-

preting how people behave toward them. 35 Crying or avoidance behaviors were

interpreted as indicating the serious nature of the disease. The children in the

leukemia ward, most of whom were between the ages of three and nine, were

able to accurately assess the seriousness of their illness even though adults had

not shared this information with them. Although they sometimes discussed

their illnesses with their peers, these children refrained from doing so with

adults. Recognizing that such conversations made adults uncomfortable, the

children talked about the taboo topics among themselves, much as children

discuss other forbidden topics, out of range of adult hearing.

Over time, the children’s interpretations of their conditions changed. At

fi rst, the illness was seen as acute, then chronic, and fi nally fatal. Medica-

tions were fi rst “healing agents,” then “something that prolongs life.” As their

perception of the drugs changed from being “always effective” to “effective

Age Approach

0–2 Provide maximum physical relief and comfort.

2–7 Minimize child’s separation from parents. Evaluate for feelings

of guilt.

7–11 Foster child’s sense of control and mastery. Evaluate for feelings of

abandonment or body mutilation. Provide details about treatment.

Maintain access to peers.

12 1   Be clear, honest, direct. Support reasonable measures for inde-

pendence. Provide privacy. Reinforce self-esteem and body image.

Allow ventilation of anger. Maintain access to peers. Consider

mutual support groups.

t a b l e 10-1 Suggestions for Communication with Seriously Ill Children

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Children with Life-Threatening Illnesses 401

sometimes” to “not really effective at all,” their attitudes and behaviors toward

taking medication likewise changed.

The children tended to know a great deal about the world of the hospi-

tal, its staff and procedures, and the experiences of other leukemic children,

making comments like “Jeffrey’s in his fi rst relapse” and noticing when other

children died. Although the children did not always know the exact name of

the disease affl icting them, they typically displayed considerable knowledge

about its treatment and prognosis.

In the “cancer narratives” of adolescents and young adults, researchers

said that “we hear their sense of pain and anger at losing control over making

their own decisions; we also hear about ways of coping, the support of friends,

and ways that they view their physical and psychological selves as they prog-

ress through treatment.” 36

Spontaneous drawings and other forms of art therapy are excellent meth-

ods for working with young children, helping them explore and express feel-

ings that otherwise might remain hidden yet be disturbing. 37 This was shown

in a study conducted at G. Gaslini Children’s Hospital in Genova, Italy. 38 The

children, affected by leukemia and other cancers, ranged in age from four to

fourteen years (median eight years). The children used drawings “as a stage

to dramatize their needs, wishes, anxieties, and joys.” The drawings depicted

their relationship to the disease, the hospital, and the environment in gen-

eral. The researchers concluded that art therapy is a “vitally important means

of narrative communication for severely sick children” that allows them to

express their need for truth and for communication. They said that the study

confi rmed their theory that art therapy is warranted as part of the total care

of severely ill hospitalized children.

The Child’s Coping Mechanisms How a child perceives an illness and the manner in which he or she

responds to it depend on age, the nature of the illness and its treatment, fam-

ily relationships, and the child’s own personal history. The main concerns

experienced by seriously ill children tend to match their understanding of

death. For example, children under fi ve years old tend to be most distressed

by separation from the mother. Children from roughly ages fi ve to nine

tend to be most concerned about the discomforting and possibly disfi guring

effects of the disease and related medical procedures. Older children tend

to be anxious in response to other children’s deaths. The way a child copes

with such concerns is infl uenced by his or her perception of the meaning and

likely consequences of an illness.

A child’s illness can result in absences from school, changes in family pat-

terns, increased dependency on others, and fi nancial or emotional strain on

the child’s family. Other sources of stress and grief include medical concerns,

such as the presence of pain and possibly the visible effects of the disease or

treatment, which may have symbolic signifi cance depending on the child’s

age and the part of the body affected.

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402 c h a p t e r 10 Death in the Lives of Children and Adolescents

To cope with the anxiety and confusion that accompany serious or life-

threatening illness, children use various coping mechanisms. Although a

child’s stage of development infl uences his or her capacity for drawing on

both internal and external resources, even very young children exhibit a wide

range of coping mechanisms. Children use distancing strategies to limit the

number of people with whom they have close relationships, thus reducing

the number of opportunities for a distressing interaction. In this way, a child

selects from the whole situation only those aspects or those people that seem

least threatening. This coping mechanism allows the child to construct as

safe and secure an environment as possible given the circumstances.

Children may cope with a painful medical procedure by making a deal that

allows some desire to be fulfi lled once the pain has been endured: “After I get

my shot, can I play with my toys?” In dealing with an overwhelming situation, sick

children may regress to behavior patterns that recall a less demanding, more

comfortable time in their lives. Children may revert to baby talk or “forget” their

toilet training during stressful times. A child whose illness prevents him or her

from engaging in a competitive sport may cope by fi nding a substitute for the

desired activity by playing board games in a highly competitive way. One might

envision scenes of sick children racing through the hospital corridors, IV bot-

tles swinging from their wheelchairs, in a spontaneous competition. Children

undergoing chemotherapy may become fatigued and exhibit depressed mood

and other affective changes, as well as such physical consequences as nausea/

vomiting and sleepiness (frequent napping). 39 As do adults, children use varied

coping mechanisms as they confront uncomfortable and frightening aspects of

a potentially life-limiting illness. Even very small children know when they are

very sick, and they are often far more aware of death than adults realize. 40

Providing and Organizing Care “Was there someone in charge of your child’s medical care?”

“Yes, me. Coordinating the various doctors, nurses, and treatments was

the most frustrating part of the process.”

The Institute of Medicine panel mentioned earlier reported the above

dialogue with a parent of a seriously ill child. The panel said: “The diag-

nosis of a child’s life-threatening medical condition often launches child

and family into a complex and confusing world of technologically sophisti-

cated treatments, arcane terminology, and highly specialized personnel and

organizations.” 41

Caring for a child who is dying involves more than just medical treat-

ment. The child and his or her whole family should receive appropriate social,

psychological, and spiritual care. Researchers note that “children’s spiritual

growth appears to parallel physical and psychosocial growth.” 42 Providing

optimal care involves implementing the principle of whole-person care for

children as well as adults. The Institute of Medicine panel found that “too

often, children with fatal or potentially fatal conditions and their families

fail to receive competent, compassionate, and consistent care that meets their

physical, emotional, and spiritual needs.” 43

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Children with Life-Threatening Illnesses 403

Pediatric Hospice and Palliative Care Children with life-limiting conditions can receive care in children’s hos-

pitals, hospices with established pediatric programs, and other institutions

that care for children with such conditions, as well as at home. One goal of

residential hospice care is to offer an alternative to hospitalization when a

child requires more intensive assessment, symptom management, and care

planning than can be successfully provided at home. Stephen Connor says,

“In general, dedicated pediatric palliative care services are like islands of

excellence in the sea of children’s health care in the United States.” 44

There are relatively few hospice programs intended to specifi cally serve

dying children and their families. The fi rst was Helen House, founded in

England in 1982. In 1995, pediatric palliative care was initiated in British

Columbia, Canada: Canuck Place, which was the fi rst freestanding chil-

dren’s hospice in North America. George Mark Children’s House, founded

in 2004 in the San Francisco Bay area, was the fi rst freestanding pediat-

ric palliative care center in the United States. Other notable children’s

hospice programs include Edmarc Hospice for Children in Virginia and

Suncoast Hospice in Florida. Typically, such programs provide services

through all stages of a child’s illness, including physician and nursing sup-

port, pain and symptom management, respite care, music and play ther-

apy, and end-of-life care, with counseling services available to all members

of the child’s family.

As mentioned in an earlier chapter, the Medicare Hospice Benefi t speci-

fi es that hospice care is reimbursed only when (1) a physician determines

that the patient has a prognosis of six months or less, and (2) the patient

forgoes curative treatment. To remedy this limitation, the state of California

recently passed the Nick Snow Children’s Hospice and Palliative Care Act,

which requires the state Department of Health Services to submit a waiver

that allows children with life-limiting conditions to receive both palliative

and curative care. 45 The goal is to promote the development of a comprehen-

sive pediatric palliative care demonstration program that improves quality of

life for children and their family members.

Home-based palliative care is an important option in the care of termi-

nally ill children. Hospice Hawaii is among the “adult” hospices that have

recently expanded services to terminally ill children. “With children,” one

social worker at Hospice Hawaii explains, “you have to think outside of the

box.” 46 Ida Martinson, a nurse-educator who helped pioneer such care,

observes,

The greatest barrier [to providing effective care to dying children and their

families] is the diffi culty in accepting the reality of the dying child by the

parents and physicians as well as the nurses. No one wants a child to die, so

continued treatment goes beyond what is desirable and useful for the child. 47

Martinson says, “Parents may have diffi culty in realizing that the care

they are providing their child in the home is as good—and most likely better

than—what we health care professionals could provide in the hospital.”

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404 c h a p t e r 10 Death in the Lives of Children and Adolescents

Adolescents and older children with life-threatening illnesses may take on increasing responsibilities for their daily treatment regimes. Here, a young cancer patient fl ushes her venous access catheter, the route used to administer chemotherapy, which must be cleaned nightly.

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Children with Life-Threatening Illnesses 405

Decisions About Medical Treatment Seriously ill children and adolescents are not merely passive participants

in the medical and social events that occur because of their illness. Depend-

ing on the child and his or her stage of developmental sophistication, he or

she may have opinions about the course of illness and treatment and may

wish to exercise some degree of autonomy and choice in making medical

decisions. Studies confi rm adolescents’ willingness and ability to participate

in end-of-life decisions. 48 Nevertheless, parents, the medical staff, and other

adults may be uncertain about, or even resistant to, the idea of a child or an

adolescent making decisions about such possible life-or-death matters.

According to Louis Gamino and Hal Ritter, the Rule of Sevens, based

on English common law, gives parents and health care providers a guideline

for assessing a minor child’s capacity to participate in medical decision mak-

ing. 49 Until the age of seven, a child is understood to be an immature minor

with no capacity for medical decision making. For a child ages seven to four-

teen, it is thought possible that the child may object to a medical procedure.

Children in this age group are moving toward a status as “mature minors,”

and their increasing cognitive capacities need to be honored. If the signifi -

cant adults disagree with the child, there may be reasons for contradicting

their claim of the child’s incapacity to make a decision. Finally, during ages

fourteen to twenty-one, the adolescent’s or young adult’s views are consid-

ered more carefully, as if he or she has capacity for medical decision making.

These individuals are considered mature minors who have capacity for deci-

sion, though there may be reasons for overriding their wishes. The greater

the harm that could occur as a result of following the child’s or adolescent’s

wishes, the stronger the argument for overriding them.

Gamino and Ritter argue that, although the legal right of consent for treating children remains with the parent, health care providers should work

to secure a child’s assent, or agreement to the proposed treatment or proce- dure. Disagreements sometimes end up in the courts. As Gamino and Ritter

point out,

In situations where mature minors want a different decision about their medical

treatment than that being chosen by the parents, courts often invoke the 50%

Risk Rule in addition to the Rule of Sevens. If the mature minor is refusing

treatment, and the various risks of not receiving the treatment are less than

50%, then the court will generally rule in favor of the mature minor. On the

other hand, if the risks to the child of no treatment are greater than 50%, then

the courts will generally rule in favor of the parents to proceed with a decision

for treatment. 50

Because of the recognition that, at least on some levels, adolescents are

maturing more quickly than in the past, some legal analysts suggest that teen-

age decision making should be simplifi ed by instituting laws that “recognize

legal age of consent by an adolescent to routine and standard medical and

surgical procedures as 16 years of age.” 51 Of course, this proposal is not as sim-

ple when medical procedures pertain to life-threatening and serious illness.

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406 c h a p t e r 10 Death in the Lives of Children and Adolescents

William Bartholome, a physician and professor of pediatrics, states,

“Many of the problems involved in responding to the needs of dying children

belong to the ‘big people’ involved.” 52 Adults sometimes question whether

it is better to tell or not to tell; that is, they wonder about the appropriate

action to take in terms of being truthful with children about a serious or life-

limiting illness. Such questions are legitimate and must be considered with

the aim of achieving a responsible balance between presenting the facts or

truth to a child and refraining from unnecessarily adding to his or her anxi-

eties, concerns, and fears. The goal of respecting the child is much more than

just being truthful (see Table 10-1 ). Bartholome says, “Children have a right

to be treated as developing persons, as persons with a developing capacity for

rationality, autonomy, and participation in health care decision making.” 53

Caring for a Seriously Ill Child A study of fathers who cared for a child with life-limiting illness charac-

terized their experience as “living in the dragon’s shadow” and “battling the

dragon.” 54 It was a continuous process that required strength, willpower, and

work. In the fathers’ perceptions, they (and their ill children) “struggled val-

iantly to overcome the dragon’s power.”

The ill child is thrust into a more or less alien world of hospitals and

medical paraphernalia. Illness separates children from their familiar sur-

roundings and the people they love. Even as a child becomes accustomed

to the rhythms of life in and out of hospital, new therapies or unfamiliar

medical settings or personnel can make everything again seem out of whack.

Changes in expected routine can be upsetting, adding to the child’s anxieties

and fears. Each time a child returns to the hospital, he or she is a different

person, at a new stage of development, with different fears and expectations.

Some children are resilient in response to the stressors of treatment, debili-

tating side effects, and the day-to-day experience of living with serious illness;

others have diffi culty coping with all the varied acute and chronic stressors

that accompany a life-threatening illness.

The participation of family members in some aspects of care can be com-

forting to a child. Although professionals are usually better equipped to care

for a child’s medical needs, parents have special expertise in the nontechni-

cal aspects of care. Parents can be involved in activities like bathing the child,

assisting at mealtimes, tucking the child in at night, and emotionally support-

ing the child. Parents should carefully consider whether it is in the child’s

best interest for them to be involved in performing medical procedures that

might cause the child pain. Generally speaking, parents should focus on their

parenting role rather than trying to perform the role of a nurse.

The crisis of a child’s illness can lead to a breakdown in communication.

A young girl told a hospital staffer, “I know I’m going to die. I want to talk to

Mother, but she won’t let me. I know she’s hurting, but I’m the one who’s dying.”

When told of this conversation by the staff member, the girl’s mother replied

angrily, “She wouldn’t be thinking of dying if you hadn’t made her talk about it.”

The communication between mother and daughter went from bad to

worse. Still refusing to discuss her daughter’s feelings, the mother’s style of

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Support Groups for Children 407

communication degenerated into baby talk: “Her doesn’t feel goody today. . . .

her doesn’t want to talk.” A lack of openness was hampering satisfaction of

the child’s (as well as the parent’s) needs for affection and reassurance.

Support Groups for Children Community support is an important supplement to a family’s internal sup-

port system. Many organizations that offer support during the crises of life-

threatening illness and bereavement have programs for all members of a

family, including children. For example, The Compassionate Friends and

the Bereaved Families of Ontario not only serve bereaved parents but also

serve children and adolescents. The Dougy Center for Grieving Children in

Portland, Oregon, has been so successful in providing bereavement support

programs to its community that it conducts facilitator trainings worldwide.

The Hospice of Frederick County in Maryland has an innovative out-

reach program, Camp Jamie, in which bereaved children are paired with a

group of caring adults, called “Big Buddies,” some of whom are also recover-

ing from losses. 55 Named after a hospice patient who died before his third

birthday, Camp Jamie provides children with “a haven to learn about coping

with grief.” In a mountain setting, participants enjoy recreational activities

and have opportunities to explore their losses in a safe environment among

peers and “big buddies.” In addition to grief education and support, campers

also enjoy activities, such as fi shing, team games, arts/crafts, hiking, sing-a-

longs, campfi res with storytellers, and the Camp Jamie Olympics. There are

opportunities for the children to express themselves and develop bonds with

others. Through interactions with other children and adults, campers learn

that they are not alone in their grief.

Similar programs have developed across the United States over the past

decades. Camp Erin, for example, is “the largest nationwide network of free

bereavement camps for children and teens ages 6–17 who have experienced the

death of someone close to them.” 56 These camps provide a weekend-long expe-

rience of traditional camp activities combined with grief education and emo-

tional support. Each Camp Erin is facilitated through a partnership with a local

bereavement agency. In Southern California, one such agency is Morning Star.

As a nationally acclaimed support center for grieving children, teens, and their

families, Morning Star offers Camp Erin to bereaved children during summers.

It is staffed by professional grief counselors and there is no charge to attendees.

Besides organizations offering bereavement support to children and

teens, other organizations provide support for the crises that accompany

life-threatening illness. HUGS—an acronym that stands for Help, Under-

standing, and Group Support for Hawaii’s Seriously Ill Children and Their

Families—was founded in 1982 by a small group of volunteers who recog-

nized the many challenges and stressors that families with seriously ill chil-

dren face. HUGS offers a wide range of services, including crisis support,

hospital and home visits, transportation to medical appointments, recre-

ational activities, and respite care. The mission of HUGS is “to help families

stay together in the face of overwhelming adversity.” 57

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408 c h a p t e r 10 Death in the Lives of Children and Adolescents

The Starlight Children’s Foundation, founded in 1983, is an organiza-

tion dedicated to improving the quality of life for children with chronic and

life-threatening medical conditions. 58 The foundation has chapters and

offi ces located throughout the United States and facilities in Canada, the

United Kingdom, Australia, and Japan. The foundation’s ”high-tech” and

”high-touch” programs are designed to help children better understand

and manage their illnesses and connect families with others facing similar

challenges to create a community so that no one feels alone. The founda-

tion does this by providing education, entertainment, and family events that

help sick children cope with the pain, fear, and isolation of prolonged ill-

ness. Among its programs are “Starlight Sites,” hospital environments where

pediatric patients can relax, play, and interact with other children during

their hospital stay, and “Starbright World,” an online social network for teens

with chronic and life-threatening medical conditions, and their siblings. Sick

teens are able to connect with other teens that are at home or in the hospital.

Users post pictures, chat, post blogs and bulletins, and fi nd new friends in

similar situations. 59

Organizations that exist to grant the wishes of children who have been

given a limited or uncertain prognosis are another support. Examples

include the Sunshine Foundation, founded in 1976, and the Make-A-Wish

Foundation, founded in 1980. 60 After the founding of Make-A-Wish, interest

in granting wishes spread across the country and to other nations. The orga-

nization now grants wishes through its 62 chapters located throughout the

United States, and it also operates in 47 other countries on fi ve continents

through affi liates. Through the efforts of such groups, seriously ill children

and their families are able to take a vacation together or fulfi ll some other

wish that seems impossible without outside help.

Telephone support groups are a type of organized social support that has

been effectively used with varied populations, including children. The tele-

phone was fi rst used as a method of outreach for suicide prevention by the

Samaritans in London in 1953. Later, the Pediatric Branch of the National

Cancer Institute created a telephone network to offer social support to

“Peanuts,” drawing by Charles Schulz, © 1995 United Features Syndicate, Inc.

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Helping Children Cope with Change and Loss 409

HIV-infected children. Organizers said the telephone offered “a sense of con-

fi dentiality not afforded in face-to-face groups,” thus providing “a creative

and therapeutic way to help HIV-infected children and their family members

cope with the impact this disease had on their lives.” 61

Helping Children Cope with Change and Loss Never overlook a child’s concerns or take them lightly when the child wants

to talk about a close friend or loved one who has died. Encourage the child

or adolescent to express his or her feelings about the loss. Heather Servaty-

Seib observes that, although “friends are central to the daily life” of teens,

the grief of young people for deceased friends “generally goes unnoticed,

is minimized, or is misunderstood.” 62 Tailor any intervention or strategy to

the individual’s needs and situation. Children usually cope more easily with

their feelings in a crisis when they feel included as participants in the unfold-

ing experience. If they are excluded, or if their questions go unanswered,

uncertainty creates more anxiety and confusion. When an adult is also strug-

gling to cope with a traumatic experience, it may be diffi cult to provide an

explanation of the painful circumstances to a child. The child’s feelings and

concerns may be dismissed or ignored. Even when adults agree that children

have a right to know the truth, they may feel uncomfortable about giving

them painful and disturbing news. They may ask themselves, Would know-

ing the truth cause the child more harm than good? In most instances, the

child’s natural curiosity effectively eliminates the option of withholding such

information.

Responding to a child’s natural inquisitiveness and concern does not

mean that one needs to overwhelm the child with excessive detail, nor does

it mean “talking down” to the child, as if he or she were incapable of com-

prehension. Nevertheless, a child’s manner of perceiving, experiencing, and

coping with change needs to be considered by parents and others who wish

to be helpful. This implies responding to the child’s questions and concerns

on the basis of his or her ability to understand. As a general guideline for

discussing death with a child, it is important to keep the explanation simple,

stick to basic facts, and verify what the child has understood.

Bibliotherapy—that is, using books as an aid to coping—can facilitate

discussion between adults and children and create opportunities for shar-

ing thoughts and feelings (a selection of books about death for children and

teens can be found in Chapter 2). 63

Discussing Death Before a Crisis Occurs In explaining death to children, honesty is in fi rst place. Be aware, how-

ever, that a parent who sets a ground rule that it’s okay to be open and honest

in talking about death may fi nd that there are times when the child wants to

initiate a discussion, and the parent is tired or would rather avoid the subject.

If talking about death is part of normal life and not a reaction to crisis, choos-

ing a good time is more of a possibility.

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410 c h a p t e r 10 Death in the Lives of Children and Adolescents

Second, don’t put off introducing the topic of death. When a close death

precedes the discussion, the parent is faced with the need to provide an

explanation in the midst of crisis. This unfortunate situation arises when a

parent puts off discussing death “because it’s not really going to happen,”

only to fi nd that “it’s happening right now, and my child has to be told some-

thing.” In these circumstances, the explanation to the child is likely to be

charged with all the emotions the parent is dealing with, making clear com-

munication more diffi cult. Thus, it is a good idea to make use of teachable

moments—occasions that come up in everyday activities—for talking with

children about death (see discussion of teachable moments in Chapter 2).

Third, set the explanation to the child’s level of understanding. By using

as a guide the child’s interest and ability to understand, the parent can provide

an explanation that is appropriate to the child’s particular circumstances.

When talking with children about death, it is important to verify what

they think you’ve told them. Have them tell you what they learned or heard

you saying about death. Children generalize from known concepts to make

new experiences fi t. This may lead to a very literal interpretation of new infor-

mation, especially among young children, who tend to emphasize the con-

creteness of things. Recognizing this, strive to keep your communication free

of associations that could be confusing. Metaphorical explanations about

death may help you draw a child-sized picture as an aid to understanding, but

unless fact and fancy are clearly distinguished, the child may grasp the fanci-

ful details instead of the underlying facts the analogy was meant to convey.

This is illustrated in the following story: A fi ve-year-old girl was told that her

grandfather’s cancer was like a seed that grew in his body; it grew and grew

The Lesson ‘Your father’s gone,’ my bald headmaster said.

His shiny dome and brown tobacco jar

Splintered at once in tears. It wasn’t grief.

I cried for knowledge which was bitterer

Than any grief. For there and then I knew

That grief has uses—that a father dead

Could bind the bully’s fi st a week or two;

And then I cried for shame, then for relief.

I was a month past ten when I learnt this:

I still remember how the noise was stilled

In school-assembly when my grief came in.

Some goldfi sh in a bowl quietly sculled

Around their shining prison on its shelf.

They were indifferent. All the other eyes

Were turned towards me. Somewhere in myself

Pride, like a goldfi sh, fl ashed a sudden fi n.

Edward Lucie-Smith

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Helping Children Cope with Change and Loss 411

until he couldn’t live in his body anymore, and he died. Her parents didn’t

notice that, ever afterward, all through childhood, she never ate another

seed. Not one. Not a cucumber seed, watermelon seed, no seeds. Finally, at

age twenty-one, she was asked, “Why are you avoiding the seeds? Isn’t that

a little bizarre? What’s wrong with the seeds?” Her automatic response was,

“You swallow them, and you die.” After all those years, she saw the fallacy of

her compulsion to avoid eating seeds. It would have been useful if someone

had asked her when she was fi ve, “What will happen if you swallow that seed?”

Discussions When a Family Member Is Seriously Ill When a member of a child’s family is seriously ill, family routine is dis-

rupted. If the truth about the illness is kept from the child, he or she may

become confused about the reasons for changes in the family’s usual pattern

of interactions. The child may feel rejected, left out of family activities, or

ignored for no apparent reason: “Why are my parents so nice to my sister, but

they ignore me all the time?” or “Geez, I get into trouble about every little

thing, while my brother gets off scot-free no matter what he does!” Siblings

of a seriously ill child may be alarmed by changes in the sick child’s appear-

ance due to disease or side effects of treatment. 64 In some cases, there may be

multiple losses, unpredictable living arrangements, and changes of school, as

well as the possibility of issues involving stigma, secrecy, and shame.

Although open communication is important in helping a child cope with

the crisis, explanations must be suited to the child’s cognitive capacity. A very

young child whose parent is seriously ill might be told simply, “Mommy has

an ouch in her tummy which the doctors are trying to fi x.” A school-age child

could be given a more complex explanation, such as that the parent needs

medical treatment because something is growing in her stomach that doesn’t

belong there.

Anxiety about a parent’s or sibling’s illness may be displayed in varied

ways. Children may feel neglected and resent adjustments they must make

in their own lives. A child may be angry because “Mommy isn’t here,” yet feel

guilty because he or she imagines somehow “causing Mommy’s illness.” To

counteract these feelings, help the child feel that he or she is a fully partici-

pating member of the family. Encourage the child to be part of the process of

dealing with the illness.

A Cemetery Conversation with Sofi a at Five Years Old Sofi a: “What are the dead people doing in the earth?” Francesco: “They rest.” Sofi a: “Are they bored?” Francesco (smiling): “To death!” Sofi a (sad): “Do they rest always?” Francesco: “Maybe they come out at night to talk to each other or perhaps to dance.” Sofi a: “Impossible! They are dead!”

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412 c h a p t e r 10 Death in the Lives of Children and Adolescents

The child can participate in caring for the sick family member in appro-

priate ways. For example, a child might pick a bouquet or make a drawing as

a gift. Such activities allow the child to express his or her feelings in a creative

way. Although children cannot be protected from the reality of death, their

experiences of it can be made less diffi cult if they have sensitive, caring sup-

port from those closest to them.

Discussions in the Aftermath of Loss Understanding another person’s experience requires the art of listening.

This is true when talking with a child or an adolescent as well as when talking

with adults. The aim is to discover what the other person thinks, feels, and

believes: What does he or she fi nd important? What are his or her concerns,

fears, hopes? If a need for support or assistance is being expressed, what kind

of help is he or she asking for? Questions of this kind are important in help-

ing children cope with loss. Rob Zucker says, “Grieving adults can become

so overwhelmed that they lose sight of their obligations to their grieving

children.” 65 We need to be willing to listen and to accept the reality of the child’s experience.

When death disrupts familiar patterns of living, the result can be confu-

sion and confl ict, creating a tangle of emotions and thoughts that are hard

to sort out. In the midst of this, children may be asked to remain “unseen

and unheard,” thus thwarting their natural tendencies to explore and grapple

with the emotions and thoughts generated by change. Paying attention to a

child’s behavior is useful for gathering information about his or her experi-

ence of crisis. Crying, for instance, is a natural response to the loss of someone

signifi cant. Admonishing a child to “Be brave!” or “Be a little man and buck

up!” denies the validity of the child’s spontaneous emotion. Be aware, how-

ever, that an absence of tears should not be interpreted as an absence of grief.

In helping children cope with loss, adults must strive to answer the child’s questions honestly and directly. Explanations should be truthful to the facts and should be as concrete as possible. Telling a child that her goldfi sh “went to

heaven” may cause her to make an elaborate picture of the pearly gates and

different sections of heaven: Here is goldfi sh heaven, cat heaven, and over here

is people heaven—a very logical concept that makes sense to a child. A study of

images of heaven in children’s storybooks found that heaven was typically por-

trayed in a simplistic fashion. The stories presented “a generic image of heaven”

combined with cultural beliefs suggesting that “death is not the end of life, but

a continuation.” 66 Regardless of the therapeutic value of assuring children that

they are able to maintain bonds with a deceased loved one, we need to be care-

ful that the concepts we convey to a child don’t turn out to be dysfunctional.

One woman recalled that, when she was three or four, a favorite dog sud-

denly “went to live on a farm.” Not until she was about seven did she realize

that the dog really wasn’t living at the puppy farm. When she realized that in

fact her beloved dog was dead, she felt angry and upset that she hadn’t had

the opportunity to properly say good-bye.

Similarly, religious beliefs are an important part of how death is under-

stood in many families. Parents want to share these beliefs with their children

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Helping Children Cope with Change and Loss 413

when coping with the death of a family member or friend. Children may

indeed be comforted by such beliefs, but they deserve to be told that these

are beliefs. Talk about them in a way that avoids confusing the child. For exam- ple, a parent’s concept of an afterlife may be different from what a child is

The classmates of a murdered child carry his coffi n to the grave. The rituals and ceremo- nies surrounding death can provide an avenue for children and adolescents to express their grief and to begin the process of coming to terms with loss.

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414 c h a p t e r 10 Death in the Lives of Children and Adolescents

able to understand. A child who is told that “God took Daddy to be with him

in heaven” may not feel very kindly toward a being who could be so capricious

and inconsiderate of the child’s feelings.

For the same reason, fairy tales, metaphors, and the like should be

avoided or used with care because children may take such explanations of

death literally. Consider the case of a four-year-old whose brother (nine) told

him that daddy had gone to heaven. The four-year-old promptly went and

told his mother, “My daddy’s on the roof!” She said, “What? Who told you

that?” He said, “Andrew did.” The older brother then explained, “We were

looking out the window and I told him that daddy was in heaven up there.” To

the four-year-old, the highest “up there” was up on the roof. If you tell a four-

year-old that someone who has died is “up there,” and you also say that Santa

Claus lands on the roof on Christmas Eve, he may decide that Santa Claus

and the person who has died are great buddies. He might make up stories

about how they work together, making toys, feeding the reindeer, and so on.

The concreteness of a young child’s concepts about death is also illus-

trated in the experience of a woman whose fi rst encounter with death

occurred when she was three and a half years old, and her mother died. It

seemed that her mother had just disappeared; she didn’t know what had hap-

pened to her. Some time later, she began to realize that her mother had died,

and she started asking questions. Some people told her that her mother had

been buried, and her thought was, “Why don’t they dig her up?” Others said

that her mother had gone to heaven, so she kept looking at the sky, watching

for her. With both of these concepts running through her young mind, she

did her best to fi gure out, “How can my mother be buried in heaven?”

When asked about their experiences involving a close death, children

often say that the most diffi cult times were when they did not know what was

happening. A child whose diagnosis of serious illness was withheld from her

by her family said later, “We’d always done everything with each other know-

ing what was going on. Suddenly, it was different. That scared me more than

what was happening to my body. It felt like my family was becoming strang-

ers.” 67 Sudden change in family communication patterns can be alarming

to a child, heightening anxiety about the crisis. A child who is kept from the

funeral of a close friend or relative may feel anxious about not being included

in an activity that had obvious importance to the signifi cant adults in his or

her life. Some children may not want to attend a funeral. Those who do, how-

ever, tend to report that it helped them acknowledge the death, provided an

occasion for honoring the deceased person, and made it possible for them to

receive social support and comfort. 68

Small boy. “Where do animals go when they die?” Small girl. “All good animals go to heaven, but the bad ones

go to the Natural History Museum.”

Caption to drawing by E. H. Shepard, Punch, 1929

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Further Readings 415

The best gauge of a child’s readiness to be informed about a potentially

painful situation is the child’s own interest, usually expressed through ques-

tions. Using these questions as a guide, caregivers can give straightforward

answers without burdening the child with facts irrelevant to his or her under-

standing of the situation. Most important, children in crisis situations need

to be reassured that they are loved.

Children are apt to point out any inconsistencies in what we tell them

about death. When one three-year-old’s playmate was killed, his mother

explained to him that Jesus had come and taken his friend to heaven. His

response was, “Well, that’s an awful thing to do; I want to play with him. Jesus

isn’t very nice if he comes down here and takes my friend from me.” In dis-

cussing death with a child, it is crucial to consider the child’s belief system,

the kind of thought processes he or she uses to understand the world. Then,

from your very fi rst statement, ask yourself, “If I explain death in this way,

how will it be understood by the child?”

Adults tend to worry about children’s encounters with death. Are they

doing all right? Will they be okay? Is death going to be too hard for them to

handle? Can they survive this particular loss? Erik Erikson said, “Healthy chil-

dren will not fear life if their parents have the integrity not to fear death.” 69

Further Readings David E. Balk and Charles A. Corr, eds., Adolescent Encounters with Death, Bereavement,

and Coping. New York: Springer, 2009. Mary Dixon-Woods, Bridget Young, and David Heney. Rethinking Experiences of Child-

hood Cancer: A Multidisciplinary Approach to Chronic Childhood Illness. Maidenhead, Berkshire: Open University Press, 2005.

Kenneth J. Doka and Amy S. Tucci, eds. Living with Grief: Children and Adolescents. Washington, D.C.: Hospice Foundation of America, 2008.

Marilyn J. Field and Richard E. Behrman, eds. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington, D.C.: National Academies Press, 2003.

Phyllis Silverman and Madelyn Kelly. A Parent’s Guide to Raising Grieving Children: Rebuilding Your Family After the Death of a Loved One. New York: Oxford University Press, 2009.

Carolyn Ambler Walter and Judith L. M. McCoyd. Grief and Loss Across the Lifespan: A Biopsychosocial Perspective. New York: Springer, 2009.

Leigh A. Woznick and Carol D. Goodheart. Living with Childhood Cancer: A Practical Guide to Help Families Cope. Washington, D.C.: American Psychological Associa- tion, 2002.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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© J

a m

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Holding their dead baby, this Harlem couple fi nds comfort in the sharing of their memories and their grief as they acknowledge the death of their fi rstborn child. Of all the losses that can be experienced during adult life, most people feel that the death of a child is the most painful.

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417

C H A P T E R 1 1

Death in the Lives of Adults

T ake a moment to refl ect on the losses that have occurred in your own life, both dur- ing childhood and more recently. How have these experiences differed? In what ways are

they similar? How has your orientation to loss changed as you’ve gotten older? What kinds of

coping mechanisms have been benefi cial in moving through the experience of loss?

Some of the losses discussed in connection with childhood and adolescence occur in

adulthood also. 1 The death of a brother or sister, or other close relative. The death of a par-

ent. The deaths of friends. Peter Marris says, “Grieving for loss is the most profoundly inno-

vative learning we undertake in our adult lives.” 2

In this chapter we look at the death of a friend and death of a parent occurring in adult

life, as well as parental bereavement, including childbearing losses, and death of a life part-

ner. The chapter concludes with an examination of the losses that typically accompany the

end of the life course. You will probably fi nd it useful to briefl y review the discussion of devel-

opmental challenges associated with the phases of adulthood in Chapter 2.

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418 c h a p t e r 11 Death in the Lives of Adults

Death and the College Student College students are generally situated within the age groups of emerging adulthood (roughly ages eighteen to twenty-fi ve) and the early years of early adulthood (ages twenty to forty). They are typically involved in expanding the scope of various forms of commitment and interaction in their lives—sex,

friendship, cooperation, partnership, and affi liation. These years involve a

tension between intimacy and isolation. In Death and the College Student, Edwin Shneid man collected brief essays on death and related topics written by stu- dents in a death education course taught at Harvard. 3 Class was scheduled

in a room with twenty chairs; two hundred students appeared for the fi rst

class meeting, and 155 completed the course. Essays were wide-ranging and

included topics such as combat death, philosophy, the death cult of James

Dean, motives for self-destruction, and suicide. Many essays refl ect what

Shneidman called “metacrises”—crises related to incidents that occurred out

of phase with the students’ chronological age. Paging through these essays, it

is evident that death was signifi cant in the lives of these students.

Surveys reveal that a considerable number of college students are within

twelve months of a family or friend death, and about a third to nearly half are

within twenty-four months of bereavement. “In terms of adverse life events,

death loss was the most common” such event among undergraduates. 4 A study

by Heather Servaty-Seib found that bereaved college students are at risk for

decreased academic performance and dropout. Students earned signifi cantly

lower GPAs during the semester of their death loss. 5

Young adults, somewhat like adolescents, may think they are “beyond

death.” This can result in risky behaviors, such as unprotected sex, sub-

stance abuse, binge drinking, and careless or incautious driving. Car acci-

dents are the leading cause of death for college students. In some instances,

these accidents are alcohol-related; at other times, they are caused by dan-

gerous activities like texting while driving. On some occasions, they are the

result of youthful exuberance, “having fun,” without necessary attention to

the tasks of driving. Whatever the reason, automobile-related accidents can

be a signifi cant source of death and bereavement experiences among col-

lege students.

I remember her as she lay in her hospital bed in July. Unable fi nally to deny the

pain. And for the fi rst time in our relationship of 21 years forced to allow some-

one else to take care of her. My father could not stand the sight and so he stayed

outside, pacing up and down in the hallways. I could not help staring at her.

Disbelief that this person with tubes running in and out like entrances and exits

on a freeway was the same woman who just six months before had laughed gaily

and danced at my wedding.

Ruth Kramer Ziony, “Scream of Consciousness”

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Death and the College Student 419

Suicide is the second-leading cause of death among college students. Sui-

cides of individuals in this age group, whose lives were mostly ahead of them,

leave the lingering question, What beautiful things might have existed in the

void now left behind? Despite efforts by college offi cials to create a safety net,

the suicide rate on campus has remained relatively static. Psychologist Thomas

Joiner compares suicide on campus to a hurricane: “It’s a catastrophe.” 6

One theory is that young people are becoming more concerned about

rewards, status, and success—all of which tend to create stress. Although coun-

seling is usually available through college health programs, the amount of time

that can be devoted to talking with an individual student about emotional or

other problems is limited. The result may be, as with health care generally, a

prescription for an antidepressant or other mood-altering drug, when talking

about a problem may have been more effective than receiving medication. (Sui-

cide of young adults and possible interventions are discussed in Chapter 12.)

College students are also at risk of infectious diseases, such as bacterial

meningitis. Because college students usually come to campus from widely

dispersed locales and live in close quarters, bacteria can readily multiply.

Although immunizations are available, and students may receive them prior

to arriving on campus, vaccines are not always 100 percent effective.

Violence—both random acts and acts occurring within known victim-

perpetrator relationships—is another threat, one that can come without

At Santa Monica College, Priscilla Morales cries as she is consoled by a parking enforce- ment offi cer after a series of killings by a gunman with an assault-style rifl e in June 2013. Morales was in the college library when the gunman, who had previously been a student at the college, opened fi re on students. He was shot to death by police when he exchanged gunfi re with them.

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420 c h a p t e r 11 Death in the Lives of Adults

warning. Young people are disproportionately represented among victims of

violence. (Violence and steps to reduce it are discussed in Chapter 13.)

Finally, individuals attending college usually question traditional reli-

gious practices and their own spiritual development. Typical questions

include these: What am I going to do with my life? What kind of person do

I want to be? How am I going to leave my mark before I eventually die? For

most students, these kinds of questions are important, and they often involve,

at least tangentially, dying and death. As a diverse group—ethnically, socio-

economically, religiously, and politically—students on campuses today are

generally active in dealing with core existential questions. 7

The Death of a Friend The death of a close friend is a loss that evokes grief similar to reactions fol-

lowing the death of a relative. 8 Yet there are fewer opportunities to openly

mourn. In this sense, a friend’s death can result in disenfranchised grief

(discussed in Chapter 9). Whereas most employers provide at least some

type of bereavement leave when death occurs in an employee’s family, such

leave is unlikely to be provided when a close friend dies, even when the

mourner and the deceased have been friends for years. There is a tendency

to believe that the most important human relationships are found within, not outside, families. But friendship involves similar bonds. Because of changes in family structure, social and geographical mobility, and other

psychological or cultural factors, friendship ties are increasingly important

for many people.

The term friend encompasses many different kinds of relationships. Most people have casual friends, close friends, and best friends, as well as “special-

purpose” friends such as colleagues, associates, and acquaintances. Many

people identify a mate as their best friend; when death ends a paired relation-

ship, it packs a double whammy because it also means the loss of the surviv-

ing partner’s best friend. Some friends do not see each other often, but, when

they do get together, their friendship “picks up where we left off.”

For older adults, friendships can be more important than family relation-

ships. For example, despite the fact that many older women live alone, they

often say that they are not lonely because of the mutually supportive relation-

ships they have developed and maintained with a circle of friends. 9

Friendships are important. When a friend dies, grief needs to be acknowl-

edged. Even when society tends to disenfranchise such grief, it is nonetheless

important to do what is needed to mourn the loss.

The Death of a Parent Many people say that a parent’s death is the hardest thing they have dealt

with in their lives. Even when the parent has been ill beforehand, the ensu-

ing grief can include a variety of emotions: sadness over the loss; relief at

the ending of the parent’s suffering; anxiety because a kind of “protection

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The Death of a Parent 421

against death” symbolized by a parent’s presence is gone; and memories,

painful as well as comforting. In most cases, the death of a parent represents

the loss of a long-term relationship characterized by nurture and uncondi-

tional support. Parents are often described as “always being there when the

chips are really down, no matter what.” In other instances, a parent’s death

may bring an ending to a relationship that was troubling or dysfunctional.

The reaction may be either relief or regret that there is no longer a chance

for reconciliation.

Individual siblings may experience a parent’s death in very different ways.

A study by Miriam and Sidney Moss revealed several themes that emerged

from the narratives of two sisters regarding the death of their father: 10

1. Each sister described very different perceptions of the family and of the

father while disconfi rming many aspects of the other sister’s view.

2. Each sister had a close bond and a caring relationship with her sister,

although they were different in personality, attitudes toward caregiving

for parents, and their views of life.

3. Each sister saw different meanings and realities related to the father’s

death, based partly on their non-shared experiences in the past.

For midlife adults, a parent’s death is an important symbolic event. 11 It

may initiate a period of upheaval and transition. Most people report that the

death of a parent changes their outlook on life, often spurring them on to

examine their lives more closely, to begin changing what they don’t like, and

to appreciate more fully their ongoing relationships. A study of middle-aged

African American women who were coping with the deaths of their elderly

mothers found that religious beliefs provided important ways of thinking

about and coping with their mothers’ deaths. 12 Besides facilitating a sense of

readiness for the anticipated loss, religious themes also helped in the “devel-

opment of a new tie that permits restructuring life with mom’s emotional, if

not physical, presence.” 13

Any death reminds us of our own mortality, but a parent’s death can

cause a person to realize, perhaps for the fi rst time, that he or she has become

an adult. Thus, the death of a parent can result in a “developmental push,”

which may lead to a “more mature stance in parentally bereaved adults who

no longer think of themselves as children.” 14

When both parents have died, there may be a consequent role change for

the adult child, who no longer has his or her parents to fall back on, even if

only in imagination. There is often a sense that, if real trouble comes, a child

can call on his or her parents. With the deaths of one’s parents, that sense

of security is gone. The bereaved adult child may feel that there is no longer

anyone who would be willing to answer his or her call for help uncondition-

ally. After the deaths of both her parents, one woman said that although she

knew friends and other relatives loved and cared about her, she felt that her

parents’ love had been unique and irreplaceable. Adjusting to the death of

one’s parents can involve both holding on and letting go, as the bereaved

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422 c h a p t e r 11 Death in the Lives of Adults

person simultaneously recognizes the reality of death and treasures comfort-

ing memories of the deceased. 15

Perhaps because of a mother’s traditional role as the primary nurtur-

ing caregiver, many people believe that the death of a mother is harder to

cope with than the death of a father. 16 Another factor may be the fact that,

statistically, fathers tend to die before mothers. Thus, a mother’s death often

represents the loss of having parents, as the bereaved adult child experiences

reactive grief over the death of the other parent as well.

Generally, for adult children, a parent’s death is less likely to evoke

intense grief than, for instance, the death of a child. The reason for this is

probably related to the fact that an adult child is involved in his or her own

life; feelings of attachment to parents have been redirected to some extent

toward others, such as a partner and children. Nevertheless, it puts a strain

on a relationship when the person whose parent has died feels that his or her

partner is not offering as much emotional support as needed or expected

or does not understand the impact of the loss. 17 The parent-child bond has

unique symbolic importance and, with the death of a parent, the bereaved

child mourns the loss of that special relationship.

You Don’t Miss Your Water At home, my mother wakes up and spends some of her day

talking back to my father’s empty chair.

In Florida, my sister experiences the occasional dream in

which my father returns; they chat.

He’s been dead and gone for a little over a year. How it would

please me to hear his unrecorded voice again, now alive

only in the minds of those who remember him.

If I could, if as in the old spiritual, I could actually get a direct

phone link to the other side, I could call him up, tell him

about this small prize of a week I’ve had teaching poetry

at a ski resort a few miles from Lake Tahoe, imagination

jackpot, brief paradise of letters.

How could I make him believe that I have gotten all of this,

this modern apartment, this pond in front of my window,

all from the writing of a few good lines of verse, my father,

who distrusted anything he couldn’t get his hands on?

Most likely, he would listen, then ask me, as he always did, just

for safety’s sake, if my wife still had her good paying job.

And I can’t tell you why, but this afternoon, I wouldn’t become

hot and stuffy from his concern, think “old fool” and gripe

back Of course I’m still teaching college. It’s summer, you know? This afternoon, I miss his diffi cult waters, and when he’d ask, as

he always would, How’re they treating you? I’d love to answer back, Fine, daddy. They’re paying me to write about your life.

Cornelius Eady

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Parental Bereavement 423

Parental Bereavement The death of a child represents the untimely loss of a potential future, the

“ultimate deprivation.” 18 A child’s death upsets the expectation that the old

die fi rst and are replaced by the young. Death may be viewed as appropriate

in old age, but in technologically advanced countries we expect that a child

will outlive his or her parents. In parts of the world today, as in earlier times,

a newborn or infant is not really viewed as a “person” until he or she has lived

long enough to exhibit the likelihood of ongoing life. In most societies, how-

ever, the death of a child is considered the least natural of deaths. 19 Bereaved

parents often maintain an inner representation of the dead child, an “image”

sustained through memories and spiritual beliefs. 20

A child’s existence grants a kind of immortality to the parent; this is

ripped away when the child dies. Parents envision their children graduat-

ing from school, getting married, raising their own children—all the various

milestones and occasions that constitute a sense of continuity into the future.

Death brings an end to the plans and hopes for a child’s life.

The overwhelming grief of parental bereavement is expressed in the soft-ground etching Überfahren (Passing Over), by Käthe Kollwitz, whose art became a means of working through her own sorrow following the death of a child. The dead child is carried by adults bent with the burden of grief; other children look on.

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424 c h a p t e r 11 Death in the Lives of Adults

Symbolically and actually, a child’s death is contrary to the caring task

of adulthood. When the basic function of parenting is understood as pro-

tecting one’s child and nurturing his or her well-being, this responsibility is

thwarted by a child’s death. Parenting is generally defi ned as protecting and caring for a child until he or she can act independently in the world. Thus,

the death of a child may be experienced as the ultimate lack of protection,

the ultimate breakdown and failure in being a “good parent.” A study by Paul

Rosenblatt showed that after a child’s death parents tended to become more

protective of their other children, exhibiting greater vigilance, more rapid

response to signs of trouble, and greater awareness of child vulnerability. 21

Among the Cree of North America, infants were given “ghost-protective”

moccasins to wear. Holes were cut in the bottom of the moccasins to safe-

guard the baby from death. If the spirit of an ancestor appeared and beck-

oned, the infant could refuse to go, pointing out that his or her moccasins

“needed mending.” 22

Many issues of parental bereavement span the adult life cycle. They are

present for twenty-year-old parents and eighty-year-old parents. They are

experienced by parents of grown children as well as by parents of infants.

A sixty-fi ve-year-old widowed mother may feel considerable loss of security

when her thirty-fi ve-year-old child dies suddenly. One such woman said, “He

was going to take care of me when I got old; now I have no one.” Whether or

not her son would have indeed taken on the responsibility she envisioned,

his death represented the loss of her imagined future. The interdependency between parent and child makes the death of a child a profound loss. 23

Childbearing Losses Pregnancy is a major life transition for adults, the expected result of

which is the birth of a viable, healthy baby. Miscarriage, stillbirth, or neonatal

death is not the anticipated outcome. These are all forms of perinatal loss (loss pertaining to the periods before, during, or after the time of birth).

Miscarriage occurs prior to the twentieth week of pregnancy. Also known as spontaneous abortion, it is defi ned as “loss of the products of conception before the fetus is viable.” 24 Most miscarriages are due to chromosomal

abnormalities in the fetus. Stillbirth, also referred to as sudden intrauterine death, is defi ned as occurring between the twentieth week of gestation (preg- nancy) and the time of birth, resulting in delivery of a dead child. The dis-

tinction between miscarriage and stillbirth is based on the fact that most

fetuses are viable—that is, able to survive outside the mother’s body—after

the twentieth week of pregnancy. In contrast to miscarriage, which occurs

naturally, induced abortion (also called artifi cial or therapeutic abortion ) is brought about intentionally, with the aim of ending a pregnancy by mechan-

ical means or drugs.

Infant death, a term referring to death that occurs before a child’s fi rst birthday, is often subdivided into the period of neonatal death, defi ned as occurring during the fi rst twenty-eight days following birth, and postneonatal death, occurring after the fi rst twenty-eight days and up to eleven months

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Parental Bereavement 425

following birth (some defi nitions extend the postneonatal period to encom-

pass the period from age twenty-eight days to under one year). We discuss

these childbearing losses in greater detail later in this chapter.

Pregnancy, induced and spontaneous abortion (miscarriage), stillbirth, and

infant death all take their meanings from the lives of those who experience them

and the social worlds in which they occur. . . . The physical reality (at what point a

death occurs), the social reality (the defi nition as death as well as the signifi cance of that death), and the psychological reality (the grief associated with that death)

are all constructed within particular, and various, social contexts. 25

Reproductive loss also includes losses resulting from infertility and ste-

rility. Whereas infertility refers to “diminished or absent capacity to produce offspring,” sterility denotes “complete inability to produce offspring” due to inability either to conceive (female) or to induce conception (male). 26 Despite

advances in medical treatment for infertility, many couples remain childless,

their urges to reproduce frustrated by forces beyond their control.

Another example of reproductive loss involves giving up a child for adop- tion. Although this might not initially be thought of as a childbearing loss because it generally results from choice, grief may accompany such decisions

nonetheless. Adoption can be envisioned as a triangle, with its three sides

being the relinquishing parents (generally the birth mother), the adoptee,

and the adoptive parents. 27 Each of these parties faces different issues. Psy-

chologists point out,

In a society that defi nes women as mothers, mothers-to-be, or childless, the

woman who has given birth and then relinquished her child for adoption is an

enigma. Having signed away her legal claim to the child, she is often perceived

as the most unnatural of women, a rejecting mother. [But] the maternal

experience does not end with the signing of surrender papers. 28

A comprehensive view of childbearing loss also includes the birth of a

child with a severe impairment, such as a congenital deformity or a mental

disability. Parents may have diffi culty accepting the reality that their child is

not as they had dreamed; they may grieve the loss of the “perfect” or “wished-

for” child. 29

When we bury the old, we bury the known past, the past we imagine sometimes

better than it was, but the past all the same, a portion of which we inhabited.

Memory is the overwhelming theme, the eventual comfort.

But burying infants, we bury the future, unwieldy and unknown, full of prom-

ise and possibilities, outcomes punctuated by our rosy hopes. The grief has no bor-

ders, no limits, no known ends, and the little infant graves that edge the corners

and fencerows of every cemetery are never quite big enough to contain that grief.

Some sadnesses are permanent. Dead babies do not give us memories. They give

us dreams.

Thomas Lynch, The Undertaking: Life Studies from the Dismal Trade

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426 c h a p t e r 11 Death in the Lives of Adults

Bereavement in connection with childbearing or reproductive loss cov-

ers a broad range of related losses. People may assume that the loss of a baby

during the early stages of pregnancy evokes feelings of disappointment, not

grief. To the parents, who have dreamed about the baby even before its con-

ception, the loss is likely to be very real, prompting grief infused with confu-

sion and pain. In the following sections, we examine in more detail losses

resulting from miscarriage, induced abortion, stillbirth, neonatal death, and

sudden infant death syndrome.

Miscarriage Parents may be told that miscarriage is simply “nature’s way” of weeding

out genetic anomalies. Such a remark offers little or no consolation to griev-

ing parents; it was their baby that nature decided to eliminate. Platitudes that minimize or deny the loss are unhelpful. When parents experience a series of

miscarriages, loss is compounded upon loss.

Parents may have diffi culty identifying their loss precisely or making

sense of what has happened. After a miscarriage, one young mother’s grief

was complicated because she had no remains to be buried. “I didn’t know

where my baby was,” she said. Even though a miscarriage may have occurred

many years ago, grief for an unborn baby can recur with other signifi cant life

events—for example, at the birth of a subsequent child or the onset of meno-

pause. A particular marker, such as reaching age forty or age sixty-fi ve, can

reawaken feelings of grief.

Induced Abortion Although induced abortion is also termed elective abortion, in many cases

it is less a choice than a medical necessity. Some people assume that women

who elect to terminate a pregnancy do not experience grief, but this is not

always true. Although women may experience relief after an abortion, some

experience a period of deep sadness that may be characterized by feelings

of guilt, anger, or regret. If a woman feels that she was pressured into sexual

intercourse or into the abortion, along with grief for the loss, she may feel bit-

ter. 30 Grief after elective abortion can be just as real as grief after involuntary

fetal or infant loss. 31 “For a woman who experiences a pregnancy loss as a

tragedy, it is a tragedy; and for a woman who experiences a loss as relief, it is

a relief.” 32 The emotional reaction to induced abortion varies. Similar ques-

tions apply to men who participate in decisions about elective abortion.

In some cases, the repercussions are not felt until much later. One

woman, who had chosen to abort a pregnancy as a young adult because she

and her partner felt their relationship couldn’t withstand the pressures of

raising a child at that time, experienced great remorse when they later found

themselves unable to have other children. “That may have been our only

chance,” she lamented. Subsequent pregnancy loss may be experienced as

“retribution” for an earlier abortion.

Confl icting views about abortion may place the bereaved in a dilemma:

Those who believe a loss occurred may not sanction the act, whereas those

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Parental Bereavement 427

who sanction the act may not recognize that grief for a perceived loss needs

to be expressed and legitimized. Complications in grieving may be exacer-

bated when customary sources of solace and social support are not readily

available. 33

When the decision for an abortion is made because of adverse informa-

tion about the health of the fetus, the inherent confl ict about the choice may

add to parents’ grief. Many genetic diseases are identifi ed by tests during the

early stages of pregnancy; when the results are unfavorable, terminating the

pregnancy may seem the best or only choice. Some tests, however, can be

done only well into the pregnancy, after the mother has already felt the fetus

moving. Parents who decide in favor of a therapeutic abortion may worry that

no one will understand their “choice” and that they will be judged harshly.

Furthermore, in this situation, couples may face not only the loss of a particu-

lar baby but also the possibility of a childless future; biological considerations

or genetic risk may preclude the choice to conceive again.

In Japan, at places like Hase Temple near Kamakura and Shiun Jizo Tem-

ple north of Tokyo, tiny stone statues called mizuko represent children con- ceived but never born. 34 Some wear bibs and stocking caps. Placed alongside

them are toy milk bottles, dolls, and twirling pinwheels, along with memori-

als written by their sponsors—women who chose to have an abortion rather

Seen here are a few of the more than fi fty thousand mizuko , or “water children,” at Hase Temple near Kamakura, Japan. For the parents who sponsor a statue, they represent a ritual resolution of grief for the souls of unborn babies.

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428 c h a p t e r 11 Death in the Lives of Adults

than give birth. The statues, each one costing several hundred dollars, are

erected as repositories for the souls of unborn babies. At Hase Temple, the

mizuko are watched over by a thirty-foot-tall wooden statue of the Japanese

Goddess of Mercy, who is also the patroness of safe birth. Even though abor-

tion is common in Japan, “mizuko worship” bears witness to an intense desire

to acknowledge the unborn fetus.

Stillbirth “Instead of giving birth, I gave death,” said a mother whose daughter

was born dead. Instead of a cradle, there is a grave; instead of a receiving

blanket, there are burial clothes; instead of a birth certifi cate, there is a death

certifi cate. Many stillbirths occur at or near full term to otherwise appar-

ently healthy infants. 35 After a stillbirth, “a family’s wishes and hopes and

dreams—the individuals’ illusions about what life ought to be—are quickly shattered by the reality of what life really is. ” 36

Researchers point out that data on the prevalence of stillbirth may be

inaccurate because of poor documentation and underreporting. 37 In the

past, it was standard practice for hospitals to take over management of

stillbirth and remove the dead infant as quickly as possible with the aim of

avoiding or minimizing the psychological trauma. “Women trusted those in

authority as to whether or not they should see their stillborn babies.” 38 As

Irving Leon points out,

The death of a baby was an unspeakable event in a hospital. Hushed silence

greeted the delivery of a stillborn. The baby was whisked away before parents could

see and hold their child. They were told to forget what happened and have another

baby as soon as possible. The mother was given tranquilizers if she became too

upset, if she “lost it” (meaning that she was grieving over what she  had lost). 39

Today, in most hospitals the situation is different, and grief for child-

bearing loss is respected. Hospital staff are now likely to encourage parents

to see and hold their baby. A recent large study of mothers who had expe-

rienced stillbirth found that the great majority saw (95 percent) and held

(90 percent) their stillborn babies. Very few expressed regret. Researchers

noted that “rituals, such as holding, caressing, and caring for the dead body

of a loved one, have been used universally by humans throughout history and

across cultures as a way of realizing and coping with loss, and they have been

described as the antidote to powerlessness. ” 40 A postmortem photograph of the child may assist in the process of griev-

ing. 41 Parents may hold a memorial service for the stillborn baby, a choice that

not only acknowledges the reality of what has happened but also provides an

opportunity to fi nd meaning and solace by sharing grief with others. Family

support is especially important. In one study, family support was the only

form of support associated with reduced maternal anxiety and depression

after a stillbirth. Researchers noted that “stillbirth is often an isolating, mar-

ginalizing experience for women,” and “the social support of many bereaved

mothers falters.” 42

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Parental Bereavement 429

Some hospitals give bereaved parents an information packet that

includes a certifi cate of stillbirth, which acknowledges the birth as well as

the death of the child. Linking objects (discussed in Chapter 8), such as a

lock of hair, a photograph, and the receiving blanket, can be comforting

to parents. Nearly 90 percent of the parents included in a study by John

DeFrain named their stillborn baby, thereby recognizing that it was indeed

part of the family, no matter how briefl y: “Naming seemed to help show

others that the baby really existed and was important, not just something

to be thrown away and forgotten.” 43 The hurt may fade as time passes; the

memories do not.

Neonatal Death When a baby is born alive but with life-threatening disabilities due to

prematurity or congenital defects, the ensuing period of uncertainty about

the baby’s survival can be a nightmare for parents. Parents may experience

an overwhelming sense of frustration and futility as medical interventions

The items placed around the grave of this infant in Hawaii—balloons, fl owers, and jars of baby food—bespeak the parents’ loss and acknowledge the enduring bonds of even a short-lived relationship.

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430 c h a p t e r 11 Death in the Lives of Adults

are discussed, are attempted, and perhaps fail. Sometimes a baby born with

one or more life-threatening conditions embarks on a life-or-death struggle

that lasts weeks. During this time, parents may have to make diffi cult ethi-

cal choices that determine whether the baby lives or dies. Meanwhile, costs

incurred in keeping the baby alive continue to mount. If the baby does

die, parents might resent the medical institution and its personnel, feeling

as if they survived a painful and futile ordeal only to be billed later for the

experience.

In circumstances involving a critically ill newborn, any decision may haunt parents as they repeatedly ask themselves if they made the right choice.

Caregivers who appreciate the heart-wrenching ethical dilemmas that occur

in the context of neonatal intensive care are in a position to provide sensitive

care and support to parents facing the prospect of making and living with

these diffi cult decisions. When the life of a critically ill infant is being sus-

tained by extraordinary medical means, the decision to terminate artifi cial

support ought to be handled with as much grace as circumstances allow. One

young neonatologist remarked, “One of the most diffi cult and important

things for me to learn was to hand over the baby to the parents so it could die

in their arms.”

Sudden Infant Death Syndrome Sudden infant death syndrome (SIDS) is defi ned as a death of an apparently

healthy infant usually before one year of age and of unknown or no defi nitive

cause. 44 Risk factors include low birth weight, prematurity, mother’s age less

than twenty years, maternal drug use or smoking during pregnancy, overly

cold or overly hot environment, and soft bedding.

The unexpected nature of the death, the age of the child and of the par-

ents (who are generally young and may be experiencing an intimate death

for the fi rst time), and uncertainty about the cause of death combine to make

SIDS deaths a diffi cult loss for all concerned.

Because the cause of death is not certain and because of generalized

concerns about the possibility of child abuse, law enforcement personnel may

question whether the parents are responsible. Tragically, parents do some-

times murder their own infants and try to pass off the deaths as natural or

accidental. The search for a cause of death in SIDS cases is characterized by

lack of clarity. Because of this and because SIDS support groups have cir-

culated information about the adverse effects of misdirected accusations

toward grieving parents, police and other investigators are usually sensitive

in handling cases that might involve SIDS. Even so, parents may question

themselves just as sternly: Was the death somehow due to something they did

or left undone? Could it have been prevented?

Continuing research into the causes of SIDS may help avoid some paren-

tal guilt. Researchers at Children’s Hospital in Boston found that babies who

died of SIDS had defects in the brain stem. These defects undermined the

action of the chemical serotonin, which is critical to breathing and arousal.

Other researchers cautioned that, although infants who die with SIDS have

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Parental Bereavement 431

anomalies with serotonin function, there are other brain-chemical systems

that have not been thoroughly studied and may play equally strong roles. 45

Studies continue. In the meantime, the unexplained nature of SIDS deaths

can lead survivors to embark on a quest for answers that may not be available.

Grief for “Unlived” Lives The kinds of losses discussed here involve grief for “unlived” lives. Judith

Savage says, “Childbearing losses are mourned not only for what was, but

also for what might have been.” 46 Grief is felt not only for the physical loss but

also for symbolic losses. Parents mourn “the child of the imagination, that

part of themselves which seems now to have no possibility of embodiment

in the world.” Writing from the perspective of a Jungian psychologist who by

age thirty-three had experienced multiple losses (her adoptive and biological

parents, her two brothers, and her infant son), Savage says,

By unraveling the mystery of the imaginative relationship, that is, the

projections of the self onto the unborn child, it becomes clear that primary

relationships are not composed merely of interchangeable functional attributes

and roles but are uniquely personal bonds that are generated from deep within

and are as much a refl ection of the individual soul as they are an accurate

refl ection of the other. 47

It is important to be aware of two distinct yet related realities: the actual relationship and the symbolic nature of the parent-child bond. Grieving par- ents often talk about lost companionship, lost dreams—all the ways in which

the child would have enriched their lives. Such discussion is concerned with

the actual loss. The symbolic loss relates to the meaning attached to the rela-

tionship, as when an individual, by parenting a child, becomes a nurturing,

supportive guide. A bereaved father said, “Not only have I lost a son who might

follow in my footsteps, but, without him, I have no feet.” It was important for

After her daughter’s death, there was no one to blame but herself. Nothing anyone

said would convince her otherwise. One doctor who had only just met her told

her she was a very good mother and should stop feeling guilty. A friend insisted

that she needed to stop blaming herself or she would lose her mind. All of their

efforts failed to eliminate Julia’s persistent magical belief that she was to blame

for her child’s death. At last, when the autopsy results arrived, her child’s doctor

explained how a very rare illness killed her daughter, and that due to the rapid

onset of symptoms, it would even have gone undetected if her baby had been

admitted to the pediatric ICU before showing any symptoms whatsoever. In effect, not

even the best medical minds could have saved her child. Julia was fi nally satisfi ed that

she was not responsible, but this only caused her more distress. If random trag-

edies like her daughter’s death could happen, she thought, then no parent can

completely ensure the safety of his or her child. Unable now to blame even herself,

she was fi lled with anxiety about the countless ways her children could be at risk.

Robert Zucker, The Journey Through Grief and Loss

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432 c h a p t e r 11 Death in the Lives of Adults

this father to acknowledge and mourn both the loss of his son and the loss

of meaning and purpose in his own life. The image of the lost child activates

powerful associations, which become part of a natural process guiding the

bereaved parent’s journey toward wholeness.

Anger may be focused on the dead child, resulting in confusing and tan-

gled emotions. We may think, What kind of parent could be angry at an inno-

cent infant? Yet, anger is a natural response to loss. As one woman said of her

stillborn daughter, “Why did she just drop in and out of my life? Why did she

bother coming at all?” Emotional responses may be accompanied by audi-

tory or kinesthetic deceptions: A baby cries in the night, waking parents from

sleep; the baby kicks inside the womb, yet there is no pregnancy, no live child.

Grief following a childbearing loss also may be infl uenced by the parents’

perceptions that the loss is neither understood nor acknowledged by others.

Bereaved parents report hearing insensitive comments, such as “It must be

easier, since you didn’t get too attached.” Well-intentioned family members

and friends may attempt to minimize the death in an effort to console the

bereaved parent. They may say, “You’re young; you can have another baby,”

unaware that such a comment, although possibly true, is inappropriate: No

other child will replace the one who died. This kind of advice and comment

is especially diffi cult for couples who postponed having children—they may

feel an added constraint of time that compounds the experience of loss.

The Death of an Older Child Many of the issues discussed in the preceding section pertain as well to

parents’ grief following the death of an older child, adolescent, or young

adult. The meaning of such a death is usually more complex, however,

because the relationship between parent and child has been of longer dura-

tion, with a larger store of memories. A child represents many things to a

parent. As Beverly Raphael reminds us, a child is “a part of the self, and of

the loved partner; a representation of generations past; the genes of the fore-

bears; the hope of the future; a source of love, pleasure, even narcissistic

delight; a tie or a burden; and sometimes a symbol of the worst parts of the

self and others.” 48 Over time, the bond between parent and child takes on

increasing complexity.

Among the major causes of death among individuals between the ages of

fi ve and twenty-four, accidents top the list. 49 As the most prominent cause of

death during the fi rst half of the human life span, injury is characterized as

“the last major plague of the young.” 50 Although more children and adoles-

cents die from injuries received in accidents than from the effects of disease,

the circumstances and challenges of a child with life-threatening illness are

usually viewed as especially poignant. Perhaps we feel, justifi ably or not, that

an accident is something that just “happens” and therefore is not preventable,

whereas we expect medicine to provide a cure for disease.

When a child’s life is threatened by serious illness, it affects the whole

fabric of family life. Parents and siblings, along with other relatives, are all

involved in coping with the illness. (See “Caring for a Seriously Ill Child” in

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Parental Bereavement 433

Chapter 10.) Few families are able to sustain total openness to the reality of a

child’s terminal illness throughout what may be a long process from diagno-

sis of the disease to the child’s death. At times, a seriously ill child may func-

tion quite normally, and the routine of medical care becomes just another

aspect of family life. At other times, the illness requires parents and other

family members to deal intensely and decisively with changes in the child’s

condition. Those around the child may feel challenged as they try to adjust

to shifts between hope for recovery and acceptance of terminality, all while

trying to support the child in the best way possible.

Parents seem to have a somewhat easier time coping when they do not

base their personal identities solely on their role as parents. In other words,

although parenting is an important part of their lives, it does not comprise

the whole of their self-image, which encompasses other accomplishments and

values as well. Some parents manage not only to cope with and survive the

devastating loss of a child but to grow from the experience. Such parents are

able to “respond to a [child’s] severe illness by making a more mature reeval-

uation of their lives and achieving a truer vision of what counts,” says Jerome

Schulman. “They learn to make each new day more enriching.” 51

The Death of an Adult Child For a young or middle-aged adult to die while his or her parents live on

seems unnatural. It is a death “out of sequence.” The consequent loss of par-

enthood may become a kind of “perpetual bereavement,” in which the strug-

gle to understand the meaning of the death continues all through life. 52

The older parent who survives the death of an adult child may also have

lost a caregiver. The child, a source of comfort and security, is gone. There

may also be a sense of “competing” with the dead child’s spouse or children

for the role of “most bereaved.” Who has priority in receiving care and com-

fort? The death of an adult child sometimes requires parents to assume care

of grandchildren, a result that can be emotionally as well as economically

disruptive.

Parents who suffer the death of a child already grown to adulthood may

fi nd themselves alone in coping with their grief. In contrast to the situation

of parents who lose younger children or individuals who survive the death of

We had waited, agonizing through the nights and days without sleep, startled by

nearly any sound, unable to eat, simply staring at our meals. Suddenly in a few sec-

onds of radio time it was over. My fi rst son, whose birth had brought me so much

joy that I jumped up in a hall outside the room where he was born and touched

the ceiling—the child, the scholar, the preacher, the boy singing and smiling, the

son—all of it was gone. And Ebenezer was so quiet. All through the church as

the staff learned what had happened, the tears fl owed, but almost completely in

silence.

Martin Luther King, Sr.

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434 c h a p t e r 11 Death in the Lives of Adults

a spouse, few support resources are available to help parents cope with the

death of an adult child. Yet, the death of a child—at whatever age—is always

a signifi cant loss.

Coping with Bereavement as a Couple One concern following the death of a child is the impact it has on the

bond between partners. Some people believe that the stress of coping with

a child’s death will make or break a relationship. Clinicians sometimes note

the presence of a kind of “general chaos,” a pervasive sense that the parents

have been robbed of past and future. With such a traumatic event, parents

expect, and are expected, to support each other. But the energy expended by

each partner in coping with his or her own grief can deplete the emotional

resources needed for mutual support. Some bereaved parents report that in

addition to losing a child, they felt they had lost their partner for a time.

The death of a child has the potential to either improve or worsen a mari-

tal relationship. 53 It may have the paradoxical effect of creating a feeling of

estrangement and a strong bond between parents at the same time. 54

Even though they share the same loss, parents might have different griev-

ing styles, which can leave each of them feeling isolated and unsupported

by the only person who shares the magnitude of the loss. Although in some

cases the mother’s loss may be more physical and less abstract, fathers often

struggle with feeling powerless to support and protect their loved ones. 55

Also, individual differences in values, beliefs, and expectations may cause

confl icts in coping styles, thereby reducing the sense of commonality in a

couple’s grief experience. 56 Parents do not necessarily grieve in an asynchro-

nous or “roller-coaster” pattern, but they may fi nd themselves grieving “out of

synch” with one another at times.

The sense of commonality in a couple’s grief is also affected by their view

of themselves as a couple. They may have diffi culty reaching agreement about the best way to regain a sense of stability and meaning in life after their child’s

death. Despite each partner’s desire and expectation to “go through grief ”

together, differences in grieving styles may create confl ict about whether

one’s partner is behaving appropriately.

Confl ict can arise out of each partner’s interpretation of the other’s behav- ior. A husband who contains his grief so that he can “be there” for his wife

may be perceived by his spouse as cold and unfeeling. The desire to be caring

and protective can be misinterpreted, resulting in confl ict rather than com-

fort. Disagreement can also relate to issues about what constitutes “proper”

mourning behavior, the couple’s “public face” of grief.

Reducing confl ict and promoting positive interactions between grieving

partners requires the willingness of each to engage in open and honest com-

munication. In this way, each partner’s emotional expression of loss helps

validate the reality of the other’s perceptions. Crying together can be helpful

in resolving confl ict and working through the loss. Accepting differences and

being fl exible about roles helps. One characteristic of couples who report

little confl ict is a positive view of each other and their relationship.

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Parental Bereavement 435

The “bridges” between partners have various qualities. Bonds may be as

strong as a suspension bridge embedded in concrete or as weak as one made

of wooden planks and bark. Using the analogy of the weight of a large truck

being driven over a fl imsy bridge reveals that some relationships are fragile

and likely will not support the burden of loss. Yet, who is to say that a poorly

constructed partnership might not have been broken regardless of the death

of a child? Some couples recognize that their bridges need upgrades and seek

resources and support to stabilize and strengthen their relationship. Other

couples move into a circle of blame and destruction. It is not predetermined

that a child’s death will cause the loss of the pair bond as well. In fact, a study

conducted for The Compassionate Friends, a self-help group of bereaved

parents, found that the divorce rate of couples who had lost a child was far

below the national divorce rate (16 percent versus about 50 percent) and that,

of the couples who divorced after the death of a child, only about 40 percent

felt that the death had contributed to the divorce. 57

Coming to terms with a partner’s behavior is enhanced by the ability to

reframe each other’s behavior in a positive way. For example, a husband who views sobbing as “breaking down” can alter his perception so that crying is

seen as emotionally cleansing and valuable, making it possible to explain the

behavior in positive terms rather than judging it as inappropriate or dysfunc-

tional. When unsettling behavior is seen as providing emotional release, it

allows a mate to support the expression instead of trying to curtail it.

Social Support in Parental Bereavement Relatives and friends of bereaved parents have many ways to offer sup-

port, including simply listening, sending cards or letters of condolence,

bringing food, doing housework or other chores, caring for other children

in the family, sharing their own grief over the loss, giving the parents time to

be alone, and so on. Individuals who are willing to talk openly with a parent

about his or her grief in the wake of a child’s death are important sources of

support in parental bereavement.

In additional, social support organizations are available to provide vari-

ous types of parental bereavement services. The Compassionate Friends,

which has chapters across the nation, offers support to bereaved parents

across a broad spectrum of losses. Another group, the Candlelighters Child-

hood Cancer Foundation, focuses on support for children with cancer, their

parents, and other family members. Two groups, Mothers Against Drunk

Driving (MADD) and Parents of Murdered Children (POMC), combine

social support with political advocacy. Such groups of bereaved parents who

have experienced similar losses constitute what some people have called

“communities of feeling” within which grief is shared. 58

It is important to keep in mind that people are different, as are their

attachments to their children. Bereaved parents should not be expected to

“follow a script” or enact some “right way” to grieve. Social support should be

offered in ways that recognize individual differences and promote genuine

empathy.

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436 c h a p t e r 11 Death in the Lives of Adults

Spousal Bereavement The ties between two people in a paired relationship are usually so closely

interwoven that, as Beverly Raphael says, the death of one partner may “cut

across the very meaning of the other’s existence.” 59 Even though we recog-

nize the possibility, the likelihood, that one spouse will die before the other,

such thoughts are usually kept safely in the background. The pressing activi-

ties of daily life occupy our attention until one day the possibility becomes a

reality that can’t be ignored.

The aftermath of spousal bereavement has been described as follows:

“Everyday occurrences underscore the absence of your mate. Sitting down to

breakfast, or dinner, opening mail, hearing a special song, going to bed, all

become sources of pain when they were formerly sources of pleasure. Each

day is full of challenges and heartbreaks.” 60

A spouse’s death requires an adjustment from being a couple to being

single, a transition that is likely to be especially hard for the survivor who

is also a parent. With children to care for and nurture, there is the added

burden of single parenthood. The way a particular person adjusts to the role

of newly widowed person depends on a host of sociocultural, personal, and

circumstantial factors.

Factors Infl uencing Spousal Bereavement Although the death of a mate is the most intensively studied of all losses

during adulthood, research has generally focused on a brief time span imme-

diately after bereavement; there are few studies of the enduring effects of a

partner’s death. 61 It is also noteworthy that studies of spousal, or conjugal,

bereavement have generally focused on heterosexually paired relationships

while mostly ignoring homosexual couples who make lifelong commitments

to each other. In same-sex relationships, grief following the death of a part-

ner may be exacerbated by confl ict with a mate’s parents who have never

made peace with their son’s or daughter’s sexual orientation or lifestyle. “If I

was effectively nonexistent to them before,” one surviving mate said, “I really

vanished after my partner died. For years, they denied our commitment

to each other; now they acted as if they could completely erase me! They

claimed everything: the body, our home, and, seemingly, my right to grieve.”

It is important to recognize that grief over the loss of a mate is independent

of legal or social sanctions about the nature of a relationship.

The patterns of intimacy and interaction between spouses are an impor-

tant determinant of how the loss of a partner will be experienced by a survi-

vor. Whereas one couple may derive their primary satisfaction from shared

activities, another couple enjoys greater independence. In some relation-

ships, the focus is on children; in others, the adult partners take precedence.

Furthermore, the patterns of a given relationship tend to be in fl ux as cir-

cumstances change over time.

Consider the differences in outlook between an older couple, who have

shared their lives over many years, and a young couple, who have been

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Spousal Bereavement 437

together only a short time. The death of a mate in old age typically follows a

lifetime of mutual commitment and shared experiences. Spousal death may

not be a “surprise” to older adults, but often it “sets off an intertwined set of

circumstances endemic to being old.” 62

Mr. and Mrs. Andrew Lyman, Polish farmers living near Windsor Lakes, Connecticut, exemplify some of the qualities that contribute to a close relationship. When such a bond is severed by death, the effect is felt in every area of the survivor’s life.

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438 c h a p t e r 11 Death in the Lives of Adults

In contrast, a young couple is just setting out to build a world together

and, when a partner dies, the survivor must remake previously shared goals.

During the years from youth to old age, a person’s standard of living and

overall quality of life are also likely to change, thus affecting the meaning

and reality of loss.

Spousal bereavement also elicits distinct behaviors related to culturally

sanctioned gender roles. In one culture, a widower might avoid crying pub-

licly because to do so would be viewed as weak and shameful. A widower in

another culture, conversely, might express his grief through many tears and

loud crying because not to do so would suggest a weakness in ability to love.

As Robert Stettersten says, “Culture structures the ways lives are lived.” 63

Individuals who have lived out traditional gender roles may fi nd the tran-

sition to widowhood especially hard. Learning to manage unfamiliar role

responsibilities in the midst of grief can be a formidable task, intensifying

feelings of helplessness. The widow who has never written a check or the wid-

ower who has never prepared dinner is confronted not only with grief at los-

ing a loved one but also with major role readjustments. New skills must be

learned to manage the needs of daily life. Widowed persons whose lifestyles

include multiple roles—such as parent; employee; friend; student; hobbyist;

or participant in community, political, and religious organizations—appear

to make an easier adjustment than do those with fewer role involvements.

In the fi rst year after the death of a mate, there are higher rates of illness

and death among widows and widowers; aged people are particularly at risk.

This is partly explained by the observation that individuals tend to neglect

their own health problems while caring for an ailing spouse. In addition, a

survivor’s ties to the outside world may have diminished while caring for his

or her spouse, thus increasing feelings of loneliness following bereavement.

A study of more than fi fty-fi ve thousand widows found that women widowed

less than a year reported “substantially higher rates of depression and poorer

social functioning, overall mental health, and general health than longer

term widows.” 64 After a three-year period of time, however, these widows

showed marked improvements in their functioning, which researchers attrib-

uted to the “resilience of older women” and their capacity for reestablishing

social connections.

Adverse effects of spousal death appear to be more common among wid-

owers, perhaps because men with conventional gender roles fi nd it diffi cult

to manage domestic matters that were once left to the now-deceased spouse.

Widowers also may be less likely than widows to seek help from others, a trait

of “self-reliance” that may be associated with gender roles. As Judith Stillion

points out, men who care for an ailing partner over an extended period of

time may be at a disadvantage in coping with the onset of normal physical

and psychological problems of bereavement if “their socialization prohibits

them from asking for help, showing strain, or even, in some instances, recog-

nizing and discussing their feelings with helping professionals.” 65

Relief following the death of a spouse, although little discussed, is an

emotion that may be experienced by people who have cared for an ailing

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Spousal Bereavement 439

spouse over a long period of time. In such cases, death may be viewed as end-

ing an ailing loved one’s suffering. Less socially accepted or acknowledged is

relief experienced when a mate’s death is the welcome end to an unsatisfac-

tory relationship.

Because women statistically live longer than men, it is estimated that

three out of four married women will be widowed at one time or another.

Widows who want to remarry face not only social pressures but also a lack of

eligible men. However, it has been suggested that widowhood is less diffi cult

for women than retirement is for men. This is because there are many other

widows with whom to share leisure time and activities; thus, a woman’s status

may increase with widowhood, whereas a man’s status usually decreases at

retirement.

Social Support for Bereaved Spouses The death of a mate results in the loss of a primary source of social inter-

actions and alters a person’s social role in the community. The availability of

a stable social support network can be crucial in determining how bereaved

spouses adjust to their changed status. A study by Rebecca Utz and colleagues

found that widowed persons used social participation “as an active coping

strategy to deal with the negative effects of widowhood.” 66 Informal activities,

such as getting together with friends and telephone contact, were particularly

important as aspects of daily life that are affected by late-life bereavement.

Formal social participation, researchers concluded, may not provide the

emotional and instrumental support that informal social participation does.

Because friendships are based on common interests and lifestyles, maintain-

ing relationships with nonrelatives appears to be important. Participation in

leisure activities with friends may help widowed people cope with role transi-

tions and maintain a sense of resiliency and positive morale despite diffi cult

life changes.

Family relationships, in contrast, may pose a potential psychological

threat to the widowed elderly because they contain elements of role reversal

between the adult child and the aging parent that suggest or demand depen-

dency from the aged widow or widower. Furthermore, an adult child’s experi-

ence of the loss differs from that of the bereaved spouse, who is likely to value

the loss as more signifi cant than does the child and to feel the effects of the

loss more intensely with respect to physical and emotional health. 67

One of the most valuable resources for the recently widowed is con-

tact with peers—that is, other bereaved people who have lost a mate and

who can serve as role models during the subsequent period of adjustment.

Exposed to the role model’s accepting attitude, the newly widowed person

learns to live with the painful or diffi cult feelings of grief and gain perspec-

tive on them.

Following the pioneering work of Phyllis Silverman at Harvard Univer-

sity Medical School, the Widowed Persons Service (WPS) began in 1973 to

implement a concept of mutual help to widowed individuals. 68 The Widowed

Persons Service, whose parent organization is the American Association

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440 c h a p t e r 11 Death in the Lives of Adults

of Retired Persons (AARP), offers newly widowed people help provided by

trained volunteers who themselves have been widowed, the key to the effec-

tiveness of such programs.

Aging and the Aged The stereotyped image of an aged person is marked by such outward signs as

dry and wrinkled skin, graying hair, baldness, failing eyesight, hearing loss,

stiff joints, and general physical debility. Indeed, the physical signs of senes- cence, or the process of becoming old, are rightly associated with the aging of the human organism. (Senescence can be thought of in terms of vulner-

ability; the risk that an illness or an injury will prove fatal increases with age.)

Most elderly individuals experience some chronic conditions. These can be divided into three categories: (1) nonfatal chronic illness, (2) serious and

eventually fatal chronic illness, and (3) frailty. 69

Common nonfatal chronic conditions include arthritis and hearing or vision

problems. The common fatal chronic conditions are cancers, organ system

failures, dementia, and strokes. Frailty is the fragility of multiple body systems

as the customary reserves diminish with age and disease. Frailty is a fatal

chronic condition; small upsets cause cascading health problems. 70

Many illnesses and disabilities—with accompanying losses in many areas

of life—occur most commonly among people aged fi fty or older. 71 However,

age alone is a poor predictor of outcome for a particular individual. 72

Older people who practice life-enhancing activities—challenging their

minds, maintaining physical fi tness, eating wisely, reducing stress, and so

on—increase the chances of “age-proofi ng” their lives. 73 Old age can be a

season of life satisfaction and ego integrity or one of dissatisfaction, despair,

and disgust. One writer said, “Growing old is like being increasingly pun-

ished for a crime we did not commit.” 74 This accounts for some of the rea-

sons given by aged people for accepting death as an alternative to continued

existence (see Table 11-1 ). Suicide may be seen by some older people as a

“What would you like for breakfast, Jack?” I asked my son-in-law on Sunday, the

day after the funeral.

“A fried egg, over,” he replied.

Such a simple thing. Yet, I’d never fried an egg.

Oh, we often had them on weekends; but my husband was the breakfast cook,

while I dashed up and down the steps putting clothes in the washer, running the

vacuum, and all the other tasks always awaiting a working wife.

I stood there, the frying pan in one hand, the egg in the other.

How many times in the future would I fi nd myself standing the same way?

How many things had I never done? How many things had I taken for granted?

Maxine Dowd Jensen, The Warming of Winter

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Aging and the Aged 441

rational choice that offers release from severe illness or other hardships of

old age. Some of the factors infl uencing suicide among older adults are dis-

cussed in Chapter 12.

Bereavement is one of many stressors that characterize the challenges

faced by the older adult. 75 As we age, we not only experience with increasing

frequency the deaths of others, we also come closer to our own death. A phi-

losopher writes, “Death is always close for the elderly, internalized. Many may

not face it, but most are well aware of it. As with the young, the time of death

is uncertain, but the elderly are more likely to realize that we may die in the

very next instant.” 76

Dementia—the loss, usually progressive, of cognitive and intellectual

functions—affects about 5 to 10 percent of people over age 65 and as many as

30 to 50 percent of people older than 85 years. 77 This loss of brain function

affects memory, language, judgment, and behavior. It may be accompanied by

emotional problems and personality changes. Alzheimer’s disease—named

after a German neurologist—is the most common form of dementia. It is a

progressive mental deterioration marked by loss of memory and ability to cal-

culate, confusion, and disorientation. It usually begins in late middle or later

adulthood and results in death in fi ve to ten years. “The disease is twice as

common among women as among men, partly because women have a longer

life expectancy.” 78 Mortality from Alzheimer’s disease has steadily increased

during the past three decades. 79 With the aging of the post–World War II

“baby boom” generation, the number of Alzheimer’s patients is expected to

swell, “making the need for adequate diagnostic techniques and therapies

more pressing.” 80

The President’s Council on Bioethics reports, “We are on the threshold

of the fi rst-ever ‘mass geriatric society.’ ” 81 ( Geriatrics is the branch of medi- cine that deals with old age and the treatment of physical and mental disor-

ders in older adults.) 82 Although the chairman of the council stated, “It is the

best of times to be old,” the sobering fact is that “the most common trajectory

toward death is a lengthy period of debility, frailty, and dementia lasting not

months, but years.” The twenty-fi rst century is being characterized as a cen-

tury of aging. 83 Others call the aging of societies a “silver tsunami.”

When are you “old”? From the time in early childhood when a person

of twenty-one appeared quite old and a person of forty seemed ancient, our

Death is preferable to inactivity.

Death is preferable to the loss of the ability to be useful.

Death is preferable to becoming a burden.

Death is preferable to loss of mental faculties.

Death is preferable to living with progressively deteriorating physical health and

concomitant physical discomfort.

t a b l e 11-1 Some Reasons Given by Aged People for Accepting Death

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442 c h a p t e r 11 Death in the Lives of Adults

perception of “old” gradually recedes as we celebrate more birthdays. At class

reunions, each person can hardly believe how much older other classmates appear! 84 A person festively celebrating his or her thirtieth or fortieth birth-

day may fi nd these milestones of life bringing thoughts about the meaning of

growing older and the lost opportunities that occur in taking one particular

path in life rather than another. 85

Aging doesn’t begin at fi fty or sixty-fi ve or eighty-fi ve. At this moment, we

are all aging. Interestingly, the expectations most people have about aging

or being old differ from the actual experience. Young adults typically expect

problems among older people to be more serious than they actually are for

those who experience them.

Bernice Neugarten reports that when she fi rst developed a course on

Adult Development and Aging, “It was generally assumed that you reached a

plateau simply called adulthood and you lived on that plateau until you went

over the cliff at age sixty-fi ve.” 86 The changing health status of older adults is

acknowledged in the National Council on Aging’s use of the terms young-old for people ages sixty to seventy-fi ve, middle-old for those seventy-fi ve to eighty- fi ve, and old-old for those over the age of eighty-fi ve. This last group is the fastest-growing segment of the aged population. As a “highly selected” group

of survivors, they tend not to match stereotypes of advanced age as a time of

fragility and dependency.

(Even these age categories may be outdated. One writer says that in 2004

he was placing ages 55–64 into the “nearly old” and 95 1   into the “oldest old”

categories. Within the next few years, he suspects he will be splitting the 95 1  

group into 95–104 as “oldest old” and 105 1   as “hyper old.”)

Most people would subscribe to the goal of improving the quality of

life while “compressing” morbidity, or illness, and extending “active” life

expectancy. 87 How long can we expect to live in the best of circumstances?

Whereas life span is defi ned as “a theoretically projected length of life based on the maximum potential of the human body in the best environment,”

a more practical concept might be that of the health span, which refers to “the period of life when one is generally healthy and free from chronic or

serious disease.” 88 Making the period of debilitating illness briefer enables

people to enjoy good health and stay active until quite near the end of their

lives. Perhaps, in place of a “natural life span,” we should think in terms of

a “full life.”

In contrast to their stereotypical image, old people tend to be more

individually distinct than any other segment of the population: They have

had more years to create unique life histories. (It is important to keep in

mind that older people are different from one another, even within the

same age category.) 89 Neugarten says, “People are ‘open systems,’ inter-

acting with the people around them. All their experiences leave traces.” 90

Mutual respect, faith, communion with others, and concern with existen-

tial issues of life are essential to the well-being of the aged. 91 Beyond that,

“there is considerable evidence that spiritual concerns, experience, and

development become increasingly important for many people in middle

and later life.” 92

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Aging and the Aged 443

In a memoir written at the age of eighty-nine, Diana Athill says,

From up here I can look back and see that, although a human life is less than

the blink of an eyelid in terms of the universe, within its own framework it is

amazingly capacious, so that it can contain many opposites. One life can contain

serenity and tumult, heartbreak and happiness, coldness and warmth, grabbing

and giving—and also more particular opposites such as a neurotic conviction

that one is a fl op and a consciousness of success amounting to smugness. 93

In a summing up, she adds, “Minuscule though every individual, every

‘self’ is, he/she/it is an object through which life is being expressed and

leaves some sort of contribution to the world.” 94

Daniel Callahan points out that, while we are right to acknowledge indi-

vidual differences among the aged, it is important to appreciate the “ shared fea- tures of old age, the features that make it meaningful to talk about the aged

as a group and about old age as an inherent part of individual life.” 95 In seek-

ing what Callahan terms a “public meaning” of aging, we need to refl ect on

“what kind of elderly person we want ourselves to be and what ideal character

traits we would like to promote and support.” In considering one’s own future

status as an elder, it is worth noting that attempts to meet all the needs of the elderly must inevitably fail, especially if those needs are defi ned as the avoid-

ance of disease and frailty.

After a lifetime together, spouses engage in the activities of daily living out of a history of habit and familiarity. Preserving independence becomes a crucial goal of people in the years of maturity.

© A

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444 c h a p t e r 11 Death in the Lives of Adults

Old age is a time for bringing plans to completion or relinquishing

the responsibility for uncompleted projects to others younger than oneself,

for refl ection and summing up, and for preparing for one’s own death. Jay

Rosenberg says, “The fact that each of us will someday die shapes and colors

our consciousness.” 96 One sign of a rational person

is that he lives a life appropriate to a dying being—that he acknowledges

without denial and without complaint the unavoidable transitoriness of his own

existence, accepts with dignity and with grace the inevitable passage from youth

to old age, which is the outward sign of that transitoriness, and prudently plans

and provides for his own death and, to the extent that he can, for the well-being

and betterment of those whose lives will continue after his life, and thus his very

being, has come to an end. 97

Occasionally, we read or hear stories about old people being “left” to die

alone, as if they have been abandoned. Some people, however, choose to die

this way. Dying alone is different from dying lonely. The image of a person

dying alone is often portrayed as a negative outcome, perhaps due to the per-

son’s antisocial behavior or neglect by family, neighbors, or social services. A

typical story line pictures individuals who die alone as “fearful, lonely, even

pathetic fi gures who need help despite themselves or their lifestyles.” 98 The

idea that older people may be exercising independence or autonomy at the

end of life and do not want attention from the community usually receives

little consideration. Rarely is it thought that these “service refusers” represent

While There Is Time I carry the folding chair

for my mother

I carry the shawl

the large straw hat

to shield her from the glare

She leans her small weight

on my arm Frail legs unsteady

feet now cramped with pain

Each day we sit for hours

at the ocean The sun is hot

but she is wrapped and swathed

her hands are icy cold

they hide their ache

beneath the blanket

Her eyes follow the

movement that surrounds us

the romp of children

fl ight of gulls

the strong young surfers

challenging the sea

When the visit is ended

when my mother leaves

I will burst from the house

run empty-handed to the beach

hold out my arms

and swoop like a bird

my hands will tag children

as I pass

I will run and run

until I fall

and weep

for the crushed feet

the gnarled fi ngers

for her longing

I will run for both of us

Maude Meehan

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Further Readings 445

a desire to simply be left alone. The fact is, some people would rather die

at home alone, rather than having to put up with “interfering” medical or

health care workers, or members of their own community, who might expose

them to the risk of being placed into an institution. For these people, dying

alone is dignifi ed and dying surrounded by machines is not dignifi ed.

The positive images and meanings of growing old are eroded when we

regard old age as a pathological state or as an avoidable affl iction. In some soci-

eties, the aged hold special status as the “elders” of a community. Elderly women

in the African American community, for example, occupy a special place as they

continue the oral traditions of passing on cultural meanings to succeeding gen-

erations. 99 Respect for elders is similarly found among Native American peo-

ples. 100 In the broader society, the wish seems to be that the old “age gracefully.”

Although many older people living with serious illness are said to be “liv-

ing on thin ice”—with prognoses that might be some years or less than a

week—growing old is not essentially a “medical problem.” Robert Butler says,

“None of us knows whether we have already had the best years of our lives

or whether the best are yet to come. But the greatest of human possibilities

remain to the very end of life—the possibilities for love and feeling, reconcili-

ation and resolution.” 101 As the culminating phase of human life, the period

of old age or maturity is an appropriate time to focus on the tasks specifi c to

that part of the human journey. Butler says,

After one has lived a life of meaning, death may lose much of its terror. For what

we fear most is not really death but a meaningless and absurd life. I believe most

human beings can accept the basic fairness of each generation’s taking its turn on

the face of the planet if they are not cheated out of the full measure of their turn. 102

Further Readings Robert C. Atchley. Spirituality and Aging. Baltimore: Johns Hopkins University Press,

2009.

Donna S. Davenport. Singing Mother Home: A Psychologist’s Journey Through Anticipatory Grief. Denton: University of North Texas Press, 2002.

Norman M. Hadler. Rethinking Aging: Growing Old and Living Well in an Overtreated Society. Chapel Hill: University of North Carolina Press, 2011.

Robert O. Hansson and Margaret S. Stroebe. Bereavement in Late Life: Coping, Adap- tation, and Developmental Infl uences. Washington, D.C.: American Psychological Association, 2006.

Therese A. Rando, ed. Parental Loss of a Child. Champaign, Ill.: Research Press, 1986. Paul C. Rosenblatt. Parent Grief: Narratives of Loss and Relationship. Philadelphia: Brun-

ner/Mazel, 2000.

Phyllis R. Silverman. Widow to Widow: How the Bereaved Help One Another, 2nd ed. New York: Brunner-Routledge, 2004.

Debra Umberson. Death of a Parent: Transition to a New Adult Identity. New York: Cambridge University Press, 2003.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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© R

o b

e r t

C .

W il

e s

After plummeting eighty-six fl oors from the observation deck of the Empire State Building—visible in the metallic refl ection at lower left—this young woman lies dead, the victim of suicide.

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447

C H A P T E R 1 2

Suicide

A ltruistic suicide—that is, the giving of one’s life for others or for a greater good—has occurred since human beings fi rst banded together in clans. Imagine, for

example, a situation in which an individual volunteered to draw the attention of a herd

of animals and thereby allow other members of a hunting party to more easily trap the

animals. The likelihood of surviving the onrushing herd was low. The reward for the clan

was survival.

Among nomadic peoples, altruistic suicide among the elderly or infi rm was accepted

as a way to maintain the mobility needed for the survival of the group. Honor was given to

the person who, recognizing that the end of life was near, willingly left the community for

certain death. Historically and across cultures, suicide also has been recognized as a way to

express ultimate commitment to a moral or philosophical principle.

These examples of altruistic suicide may not conform to the ideas most people have

when they hear the word suicide. Although it has been documented throughout recorded his-

tory, Judith Stillion says that “suicide is arguably the most complex and the least understood

of all human behaviors.” 1

Why would someone end his or her own life? People question the awesome fact that each

of us has the power to decide whether or not we live. Questions about intention and choice

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448 c h a p t e r 12 Suicide

are central in understanding suicide and other self-destructive behaviors.

Usually, no single answer explains why a person dies by suicide. Kay Redfi eld Jamison says,

Suicide is a death like no other, and those who are left behind to struggle with

it must confront a pain like no other. They are left with the shock and the

unending “what if’s.” They are left with anger and guilt and, now and again, a

terrible sense of relief. They are left to a bank of questions from others, both

asked and unasked, about Why; they are left to the silence of others, who are

horrifi ed, embarrassed, or unable to cobble together a note of condolence, an

embrace, or a comment; and they are left with the assumption by others—and

themselves—that more could have been done. 2

As a complex human behavior, suicide involves diverse motives and

intentions.

Comprehending Suicide As you consider what might infl uence a person to die by suicide, you may think,

“There’s nothing that could cause me to end my own life intentionally.” For

individuals who are confi dent about their resources to deal with the demands

of life, suicide seems a radical solution indeed. In the search for answers about

suicide, our fi rst step must be to fi nd a framework for organizing this complex-

ity into manageable form. The four defi nitions of suicide given in Table 12-1

help establish a framework useful for all of these approaches.

Notice that each defi nition emphasizes certain aspects of suicidal inten-

tion and behavior. The standard dictionary defi nition is a good starting point

for understanding suicide, although it is vague. As you review the differ-

ent defi nitions, pay attention to how each explains the dynamics of suicide.

Notice, too, that suicidal behavior may be immediate or long term. Thus,

alcohol abuse can be suicidal behavior because, in attempting to solve exis-

tential problems, it makes use of something that can be fatal over time. Ask

yourself, What kinds of human behavior does the defi nition include? Is sui-

cide a specifi c act, or is it a behavioral process? What is the context of suicide?

What are the circumstances in which it occurs?

Suicide is . . .

The act or an instance of taking one’s own life voluntarily and intentionally, espe-

cially by a person of years of discretion and of sound mind. ( Webster’s New Collegiate Dictionary )

Self-killing deriving from one’s inability or refusal to accept the terms of the human

condition. (Ronald W. Maris)

All behavior that seeks and fi nds the solution to an existential problem by making

an attempt on the life of the subject. ( Jean Baechler)

The human act of self-infl icted, self-intentioned cessation. (Edwin Shneidman)

t a b l e 12-1 Four Defi nitions of Suicide

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Comprehending Suicide 449

Suicidal behavior includes three types of self-destruction: (1) completed suicide, (2) attempted suicide, and (3) suicidal gestures. (Thoughts and plans about suicide are referred to as suicidal ideation. ) The fi rst of these results in death, whereas the second is intended to be self-lethal but does not result

in death. The third category represents attempts with low lethal potential,

such as infl icting superfi cial scratches on the wrist or overdosing on vitamins.

Although suicidal gestures are often “pleas for help” from individuals who

still wish to live, they should not be dismissed lightly. 3

Statistical Issues In the most recent year for which statistics are available, over 38,000 peo-

ple died by suicide in the United States. 4 For the nation as a whole, suicide

ranked tenth among all causes of death. It ranked third among persons fi fteen

to twenty-four years of age and second among those twenty-fi ve to thirty-four

years old. 5 Among those who die by suicide, males outnumber females by about

four to one. In contrast to the male-female ratio for deaths by suicide, about three females attempt suicide for every male who does so. 6 According to a recent study, more than eight million Americans seriously consider suicide each year. 7

Besides the cost in terms of lives lost, suicide has a powerful impact

on those who are left to grieve a death by suicide. Pioneering suicidolo-

gist Edwin Shneidman says that the person who dies by suicide “puts his

psychological skeleton in the survivor’s emotional closet.” 8 It is estimated

that each suicide affects at least six other people. These survivors of suicide

include family members, friends, signifi cant others, and loved ones. Based

on an average of one suicide every eighteen minutes in the United States,

this means that there are at least six new survivors every eighteen minutes as

well. “Those who are left behind in the wake of suicide are left to deal with

You may notice that I have not used the common terminology “committed sui-

cide.” It’s because I believe this phrase incorrectly and unfairly accuses the sui-

cide victim of an act over which they had no control. (If they had control, they

would not have suicided. If they had, in other words, been in their right mind,

they would not have taken their life.) The topic of “rational suicide” or physician-

assisted suicide/death with dignity, as in the case of debilitating terminal illness, is

a whole other topic of its own and outside the scope of these comments. The word

“commit” is frequently paired with negatively judged acts: commit adultery, com-

mit murder, commit a crime, commit a felony. I strongly believe that, because the

suicidal person’s mind is not working properly, there is a moment where suicide is

no longer a choice. . . . If at that moment the person has access to the means to die,

the suicide will happen. If at that moment the person is prevented from suiciding

because he or she does not have the means, the suicide can be prevented. People

refer to suicide as an “easy way out,” but if you think about it, would it be easy for

someone who is thinking clearly to slit their wrist, jump off a bridge, or pull the

trigger of a gun?

Donna Schuurman, Never the Same: Coming to Terms with the Death of a Parent

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450 c h a p t e r 12 Suicide

the guilt and the anger, to sift the good memories from the bad, and to try

to understand an inexplicable act.” 9

The actual number of suicide deaths each year is likely to be much higher

than statistics indicate. There is general agreement that offi cial counts under-

state the number of suicides, perhaps by as much as half. A death is unlikely to

be classifi ed as a suicide unless the coroner or medical examiner suspects suicide

because of the deceased’s history of suicidal tendencies or acts of self-injury, or

because the deceased left a note, or because the circumstances of death clearly

point to suicide. “A suicide classifi cation is therefore neither a matter of elimina-

tion nor a default option. Rather, it is a manner of death that must be positively

demonstrated. This has been called ‘the fi fty-one percent rule of suicide.’” 10

In some cases, an examination of circumstances surrounding an auto-

mobile accident, for example, leads to the conclusion that what seemed an

accident was really a suicide in disguise. In fact, some authorities believe that

if such “autocides” were added to known statistics, suicide would be ranked as

the number-one killer of young people.

When the circumstances of a death are equivocal (meaning that the

causes are uncertain or unclear), and there are questions about whether the

manner of death was suicide or accident, it is likely to be classifi ed as acci-

dental unless a careful investigation proves otherwise. One investigator says,

“When it’s not a simple black or white case but one full of gray values, we never

end up in the suicide range. You owe that to the family and the decedent.” 11

Victim-precipitated homicide also may mask a person’s suicidal intent.

Someone who deliberately provokes others by fl ashing a knife, wielding a

gun, or goading others with threats of violence may be attempting to enlist

the unwitting help of others in causing his or her own death. Individuals

can create violent situations in which they are likely to be killed, thereby

possibly “dying as heroes.” 12 A subcategory of victim-precipitated homicide,

“suicide by cop,” occurs when individuals engage in life-threatening and

criminal actions that force police to shoot and kill them. 13 Researchers say

there are two categories of suicide by cop: (1) the “fl eeing felon,” who tries to

escape and, once cornered, decides he is going out in a “blaze of glory,” and

(2) the emotionally disturbed person who is seeking a way out of mental pain

or some life failure. This distinction is recognized in the advice: It’s one thing

to kill a “bad guy,” and quite another to kill a “sad guy.” 14 Similarly, research

indicates that some individuals murder others and then seek the death pen-

alty as a form of suicide, a situation that has been termed the “murder-suicide

syndrome.” 15 All these types of victim-precipitated deaths are variously classi-

fi ed as homicide, suicide, or undetermined. 16

In summarizing the diffi culties in compiling accurate suicide statistics,

Shneidman says,

Because of religious and bureaucratic prejudices, family sensitivity, differences

in the proceedings of coroner’s hearings and postmortem examinations,

and the shadowy distinctions between suicides and accidents—in short, the

unwillingness to recognize the act for what it is—knowledge of the extent to

which suicide pervades modern society is diminished and distorted. 17

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Comprehending Suicide 451

The Psychological Autopsy Developed in 1961—primarily by Norman Farberow, Edwin Shneidman,

and Robert Litman—the psychological autopsy is an impartial investigation by behavioral scientists to look for the motivational or intentional aspects of

cases of ambiguous death. 18 The fi ndings of a psychological autopsy improve

the accuracy of death classifi cation. Such an autopsy attempts to re-create

the personality and lifestyle of the deceased and the known circumstances

of his or her death. Information gathered from interviews, documents,

and other materials is used to determine the mode of death: natural, acci-

dent, suicide, or homicide. 19 With this information in hand, “The historical

gestalt [pattern] that emerges from the data can clarify the most probable

mode of death.” 20

Of particular importance is the information pieced together from inter-

views with the deceased’s friends and relatives, as well as other members of

the community. This involves learning about current and previous stressors,

psychiatric and medical histories, and the general lifestyle of the deceased,

as well as any communication about suicidal intent. The person’s routine in

the days and hours before death is considered carefully as investigators try

to create a picture of the person’s character, personality, and state of mind.

Based on an assessment of all the data gathered, a judgment is made about

the mode of death (see Table 12-2 ).

An explosion aboard the USS Iowa that killed forty-seven sailors brought increased public attention to the use of psychological autop-

sies. 21 Based on an “equivocal death analysis” conducted by the FBI, the

U.S. Navy attributed the tragedy to alleged suicidal acts by Gunner’s Mate

Clayton Hartwig. Because of questions about the investigation, the House

Armed Services Committee convened a panel of distinguished psycholo-

gists to conduct a peer review of the FBI’s report and the Navy’s subsequent

conclusion. After weighing the evidence, the committee rejected the Navy’s

allegation that Hartwig intentionally caused the explosion; they character-

ized the inquiry as an “investigative failure,” particularly with respect to

1. To help clarify the mode of death: natural, accident, suicide, or homicide (a clas- sifi cation system known by the acronym NASH). Note that mode of death differs from cause of death. The mode of death may be uncertain, although the cause may be clear.

2. To determine why a death occurred at a particular time; in other words, to exam- ine the possible connection between the individual’s psychology or state of mind and the timing of his or her death.

3. To gain data that may prove useful in predicting suicide and assessing the lethal- ity of the suicidal person, thus helping clinicians and others identify trends in suicidal behavior and high-risk groups.

4. To obtain information that can be of therapeutic value to survivors in resolving emotional turmoil and questions that follow upon a loved one’s death by suicide.

t a b l e 12-2 Four Purposes of the Psychological Autopsy

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452 c h a p t e r 12 Suicide

the FBI’s analysis. Later tests indicated that the blast may have been due to

mechanical error. The Navy ultimately recanted its allegations of Hartwig’s

responsibility, and the Chief of Naval Operations issued a formal apology

to Hartwig’s family.

In commenting about the case, the committee’s psychologists cited sev-

eral limitations of reconstructive psychological procedures, including the

FBI’s equivocal death analysis and psychological autopsies (see Table 12-3 ).

They concluded that such psychological reconstruction should not result in

an assertion of “categorical conclusions about the precise mental state or

actions suspected of the actor at the time of his or her demise.” 22 At pres-

ent, the judiciary appears undecided about the admissibility of psychological

autopsies as evidence; some courts admit them into evidence, whereas others

exclude them.

The Hartwig case demonstrates that a lack of scientifi c precision may

result in erroneous conclusions about the data collected through the use of

psychological autopsies. Proponents of such investigative techniques point

out that even medical autopsies are not perfect—yet they are viewed as having the potential to clarify circumstances surrounding death.

Despite its limitations, the psychological autopsy has proved to be a use-

ful tool in assessing risk factors for suicide, especially factors that place young

people at risk. 23 However, recently it has been pointed out that using a psy-

chological autopsy to establish a diagnosis of a mental disorder does not pro-

duce valid results, and researchers say such efforts should be abandoned. 24

Nonetheless, they endorse uses of psychological autopsies that focus on add-

ing to the understanding of suicide, a goal more in line with the original

intent of such tools. As both an investigative approach and a research tool, it

seems clear the psychological autopsy deepens our understanding of suicide

and suicidal behavior.

1. Lack of standardized procedures. Several guidelines for conducting a psychological autopsy have been proposed, but a set of standardized procedures does not exist. Thus, critics question the reliability and validity of psychological autopsies. Pro- ponents, on the other hand, argue that wide latitude is needed to accommodate unique situations.

2. Retrospective nature. Examiners are required to offer observations or opinions about a person’s past mental state.

3. Distorted information. Third-party informants may distort representations of the decedent for a variety of reasons. Everyone who participates in a psychological autopsy has some stake in its outcome. Information from friends or relatives may be biased; public agencies may shape the story to fi t certain preconceived parameters.

4. Lack of availability. The individual of interest may not be available for examina- tion, a fact that makes this the greatest limitation of the psychological autopsy.

5. Too few studies. There are few studies examining the reliability and validity of data obtained by psychological autopsies.

t a b l e 12-3 Limitations of the Psychological Autopsy

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Explanatory Theories of Suicide 453

Explanatory Theories of Suicide The study of suicide has followed mainly two lines of theoretical investiga-

tion: (1) the sociological model, which has its foundation in the work of

nineteenth-century French sociologist Emile Durkheim, and (2) the psycho-

logical model, which is based on the work of Viennese psychoanalyst Sig-

mund Freud. Most scholars pursue an integrated approach to understanding

suicide, one that combines sociological and psychological insights. Moreover,

David Lester points out, “There is some evidence that theories of suicide

proposed by Western scholars may not be applicable to other nations and

cultures.” 25 Thus, he asks, “Which culturally specifi c ethnic variables have

been overlooked that might be important?” Lester says, “More work needs to

be done on taking the ideas about suicide held in nonWestern societies and

exploring whether new and different hypotheses, and even comprehensive

theories of suicide, can be developed from them.” 26 Although the following

discussion can provide a good foundation, there is more to be done toward

fully understanding suicide.

The Social Context of Suicide The sociological model, as its name implies, focuses on the relationship

between the individual and society. People live within networks of social

relationships ranging from the family to society as a whole, and social forces

infl uence the circumstances surrounding suicide. Durkheim theorized that

these social forces are manifested in the degree of integration and regulation

present in a given society. 27

Degree of Social Integration The degree to which a person is part of (integrated into) his or her soci-

ety is important. At one extreme, we fi nd situations in which the individual

feels alienated from the institutions and traditions of his or her society. This

is known as low integration or low belongingness. 28 The person has too few ties with his or her community. Without an adequate sense of social connected-

ness, a person becomes overly dependent upon his or her own resources.

In this type of social environment, the suicides that occur are termed egois- tic. An individual’s mental energies are concentrated on the self to such an extent that social sanctions against suicide are ineffective. People who are

disenfranchised or who live at the fringes of society may have no reason to

hold to life-affi rming values, because they do not experience themselves as

meaningfully related to the community. In Durkheim’s view, when a person

is detached from society, individual personality takes precedence over collec-

tive personality. Egoistic suicide is a type of suicide that springs from exces-

sive individualism.

Conversely, when a person has a strong degree of social connectedness

and integration, he or she may identify with its values or causes to such an

extent that the sense of his or her own personal identity is diminished. Under

certain circumstances, the values or customs of the group may demand

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454 c h a p t e r 12 Suicide

suicide. This is the case in what Durkheim called altruistic or institutional sui- cide, which has been defi ned as “the self-destruction demanded by a society . . . as a price for being a member of that society.” 29

In feudal Japan, for example, when samurai warriors sacrifi ced their

lives to maintain the honor or reputation of their lords, their society viewed

such suicide as heroic. In certain circumstances, ritual disembowelment,

called seppuku or hara-kiri, was culturally accepted and expected, and it was accomplished by a prescribed etiquette. 30 When a warrior experienced dis-

grace in battle, seppuku was a way to regain honor. It demonstrated devotion

to a superior, and the samurai might be expected to exhibit his devotion

in this manner upon the death of his lord. At other times, seppuku could

be an honorable way for a samurai to make a public statement of disagree-

ment with a corrupt superior. Such acts were widely revered by Japanese

people when they were based on authentic moral intentions. Suicide as pro-

test also occurred during the Vietnam War, when Buddhist monks died by

self-immolation to protest their country’s governmental policies. According

to Durkheim, highly integrated societies naturally encourage altruistic and

fatalistic suicide. 31

Flames engulf the body of Buddhist monk Thich Quang Duc, whose self-immolation in downtown Saigon on June 11, 1963, was intended as a protest against persecution of Buddhists by the government of South Vietnam.

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Explanatory Theories of Suicide 455

Similarly, historically, certain castes in India were expected to practice

satī (also called suttee ), which called for a “faithful wife” to die on the fi re as her husband’s body was burned on the cremation pyre. Such self-immolation,

or “following into death,” was condoned by religious and cultural beliefs. 32

Reluctance to enact such ritual suicide could meet with social disapproval.

Indeed, a reluctant widow might be “helped” onto the burning pyre. To these

examples of seppuku and satī could be added the deaths of kamikaze pilots

in Japan’s air attack corps during World War II and the example of the dedi-

cated captain who goes down with the ship. In discussing altruistic suicide,

Durkheim introduced the concept of heroic suicide in referring to deaths in combat, as in the case of Medal of Honor recipients who voluntarily sacrifi ced

their own lives to save the lives of others. 33

Mass suicide, defi ned as the simultaneous suicide of the members of a social group, also occurs within a highly integrated social context.

Researchers have denoted two types of mass suicide: (1) hetero-induced, which typically occurs in defeated and colonized populations, and (2)

self-induced, in which the motivation is related to a distorted evaluation of reality. An example of the fi rst type occurred in 219 BCE, when the Car-

thaginian commander Hannibal sacked the commune of Sagunto. Its lead-

ing citizens, preferring death to capture, died together by suicide. This is

a type of suicide enacted by soldiers who realize they are losing the battle.

The second type has become familiar in recent decades, when the “mystic

delirium” within a sect has led to the self-destruction of the group as an act

of self-assertiveness. 34

For example, on November 20, 1978, at a previously little-noticed jungle

clearing in Jonestown, Guyana, more than nine hundred people died in what

is considered the largest mass suicide in history. 35 Family members died in

one another’s arms as the Reverend Jim Jones, in hypnotic tones from his

throne above the crowd, instructed the followers of his Peoples Temple com-

munity to drink cyanide-laced fruit punch. In 1993, in Waco, Texas, seventy-

fi ve followers of David Koresh’s Branch Davidians died among the fl ames

after setting fi re to their camp. More recently, the desire to leave this planet

for a better existence in a “parallel dimension” led to the mass suicide in 1997

of thirty-nine members of the Heaven’s Gate cult in a San Diego suburb. 36

Degree of Social Regulation In Durkheim’s model, insuffi cient social regulation creates the condi-

tions for anomic suicides. In the typical example, the relationship between an individual and society is suddenly shattered or disrupted. Such social

estrangement is characterized by the term anomie (from the Greek anomia, meaning “lawlessness”). The classic example of this situation occurs when

societies undergo rapid social change, and people lose their moorings to tra-

ditional values and lifeways. Suicide among youth worldwide is partly attrib-

uted to cultural changes whereby individualism and autonomy tend to loosen

bonds between individuals and society. Anomie (lack of regulation) and ego-

ism (lack of integration) reinforce each other.

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456 c h a p t e r 12 Suicide

Sudden trauma or catastrophe can also weaken the ties between an indi-

vidual and society. The loss of a job, the amputation of a limb, the death of a

close friend or family member—any of these losses can be an anomic event.

Any disruptive change—whether positive or negative—can precipitate a state

of anomie.

At the other extreme of regulation, we fi nd societies characterized by

excessive social constraints. Lack of freedom and absence of choice can gen-

erate a sense of fatalism, a feeling that there is nowhere to turn and that

nothing good can be achieved. This produces what Durkheim termed fatal- istic suicide. Suicide in jail is due partly to the rigid regulation found in such environments. (When three Guantanamo Bay detainees died by hanging

themselves with fabricated nooses made from clothes and bedsheets, another

detainee explained what led to their deaths by saying, “I would rather die

than live here forever without rights.”) 37

Viewed from a social perspective, suicide is caused by a disturbance

in the ties between an individual and society. An imbalance in the degree

of social regulation or social integration, or both, heightens the potential

for suicide. Thus, according to the sociological explanation, each form of

suicide—egoistic, altruistic, anomic, fatalistic—is related to a particular kind

of interplay between society and the individual.

Psychological Insights About Suicide Drawing on theories proposed by Sigmund Freud, the psychological

model of suicide focuses attention on the mental and emotional processes,

both conscious and unconscious, that occur within the mind of an individ-

ual. It assumes that a person’s behavior is determined by both past experi-

ence and current reality. Among the key insights from psychological studies

of suicide are the following:

1. The acute suicidal crisis is of relatively brief duration; that is, it lasts hours or days rather than weeks or months—though it may recur. A person is at the

peak of self-destructiveness for a short time and gets help, cools off, or dies.

2. The suicidal person is likely to be ambivalent about ending his or her life. A person on the brink of suicide both wants to die and doesn’t want to

die. While plans for self-destruction are being made, the person also

entertains fantasies of rescue or intervention.

3. Most suicidal events are dyadic events—that is, two-person events. In some way, they involve both a suicidal person and a signifi cant other.

Suicide Note Written by a Married Man, Age 45

My darling,

May her guts rot in hell—I loved her so much.

Henry

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Explanatory Theories of Suicide 457

In the psychological view, suicide involves strong unconscious hostility.

Under conditions of enormous stress, the intrapsychic pressures impelling

a person toward self-destruction increase to the point that they overwhelm

the defense mechanisms of the ego, or self. This, in turn, causes a regression

to primitive ego states, which involve powerful forces of aggression. Whereas murder is aggression turned upon another, suicide is aggression turned upon

oneself. In this sense, suicide may be viewed as murder in the 180th degree.

In the German language, suicide is murder of the self, Selbstmord. Even with aggressive forces mobilized, however, the urge toward self-

preservation works against the self’s acquiescence in its own death. Thus,

another psychological process comes into play: ambivalence. Analysis of sui- cidal behavior usually reveals the presence of confl icting forces that compete

for the greater share of the person’s mental energies. Suicidal persons tend

to be indecisive. They may even count on being rescued. Shneidman says the

prototypical suicidal person wants “to cut his throat and to cry for help at the

same time.” 38

Even when a person appears to be intent on suicide, the natural urge

toward self-preservation works against the self’s acceptance of its own death.

At issue is the will to live versus the will to die. “Most people who commit acts

of self-damage with more or less conscious self-destructive intent do not want

either to live or to die, but to do both at the same time.” 39

The balance between these opposing polarities may be delicate, with an

otherwise minor incident tipping the scales one way or the other. Although

one of these forces is eventually stronger than the other, the weaker one never-

theless affects the person’s behavior. Suicidal acts are often examples of risk-

taking behavior or gambles. The outcome of the confl ict between the self-

destructive and life-preserving impulses depends on a variety of factors, some

of which are outside the individual’s control.

Toward an Integrated Understanding of Suicide In an illuminating study of the death of Socrates, Sam Silverman reviewed

the factors that may have entered into his decision to drink the hemlock (a

poisonous herb) given to him. Among these factors were his awareness of

aging, his declining relationships with others, his marriage and family life,

and the political context of the times and his place in it. “He must have been

tired, disillusioned, and generally depressed by how things had gone and by

his age,” Silverman says. 40 Furthermore, his support systems were crumbling.

Because he believed that suicide was not permitted, however, it wasn’t an

option. Silverman suggests that Socrates chose, in essence, “suicide by cop,”

letting a jury of his Athenian peers decide his fate.

Because suicidal behavior is multidimensional and multifaceted, the

social and psychological explanations of suicide interact in an integrated

fashion. After devoting a lifetime to studying suicide, Edwin Shneidman dis-

tilled his learning into fi ve words: Suicide is caused by psychache. 41 Shneidman says: “Psychache is at the dark heart of suicide; no psychache, no suicide.” 42

However, Shneidman points out that over 99 percent of individuals who

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458 c h a p t e r 12 Suicide

suffer from even severe psychache do not kill themselves. He observes, “Much

psychache without suicide; no suicide without psychache.” 43

The term “psychache” refers to the unbearable mental pain that is caused

by the frustration of a person’s most important needs, which are unique to

each individual. Shneidman believes that most suicide cases tend to exhibit

themselves in one of four clusters of frustrated psychological needs: 44

1. Thwarted love, acceptance, or belonging

2. Fractured control, helplessness, and frustration

3. Assaulted self-image and avoidance of shame, defeat, humiliation, and

disgrace

4. Ruptured key relationships and attendant grief and bereftness

Suicide has been called “a very bad decision on a very bad day.” It is the

outcome of a person’s desire to reduce intolerable pain. An individual who is

suicidal is likely to be in a state of isolated desperation, a dark corner where it

seems there is no hope of relief. A common theme among the various paths

to suicide is that it is seen as the ultimate form of gaining control over insur-

mountable diffi culties in life.

The sequence leading to suicide often begins with interactions between

biochemical imbalances in the brain, personality factors, and life stress.

Most suicides are the outcome of a disease in the brain, an illness such as

depression, anxiety, schizophrenia, bipolar (manic-depressive) disorder, or

some other mood disorder. Clinical depression, a state of intense sadness and

Richard Cory Whenever Richard Cory went down town,

We people on the pavement looked at him:

He was a gentleman from sole to crown,

Clean favored, and imperially slim.

And he was always quietly arrayed,

And he was always human when he talked;

But still he fl uttered pulses when he said,

“Good-morning,” and he glittered when he walked.

And he was rich—yes, richer than a king—

And admirably schooled in every grace:

In fi ne, we thought that he was everything

To make us wish that we were in his place.

So on we worked, and waited for the light,

And went without the meat, and cursed the bread;

And Richard Cory, one calm summer night,

Went home and put a bullet through his head.

Edwin Arlington Robinson

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Some Types of Suicide 459

self-reproach, is a major risk factor. A key aspect of depression is the person’s

sense of hopelessness. Suicide risk is also higher with some personality disor- ders, such as borderline and antisocial personality, especially when combined

with substance abuse. (Alcohol or substance abuse is a contributing cause in

many suicides.) Whereas mental illness is an ongoing risk factor for suicide, the specifi c timing of suicidal acts tends to be related to stressful life events. Nonetheless, virtually everyone who dies by suicide experiences one or more

mental disorders at the time of death. 45

In studies of attempted and completed suicides, there appears to be a

neurobiological determinant related to the brain’s reduced ability to make

and use serotonin, a key neurotransmitter. Serotonin is lower in suicide

attempters, and postmortem studies of suicide victims reveal decreased sero-

tonin activity in the prefrontal cortex. 46 Low levels of serotonin (5-HT) or

its neurotransmitter metabolite (5-HIAA) may be correlated with suicidal

behavior. Serotonin levels appear to be related to a calming infl uence on the

mind and, when levels are low, to an increased risk of suicide. As scientists

learn more about the role of biological markers like serotonin, it may be pos-

sible to reduce vulnerability to suicide by identifying individuals at risk and

offering appropriate therapy.

Many people are not aware of the role of brain disease in suicide. As a

result, they tend to treat suicide as a failure of personal responsibility and as a

matter of shame. This mistaken attitude can severely limit an understanding

of suicide. In fact, our recognition of the strong connection between diseases

of the brain and suicide challenges the conventional notion that suicide is

chosen by a person out of his or her free and rational choice.

Some Types of Suicide Various classifi cation schemes have been applied to suicide to comprehend its

cultural and personal meanings (see Table 12-4 ). To provide a more complete

picture of suicide and other self-destructive behaviors, it is worthwhile to look

more closely at a few typical categories of suicide. Notice that an instance of

suicide may include elements from more than one category.

Suicide as Escape Suicide may be a means to put an end to intense physical pain or men-

tal anguish. In such cases, it is called surcease suicide, an escape “forced by life’s becoming literally unbearable.” 47 A person with a severely debilitating

or terminal illness may view suicide as a way to gain release from burden-

some suffering. Ending one’s life in such a situation is sometimes termed

rational suicide because the reasoning used—that death will bring release from pain—conforms to normal logic. Physician-assisted death (discussed in

Chapter 6) can be considered an example of this type of suicide.

In other instances, a desire to escape through suicide results from

destructive logic. When an individual’s self-concept or sense of identity is

confused, and when this confusion is coupled with problems in relating to

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460 c h a p t e r 12 Suicide

others, it can result in the person’s self-perception as a failure. In this case,

suicide may be termed referred, bringing to mind the analogy of a physical pain that is experienced at some distance from its source. An infl ammation

of the liver may be experienced as pain in the shoulder. Just as this physical

phenomenon is characterized as referred pain, so the root causes of referred

suicide are likewise only indirectly related to the end result—namely, suicide.

The intention to end one’s life is not based on a dispassionate or rational

assessment of the situation but, instead, results from an overwhelming sense

of anguish and confusion about one’s options.

In China, suicide has become the leading cause of death among young

adults, a quarter million of whom die by suicide each year, while another

three million make suicide attempts. 48 Many are college students who leave

notes expressing regret at failing to live up to their parents’ expectations.

These expectations may be related to something outside the person (“If I

can’t be a good enough daughter to please my parents, I give up!”) or to feel-

ings of frustration (“Everybody thinks I’m doing okay, but I feel rotten”). Not

performing up to expectations or role defi nitions can provoke a crisis of self-

concept that leads to a desire to escape the unsatisfactory situation.

Desire to escape may arise from loss of meaning in one’s life. Despite

signifi cant accomplishments, a person may feel, “Okay, now what?” Accumu-

lating successes one after another may seem a Sisyphean effort, a continual

struggle for achievement without a corresponding sense of accomplishment.

Conversely, success may be accompanied by feelings of dissatisfaction—“If

Some Cultural Meanings of Suicide Suicide is sinful: A crime against nature, a revolt against the preordained order of

the universe.

Suicide is criminal: It violates the ties that exist, the social contract between persons

in a society.

Suicide is weakness or madness: It refl ects limitations or deviancy (“He must have

been crazy” or “He couldn’t take it”).

Suicide is the Great Death, as in seppuku, suttee, and other culturally approved forms of ritual suicide.

Suicide is the rational alternative: The outcome of a “balance-sheet” approach that

sizes up the situation and determines the best option.

Some Individual Meanings of Suicide Suicide is reunion with a lost loved one: A way to “ join the deceased.”

Suicide is rest and refuge: A way out of a burdensome and depressing situation.

Suicide is getting back: A way of expressing resentment and revenge at being

rejected or hurt.

Suicide is the penalty for failure: A response to disappointment and frustration at

not meeting one’s own expectations or those of others.

Suicide is a mistake: The attempt was made as a cry for help and was not intended to

be fatal, but there was no rescue or intervention, and the outcome was death.

t a b l e 12-4 Meanings of Suicide

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Some Types of Suicide 461

Depression, hopelessness, despair, and psychache are depicted in this lithograph, Nachden- kende Frau, by Käthe Kollwitz. Such intense sadness is caused by frustration of a person’s most important needs and is a major risk factor for suicide.

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this is success, it’s not worth the effort.” The causal chain begins with events

that fall short of standards and expectations. 49 The individual seeks to escape

from a negative sense of self. Drastic measures seem acceptable, and suicide

becomes the ultimate step in the effort to fi nd release.

Cry for Help Considered as a cry for help, suicide aims to force a change. The person no

longer wishes to continue living life as it is. The goal is not to die but to solve

some problem. Suicide, or the threat of suicide, is perceived, at least tempo-

rarily, as a means of eliminating the problem. Suicidal behavior is, in effect,

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462 c h a p t e r 12 Suicide

a message that “something has to change in my life; I can’t go on living this

way.” In distinguishing between a suicide threat and a suicide attempt, some

defi nitions may be appropriate:

A suicide threat is “any interpersonal action, verbal or non-verbal, without a direct self-injurious component, that a reasonable person would interpret as

communicating or suggesting that suicidal behavior might occur in the near

future.” A suicide attempt is “a self-infl icted, potentially injurious behavior with a non-fatal outcome for which there is evidence (either explicit or implicit) of

intent to die.” 50

Some experts express the view that self-harm, such as cutting one’s wrist

or taking a drug overdose, can be considered an act of “self-preservation” or

even “self-assertion.” 51 From this perspective, self-injury among young peo-

ple could be viewed as a coping mechanism to deal with emotional distress

and validated as representing a young person coping the best way he or she

can. Looked at in this way, efforts can be taken to help the young person

move away from self-harm toward safer and healthier methods of coping.

The intent may be to express frustration or gain attention, but the danger

of a fatal outcome is not acknowledged. Many suicide attempts represent a

The Suicide When the suicide moved in across the street,

People knew her as the woman with blonde hair.

She hadn’t decided on her method yet.

A gun? Some pills? The blood released from its knot

of life? At fi rst, there was nothing to fear

When the suicide moved in across the street.

She couldn’t sleep at all, she said. At night

She wove her drunken mind around a star.

She hadn’t decided on her method yet.

Later, they read the signs: the way each thought

Stumbled on the grass, the telling whisper.

When the suicide moved in across the street,

She tried to tell them how immediate

Death was, how soft, its under-wings like Mother.

She hadn’t decided on her method yet.

They didn’t hear. She asked for tea, the gate

Closing in her eyes. She asked for sugar.

When the suicide moved in across the street,

She hadn’t decided on her method yet.

Kim Bridgeford

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Some Types of Suicide 463

kind of communication that says, in effect, “I am deadly serious; you’d better

pay attention!” This message may be directed inwardly to oneself or meant

for others.

There may be two distinct populations of individuals who engage in

suicidal behavior: (1) attempters (who tend to make repeated but not lethal attempts) and (2) completers (whose fi rst attempt typically results in death). Attempters and completers may have quite different aims with regard to

their suicidal acts. 52 “Intention in the behavior may or may not be to die, or

may or may not be to infl ict injury or pain on oneself.” 53 Some suicidologists

believe that attempted suicide should be viewed as the norm, whereas com-

pleted suicide should be seen as a failed behavior in which a person inap-

propriately died.

A cry for help is associated with individuals who threaten or attempt sui-

cide, as distinct from those who actually kill themselves. Often, in the fi rst

group the lethality of the attempt is low. (Lethality refers to capability of causing death). It appears the aim of the behavior is to communicate to oth-

ers how desperate or unhappy the person feels. When low-lethality suicidal

behavior is met with defensive hostility or attempts to minimize its serious-

ness, however, the risk of suicide may increase, along with the possibility that

a future attempt will be lethal. In responding to the cry for help, it is crucial

to recognize that a problem exists and take steps toward expanding commu-

nication and proposing remedies. Whatever the intention, suicidal behavior

can be deadly. Psychological autopsies indicate that some people who have

died by suicide didn’t intend their actions to result in death, but help didn’t

arrive in time.

Attempted suicides outnumber completed suicides by a signifi cant mar-

gin. A standard estimate is that there are twenty-fi ve attempts for every death

by suicide. There are more suicide attempts among females than among

males, whereas males die by suicide more often than do females. These gen-

der differences may be explained partly by the methods chosen; males tend

to use more lethal methods, such as guns, whereas females tend to take pills

or slash wrists. (Unfortunately, this gap may be narrowing, as females appear

to be adopting increasingly lethal methods, such as fi rearms.) Alcohol abuse,

a risk factor for suicide, is also more common among males. Furthermore,

it may be that males consider a “failed” suicide attempt to be cowardly or

unmasculine and therefore make a special effort to be “successful.” Besides

this “suicidal success syndrome,” males are less likely than females to report

suicidal thoughts or seek help. By trying to hide their feelings of depression

or hopelessness, males are less likely to seek out suicide prevention or crisis

intervention programs.

People who survive a suicide attempt may view their continued existence

as a second chance or “bonus life.” If this opportunity is used well, the person

may arrive at a more positive self-identity and fi nd ways to get beyond the

pain that led to the attempted suicide. By altering the distressing situation or

one’s attitude toward it, a cry for help may lead to constructive change and

healing.

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464 c h a p t e r 12 Suicide

Subintentioned and Chronic Suicide As defi ned by Edwin Shneidman, a subintentioned death is “one in which

the person plays some partial, covert, subliminal, or unconscious role in has-

tening his own demise.” 54 Some fatalities reported as accidents result from

the victim’s taking unnecessary and unwise risks. Such behavior might be

called careless or imprudent. Probing deeper into causes, however, reveals

that accidents are sometimes the end result of a self-destructive pattern of

behavior. Similarly, homicide investigations sometimes turn up evidence of

subintentional factors that led a victim to behave in ways that provoked his or

her death at another’s hands.

Besides subintentioned death, Shneidman delineates two other pat-

terns of death-related behaviors: intentioned and unintentioned. Table 12-5 presents an outline of these three patterns. Notice that, within each of

these categories, a person might exhibit a variety of attitudes and behav-

iors regarding death. As you review this table, ask yourself: Where do I

stand on this list? What does that tell me about my own regard for life

and death?

Chronic suicide, a term coined by Karl Menninger, refers to individuals who destroy themselves by means of drugs, alcohol, smoking, reckless living,

and the like. Although individuals who shorten their lives by chronic suicide

may consciously fi nd the idea of suicide repugnant or unacceptable, an analy-

sis of their lifestyles typically reveals the presence of a “death wish.”

Risk Factors Infl uencing Suicide Another way to increase our understanding of suicide is to examine risk fac-

tors that infl uence suicide and suicidal behaviors. Besides the neurobiologi-

cal and genetic factors discussed earlier in this chapter, here we focus on

risk factors related to culture, personality, and the individual situation. Typi-

cally, various risk factors overlap and are mutually infl uential in a particular

instance of suicidal behavior.

Suicide Note Written by a Divorced Woman, Age 61 You cops will want to know why I did it, well just let us say that I lived 61 years too

many.

People have always put obstacles in my way. One of the great ones is leaving

this world when you want to and have nothing to live for.

I am not insane. My mind was never more clear. It has been a long day. The

motor got so hot it would not run so I just had to sit here and wait. The breaks were

against me to the very last.

The sun is leaving the hill now so hope nothing else happens.

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Risk Factors Infl uencing Suicide 465

Intentioned Death: Death resulting from the suicide’s direct, conscious behavior to bring it about. A variety of attitudes or motives may be operative:

The death seeker wishes to end consciousness and commits the suicidal act in such a way that rescue is unlikely.

The death initiator expects to die in the near future and wants to choose the time and circumstances of death.

The death ignorer believes that death ends only physical existence and that the per- son continues to exist in another manner.

The death darer gambles with death or, as Shneidman says, “bets his life on a rela- tively low objective probability that he will survive” (such as by playing Russian

roulette).

Subintentioned Death: Death resulting from a person’s patterns of management or style of living, although death was not the conscious, direct aim of the person’s

actions:

The death chancer, although in many ways like the death darer, may want higher odds of survival.

The death hastener may expedite his or her death by substance abuse (drugs, alcohol, and the like) or by failing to safeguard well-being (for example, by inadequate

nutrition or precautions against disease or by disregard of available treatments).

The death facilitator offers little resistance to death, making it easy for death to occur, as in the deaths of patients whose energies, or “will to live,” are low because of

their illness.

The death capitulator is one who, usually out of a great fear of death, plays a subin- tentional role in his or her own death, as may a person upon whom a so-called

voodoo death has been put, or as may a person who believes that someone

admitted to a hospital is bound to die.

The death experimenter does not consciously wish to die but lives on the brink, usually in a “befogged state of consciousness” that may be related to taking drugs in

such ways that he or she may become comatose or even die with little concern.

Unintentioned Death: Death in which the decedent plays no signifi cant causative role. However, various attitudes toward death may shape the experience of dying:

The death welcomer, though not hastening death, looks forward to it (as might an aged person who feels unable to manage adequately or satisfactorily).

The death accepter is resigned to his or her fate; the style of acceptance may be pas- sive, philosophical, resigned, heroic, realistic, or mature.

The death postponer hopes to put death off for as long as possible. The death disdainer feels, in Shneidman’s words, “above any involvement in the stop-

ping of the vital processes.”

The death fearer is fearful of and possibly phobic about anything related to death; death is something to be fought and hated.

The death feigner pretends to be in mortal danger or pretends to perform a suicidal act without being in actual danger, possibly in an attempt to gain attention or to

manipulate others.

t a b l e 12-5 Patterns of Death-Related Behavior and Attitudes

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466 c h a p t e r 12 Suicide

Culture Cultural messages about suicide acceptability can infl uence the kinds of

behavior engaged in by members of a social group. For example, a society

or group may believe that suicide to end physical suffering from terminal

disease is more acceptable than suicide to escape mental pain or other life

problems. It has been pointed out that suicide has different meanings for dif-

ferent cultures.

Cultural disruption and stress appear to play a part in suicide among

Native Americans. Forced onto reservations, their cultures undermined,

native peoples of North America have undergone severe dislocations. Con-

fl icts between their traditional ways and the ways of contemporary white

society can lead to feelings of powerlessness and anxiety. An added burden

is experienced by Native Americans who live in large cities, where support

systems, family ties, and traditional customs are lacking. These stresses,

sometimes combined with such dysfunctional behaviors as alcohol and drug

abuse, can heighten suicide risk.

Kathleen Erwin has examined how social factors may infl uence gay and

lesbian suicide. 55 Explanations for the elevated rate of suicide among homo-

sexual populations have been sought mostly in theories centering on indi-

vidual psychology. More recently, however, the antecedents of gay and lesbian

suicide have been located in a sociocultural model that highlights the role

of social forces that have been intolerant and oppressive toward homosexu-

als. The earlier focus on individual psychology is being balanced by a recog-

nition that social factors are important, perhaps decisive, in suicide among

homosexuals.

Within African American communities, many young people consider sui-

cide a weak, cowardly way out of their problems, a view that is also held by

many of their elders. The rate of suicide among African Americans is lower

than the rate among white Americans, a phenomenon due at least partly

to a common perception among African Americans that suicide is a “white

thing.” Kevin Early and Ronald Akers report that religion and family play

important roles in “buffering” social forces that might otherwise promote

suicide among African Americans. Early and Akers found that suicide is typi-

cally viewed as “inherently contradictory to the black experience and a com-

plete denial of black identity and culture.” 56

The acceptability of violence as a solution to problems is another cultural

factor that affects suicide risk. The availability of lethal weapons as well as

the prevalence of violence in the media contribute to a sense that violence

is an acceptable alternative when the going gets rough. Easy access to guns

is an important factor in suicide among children and young adults, who are

increasingly using guns to end their lives instead of methods that are more

likely to fail. The apparent acceptance of violence in our lives can change

posturing into deadly deeds.

In considering cultural messages, the idea that suicide is contagious has

a long history. Following publication of Johann Wolfgang von Goethe’s The

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Risk Factors Infl uencing Suicide 467

Sorrows of Young Werther in 1774, an epidemic of suicide among young peo- ple was thought to be stimulated by the book. The infl uence of suggestion

on suicidal behavior has been termed the “Werther effect.” The question of

whether such a “contagious” or imitative effect actually exists remains contro-

versial. (Suicide “clusters” are discussed later in this chapter.) What is clear is

the fact that the social environment is a signifi cant infl uence on suicide and

suicidal behaviors.

Cultural factors in suicide are highlighted in what Brian Barry calls “the

balance between pro-life and pro-death forces operating at any given time”

(see Table 12-6 ). 57 In Barry’s view, people in modern societies have accepted

two fundamental assumptions about life that no previous generation has

embraced so thoroughly: fi rst, the belief that we deserve signifi cant fulfi ll-

ment in our jobs, marriages, and overall lives; and second, the belief that,

rather than accepting unalterable circumstances, we must live and die on

our own terms. In other words, not only do we aspire to a good life, but we

have convinced ourselves that we are entitled to it. If this sense of entitlement

is not realized, we may feel it’s appropriate to protest by removing ourselves

from an intolerable situation, even when the outcome is death.

Suicide bombings, too, refl ect an understanding that the cultural

collective—religion, sect, nation—is more important than the individual,

leading to the terrorist’s belief that he or she is engaged in a worthy struggle

that makes suicidal sacrifi ce not only desirable but imperative (this topic is

discussed in Chapter 13).

Personality Some people seem to live with a basic optimism; others, with a basic pessi-

mism. This personality difference can have an impact on the onset of suicidal

thoughts. Fear or anxiety about death may also infl uence suicidal behavior.

A higher degree of anxiety may inhibit suicidal behavior, whereas perceiving

death as an attractive prospect may encourage it. Thus, the meanings attrib-

uted to death may infl uence the way individuals evaluate the possibility of

suicide. Personality factors that contribute to suicidal thoughts and behaviors

include low self-esteem, diffi culties with intimate relationships, hopelessness,

lack of coping skills, feelings of stagnation, and despair.

Belief that problems can promote

growth

Belief that problems are intolerable

Perceived ability to solve life problems Perception that life problems are intrac-

table or unyielding

Willingness to struggle and suffer if

necessary

Sense of entitlement to a rewarding life

A healthy fear of death and its

aftermath

A philosophical stance that sees suicide as a

means of obtaining relief

t a b l e 12-6 Pro-Life Versus Pro-Death Forces

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468 c h a p t e r 12 Suicide

An individual’s fascination with the “mystique” of death, especially self-

willed death, can increase suicide risk. Some suicides appear to be related

to a “poetic” or “romantic” attraction to death. Following the example of

Thomas Chatterton, who killed himself in 1770 at the age of seventeen, the

Romantics thought of death as “the great inspirer” and “the great consoler.”

In other words, death is a lover to be courted. The poet Sylvia Plath wrote,

“I will marry dark death, the thief of the daytime.” 58 Do the suicides of such

writers as Ernest Hemingway, Anne Sexton, and Plath herself, and, more

recently, the suicide of musician Kurt Cobain, refl ect a desire to embrace

the mystery of death? Or do they result from commonplace human experi-

ences? Investigated deeply, failure to fi nd meaning in life and relationship

problems are common threads. As someone said, “The death of love evokes

the love of death.”

The Individual Situation The intersection of culture and personality creates the unique life situ-

ation experienced by a particular person. Every person is subject to a con-

stellation of environmental factors that involve varying degrees of suicide

risk. These include the social forces existing within society as a whole, as well

Suicide Note Written by a Married Man, Age 74

What is a few short years to live in hell. That is all I get around here.

No more I will pay the bills.

No more I will drive the car.

No more I will wash, iron & mend any clothes.

No more I will have to eat the leftover articles that was cooked the day before.

This is no way to live.

Either is it any way to die.

Her grub I can not eat.

At night I can not sleep.

I married the wrong nag-nag-nag and I lost my life.

W.S.

To the undertaker

We have got plenty money to give me a decent burial. Don’t let my wife kid you

by saying she has not got any money.

Give this note to the cops.

Give me liberty or give me death.

W.S.

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Risk Factors Infl uencing Suicide 469

as the particular characteristics associated with an individual’s family, eco-

nomic situation, and so on.

Stressful life events are associated with suicidal behaviors. For example,

individuals who have been bereaved as a result of suicide may be vulnerable

to increased risk of suicide themselves. In crisis suicide, the usual example is that of an adolescent who experiences traumatic change in his or her life,

such as loss of a loved one or threatened loss of status in school.

With the wars in Iraq and Afghanistan, suicide rates in the military have

risen rapidly, surpassing rates for society at large. In 2012, there were more

deaths in the military from suicide than from combat. 59 More troubling, the

military may be undercounting the problem because of the way it calculates

the suicide rate. There is an increase in the number of military family mem-

bers killing themselves as well. Senior offi cers have convened teleconferences

to discuss causes and what needs to be done to help reduce these suicides. 60

Besides military personnel simply “falling through the cracks,” other factors

noted are working long, solitary hours; errors in mental health screening;

health workers failing to recognize signs of distress; outdated assessment

questionnaires; and even high-energy drinks taken in combination with

drugs soldiers take for combat stress (one such drink has 100 milligrams of

caffeine per can, 25 percent more than Red Bull and about three times as

much as a can of Diet Coke). Numerous reports have been commissioned

and many dollars spent on research and prevention programs, yet experts

concede they are not much closer to understanding the root causes of why

military suicide is rising so fast.

An emerging consensus among researchers is that, just as among civil-

ians, a dauntingly complex web of factors usually underlies military suicide:

mental illness, sexual or physical abuse, addictions, failed relationships,

fi nancial struggles. A recent report found that half of the troops who killed

themselves had experienced the failure of an intimate relationship and about

a quarter had received diagnoses of substance abuse.

An Institute of Medicine study reported that being deployed to a war

zone can result in numerous adverse outcomes, and suicidal ideation, sui-

cide attempts, and suicide are increasingly associated with modern mili-

tary service. 61 The report noted that the relative risk of suicide is higher

in individuals deployed to combat zones than in those never deployed. It

said, “Some risk factors might be mitigated or prevented, but others, such

as deployment and combat exposure, are diffi cult to prevent in a military

population.” 62

Deployment and exposure to combat can act as catalysts that worsen

existing problems in a service member’s life, like drug abuse, or cause new

ones, like posttraumatic stress disorder or traumatic brain injuries, which

may contribute to suicidal behavior. Yet, some researchers contend, deploy-

ment and combat by themselves cannot explain the spiking suicide rates.

Some reports indicate that, in recent years, about half of service members

who killed themselves had never deployed to Iraq or Afghanistan, and more

than 80 percent had never been in combat.

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470 c h a p t e r 12 Suicide

This has caused some commentators to point out that the United States

has been engaged in wars for more than a decade; and, it is argued, some of

them are waged only to increase global dominance. The traditional ideals of

duty, honor, country may not be as applicable to current military confl icts as they once were. In his farewell address to cadets at West Point in 1962, Gen-

eral Douglas MacArthur said:

Those three hallowed words reverently dictate what you ought to be, what you

can be, what you will be. . . . The code which those words perpetuate embraces

the highest moral laws and will stand the test of any ethics or philosophies ever

promulgated for the uplift of mankind. Its requirements are for the things that

are right, and its restraints are from the things that are wrong. 63

Do these words, which speak of “morals” and “ethics,” and the “uplift”

of humankind, still provide a basis for the motives and consequence of con-

temporary wars? Could it be that one or more of Durkheim’s explanations of

suicide—anomie or fatalism perhaps—suggest that a lessening of traditional

values of honor and a feeling that there is nowhere to turn and that nothing

good can be achieved are at least partly responsible for suicides among the

military and veterans, and their families?

Recently, in another example of perhaps diminished expectations and

purpose, the suicide rate among the middle-aged in the United States has

shown a dramatic spike. The highest increases have been among men in their

fi fties and women in their early sixties. Although there are so far no large-

scale studies to explain the reasons for this increase in “boomer” suicides

(referring to the baby boomer generation now passing through those ages),

some observers point out that a reluctance to accept the realities of aging

may be among the causes. “To those growing up in the 50s and 60s, America

seemed to promise a limitless array of possibilities,” as well as the freedom

to “embrace new ways of living.” 64 Now, this illusion of virtually unlimited

choice is being shattered by the recognition that the expectation of “leading

glorious lives didn’t come to fruition.” This uptick in suicide rates among

boomers, who are at ages when rates have historically been stable (for men)

or beginning to decline (for women), may be due to social or historical

events, the so-called period effect. 65 With individuals ending their lives at their supposed peak, the question is being asked: What’s gotten so rotten in the

modern world? Moreover, in mainstream society, we don’t venerate or honor

our elders as some cultures do. All these factors may be part of the explana-

tion for a rising suicide rate among the late middle-aged.

Physicians are another group in which suicidal risk is a matter of con-

cern. On average, the United States loses the equivalent of an entire medi-

cal school class to suicide each year (as many as four hundred physicians). 66

Depression is a leading risk factor, coupled with knowledge of and access to

lethal means of suicide. The report noted that, although female physicians

attempt suicide far less often than their counterparts in the general popu-

lation, their completion rates equal those of male physicians and, thus, far

exceed those of the general population.

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Life-Span Perspectives on Suicide 471

The infl uence of peers also affects an individual’s suicide risk, especially

among adolescents and young adults. A study of suicide among young Micro-

nesian males found an “epidemic-like” increase during a twenty-year period. 67

This period was marked by rapid sociocultural transformation, as traditional

styles of living gave way to a capitalist economy and modern forms of educa-

tion, employment, health services, and technology. Investigators found links

among the suicides, with several occurring among a small circle of friends

over several months. There were also cases of self-destructive behavior in

reaction to the suicide of a friend or relative, as well as suicide pacts between

two or more people. Taken together, these phenomena pointed to the exis-

tence of a “suicide subculture” wherein suicide leads to another suicide. In

an environment characterized by a general familiarity with and acceptance

of the idea of suicide, suicide had become a culturally patterned and partly collective response to personal dilemmas and problems.

Finally, an individual’s experience of loneliness, of being alone, can be a

signifi cant factor in suicide. It is not so much a matter of how many support-

ive people an individual has in his or her life that counts. Rather, it is that

individual’s perception of support that matters. According to Thomas Joiner, people (men especially) can become so focused on status, money, and suc-

cess that they become oblivious to the fact that they are lonely. Indeed, they

may push away friends and family members who sense something unhealthy

and try to intervene. Yet, when questioned, such people (again it seems, men

especially) do not acknowledge the fact of their loneliness. Joiner concludes:

“Loneliness is a vicious killer. It preferentially stalks men. Like the victims

of many killers, the victims of loneliness don’t realize the danger until it’s

too late.” 68

Life-Span Perspectives on Suicide The risk factors for suicide change through life as human beings encounter

changing circumstances related to different periods of human development.

The causes of suicide among adolescents, for example, tend to be distinct

from those of people in old age. In studying various risks that pertain to dif-

ferent segments of the life span, notice which factors affect people of all ages

and which factors tend to exert a particular infl uence on people in specifi c

age groups.

Childhood Suicide is rarely reported in young children, but many researchers and

clinicians believe that suicidal behavior is found among even very young chil-

dren. Because suicide risk is higher among those who have made an earlier

attempt, children with a history of suicidal ideation or suicide attempt are at

risk for multiple recurrence of suicidal ideas or acts. 69

Researchers believe that the rate of suicide among children would be

higher if childhood accidents were examined more carefully for intent. Some

of the childhood deaths resulting from running in front of cars or plastic bag

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472 c h a p t e r 12 Suicide

suffocation are probably intentional rather than accidental. Although young

children usually do not have access to sophisticated means of self-destruction

as do people at older ages, they nevertheless engage in acts of self-harm, and

some kill themselves. In the case of young children, however, labeling a death

as suicide may be problematic because of questions about whether a child

possesses a mature concept of death and thus is fully aware of the conse-

quences of his or her actions. 70 (Recall the discussion of childhood devel-

opment in Chapter 2.) There is evidence that children who attempt suicide,

especially those on the cusp between childhood and adolescence, tend to

be in a transitional stage between concrete operational thought and formal

operational thought, which may involve heightened vulnerability to suicidal

ideation and behaviors. 71

Adolescence and Early Adulthood Adolescent suicide begins to appear in the age group of ten- to fourteen-

year-olds and increases signifi cantly among older adolescents and young

adults, which suggests that developmental changes play a role, possibly one

related to cognitive development and conceptualization of death.

Social disruption is an important factor in self-destructive behaviors

among the young. Psychiatric diagnosis, dysfunctional personality traits, and

psychosocial problems also increase the risk of suicide. Suicide in adolescents

is linked with interpersonal confl ict (with parents as well as boyfriends or

girlfriends), interpersonal losses (including disruption of a romantic attach-

ment, as well as other separations), and external stressors (most notably legal

or disciplinary problems, which are often related to tendencies to engage in

impulsive violence). 72 Being a victim of bullying or cyberbullying, or engaging

in risky sexual behavior, especially at younger ages, also appears to increase

suicidal risk. 73

Family problems are signifi cant. Suicidal young people tend to be

exposed to family violence, disengaged families and defi cient family sup-

port, physical abuse, parental suicidal behavior, instability in their living

situations, and other acute and chronic stressors related to family life. The

young person’s response to such turmoil may give rise to a variety of affective

and cognitive states, such as rage, hopelessness, despair, guilt, revenge, self-

punishment, and retaliatory abandonment. 74 Substance abuse is a common

Suicide Note Written by a Single Woman, Age 21 My dearest Andrew,

It seems as if I have been spending all my life apologizing to you for things

that happened whether they were my fault or not.

I am enclosing your pin because I want you to think of what you took from me

every time you see it.

I don’t want you to think I would kill myself over you because you’re not worth

any emotion at all. It is what you cost me that hurts and nothing can replace it.

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Life-Span Perspectives on Suicide 473

theme, both in families and among young suicide-prone individuals. Active

substance abuse, combined with depression and the availability of a hand-

gun, is potentially lethal.

Upheavals in family life and in lifestyles generally add to the pressures

experienced by young people. Suicide may be seen as a way to impose some

control over confusing and upsetting events or to escape them. As Paulina

Kernberg points out,

An important meaning of suicide is that it can serve as an act of mastery, of

ultimate control, of competency in individuals who are suffering loss of a sense

of control over themselves and their lives. It is, as it were, the ultimate “locus of

control.” 75

Substance abuse, delinquency, and suicide are linked on a continuum of

“escape behaviors” in which young people engage to avoid feelings of depres-

sion and hopelessness. Risk-taking behavior may represent a way out for the

individual who no longer cares whether he or she lives or dies. Flirting with

death, as in “playing chicken,” may be engaged in with little concern for

the outcome. When substance abuse and risky behaviors no longer provide

Unable to earn a living by writing and too proud to accept food offered to him by his land- lady, this seventeen-year-old killed himself by taking poison. Painted in 1856 by Henry Wallis, The Death of Chatterton depicts an adolescent suicide that was precipitated by crisis arising out of the developmental transition from child to adult.

H e n

r y W

a ll

is ,

T a te

G a ll

e r y,

L o

n d

o n

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474 c h a p t e r 12 Suicide

suffi cient distraction from painful lives, young people may opt for suicide to

provide the ultimate numbness. 76

Adolescents and young adults may be susceptible to a kind of “conta-

gion,” whereby one person’s suicide triggers another. So-called cluster suicides typically take place within the same locale, are closely related in time, and

involve the same method. 77 (Mass suicide can be considered as a special form

of clustering.) The term copycat suicide is also used to describe cluster suicides, especially when imitation occurs in connection with the depiction of a sui-

cide in the media. In a study of two Texas clusters, researchers concluded

that exposure to reports of suicides may affect individuals who are already at

risk. Sensational or romanticized media coverage may foster an affi nity with

those who die by suicide and confer an aura of celebrity on them. In suicide-

susceptible individuals, this could evoke the impression that suicide will claim

special—albeit posthumous—attention from their family and peers.

Suicide pacts are a similar phenomenon in that they relate to an arrange- ment between two or more people who determine to kill themselves at the

same time and usually in the same place. 78 Four teenagers in New Jersey, two

boys and two girls, decided to die together by sitting in a car with the motor

running inside a locked garage. Reportedly, they were distraught over the

death of a friend. They were discovered dead the next morning. Two days

later, another suicide pact took the lives of two teenage girls in Illinois who

killed themselves in similar fashion.

Another instance of adolescents entering into a suicide pact involved a

boy and girl who reportedly became obsessed with the possibility of reincar-

nation. They crashed their car into their old junior high school building,

causing the boy to be killed instantly. The girl, who apparently had last-

second doubts about reincarnation, barely survived by diving under the car’s

dashboard.

An unusual and one-sided version of the suicide pact occurs in the phe-

nomenon of graveside suicides, in which a pathological grief reaction leads

a bereaved person to kill himself or herself at the grave of a deceased loved

one. Cemeteries are symbolic of the reunion of the living and the dead, and

graveside suicides are analogous to a death pact between two persons in

which the second person’s death occurs as a reaction to the death of the fi rst

person, without the knowledge of the fi rst person. 79

Romeo and Juliet also embody another popular misconception: that of the great

suicidal passion. It seems that those who die for love usually do so by mistake and

ill-luck. It is said that the London police can always distinguish, among the corpses

fi shed out of the Thames, between those who have drowned themselves because

of unhappy love affairs and those drowned for debt. The fi ngers of the lovers are

almost invariably lacerated by their attempts to save themselves by clinging to the

piers of the bridges. In contrast, the debtors apparently go down like slabs of con-

crete, apparently without struggle and without afterthought.

A. Alvarez, The Savage God

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Life-Span Perspectives on Suicide 475

In Japan, mental health authorities are concerned about the phenom-

enon of “net suicide,” or suicide pacts arranged between strangers who

meet on the Internet. 80 Although similarly arranged suicides have occurred

to a limited degree elsewhere, in Japan the incidence of such suicides has

averaged about sixty people (twenty cases of net suicide) a year. With mass

media publicity, more people are accessing “suicide Web sites,” which has

led to the secondary effect of “chain suicide,” whereby one suicide facili-

tates the occurrence of a subsequent suicide (discussed earlier in reference

to copycat suicides).

Whereas the motives for suicide among adolescents often involve issues

relating to family and peer relationships, for young adults the major issues

tend to involve academic achievement, courtship, family formation, and

career. A desire for perfection, whether socially or self-imposed, can lead to

suicidal ideation when accomplishments fall short of ideals. One study found

an exceptionally high rate of suicide among men ages twenty to thirty-four

years who had been recently widowed. 81

At present, the most promising approaches for reducing suicide among

young people appear to be in two major areas: fi rst, providing treatment

for disorders that increase the risk of suicide, such as depression, substance

abuse, and family confl ict; and, second, targeting prevention efforts at high-

risk groups, such as affectively disordered young men who exhibit substance

abuse and other antisocial behavior. The treatment options include hospital-

ization for psychological evaluation, subsequent close outpatient follow-up,

removal of fi rearms and securing of lethal medications from the home, and

therapy for any associated psychiatric disorder. 82

Middle Adulthood Middle age, roughly between ages thirty-fi ve or forty and sixty-fi ve, has

been called the “terra incognita” of the human life span. This is a period of

generativity, of giving back to society some of the gifts of nurture and suste-

nance received during earlier periods of life. It is a time of shifting from valu-

ing physical capabilities to valuing wisdom, of building new relationships as

old ones are lost or altered, and of gaining greater fl exibility in life. This part

of the life span has also been characterized as “middlescence,” suggesting

that, for many adults, middle age may be as turbulent as adolescence.

This is also a time of coping with the loss of dreams and ambitions, com-

ing to terms with the realization that one may not reach the goal of being

a great artist, writer, or company president, or whatever vision one had for

oneself earlier in life. It may not be possible to achieve a perfect marriage or

raise perfect children.

The motive for suicidal behavior may be related to diffi culties in an

individual’s career or marriage. In some cases, the nature of the career

itself has an impact on suicidal behavior, as may be the case with the rela-

tively high rate of suicide among police offi cers. The major factors infl u-

encing suicide among the middle-aged often include an accumulation of

negative life events, affective disorders—especially major depression—and

alcoholism.

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476 c h a p t e r 12 Suicide

Late Adulthood Although teenage suicide attracts more media attention, elderly people

are at higher risk for suicide than any other age group. This is especially true

of elderly white males, particularly widowers. Major risk factors include being

divorced or widowed, living alone, and psychiatric or physical illness. 83 Older

people are not as likely as people in younger age groups to have expressed

suicidal ideation or to have made a previous suicide attempt. 84 Research-

ers seem to agree that elderly people who attempt suicide genuinely want

to die, unlike younger people, whose attempts are often a cry for help (see

Figure 12-1 ). 85

Double suicides (a type of suicide pact) occur with greatest frequency

among the elderly. The typical double suicide involves an older couple with

one or both partners physically ill. Heavy alcohol use by one or both part-

ners is also common. Such couples tend to be dependent on each other

and isolated from external sources of support. There seems to be a “spe-

cial chemistry” between couples who die by suicide together, with the more

suicidal partner dominant and the more ambivalent partner passive in the

relationship. 86

Contemplating Suicide Imagine for a moment the progression of thoughts of someone consider-

ing suicide. Assume that, in some situation, suicide appears to be the only

recourse or at least an option to be considered further. The next step might

involve formulating some means of killing oneself. At this point, the means

have not been acquired, but the possibilities are considered.

Many people have reached this stage—perhaps through mere fantasiz-

ing or perhaps with serious intentions. For some, the shock of recognizing

that one is harboring such thoughts is enough to force a more life-affi rming

decision. For others, the next step toward suicide is taken, a step that greatly

raises the level of lethality with regard to suicidal intention.

This stage involves acquiring the means to kill oneself, setting into

motion the logistics that make suicide a real possibility. This stage is refl ected

in the remark, People die by suicide when they have both the desire to die

and the ability to die. A change of mind away from suicide is still possible.

Otherwise, the fi nal step in the suicidal progression comes into play: actually

using the means that have been acquired to proceed with the suicidal act.

These steps toward lethality have been described as occurring in a defi -

nite sequence, but they are likely to be experienced as anything but logical

and orderly. Still, recognizing the steps that must be taken to carry out the

suicidal act is helpful for understanding both the amount of sustained effort

involved and the many decision points at which a change of mind or outside

intervention is possible.

Sometimes a particular method is chosen because of the image it repre-

sents to the suicidal individual. One might imagine drowning as a dreamy

kind of death, a merging back into the universe. Or one might associate an

overdose of sleeping pills with the death of a movie star. Despite the image

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Contemplating Suicide 477

Figure 12-1 Suicide Note and Report of Death The facts of suicide as reported in a newspaper may reveal little of the intense human factors—the personal and social dynamics—that precipitated the suicidal act. Compare this handwritten note with the corresponding report on the following page.

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478 c h a p t e r 12 Suicide

associated with a particular method, the reality is likely to be quite different.

Some people who overdose on drugs do so expecting a quiet or peaceful

death. But the actual effects of a suicidal drug overdose are usually far from

peaceful or serene.

Sometimes a particular method of suicide is chosen for its anticipated

impact on survivors. A study of suicide notes found that people using horrifi c

methods of suicide often communicated that rejection was a critical factor

in the decision for self-injury. 87 An individual who wants survivors to “really

pay for all the grief they caused me” might select a method that graphically

communicates this rage. Someone who did not want to “make a scene” might

select a method imagined as being less disturbing to survivors.

Resume

Razors pain you;

Rivers are damp;

Acids stain you;

And drugs cause cramp.

Guns aren’t lawful;

Nooses give;

Gas smells awful;

You might as well live.

Dorothy Parker

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Suicide Notes 479

Experience and familiarity also infl uence the choice of suicidal method.

An experienced hunter, knowledgeable about rifl es, might be inclined to

turn to a fi rearm for suicide because of its accessibility and familiarity. Some-

one who understands the effects of various drugs might use them to concoct

a fatal overdose. In short, the method of suicide tends to refl ect a person’s

experience and state of mind. It may be a spontaneous choice, in which the

person uses whatever lethal devices are readily at hand, or it may be the out-

come of deliberate thought and even research.

Choosing a method of killing oneself can be likened to making travel

arrangements for a cross-country trip. A person wanting to travel from the West

Coast to the East Coast must consider the kinds of transportation available—

automobile, train, airplane, and so on. Some of these are quite rapid; others

are relatively slow and deliberate. For example, once you board an airplane

and it lifts off the runway, there is no opportunity to change your mind and

disembark before reaching the destination. However, if you were bicycling

from coast to coast, you would have innumerable opportunities to decide on

a different destination.

Similarly, some methods of suicide offer little hope of changing one’s mind

after the lethal act is initiated. Once the trigger is pulled on a revolver placed

next to one’s skull, there’s virtually no possibility of altering the likelihood of a

fatal outcome. However, the would-be suicide who cuts his or her wrists or takes

an overdose of drugs might have time to alter an otherwise fatal outcome by seek- ing medical help. If help is not forthcoming, the likelihood of dying may be as

great as with a gunshot wound to the head—but there is a chance of intervention.

Among methods used for the suicidal act, then, there is an order of lethality.

Suicide Notes Suicide notes have been called “cryptic maps of ill-advised journeys.” 88 Such

notes are usually written in the minutes or hours preceding suicide. Although

it is often assumed that nearly all suicides leave notes for their survivors, in fact

Once you’ve pulled the trigger, it’s done. You can’t change your mind. Not like swimming out from the shore, or taking pills, or wrapping your head

in a dry-cleaning bag, or sitting in the car with an exhaust hose threaded through

the window, or using a knife or a razor—all those methods that allow for second

thoughts: what am I doing? In the midst of killing yourself, you might begin to

consider emergency rescue plans. Swimming back. Throwing up. Unwrapping the

bag. Opening the car door and getting out. A tourniquet, a call to 911.

Even jumping allows for vacillation (no rescue possible there, but all that

awful time to regret it on the way down).

With the gun lying on your tongue, the deed and the result are pretty much

simultaneous.

There’s no separation between action and oblivion.

Joan Wickersham, The Suicide Index

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480 c h a p t e r 12 Suicide

only about one in six people who complete suicide write a fi nal message. 89 As a

partial record of the mental state of suicides, such notes are of immense inter-

est to scholars and helping professionals, not to mention bereaved families.

Imagine yourself in circumstances that would lead to writing a suicide note.

What kinds of things would you want to say in your last words to your survivors?

Actual suicide notes display a variety of messages and intentions. Some

notes explain to survivors the decision to die by suicide. Others express anger

or blame. Conversely, some notes emphasize that the suicide is “no one’s

fault.” The messages in suicide notes range from sweeping statements of the

writer’s philosophy or credo regarding suicide to detailed listings of practical

chores that will require attention after the writer’s death. For example, one

note instructs survivors, “The cat needs to go to the vet next Tuesday; don’t

miss the appointment or you’ll be charged for it. The car is due for servicing

a week from Friday.” Suicide notes represent the writer’s “last chance to take

care of business, decide who gets what, or to make funeral wishes known.” 90

Suicide notes may include expressions of love, hate, shame, disgrace, fear of

insanity, self-abnegation; feelings of rejection; explanations for the suicidal act

or defense of the right to take one’s life; disavowal of a survivor’s responsibility

Suicide Note Written by a Married Man, Age 45 Dear Claudia,

You win, I can’t take it any longer. I know you have been waiting for this to

happen. I hope it makes you very happy, this is not an easy thing to do, but I’ve

got to the point where there is nothing to live for, a little bit of kindness from you

would of made everything so different, but all that ever interested you was the

dollar. It is pretty hard for me to do anything when you are so greedy even with this

house you couldn’t even be fair with that, well it’s all yours now and you won’t have

to see the Lawyer anymore.

I wish you would give my personal things to Danny, you couldn’t get much

from selling them anyway, you still have my insurance, it isn’t much but it will be

enough to take care of my debts and still have a few bucks left.

You always told me that I was the one that made Sharon take her life, in fact

you said I killed her, but you know down deep in your heart it was you that made

her do what she did, and now you have two deaths to your credit, it should make

you feel very proud.

Good By Kid

P.S. Disregard all the mean things I’ve said in this letter, I have said a lot of

things to you I didn’t really mean and I hope you get well and wish you the best of

everything.

Cathy—don’t come in.

Call your mother, she will know what to do.

Love,

Daddy

Cathy don’t go in the bedroom.

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Suicide Prevention, Intervention, and Postvention 481

for the suicide; instructions for distributing property and possessions. They typi-

cally display dichotomies of logic, hostility toward others mixed with self-blame,

the use of particular names and specifi c instructions to survivors, and a sense

of decisiveness about suicide. Suicide notes often convey an intense love-hate

ambivalence toward survivors, as expressed succinctly in the following note:

Dear Betty:

I hate you.

Love,

George

This example of ambivalence also points up the dyadic nature of suicide—

here, involving husband and wife. Suicide notes provide clues about the inten-

tions that lead a person to suicide but rarely tell the whole story—and they

often raise more questions than they answer. The message in a suicide note

may come as a surprise to survivors who had no hint of the feelings described

by the writer. Suicide notes can have a signifi cant effect on survivors. Whether

the fi nal message is one of affection or blame, survivors have no opportunity

to respond. Death by suicide represents the ultimate last word.

Suicide Prevention, Intervention, and Postvention Starting in 1953, Chad Varah, an Anglican clergyman, developed a tele-

phone service in London staffed mainly with volunteers whose goal was to

“befriend the suicidal and despairing.” This service, called The Samaritans,

has become an international movement, and Varah has been hailed as “sui-

cidology’s most powerful practitioner” and “the patron saint of the suicide

prevention volunteer.” 91

In the United States, a comparable milestone was the founding of the

Los Angeles Suicide Prevention Center in 1958 by Norman Farberow and

Edwin Shneidman. 92

The importance of the Los Angeles Suicide Prevention Center cannot

be overstated in any history of suicide. The work begun in that center by

Shneidman and his associates, and expanded upon later when Shneidman

became director of the Suicide Center in the National Institute of Mental

Health, changed the nation’s view of suicide and suicidal behavior. The most

important change was a shift away from seeing suicide as an act committed

by an insane person to seeing it as an act committed by a person who felt

overwhelming ambivalence toward life. 93

The activities of the Los Angeles Suicide Prevention Center exemplify

the understanding of suicide as a subset of a larger class of self-destructive

behaviors, all of which require attention.

The typical suicide prevention center operates as a telephone-answering

center with round-the-clock availability to people in crisis. Hotline services

are mainly intended to serve as a short-term resource for people contemplat-

ing suicide. The caller’s anonymity is respected, and his or her expressed

need for help is accepted unquestioningly. Staff members—some of them

professionals, many of them volunteers who receive training—use crisis

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482 c h a p t e r 12 Suicide

intervention strategies to reduce the caller’s distress. Like other public health

services, suicide crisis centers vary in their standards of professionalism; over-

all, however, they have a positive impact on countless people.

One hotline volunteer described the reaction of a caller when asked,

“Who will fi nd your body?” The answer, “My kids when they get home from

elementary school,” was enough to cause the caller to rethink the suicidal

impulse and prompt a reaching out for resources.

Prevention There is little reason to be optimistic about preventing suicide, if by “pre-

vention” we mean eliminating it from human behavior. The causes of human

unhappiness and dissatisfaction would have to be eliminated. But efforts to

create a social utopia must inevitably fall short of perfection. This is not to say

that efforts to relieve human suffering are not worth pursuing, only that they

are inherently limited.

In any program of suicide prevention, an essential element is education.

The lessons to be learned, which can be applied across the life span, include

the following key points: First, it is crucial to acknowledge the truth that life is

complex and that everyone will inevitably have experiences of disappointment,

failure, and loss in life. Second, we can learn to deal with such experiences by

developing appropriate coping techniques, including skills of critical thinking.

Individuals “who form a habit of analyzing situations from a variety of perspec-

tives, asking appropriate questions, and testing the reality of their own think-

ing are far less likely to settle easily into the cognitive infl exibility that focuses

on suicide as the solution.” 94 A corollary of such coping skills involves the culti- vation of a sense of humor, especially the ability to laugh at oneself and at life’s

problems, to see the humor in situations. It is also important to learn to set

appropriate and attainable goals. Positive self-esteem is a preventative against

suicide. Studies have also shown that religiosity (that is, how religious a person

is) potentially serves as a protective factor against suicidal behavior. 95 Yet, the

infl uence of religion is often overlooked or minimized.

Another strategy for prevention involves setting up physical barriers in

places where suicides are likely to occur. In Washington, D.C., the number-

one jump site historically has been the Duke Ellington Bridge, a three-arch

concrete structure with pedestrian lookouts. After three suicides from the

bridge within a ten-day period, authorities ordered the construction of an

eight-foot-high fence. However, the construction was opposed by neighbor-

hood groups and by the National Trust for Historic Preservation because the

fence would block scenic views and diminish the architectural aesthetics of

the structure. Further, it was argued, such protective fences do not prevent

suicides. The barrier was installed, however, and only one suicide occurred

from the Ellington Bridge during the next four years. This is in compari-

son with ten suicides from the nearby Taft Bridge, which had no fence. 96

Although it appears the fence did prevent some suicides, there are too many

variables and unknowns to reach a confi dent conclusion. It is possible that

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Suicide Prevention, Intervention, and Postvention 483

individuals who would have jumped from the Ellington Bridge simply found

other ways to kill themselves. To a suicide-prone person, what is the meaning

of a bridge barrier? Could it at least alleviate the sense of crisis that drove

an individual to consider suicide? These questions are diffi cult to answer,

but intervention during a suicidal crisis can reduce its lethality and give the

would-be suicide an opportunity to reassess a painful situation and perhaps

fi nd a more constructive, healthier solution.

Intervention Suicide intervention emphasizes short-term care and treatment of per-

sons who are actively experiencing a suicidal crisis. The aim is to reduce

the lethality of the crisis. Although many suicide intervention programs are

called “suicide prevention centers,” such programs generally use theories and

techniques common to crisis intervention. Antoon Leenaars notes,

Suicide intervention is optimally practiced in cooperation with a number of

colleagues, representing various disciplines, and even individuals outside the

helping professions. . . . The treatment of a suicidal person should refl ect the

learning and response of individuals with different points of view. 97

Unfortunately, researchers have found that a surprisingly high percentage of

the interventionists studied were apt to respond, “Come on now, things can’t

be all that bad.” Or a client calls in and says, “I’m thinking about suicide,” and

the counselor responds, “You say you’re suicidal, but what’s really bothering

you?” In both of these examples, there is an implicit negation of the suicide

threat. 98

When individuals express suicidal thoughts or exhibit suicidal ideation,

several avenues of exploration can be helpful: 99

1. Imminence. How soon does the person expect to suicide? Is it a future thought or a present plan?

2. Provocation. What has happened to make the suicide feasible now? Is the person experiencing a new crisis or problem?

3. Plan. Does the person have a plan? How well defi ned is that plan? 4. Means. Are the means to complete the plan available to the person? Are

circumstances such that the person can carry it off?

The cardinal rule in suicide intervention is to do something. The basic questions are “Where do you hurt?” and “How can I help you?” 100 Thus, sui-

cide intervention involves (1) taking threats seriously; (2) watching for clues

to suicidal intentions and behaviors; (3) answering cries for help by offer-

ing support, understanding, and compassion; (4) confronting the problem

by asking questions (“Are you considering killing yourself?”) and being

unafraid to discuss death by suicide with the person in crisis; (5) obtaining

professional help to manage the crisis; and (6) offering constructive alterna-

tives to suicide. A key theme of suicide intervention is that talking is a positive

step toward resolving the crisis.

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484 c h a p t e r 12 Suicide

Postvention Suicide postvention, a term coined by Edwin Shneidman, refers to the

assistance given to all survivors of suicide: those who attempt suicide, as well as the families, friends, and associates of those who die by suicide. The

bereaved survivors of suicide often experience feelings of guilt and self-

blame. 101 Those left behind face such questions as “Did she have a choice?”

If yes, then the suicide did something unforgivable. If no, then the question

becomes “How can we blame the victim?” Joan Wickersham, whose father

died by suicide, says it’s as if the victim leaves the message, “I’m gone, and you

can’t even be sure who it is that’s gone, because you never knew me.” 102 Survi-

vors who witness someone die by suicide may face special challenges. 103 (Grief

issues for people bereaved by suicide are discussed in Chapter 9.) Postvention

efforts often play an important role in suicide prevention.

Graffi ti I fi nd a snapshot

buried in my father’s drawer.

A picture of the grandfather I never knew.

Small, stooped yet dignifi ed he stands

beside my brother’s wicker pram

surrounded by his family.

My mother tells the story, hidden in the past

of the last time she saw him.

She was big with child, and so allowed to sit

while his two daughters served the sons

who gathered at the table.

Grandma who reigned as always at the head

arranged the seating of those sons

not in the order of their age

but of the weekly wage they earned

and without question brought to her.

I learn that you, mild gentle man

never at home in the new language, the new land,

subdued by failure, each passing year withdrew

further into old world memories, and silence.

Rising that evening from the table, as usual

scarcely noticed as you went to lie down

on your narrow bed, there was no sign, no signal.

Only that as you passed, you bent

with a shy unaccustomed show of tenderness

to murmur “ Liebchen ” and to kiss my mother’s head. She tells me that I leaped and struggled in her womb

when from your room you shattered silence

with a shot. Your life exploding

sudden messages across blank walls in bursts of red.

Maude Meehan

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Helping a Person Who Is in Suicidal Crisis 485

Helping a Person Who Is in Suicidal Crisis Warnings that an individual is considering suicide may be communicated

in a variety of ways. Evans and Farberow point out that suicidal intent may

be expressed in four main ways: (1) verbal direct (“I will shoot myself if you leave me”), (2) verbal indirect (“A life without love is a life without meaning”), (3) behavioral direct (for example, a chronically ill person hoarding pills), and (4) behavioral indirect. 104 Among the warning signs that fall under this last cat- egory, Evans and Farberow mention these:

1. Giving away prized possessions, making a will, or attending to other

“fi nal” arrangements

2. Sudden and extreme changes in eating habits or sleep patterns

3. Withdrawal from friends or family, or other major behavioral changes

accompanied by depression

4. Changes in school or job performance

5. Personality changes, such as nervousness, outbursts of anger, or apathy

about health or appearance

6. Use of drugs or alcohol

The recent suicide of a friend or relative, or a history of previous suicide

attempts, should also be taken as a warning sign of suicide risk.

A number of commonly held beliefs or myths have grown up about sui-

cide and about the kind of person who is likely to die by suicide. Unfortu-

nately, many of these beliefs—because false—are harmful, for they have

the effect of depriving the suicidal person of needed help. For example, the

notion that people who talk about suicide don’t kill themselves has been

called the “grand old myth of suicide,” one that may be used to excuse the

failure to respond to another person’s cry for help, or even to justify words

or actions that actually encourage a suicidal act. When a teen chatted about

his intentions and then broadcast his suicide from a lethal mixture of drugs

on a webcam, other bloggers urged and even taunted the young man to go

ahead with the suicide. 105

In fact, most people who engage in suicidal acts do communicate their

intentions to others as hints, direct threats, preparations for suicide, or

other self-destructive behaviors. When such cries for help go unheeded by

friends, family members, coworkers, or health care personnel, the end result

can be tragic.

If a person says, “I feel like killing myself,” that statement should

not be taken lightly or brushed aside with the quick response, “Oh, well,

you’ll probably feel better tomorrow.” To the person in crisis, there may

seem little hope of a tomorrow at all. Pay attention to the message being

communicated.

Similarly, responding to a suicidal statement with a provocation—“You

wouldn’t be capable of suicide!”—or with a tone of moral superiority—”I

don’t want to hear such unhealthy talk!”—can worsen rather than ease the

crisis. A litany of the “good reasons” why the person should not die by suicide

also offers little practical assistance to a person in crisis.

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486 c h a p t e r 12 Suicide

More helpful is listening carefully to exactly what the person is com-

municating; the tone and context of statements should reveal to the sensi-

tive listener something about the communicator’s intent. Often, remarks

about suicide are made in an offhand manner: “If I don’t get that job, I’ll

kill myself!” Perhaps the remark is intended as a fi gure of speech, much as

in the joking threat, “I’ll kill you for that!” There is a tendency to discount

such statements in a culture where “talk is cheap” and “actions speak louder

than words.” 106 Suicidal threats need to be taken seriously. To do otherwise is

to fall prey to the myth that talking about suicide means the person will not

really go through with it. Knowing the patterns of suicidal behavior can help

distinguish facts from fallacies. It is also helpful to become acquainted with

the crisis intervention resources available in your community.

Lastly, it is important to recognize that no one can take ultimate responsi- bility for another human being’s decision to end his or her life. This recogni-

tion may go against the wish to preserve life, yet there are limits to what can

be done to assist another person in crisis. In the short term, it may be feasible

to keep someone from taking his or her life. Constant vigilance or custodial

care can prevent suicide during an acute suicidal crisis. Over the longer term,

however, taking responsibility for preventing someone else’s suicide is likely

to be unsuccessful. A terminally ill man dying in great pain said to his wife,

“You’d better keep my medication out of reach, because I don’t want to keep

Once a person is this close to the suicidal act, the chance of a successful intervention is usually slight. Fortunately, in this dramatic instance intervention was successful.

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Further Readings 487

up this struggle any longer.” The wife had to decide whether she could take

responsibility for whether he would continue to live with pain or end his life

by an overdose. After much soul searching, she concluded that, although she

had compassion for his predicament, she could not take responsibility for

safeguarding his medication, doling out one pill at a time, constantly fearful

that he might locate the drugs and attempt suicide anyway.

Not taking responsibility does not mean that one must go to the oppo-

site extreme: “Well, if you’re going to kill yourself, then get it over with!”

Although there are limits to how much one person can protect another, it is always possible to offer life-affi rming support and compassion. A person who

seems intent on suicide may be hoping for some intervention. The person

who is cast in the role of helper in such a drama can affi rm the fact that there

are choices other than suicide. It is important to sustain or stimulate that

person’s desire to live.

One way to help people in crisis is to help them discover what about

themselves can matter, however small or insignifi cant it may seem. It is impor- tant to fi nd something that matters to the person. What are the possibilities of sustaining that value into the present? Asking the person what he or she

needs in order to feel worthwhile may be a matter of survival. In the short

term, external support can help to ensure survival during the height of crisis.

Suicidal thoughts and behaviors indicate a critical loss of a person’s belief

that he or she is someone who matters. The feeling that nothing matters, in

the sense that one’s life is in complete disarray, is not by itself the stimulus

for suicide. More important is the person’s belief that “ I don’t matter.” Those two streams of thought in combination—the sense that the external situation

is unsatisfactory and that one does not matter enough to improve it—can be

lethal. It is important to remember, “Suicide is a permanent solution to what

is most likely a temporary problem.” 107

Further Readings George Howe Colt. November of the Soul: The Enigma of Suicide. New York: Scribner, 2006. Fred Cutter. Art and the Wish to Die. Chicago: Nelson-Hall, 1983. Norman L. Farberow, ed. Suicide in Different Cultures. Baltimore: University Park Press,

1975.

Keith Hawton and Kees van Heeringen, eds. The International Handbook of Suicide and Attempted Suicide. New York: Wiley, 2000.

Thomas Joiner. Why People Die by Suicide. Cambridge, Mass.: Harvard University Press, 2005.

Updesh Kumar and Manas K. Mandal, eds. Suicidal Behavior: Assessment of People-at- Risk. Los Angeles: Sage, 2010.

Edwin S. Shneidman. Comprehending Suicide: Landmarks in 20th-Century Suicidology. Washington, D.C.: American Psychological Association, 2001.

Joan Wickersham. The Suicide Index: Putting My Father’s Death in Order. New York: Harcourt, 2008.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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Calling attention to the perils posed by threatening encounters with death— accidents, disasters, violence, war, terrorism, and epidemic diseases—this draw- ing depicts victims embraced by Azrael, the angel of death.

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489

C H A P T E R 1 3

Risks, Perils, and Traumatic

Death

I n 1721, the novelist Daniel Defoe wrote A Journal of the Plague Year, a fi ctional account of the Great Plague that had devastated London in 1665. Victims exhibited symptoms simi-

lar to the pestilence caused by the Black Death, a deadly pandemic that swept Europe in

the fourteenth century. Drawing on published accounts and his recollection of tales heard

during childhood, he vividly depicted a plague-stricken city and the terror of its helpless

citizens, confronted by a horror they could not comprehend. What prompted Defoe to write

about a plague that had taken place two generations earlier? He knew that a plague again

threatened to sweep across Europe, a plague that potentially could cause death and destruc-

tion on the scale of the Great Plague of 1665. He wrote to alert a largely indifferent populace

to the threat so that precautions could be taken to avert catastrophe.

Why this history lesson? Today, we no longer fear the Black Death. Yet, as individuals and

as societies we are subject to risks and perils that are no less threatening than the more easily

identifi ed plague of Defoe’s time. The essayist E. B. White wrote, “To confront death, in any

guise, is to identify with the victim and face what is unsettling and sobering.” 1

As we engage in life’s pursuits—on our jobs, in our recreational activities, and in other

pursuits—we encounter subtle and sometimes dramatic perils that expose us to the pos-

sibility of imminent injury or destruction. The word peril, which dates from the thirteenth

century, refers to the risk of being injured, destroyed, or lost. Perils are evident in accidents,

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490 c h a p t e r 13 Risks, Perils, and Traumatic Death

disasters, violence, war, terrorism, emerging epidemic diseases, and other

instances of traumatic death. Anthony Giddens says, “We live in a world

where hazards created by ourselves are as, or more, threatening than those

that come from outside.” 2 Some of these encounters with death are termed

“megadeaths” because of the massive loss of life that typically occurs. 3 No

one is immune to risks.

After a classroom discussion about various activities, one student said,

“It seems we’re coming around to the point that everything we do involves

risks. You could even stab yourself with a knitting needle!” Perhaps, but fall-

ing backward from a rocking chair while knitting would strike most people as

less risky than, say, driving a formula race car or heading out on an expedi-

tion to the Himalayas.

Accidents and Injuries In contrast to intentional injuries, which are infl icted purposefully by oneself

or another person, an injury that occurs when no harm is intended is consid-

ered an unintentional injury. 4 Is this category of injury due to accidents that happen because of “fate” or simple “bad luck”? The defi nition of an accident

as an event that occurs “by chance or from unknown causes” can be expanded

with the recognition that accidents also occur because of carelessness, lack of

awareness, or ignorance. Suppose a gun is brought into a household. The very

presence of the gun increases from zero the chance that there may be an acci-

dental fi ring of the weapon. Of course, such an event may never happen. But if

a gun were not in the home, there would be no chance of an accidental fi ring. Paul Insel and Walton Roth tell us that “most injuries are caused by a

combination of human and environmental factors,” adding that “a common

human factor that leads to injuries is risk-taking behavior.” 5 We discuss vio-

lence and intentional injuries later in this chapter. Here we focus on uninten-

tional injuries: motor vehicle injuries, home injuries (falls, fi res, suffocation

The Fast Lane Takes Its Toll I was ripped off the bike and slammed face fi rst into the van, carving a very nice

Pirates of the Caribbean scar from my hairline down my forehead, across my left eye, and down over the bridge of my nose—all deep into my skull. Very cool looking.

I remember once standing in line at Spago’s, barking at Wolfgang’s people

because they sat other customers before me. There were 10 people waiting when I

showed (unannounced), and I expected to be immediately moved to the front of

the line, not second to the front. Those were my values. That’s what I thought was important. That’s what I thought was fun. And that’s what I thought was power.

Now I spend 15 minutes 50 times every day trying to bend one fi nger two

degrees as part of my physical therapy. As you can imagine, I am no longer quite as

concerned with my position in line at Spago’s.

Stephen St. Croix, Life in the Fast Lane

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Risk Taking 491

and choking, fi rearms), leisure injuries (sport, recreation), weather-related

injuries (heat, cold, wind, lightning, fl ooding), and work injuries, to list the

main categories.

The choices people make affect the probabilities of accidents. Drivers

who have been drinking tend to take greater risks than do sober drivers. A

driver’s judgment and performance are inversely related to the amount of

alcohol consumed, whereas a driver’s tendency to overrate his or her driving

abilities is directly related to the amount imbibed. About half of the drivers

involved in accidents are under the infl uence of alcohol. One-third of all traf-

fi c fatalities involve drivers with a blood alcohol content (BAC) of 0.8 percent (the legal limit in all states) or higher. 6

Young drivers tend to be disproportionately at fault for the crashes in

which they are involved. 7 Lack of experience compounded by unsafe use of

cell phones, iPods, CD players, and the like can be deadly. To increase teen

driver safety, some states have instituted “graduated driver license” laws that

help teens gain experience incrementally. In California, for example, the law

requires drivers under age eighteen to have their license for a year before

being allowed to drive between 11 p.m. and 5 a.m. or before being allowed

to transport passengers under the age of twenty without an adult in the car.

Unsafe conditions in the environment are sometimes called “accidents

waiting to happen.” Such conditions may be due to negligence or simply

ignorance of the threat. Consider the situation of a swimming pool left unat-

tended and easily accessible to young children; if a toddler happens by, falls

into the pool, and drowns, the owner of the pool and the child’s guardians

may be judged negligent.

A wrongful death occurs when a person is killed due to the negligence or misconduct of another individual, company, or entity. A lawsuit for wrongful

death may be brought by the decedent’s immediate family members, usually

surviving spouses and children, sometimes parents. Wrongful death claims

arise out of a number of circumstances, such as automobile or airplane acci-

dents or exposure to hazardous conditions. Wrongful implies that a death could have been avoided by different actions or choices on the part of the

person(s) involved. Thus, in cases of wrongful death, there is someone to

blame or hold accountable. 8

Unsafe conditions are often related to the attitudes and value systems of

the person or group responsible or of society as a whole. It is naive to believe

that the risks we encounter in our lives can be totally eliminated; nonethe-

less, usually they can be minimized. Lack of resolve to take necessary actions

in correcting unsafe conditions prompts the question, How negligent must a

society be before “accidental” deaths are tantamount to homicide? 9

Risk Taking The degree of risk we assume is subject to our own choices about how to live

our lives. In this sense, “ Risk refers to hazards that are actively assessed in relation to future possibilities.” 10 Our willingness to take risks is infl uenced

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492 c h a p t e r 13 Risks, Perils, and Traumatic Death

by the images communicated in the media and popular culture. Devotees of

a strain of hip-hop music called hyphy engage in stunts in which a driver gets out of his car and dances around to a hip-hop beat on top of the slowly mov-

ing vehicle. 11 Called “ghost-riding the whip,” this stunt has led to numerous

minor injuries and has killed at least two people.

In some cases, we can exercise considerable choice about the nature and

degree of risk to which we are exposed. Think about your own life. What

risks do you face in connection with your job, leisure activities, and overall

lifestyle? Are any of these risks potentially life threatening? Do you take “cal-

culated” risks? Are some risks avoidable?

Some occupations involve dangers that most people, if given a choice,

would avoid. Such jobs include high-rise window washer, movie stuntperson,

test pilot, and explosives expert, as well as police offi cer and fi refi ghter. We

could add scientists who handle hazardous materials, mine workers, electri-

cians, heavy-equipment operators, and farmworkers who use toxic pesticides.

As you add your own examples to this list, notice whether they involve the risk

of sudden death (as from an explosion or a fall from a high-rise building) or

long-term exposure to hazardous materials or conditions. Sometimes, risks that

could harm or kill are identifi ed only after years of exposure to a hazardous

condition. Other times, people accept risks as something that “comes with the

territory,” like the hazards encountered in such professional sports as football.

To keep from tumbling through space at 125 miles per hour, this mile-high skydiver spreads arms and legs to control freefall before opening the parachute. Although risks are ever pres- ent in our lives, we expose ourselves to many of them by personal choice.

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Risk Taking 493

In Japan, job-related stress is legally recognized as a cause of death. 12

Mostly affecting men in their prime working years, victims of karoshi— sudden death from overwork—are found in virtually every occupational

category. Karoshi is characterized as a buildup of fatigue caused by “long

hours of work that clearly exceed all normal physiological limitations,” dis-

ruptions in an individual’s normal daily rhythms (often related to travel or

lengthy commutes), and other job-related strains placed on workers. The

rise of global markets (with corresponding time differences) has forced

workers to conduct business far into the night after the normal day’s work

has been completed. Karoshi is accompanied by a growing recognition that

exhaustion induced by chronic overwork can harm or kill even the healthi-

est person.

The possibility of death is also found in recreational activities: moun-

tain climbing, parachuting, scuba diving, motorcycle racing, and the like.

Such activities are sometimes characterized as thrill seeking, although this

phrase suggests motives that participants in these activities might not ascribe

to themselves. However, one climber said, “Without the possibility of death,

adventure is not possible.” 13

Although mountain climbing involves obvious risks, two climbers can

relate to these risks differently. One climber displays an attitude of aban-

don that could only be called foolhardy or death defying. The other devotes

many hours to obtaining instruction, preparing equipment, conditioning for

the climb, and asking advice from experienced climbers before deciding to

set foot on a mountain. In short, risk can be minimized. An activity may be

attractive to some individuals because of its inherent risk; other people accept risk as inseparable from other attractive features of the activity. When behav-

ior involves doing dangerous things just for the thrill of it, or as a way to

I stared in a horrifi ed trance as a fi gure appeared, frozen in the air for the brief-

est moment, its arms outstretched above its head as if in utterly hopeless sup-

plication. Then it continued its relaxed, cart-wheeling descent, with only the

thundering crashes attesting to its frightening impacts on the rock. It disap-

peared into a gully.

“Don’t look!” I screamed to my wife, who was, of course, as helplessly trans-

fi xed as I was. And the sounds continued. After a time, the fi gure came into view

at the base of the gully and continued down the pile of rubble below. My last view

of it is frozen in time. The fi gure’s arm was curled easily over its head, and its pos-

ture was one of relaxation, of napping. It drifted down that last boulder fi eld like

an autumn leaf down a rippling brook. Then it disappeared under the trees, and

only the pebbles continued to clatter down the rock. Suddenly it was very, very still.

I looked down to Debby and had to articulate the obvious: “That was a man,”

I said quietly, numbly.

William G. Higgins, “Groundfall”

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494 c h a p t e r 13 Risks, Perils, and Traumatic Death

“laugh in the face of death,” it may represent an attempt to deny fear or anxi-

ety about death. 14 Baruch Fischhoff and John Kadvany observe,

Popular wisdom holds that teens have a unique sense of invulnerability. That

belief can seemingly explain many dubious teen risk decisions. “They think that

nothing can happen to them.” Evidence suggests more complex explanations.

Contrary to the myth of perceived invulnerability, many teens exaggerate

their chances of dying young, so much so that they might take risks because

they do not expect to live, rather than because they do not expect to die. 15

When death results from a high-risk sport or similar activity, it can have

a strong impact on others who engage in the same activity. In addition to its

effect on those most immediately involved (for example, people who rented

equipment or provided instruction to the deceased), the death may affect the

larger community of participants in the sport. Such a death challenges the

assumption that cautious practice of the sport ensures safety. 16 Rumors may

circulate that the deceased failed to take necessary precautions or followed

an unwise course of action. Such rumors may serve to mitigate feelings of

guilt about having been unable to prevent the death. “Blaming the victim”

can be a means of coping that allows individuals to feel comfortable continu-

ing the activity despite the risks.

Disasters At a magnitude of 9.0, the Great East Japan Earthquake of March 11, 2011,

triggered a massive tsunami and dealt unprecedented damage to a wide area

spanning from the regions of Tōhoku to Kanto. It is considered the most

powerful earthquake ever to hit Japan. Although Japan had hazard maps

indicating areas that would be fl ooded in a tsunami, the resulting tsunami

caused by the Tōhoku earthquake “inundated a far wider range of areas than

those anticipated in the maps.” 17 The tsunami waves reached heights of more

than 130 feet and traveled six miles inland. Entire towns were devastated.

The death toll was about 16,000 people, with more than 6,000 injured, and

nearly 2,700 missing. 18

Particularly important was damage caused by the tsunami to Japan’s

nuclear reactors, especially the meltdowns, explosions, and radioactive leak-

age at the Fukushima Daiichi Complex; associated evacuation zones affected

over 200,000 residents, many of whom were still “nuclear refugees” months

later. 19 Tests showed that winds carried radioactive particles much farther

than initially thought, leading to the realization that there was an “enormous

spread of radiation.” 20 Experts said it was the second-worst nuclear accident

in history (following Chernobyl in the Ukraine).

Devastating, too, was the 2008 earthquake in Sichuan, China, at the edge

of the Qinghai-Tibet Plateau:

Nothing prepares you for the desolation of a city recovering from an

earthquake. It’s not the physical destruction that is so diffi cult to confront,

although that is bad enough. Rather, it’s the people. Traumatized people.

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Disasters 495

The roof of the world suddenly collapsed and shifted east, crushing

all those people in isolated farmhouses, in whole villages such as Fei Shui,

provincial towns such as An, and large cities such as Mianyang.

In Beichuan, the epicenter of the earthquake, most of the buildings were

still standing after the initial shock. People were standing around thanking

their lucky stars when a mountain collapsed into the valley and buried

everyone. Just like that. Ten thousand residents dead and buried in seconds.

The community of Beichuan has been wiped off the face of the earth. 21

The magnitude 8.0 Great Sichuan Earthquake affected 46 million peo-

ple. It killed more than 69,000 people. Over 18,000 were listed as missing.

Nearly 375,000 were injured. It was the deadliest earthquake in China since

the 1976 Tangshan earthquake, which reportedly killed at least 240,000

people. Persistent heavy rains and landslides affected rescue efforts. Strong

aftershocks continued for months after the main quake. Due to China’s “one-

child” policy, many parents lost their only child when thousands of schools

collapsed in the quake. The scale of the disaster prompted the Chinese gov-

ernment to dispose of dead bodies with little ceremony, closing the door on

any opportunity family members had of identifying their kin by sight and

celebrating traditional Chinese death rituals.

Caused by the 2011 Tōhoku earthquake, a tsunami with waves, in some places, reaching more than 120 feet above sea level overfl ows a fl oodwall, tossing cars, as it surges into the city of Miyako in northern Japan. Only a small number of boats survived from the town’s 960-ship fi shing fl eet. The city was devastated.

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496 c h a p t e r 13 Risks, Perils, and Traumatic Death

Although the term is sometimes applied loosely to any event with nega-

tive consequences, a disaster is generally defi ned as a life-threatening event that affects many people, usually within a brief period of time, bringing sud-

den or great misfortune. Earthquakes and hurricanes are commonly associ-

ated with major disasters, but fl oods and fi res can also be among the causes.

Consider the following account of the 2009 bushfi res in Australia:

They were the most dangerous weather conditions, and they colluded to

propel 190 separate fi res on winds up to 95 kilometers per hours to raze

2,000 houses, schools, shops, community centers, even entire towns. We could

have sat shocked and numbed as the horror toll of Australia’s worst natural

disaster climbed to an incomprehensible tally of more than 200 dead and an

incalculable loss of pets, stock, and wildlife.

In the wake of this, the instantaneous response of people of compassion

across the world was to ask themselves: What can I do? How can I help people

who have lost everything? 22

A similar compassionate response to disasters, both among victims them-

selves and by those outside the affected area, leads to a narrative of help that is

sometimes ignored in media reports. For example, in the wake of Hurricane

Katrina, in contrast to media accounts of criminal activity and other nega-

tive portrayals of New Orleanians, especially those most vulnerable, “insider

accounts” revealed that survivors showed a depth of compassion and intro-

spection rarely seen or heard in news stories. Disaster survivors’ stories are

among their most important remaining possessions (see Figure 13-1 ). Many

emerge from the ruins with little more than memories and their accounts of

heroism and endurance. 23

Disasters result from natural phenomena—such as those just described—

as well as from human activities. This latter category includes chemical

spills, building collapses, nuclear contamination, fi res, and airplane crashes.

It includes devastating industrial accidents, as with the fi re at the Triangle

Shirtwaist Company, a garment factory, that killed 146 young women in New

York City in 1911, which still rates as the worst industrial factory fi re in the

United States. The worst factory fi re ever occurred in 1993, when a toy factory

in Thailand killed 188 workers and severely injured 469 more. The actual

death toll may have been higher because the four-story building collapsed

and many bodies were incinerated, some never to be found. In both of these

disasters, it was reported that failures on the part of factory owners, elected

offi cials, and bureaucracies responsible for enforcing public safety and health

standards had resulted in unsafe working conditions that led to disaster. 24

On April 24, 2013, an eight-story building in the capital city of Bangla-

desh collapsed. When the search for the dead concluded, the toll was more

than 1100, mainly garment workers who had been ordered to return to work

despite warnings about cracks that had been discovered in the building the

previous day. Moreover, the upper four fl oors had been constructed without

a permit, and architects warned that the structure was not strong enough to

support the weight and vibration of heavy machinery. All these warnings were

ignored by the building’s owner.

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Disasters 497

What is your reaction to reading about these recent events in Australia,

Bangladesh, China, and Japan? What can we learn about disasters and our

responses to them?

Risk theorists point out that modern technological systems are com-

plex and fail in ways that cannot always be anticipated, with minor events

unexpectedly interacting to produce a major problem, a phenomenon that

Charles Perrow calls a “normal accident.” 25 As one writer concludes, “We

have constructed a world in which the potential for high-tech catastrophe

is embedded in the fabric of day-to-day life.” 26 Experts say that disasters are

becoming more frequent worldwide, now happening at a rate of about 1000

a year. Climate change may be a factor. They are also “becoming more cata-

strophic, as population growth makes increasing numbers of people vulner-

able to the impact of disasters.” 27

Figure 13-1 Japanese Child’s Tsunami Drawing A fi rst-grade child’s portrayal of the tsunami caused by the Tōhoku earthquake shows a torrent of water as 33-foot waves triggered by the earthquake sweeps into her city of Kesennuma, a port on the coast near the quake’s epicenter. She draws the swirling wall of water carrying people, cars, and fi sh as it begins to engulf houses in the town of more than 73,000 people. The sun, drawn in red with large black eyes and an open mouth, looks down upon the devastation. Haruna and her older sister, Natsumi, expressed the hope that, through their drawings, “as many people as possible in the world can learn what happened to them.”

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498 c h a p t e r 13 Risks, Perils, and Traumatic Death

Reducing the Impact of Disasters Communities can decrease the risk of injury and death by taking pre-

cautionary measures to lessen the impact of a potential disaster. Adequate

warnings of an impending disaster may be withheld due to greed, political

expediency, uncertainty about the nature and extent of the threat, or con-

cerns about causing panic. The tragedy that followed the eruption in 1902

of the Mount Pelée volcano, on the island of Martinique in the West Indies,

shows how information that could warn potential disaster victims may be

mismanaged, with disastrous consequences. The offi cials of the nearby com-

munity of Saint-Pierre were alerted to the likelihood that the volcano would

erupt. But, concerned that the population would panic if notifi ed and thus

thwart their plans for an upcoming local election, offi cials withheld warning

of the danger from the populace. As a result, almost the entire population of

the small community was incinerated. The May 1980 eruption of Mount St.

Helens, in Washington state, provides comparison. Even though this erup-

tion was larger, only sixty lives were lost, compared with the 30,000 casualties

resulting from the eruption of Mount Pelée. In part, this difference was due

to adequate warnings of the hazard and timely establishment of a restricted

zone of access. 28

Individuals who live in areas where disasters are a common occurrence—

for instance, earthquake or hurricane—may rationalize the danger as “play-

ing the percentages.” Similarly, predictions of potential disasters are often

met with the response, “I’ve never been affected before. Why should I worry

now?” This is the apparent attitude of people who, hearing about an incom-

ing tsunami, head for the ocean. It seems that people deliberately underesti-

mate the risks to themselves. 29

Warnings are not always timely or adequate, as with the 2004 Indian

Ocean tsunami triggered by a magnitude 9.0 earthquake off the Indonesian

island of Sumatra. Traveling at a speed of 500 miles an hour, the tsunami

brought huge waves to coastal areas across the Indian Ocean, killing over

230,000 people in more than a dozen countries. Especially hard hit were Indo-

nesia, Sri Lanka, India, and Thailand. Relief workers had to get food, water,

and medical supplies into remote areas where roads had been destroyed, as

well as identify dead and missing, a job made diffi cult by the large number of

tourists vacationing in the region. As plans were put into practice for a better

warning system, experts concluded that equally needed were more effective

systems of evacuation and disaster relief.

Similar conclusions accompanied events when Hurricane Katrina came

ashore in southern Louisiana in August 2005. It killed more than 1500, left

hundreds of thousands homeless, laid waste to 90,000 square miles of land,

and ravaged one of America’s most storied cities. 30 The storm surge oblit-

erated coastal communities. The suffering of survivors continued for days

and weeks after the storm passed. A Senate investigation reported a “failure

of government at all levels to plan, prepare for, and respond aggressively to

the storm.” 31

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Disasters 499

Coping with the Aftermath of Disaster What can be done when disaster strikes? What kind of help is needed in

its aftermath? Imagine the situation: People are injured, some are missing,

others are dead. In the wake of a disaster, the survivors may experience an

“existential crisis” marked by a profound sense of emptiness and despair. 32

They are likely to be in a state of shock, uncertain of the whereabouts of loved

ones and about the future. Community grief can be a complex process that

takes months or years to fully resolve. 33 One writer says, “Where counseling

is provided, the focus should be on providing information and support, help-

ing the community towards its own recovery.” 34

Among the fi rst steps to be taken in responding to a disaster are a set of

core actions collectively defi ned as psychological fi rst aid. Following the onset of disaster, the actions of local, regional, or national authorities lie in three

areas: (1) the rescue and treatment of survivors; (2) the repair and mainte-

nance of basic services; and (3) the recovery and management of bodies. 35

Meeting the immediate needs of survivors—providing food and shelter, car-

ing for medical needs, and restoring vital community services—is essential.

Even as attention is focused on physical needs, however, the emotional needs

of survivors must be addressed. 36 Ministering to these needs might include

forming a missing persons group to help alleviate the anxieties of survivors

worried about the safety of relatives.

Locating and caring for the dead is an important aspect of helping survi-

vors cope with the trauma of disaster. The humanitarian care and treatment

of the dead have an important effect on the recovery of a community after any

disaster. 37 The comment of one relief agency worker, “It doesn’t really make

too much sense to dig up the dead and then go and bury them again,” reveals

an unfortunate ignorance of the human emotions that surround disposition

of the dead. Although most efforts directed toward coping with disaster are

focused on the emergency or crisis period, regaining emotional stability can

take years. The disaster response team that comes to assist survivors recover-

ing from disaster is usually present for only a brief time; it rapidly dissolves

with the end of the emergency period.

On the day before a hurricane hits, the phone rings.  A man’s voice speaks; he

sounds like a computer, like he has an iron throat. I cannot remember exactly

what he says, but I remember it in general. Mandatory evacuation. Hurricane making landfall tomorrow. If you choose to stay in your home and have not evacuated by this time, we are not responsible. You have been warned. And these could be the consequences of your actions. There is a list. And I do not know if he says this, but this is what it feels like: You can die.

This is when the hurricane becomes real.

Jesmyn Ward, Salvage the Bones

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500 c h a p t e r 13 Risks, Perils, and Traumatic Death

Responding to disasters usually requires priority setting, rationing, and

triage, all of which can involve coercive measures that override individual lib-

erty and property rights. 38 When disasters involve traumatic death, the mini-

mal goals that must be kept in mind for strategies of intervention include the

following: 39

1. Normalizing the situation

2. Minimizing recovery time

3. Reducing distress

4. Restoring function

5. Mobilizing resources

Also to be considered are the helpers who come to the aid of the survi-

vors of a disaster. They may also become “survivors” because of their intense

encounter with human suffering and tragedy. Consider the experience of

a Kansas City doctor who arrived at the scene of a hotel disaster to fi nd,

among the debris left when a balcony collapsed onto the lobby below, bodies

chopped in half, decapitated, and maimed. He watched as a critically injured

man’s leg, trapped under a fallen beam, was amputated with a chain saw.

When things returned more or less to normal, he said that he felt the need

to spend some time away from reminders of the disaster to cope with his own

experience as a survivor.

With federal support lacking, local and state death systems in Louisiana were over- whelmed. Bodies of the dead lay in the streets of New Orleans for days following Hurricane Katrina’s devastation, a scene that most of the U.S. population thought could never occur in their country.

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Violence 501

When a storm dumped twenty inches of rain in one night on a coastal

community in California, residents awoke the next morning to the news that

twenty-two people had been killed, more than a hundred families had lost

their homes, and another 3000 homes had been severely damaged. Within

a few days, an impromptu organization was set up to help survivors deal with

the psychological trauma of their losses. Known as Project COPE (Counseling

Ordinary People in Emergencies), it provided counseling to disaster victims

and coordinated the services of more than a hundred mental health profes-

sionals. 40 Counselors found that the grief reactions of people who had lost

loved ones or property were heightened by the sudden, capricious nature of

their losses. Some who had lost only material possessions felt guilty for mourn-

ing the loss of property when others had had family members die. Some felt

guilty for surviving the disaster. Those made homeless by the storm felt iso-

lated and alone. Bureaucratic delay and uncooperative insurance companies

and government agencies caused people to feel angry and frustrated. Many

victims felt anxious, vulnerable, and depressed. For some, old problems related

to personal or relationship issues reemerged in the aftermath of the disaster.

COPE set up programs to respond to each of these problems. Survivors

were reassured that their reactions were normal and their grief legitimate.

Counselors helped them sort out their priorities so they could begin to solve

problems created by the disaster. Emergency crews and relief workers were

included in these helping efforts. Although we cannot eliminate the encoun-

ter with death that accompanies disaster, steps can be taken to reduce its

impact, preserve life, and demonstrate compassion for survivors.

Violence Violence is one of the most potent of our encounters with death. It can

affect our thoughts and actions even when we have not been victimized our-

selves. Potentially, anyone may become its victim. In the most recent year for

which statistics are available, nearly 14,000 murders occurred in the United

States. 41 In two-thirds of these, fi rearms were used as the murder weapon.

While almost 15 percent of these murders were related to the commission of

The recent discovery that humans have only twice as many genes as fruitfl ies has

tipped the balance in the nature-nurture debate back to nurture. On this evi-

dence it is our culture, history and belief-systems which make us what we are. We

look at the rest of nature and see carnivores killing to eat, but we do not see zebras

forming armies to wage war on gnus. It is only humans, with their congenital vice

of inventing differences of politics and faith, who murder one another because

they disagree, and what makes the tragedy more poignant is that the less secure

their grounds for belief, the more anxious and violent their adherence to it—and

the greater their readiness to kill and die in its defence.

A. C. Grayling, Life, Sex, and Ideas

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502 c h a p t e r 13 Risks, Perils, and Traumatic Death

a felony, about 85 percent were related to gang killings, alcohol-infl uenced

brawls, “romantic triangles,” arguments over money or property, and other,

unspecifi ed causes.

Emergency room physicians report being besieged by patients whose inju-

ries are identical to wounds incurred by soldiers in combat. These wounds

result from semi-automatic assault weapons that fi re dozens of bullets per

minute at several times the velocity of an ordinary pistol: “Organs that would

have been merely grazed or even cleanly pierced by a handgun bullet are

exploded by assault weapon fi re, requiring massive transfusions of blood.” 42

Young people are disproportionately represented among victims of vio-

lence. 43 One of the most troubling aspects of handgun violence “is the fact that

children very often are the victims of fatal gunshot wounds, self-infl icted either

intentionally or accidentally, or received as innocent bystanders in scenes of

domestic or street violence.” 44 Rap musician Ice-T has drawn attention to the

condition of his hometown, South Central Los Angeles. Gang warfare, he says,

is comparable to other wars: Members of gangs are like “veterans from war,”

and “thousands of people have died on each side of this bloody battlefi eld.” 45

In Detroit, a mother whose sixteen-year-old son had been shot while

walking to a neighborhood store with friends told a reporter that similar

shootings occurred every night. “They shoot like it’s their job or something,”

she said. “All I want to do is move to someplace safe,” she added. “Someplace

where there’s no shooting on your block or the next block over. That’s all.

That’s good enough. Just two safe blocks.” 46

Violence resulting from gang warfare has even intruded upon the serene

setting of the cemetery. In Anaheim, California, two men died of multiple

gunshot wounds they received while visiting the graves of two fellow gang

members who had been murdered the previous year. 47

For some, guns are more than just weapons; they are potent symbols of

power and energy. One young man said,

When you are carrying a gun, I think other people can tell. Some kind of way

a gun makes you light up. If you don’t have a gun on you, a dude might mug

you down. People don’t mug you if you’ve got your gun on. They can detect

something about you that wasn’t there before. 48

Children who witness violence have been called “silent victims.” They

may be physically unharmed but are nevertheless emotionally affected

as they hear gunshots outside their homes, witness shootings on the play-

ground, or have a family member (often an older sibling) involved with vio-

lence. 49 In describing a community-based approach to violence prevention in

Richmond, California, Larry Cohen and Susan Swift remark,

Interpersonal violence, although most concentrated among youth in densely

populated, low-income communities, affects everyone in the United States.

An awareness of violence permeates the environment, determining where

people prefer to live, where they shop, how they respond to strangers on the

streets, where they walk and drive, and how late at night they stay outside of

their homes. Unlike any other environmental threat, violence has turned into a

public health epidemic. 50

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Violence 503

Random Violence The most threatening of violent acts are those that occur without appar-

ent cause. Victims are selected seemingly at random, thus heightening anxi-

ety that violence could unexpectedly confront anyone. In July 2012, a mass

shooting inside a movie theater in Aurora, Colorado, killed twelve people

and injured seventy others. In December of the same year, a gunman fatally

shot twenty children and six adult staff members in a mass murder at Sandy

Hook Elementary School in Newtown, Connecticut. People expressed feel-

ings of being personally threatened because these violent acts had taken

place “so close to home.”

One woman described a potential encounter with death that began inno-

cently enough when she answered a knock on her door. Recognizing a former

schoolmate whom she hadn’t seen in a long time, she invited him in, and they

began to chat. She began to feel uneasy, although she couldn’t say why. About

two months later, she heard on the news that her visitor had been arrested (he

was subsequently convicted) for the brutal murders of several young women.

The murders had occurred around the time of his unexpected visit. Recall-

ing the experience, this woman commented, “I sometimes wonder how close

we are to death at times and just not realize it. It seems we really never know.”

Serial Killers and Mass Murderers Serial killers, the category of murderer encountered by the woman just

described, take the lives of several victims over a span of time. Mass murderers, in contrast, kill many victims at once, in one place, such as a school or place

of employment. Reviewing the motivations of serial killers, Dana DeHart and

John Mahoney conclude that “one of the more disturbing aspects of serial

murder is that virtually everyone is at some risk. Even cautious and circum-

spect persons are not safe from a serial killer; the victims need not provoke or

even be acquainted with the killer.” 51

In 2007, in two separate attacks about two hours apart, a twenty-three-

year-old senior at Virginia Tech in Blacksburg killed twenty-seven students

and fi ve teachers and wounded many others before killing himself. The mas-

sacre was reportedly the deadliest shooting incident by a single gunman in

U.S. history. The shooter, Seung-Huo Cho, mentioned “martyrs like Eric and

Dylan,” apparently referring to the perpetrators of shootings at Columbine

High School. Cho had previously received therapy for a severe anxiety disor-

der, although the university had not been informed of this diagnosis because

of federal privacy laws. This event, like those that preceded it and those that

followed it, sparked debate about U.S. laws and culture, particularly gun vio-

lence, fi rearms laws, privacy issues, and the mental health system.

Mass murders and serial killings are not limited to the United States,

however. In 2002, a gunman shot sixteen people before killing himself at

a school in eastern Germany. And, in 2009, a seventeen-year-old former

student at a technical school near Stuttgart, Germany, killed nine students

and three teachers before continuing his murderous spree, killing several

passers-by before being killed by police in a shoot-out. Nor is mass murder

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504 c h a p t e r 13 Risks, Perils, and Traumatic Death

Distraught students grieve the violent deaths of friends in the aftermath of a shooting ram- page carried out by schoolmates on their campus.

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Violence 505

an affl iction only of our current times. In 1927, in Michigan, a school board

offi cial killed his wife, then blew up the town’s school, killing a total of forty-

four people, including thirty-nine students and teachers.

Familicide Familicide is the murder of family members by another family member. 52

In other words, familicide is a multiple-victim homicide in which the killer’s

spouse or partner and one or more children are killed. Although familicide

is relatively rare, it is nevertheless the most common form of mass killing. It

is distinguished from other types of mass murder in that victims are family

members rather than being anonymous or unknown to the murderer. Most

familicides are perpetrated by men, who, after the murders, kill themselves

as well. Regardless of gender, familicide is often followed by the suicide of the

murderer.

Among the reasons cited for familicide are custody disputes following

marital separation; a parent’s wish to stop children’s suffering, perhaps due

to domestic violence or sexual abuse; feelings of shame resulting from a job

loss or perceived inability to provide for family members; other fi nancial

reversals; and a history of mental illness, including severe depression or psy-

chosis, such as schizophrenia or a manic-depressive disorder.

Some experts fi nd that women are more likely to kill their children than

men are, whereas men are more likely to kill both their children and their

spouse. Women may have different motives or reasons for familicide than do

men. Women tend to kill their children because of a delusional sense of altru-

ism, or selfl essness. Mothers are more likely than fathers to be diagnosed as

mentally ill at the time of their offenses.

For someone who is psychotically depressed, the whole world is dull gray,

and one’s children are seen through a lens of suffering and emotional pain,

causing the killer to believe that the children, too, are suffering. Thus, the

killer may believe that they would be better off in heaven or some other para-

dise. Killing is perceived as a selfl ess decision, one carried out with the hope

of relieving suffering but with horrifi c results.

Psychosis can lead a perpetrator to believe that the killing of a child is

done with the goal of ending the child’s suffering or because the child is

demonically possessed. In the second case, the killer may see the child not

as suffering but as unredeemably evil. For the protection of others, he or she

must be killed.

Familicide also encompasses murders in which a parent or parents and

other relatives such as siblings, in-laws, or grandparents are killed. The kill-

ing of a close relative is referred to as parricide. Parricide is commonly associ-

ated with delusional or faulty mental processes. Patricide is the act of killing

one’s father, and it is most often committed by a son against the father. Other

terms related to familicide include fi licide (the killing of one’s child or chil-

dren), mariticide (the killing of one’s spouse), and fratricide or sororicide

(the killing of one’s brother or sister).

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506 c h a p t e r 13 Risks, Perils, and Traumatic Death

Steps Toward Reducing Violence The term psychic maneuvers has been used to describe the factors that

facilitate murder and other homicidal acts (see Table  13-1 ). You may fi nd it

interesting to review this list three times. First, consider how each of these

psychic maneuvers might function in your own life. Notice that they do vio-

lence to ourselves and others, even when they function far more subtly than

the overt act of homicide. Second, note how these psychic maneuvers func-

tion within society, how they contribute to violence between individuals and

between groups. The third time, consider how each of these psychic maneu-

vers may be a dysfunctional strategy found in confl icts between nations.

Victims sometimes play a role in encouraging violent acts against them-

selves. Homicide investigators have found that victims are not always as

innocent as might initially be assumed. Consider the example of a husband

who has been repeatedly threatened by his angry wife, who wields a loaded

revolver. His response to this threat is, “Go ahead, you might just as well kill

me.” What can be said about his role as a victim in such circumstances? Or

consider another such incident: A daughter, overhearing her parents argu-

ing, tries to intercede but is told by her mother, “Never mind, honey, let him

kill me.” After the daughter leaves the house to seek assistance, her father

obtains a revolver from another room and shoots and kills the girl’s mother.

Investigators note that, during domestic strife, wives have made state-

ments like “What are you going to do, big man, kill me?” coupled with

dares like “You haven’t got the guts.” Such statements combine “elements of

Anything that physically or psychologically separates the potential killer from the victim. For example, the use of a gun leads to a concentration on the means (pulling the trigger) rather than the end result (the death of a person). Psychological sepa- ration occurs when the victim is perceived as fundamentally different from oneself.

Anything that permits the killer to defi ne murder as something else, such as “making an example of the victim,” “making the world safe for democracy,” “implementing the fi nal solution,” or “exterminating the terrorists.”

Anything that fosters perceiving people as objects or as less than human. This happens when victims become “cases,” “subjects,” or “numbers,” as well as when the killing occurs from a distance, as with high-altitude bombing or submarine warfare.

Anything that permits one to escape responsibility by blaming someone else: “I was just carry- ing out orders.”

Anything that encourages seeing oneself as debased or worthless: “If I’m treated like a rat, I might as well act like one. What have I got to lose?”

Anything that reduces self-control or that is believed to have this effect: alcohol, mind- altering drugs, hypnotism, mass frenzy, and the like.

Anything that forces a hasty decision or that does not permit time for “cooling off.” That is, a situation may force one to decide to shoot or not to shoot with no opportunity for deliberation.

Anything that encourages a person to feel above or outside the law: The notion that rank, prestige, wealth, or the like makes it possible for one to “get away with murder.”

t a b l e 13-1 Factors Favoring Violence

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War 507

seduction and lethality.” 53 In some instances, there are indications that the

victim not only seemed to be “asking for it” but also was the one responsible

for escalating the confl ict to the level of physical violence.

While recognizing that victims sometimes do contribute to bringing vio-

lence on themselves, we should be cautious about blaming victims. Lula Red-

mond underscores the fact that labeling victims as bad, careless, seductive,

or “with the wrong crowd,” or as somehow “asking for it,” denies the reality

that everyone is vulnerable to victimization. 54 Blaming the victim is a conve-

nient, albeit erroneous, way to overcome one’s own sense of vulnerability and

thereby regain a sense of personal security. If suitable “explanations” can be

found for a victim’s death, they provide convincing, though perhaps unwar-

ranted, proof that a similar encounter could never happen in one’s own life. More effective than blaming the victim is understanding the factors that

favor violence and taking action to reduce their presence in our own lives and

in society as a whole. Discovering ways to break the cycle of violence is impor-

tant, whether in the home, the community, or the world at large. 55

The sense of social isolation that helps breed violence is counteracted

when families take care to communicate positive community values. When

residents work together to create a safe and orderly environment and when

neighbors themselves take a measure of responsibility for maintaining social

order, studies show that violence is reduced. 56 Cohen and Swift argue that

“stopping the momentum of violence requires a ‘critical mass’ of people who

are willing to speak out and to work together to change the structures and

policies that frame the way we live.” 57

War Within the context of ordinary human interaction, our moral and legal

codes stand in strict opposition to killing. In war, however, killing is not only

accepted but may be heroic. War abrogates conventional sanctions against

killing by substituting a different set of conventions and rules about moral

conduct. The expectation that one will kill and, if necessary, die for one’s

country is a concomitant of war. As Arnold Toynbee says, “The fundamental

postulate of war is that, in war, killing is not murder.” 58

At the beginning, World War I seemed to many people little more than

a game, almost idyllic, even ennobling and beautiful. Of course, such senti-

ments did not last. The war’s devastatingly huge impact, especially on Europe,

simply states the obvious. It has been called “the turning point in the history

of the earth.” 59

In Dalton Trumbo’s classic antiwar novel, Johnny Got His Gun, we fi nd a veteran “without arms legs ears eyes nose mouth” who devises a means of

communicating with the outside world by “tapping out” messages on his pil-

low with his head. 60 He asks to be taken outside, where he can become an

“educational exhibit” to teach people “all there was to know about war.” He

thinks to himself, “That would be a great thing to concentrate war in one

stump of a body and to show it to people so they could see the difference

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508 c h a p t e r 13 Risks, Perils, and Traumatic Death

between a war that’s in newspaper headlines and liberty loan drives and a war

that is fought out lonesomely in the mud somewhere, a war between a man

and a high explosive shell.”

In more than twenty countries around the world, children are direct partici-

pants in war. An estimated 200,000 to 300,000 children serve as soldiers for both

rebel groups and government forces in armed confl icts. According to a United

Nations report, these child soldiers, girls as well as boys, are forcibly recruited as

combatants, denied a childhood, and often subjected to horrifi c violence. 61

Chivalrous notions of combat, in which mounted men-at-arms meet gal-

lantly to do battle on an uninhabited hill or plain, have been replaced in

modern times by the reality of mass technological warfare.

Technological Alienation In recalling the epic battles of Achilles and Agamemnon, of the legend-

ary King Arthur and the Knights of the Round Table, or of the samurai in

medieval Japan, we encounter a view of warfare as heroic. The enemy is seen

as a worthy opponent with whom one is engaged in a “metaphysic of strug-

gle.” 62 This sense of chivalry is now largely absent from warfare. Instead of

individual initiative and courage, modern warfare emphasizes bureaucratic

cooperation and calculation. Technological alienation has been called the most characteristic feature of the modern war machine. 63

Not until World War I did warfare involve civilians on a large scale. In

April of 1937, during the Spanish Civil War, the world was horrifi ed by the

aerial bombing of the Basque town of Guernica that killed civilians of both

sexes and all ages. By the end of World War II, civilian victims of warfare out-

numbered military casualties. The estimated number of civilians killed dur-

ing the Second World War is shown here: Britain (70,000), France (391,000),

Japan (953,000), Germany (2,000,000), Soviet Union (7,700,000), and China

(20,000,000). 64 In the recent war in Iraq, it is estimated that civilian deaths

may have accounted for 90 percent of total deaths. 65

Early warfare had limits: the bow and arrow, the bullet from a gun, the

artillery shell. These conventional limits of warfare were radically altered

with the advent of the atomic bomb, unleashed on Hiroshima and Nagasaki

in August 1945.

The ease of access to target and the instant nature of macro-impact [large-scale

destruction] mean that both the choice of city and the identity of the victim

have become completely randomized, and human technology has reached a

fi nal platform of self-destructiveness. . . . At Hiroshima and Nagasaki, the “city

of the dead” is fi nally transformed from a metaphor into a literal reality. 66

At Hiroshima, the bomb fell near the center of the city, and its explosive

force, heat, and radiation engulfed all of the city. A soldier who saw the city

the next day left this description:

I could fi nd nothing but a wide stretch of burned ruins with a lot of debris.

Where had the former city of Hiroshima gone? . . . The seven rivers that ran

through the city were full of corpses, soot, smoke, and charred driftwood,

stretching like black lines through Hiroshima, which was reduced to ashes. 67

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War 509

The characteristic human response to such carnage is one of psychic numbing. Exposed to mass death, the self-protective psychological response is to become insensitive and unfeeling. “Jet pilots who coolly drop bombs on

people they never see tend not to feel what goes on at the receiving end,” and

“those of us who watch such bombing on TV undergo a different though not

unrelated desensitization.” 68

Because of the sheer horror of it, we tend to think the bombing of Hiro-

shima was the worst attack on a city in history. But, as Ward Wilson points

out, “the fi rst of the conventional raids, a night attack on Tokyo on March

9–10, 1945, remains the single most destructive attack on a city in the history

of war.” 69

Confronted by the death-dealing potential of modern weaponry, it is

worth remembering the story of Dalton Trumbo’s veteran, who wanted to

be a living exhibit of the ravaging, destructive effects of war. His request was

denied, the story explains, because “he was a perfect picture of the future

and they were afraid to let anyone see what the future was like.” Images of the

dead and dying, of the emaciated, of terrifi ed children, and of ravaged cities

seem not to fi t the earlier codes of noble sacrifi ce. 70

The dropping of the atomic bombs on Japan seems to have marked the

removal of all moral restraints. Distinctions between combatants and non-

combatants had been blurred, if not erased. According to a widely cited study

by the International Red Cross, nine out of ten casualties in modern warfare

are civilians—men, women, and children who simply “got in the way of some-

body’s war.” 71

Glenn Vernon observes that “confrontation with wartime killing may be

one of the most diffi cult experiences of those who have been taught to avoid

killing.” 72

The Conversion of the Warrior War activates a special set of conventions that make it psychologically pos-

sible for individuals to go against the grain of what they have learned about

right and wrong—to put aside ordinary rules of moral conduct. As long as the

combatant “keeps more or less faithfully to the recognized rules,” Toynbee

says, “most of humankind have been willing to alter their moral sense in such

Perhaps the whole root of our trouble, the human trouble, is that we will sacrifi ce

all the beauty of our lives, will imprison ourselves in totems, taboos, crosses, blood

sacrifi ces, steeples, mosques, races, armies, fl ags, nations, in order to deny the fact

of death, which is the only fact we have. It seems to me that one ought to rejoice in

the fact of death—ought to decide, indeed, to earn one’s death by confronting with passion the conundrum of life. One is responsible to life: It is the small beacon in

that terrifying darkness from which we come and to which we shall return. One

must negotiate this passage as nobly as possible, for the sake of those who are com-

ing after us.

James Baldwin

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510 c h a p t e r 13 Risks, Perils, and Traumatic Death

a way as to regard the killer in war as ‘being righteous.’” 73 One convention of

warfare, Toynbee points out, is to dress the part. The psychological effect of

the uniform is that it “symbolizes the abrogation of the normal taboo on kill-

ing fellow human beings: it replaces this taboo by a duty to kill them.”

The tension and hyperalertness of combat can produce an addictive

“high.” A Marine who fought in the Gulf War describes the moments before

combat:

We are all afraid, but show this in various ways—violent indifference, fake ease,

standard-issue bravura. We are afraid, but that doesn’t mean we don’t want to

fi ght. It occurs to me that we will never be young again. . . . The supposedly

anti-war fi lms have failed. Now is my time to step into the newest combat zone. 74

Joel Baruch, another combat veteran, says, “Changes in personality and

mood are rooted in the special climate of the combat zone. These mutations

evolve in such a wily fashion that the person who undergoes them is not aware

of the alterations himself.” 75 The conventions of war are mind- and personality-

altering. Here is Baruch’s account of his fi rst encounter with death on the

battlefi eld:

Stone dead, he was. Eyes wide open, staring at nothing. A thin veneer of blood

curling at the corner of his lips. Two gaping holes in his chest. Right leg half

gone. My fi rst combat fatality. A lifeless body where only moments before a

heart beat its customary seventy pumps in one orbit of the minute hand. It is

one thing to hear about death; to watch it happen is quite another. I went over

to the nearest tree and vomited my guts out.

By his next experience of combat death, however, Baruch began to ques-

tion whether he was becoming callous and unfeeling: “I was becoming imper-

vious to the death of my fellow soldiers, and, in addition, I was negating the

possibility of my own . . . demise.” Another veteran explains,

Social context is much more important than most people realize. We pretty

much live within the boundaries of one social context. If you lived in a different

society, you would consider a different set of behaviors as normal. What’s

bewildering and frightening in the combat situation is how quickly “normal”

can change. 76

Each of us experiences differences in our behavior according to social

context. How we behave among our relatives is likely to be different from how

we behave among strangers or business associates. Usually, such differences

are subtle and rarely met head on. The contradictory values that exist for

the soldier in combat, however, require what the veteran just quoted calls “a

much more total ‘schizophrenia’”:

When you’re there you don’t really remember what it’s like to come back into

the social context of a society where killing is abhorrent. And, when you come

back home, you don’t really remember the context of the combat situation,

except perhaps in your nightmares.

A soldier who fought in the Iraq War with the 1st Infantry Division said,

“I don’t think we should be fi ghting a war there for any reason whatsoever,

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War 511

but . . . there’s no politics involved when it actually happens, when it comes

down to you having to exchange rounds with someone.” 77 Heroic intentions

and patriotic feelings may be reasons for donning the uniform, but in combat

the emphasis is likely to be on survival. 78

When societies refl ect on their participation in war, they often speak in

terms of patriotism, the heroism of fi ghting for one’s country, the need to

defend the things that are held dear. When we listen to the words of those

who have experienced combat, however, we hear a different value system at

work. We hear about individuals fi ghting for their lives.

Coping with the Aftermath of War Combatants do not necessarily resolve their losses merely by leaving the

war zone or by being discharged from military service. They may experience

nightmares and fl ashbacks to traumatic scenes. Many experience such symp-

toms as numbness, irritability, depression, relationship problems, and survi-

vor’s guilt at having survived when others did not.

The term posttraumatic stress disorder (PTSD) has been used to describe such symptoms, although such reactions have also been termed delayed grief syndrome or posttraumatic grief disorder. 79 Known as “shell shock” during World War I and “battle fatigue” during World War II, PTSD fi rst became promi-

nent in the aftermath of the Vietnam War.

Psychiatrist Jonathan Shay fi nds parallels between the grief and rage

experienced by modern combat veterans and the description in Homer’s

An Army casualty team moves a transfer case containing the remains of Spc. Javier Sanchez, Jr., who died in Afghanistan, in the hills south of Kabul, when his unit was attacked with an improvised explosive device (IED) while on patrol.

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512 c h a p t e r 13 Risks, Perils, and Traumatic Death

Iliad of similar symptoms experienced by warriors who fought in the Trojan Wars three thousand years ago. 80 In the Iliad, we read about chilling atroci- ties committed by Achilles in a berserk rage following the battlefi eld death of

his friend Patroclus. Shay says, “There have been technological changes, but

there have been no changes to the human mind and heart and soul.” One

of the lessons to be learned from the Iliad, says Shay, is that soldiers should be allowed to grieve: “Snatching bodies off the battlefi eld in black bags and

spiriting them back to stateside mortuaries without permitting comrades to

mourn the fallen is profoundly damaging to survivors.”

Combat leaves haunting memories. After the shooting stops, the mind

must sort out the almost incomprehensible facts of war. One helicopter door

gunner told his friends to stop boasting about achieving high casualties after

he saw dead enemy troops for the fi rst time. “It’s different when you see their

faces, with blood coming out of their wounds,” he said. 81 A Marine captain

who served in Afghanistan said:

My squad saw a motorcycle racing toward us. The two riders did not respond

to our shouts to stop, and we began fi ring and killed them. The riders turned

out to be unarmed civilians, and one looked no older than 16. Every day I think

about those people and others whose deaths I ordered. I am haunted by the

feeling that “I’m no longer the ‘good’ person I once thought I was.” 82

The Veterans Administration has a phrase for this feeling: moral injury. Even if killing is necessary in war, taking the lives of other human beings vio-

lates a deep prohibition that often cannot be rationalized away.

Of the more than 2.3 million soldiers who have served in Afghanistan

and Iraq, the Veterans Administration has treated more than 210,000 for

posttraumatic stress disorder while acknowledging a much bigger epidemic

that is hidden because the stigma of mental health problems prevents many

veterans from seeking help. Veterans are returning to “a county largely oblivi-

ous to the wars in which they served, heightening their feelings of loneli-

ness and alienation.” 83 Reports indicate that the military has been remiss in

treating PTSD. Confusing paperwork and inconsistent guidelines are among

the factors that have hindered the services in dealing with behavioral care

issues. The recent past has also seen an epidemic increase in the number of

military suicides and suicides of veterans (discussed in Chapter 12). 84 Medita-

tion, hundred-mile “Last Patrol” walks, sweat-lodge rituals, honoring dances,

and other traditional as well as novel activities have helped some veterans

come to terms with their experiences and heal from wounds received in war.

Some Iraq veterans have attended a unique fl y-fi shing camp in Idaho geared

to help veterans with severe traumatic brain injury rebuild physical skills,

rediscover confi dence and independence, and reintegrate into their com-

munities. Before camp, therapists consult with each veteran and help them

identify goals and map out a plan to achieve them. Afterwards, they follow up

with the veterans for three years. The veterans learn to recognize what trig-

gers their stress and how to manage it through recreation. One veteran said,

“Everything I lost, they gave it back to me tenfold.” 85

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War 513

Besides PTSD and other mental health issues, thousands of veterans are

returning with catastrophic injuries, such as double and triple amputations

and debilitating spinal cord damage. Improvised explosive devices are caus-

ing an increase in traumatic brain injuries, considered the “signature injury”

of these wars. 86

The families of men and women in the military make sacrifi ces that

often go unnoticed (see Figure 13-2 ). In recalling her odyssey as the wife of

a Marine Corps offi cer, Marian Novak says, “I watched my husband train for

war; I waited thirteen months for him to return from it; and then I waited

another fi fteen years for him to truly come home.” 87 War creates a “phan-

tom army” composed of the spouses, children, parents, and friends who serve

invisibly at home. Lee Woodruff, whose husband was seriously injured during

the Iraq War, said,

I bristled when, in an effort to make me feel better, people would say to me,

“Things happen for a reason” or “God doesn’t give you more than you can

handle.” It felt like greeting-card philosophy to try to package something so

complex into bite-sized chunks. 88

The euphemistic term “collateral damage” encompasses not only the

civilian deaths that occur in a war zone but also the grief experienced by

families whose lives are disrupted by the injury or death of loved ones serving

in war zones.

The Vietnam Veterans Memorial in Washington, D.C., has become a

“wailing wall” for the families and friends of the more than fi fty-eight thou-

sand whose names are engraved there, as well as for those who served and

survived. Many visitors have left mementos, ranging from a pair of old cow-

boy boots found at the base of the memorial shortly after its dedication, to

teddy bears, baseball caps, newspaper clippings, diaries, and tear-stained let-

ters. One of the fi rst letters was left by the mother of an army sergeant whose

death had occurred nearly fi fteen years before her visit. In the letter, she

described fi nding her son’s name for the fi rst time:

We had been looking for about a half-hour when your father quietly said,

“Honey, here it is.” As I looked to where his hand was touching the black wall, I

saw your name, William R. Stock.

My heart seemed to stop. I felt as though I couldn’t breathe. It was like a bad

dream. I felt as though I was freezing. My teeth chattered. God, how it hurt. 89

Making War, Making Peace About war and terrorist threats, Wilton S. Dillon wrote: “Understanding

is not to forgive and forget, alone, but a way to inform us in developing our

One more month, I thought. He would have been home in one more month.

Figure 13-2 A Widow’s Lament

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514 c h a p t e r 13 Risks, Perils, and Traumatic Death

Among the most poignant losses experienced in life are those related to war. The Vietnam Veterans Memorial in Washington, D.C., is a focal point for the grief of individuals and a nation. For many who served in wartime, as well as for other survivors, the effects are perva- sive. Here, visitors ponder the names of individuals engraved on the face of the memorial’s black wall, which refl ects back the viewers’ images, accentuating the personal impact of loss.

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War 515

strategies by genuinely knowing ourselves as well as others while preparing to

make war and, ultimately, peace.” 90

War is defi ned as a condition of hostile confl ict between opposing forces, each of which believes its vital interests are at stake and seeks to impose con-

trol on the opposing side through the use of force. In the classic nineteenth-

century study On War, Karl von Clausewitz described war as the continuation of political policy by other means. John Horgan says, “War, once invented,

becomes a tradition, a custom, a habit, and its own cause.” 91

Human beings may have an innate tendency to divide the world into “us”

and “them.”

In the beginning we create the enemy. Before the weapon comes the image.

We think others to death and then invent the battle-axe or the ballistic missiles with which to actually kill them. Propaganda precedes technology. . . . It seems

unlikely that we will have any considerable success in controlling warfare unless

we come to understand the logic of political paranoia, and the process of

creating propaganda that justifi es our hostility. 92

Dennis Klass, an expert on the subject of grief and on the phenomenon

of continuing bonds of the bereaved with the dead (discussed in Chapter 9),

points out that such bonds do not always lead to peace and harmony. “We

only need to watch the nightly news to see that bonds with the dead play an

integral role in long and bitter wars.” 93

Joining with others against a common enemy creates a sense of commu-

nity and connectedness. Through an analysis of news stories, Debra Umber-

son and Kristin Henderson distinguished four major themes in how media

reports generate public support for war while facilitating denial of death:

(1) rhetorical devices that distance the reader from death and encourage

denial of death in the war, (2) offi cial denial of responsibility for war-related

deaths and reassurance to the public that death will be “minimal,” (3) rhetoric

that prepares the public for death in war and to view the deaths as just, and

(4) ambiguity and uncertainty about the actual death toll from the war. 94

If we come to view other human beings as hostile, even ambiguous

actions may be perceived as threatening. When we act to defend ourselves

against this perceived threat, their reaction confi rms our initial assumption

(see Table  13-2 ). It is important to recognize, however, that sometimes our

images of the enemy are accurate. Sam Keen says, “Short of utopia there

are real enemies. It is a luxury of the naive and sheltered to think that right

thinking, good intentions, and better communication techniques will turn

all enemies into friends.” 95 However, it is still good advice to “do no harm”

insofar as possible; in other words, “whatever we do, we shouldn’t make a bad

situation worse.” 96

Viewed symbolically, war allows us to ritually affi rm our own deathless-

ness by killing the enemy, who is Death. This idea is refl ected in the promise made by some religions that warriors who fall in battle go directly to Valhalla

or Paradise. “War as the bringer of death,” says Keen, “wears the face of hor-

ror, but also of ecstasy.” 97

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516 c h a p t e r 13 Risks, Perils, and Traumatic Death

Genocide Genocide, defi ned as the deliberate and systematic effort to destroy an entire

national, racial, political, or cultural group, occurred with horrendous

results during the twentieth century. 98 The term genocide (from the Greek word genos, “family, tribe, race,” and the Latin -cide, “killing”) was coined in 1944 by a Polish jurist named Raphael Limkin who had studied the Arme-

nian genocide, which occurred early in the twentieth century. There is no

consensus about how many lives were lost in the Armenian genocide, but esti-

mates range from 300,000 to 1.5 million.

Between 1941 and 1945, Nazi Germany exterminated six million Jews

in the Holocaust and killed another fi ve million people deemed to be politi-

cal opponents, mentally ill, retarded, or somehow “genetically inferior.”

The Holocaust Museum in Washington, D.C., memorializes this period of

genocide.

When the Khmer Rouge came to power in Cambodia, two million Cam-

bodians died from execution and starvation, an example of autogenocide, a group’s killing of its own people. After the assassination of the president of

Rwanda in 1994, as many as a million people, mainly members of the Tutsi

tribe, were massacred in an attempt to exterminate them. The genocide in

Darfur (Sudan), as Robert Kastenbaum points out, demonstrates that “large-

scale violence did not end with the 20th century and its staggering toll of

death and destruction.” 99

In the wake of traumatic bereavement from such losses, there may be

few opportunities to grieve. For example, in Rwanda, many of the dead did

not receive proper funeral rituals. According to Rwandan beliefs, says Paul

Rosenblatt, “when proper funeral and mourning practices are not followed,

misfortunes arise.” 100 The neglect or repression of grief may contribute to

further genocide by perpetuating a cycle of violence focused on revenge.

• The enemy as stranger. “Us” versus “Them.” • The enemy as aggressor. “Good” versus “Evil.” • The faceless enemy. “Human beings” versus “Dehumanized barbarians.” • The enemy as enemy of God; war as applied theology. “Holy” versus “Unholy.” • The enemy as barbarian (threat to culture, heathen, pagan). • The greedy enemy (appetite for empire). • The enemy as criminal, as committer of atrocities, as torturer (anarchists, terror-

ists, outlaws). • The enemy as torturer or sadist. • The enemy as rapist, desecrator of women and children. (“Woman as bait and

trophy.”) • The enemy as beast, reptile, insect, germ. (Gives sanctions for extermination.) • The enemy as death. (“The ultimate threat.”) • The enemy as worthy opponent. (“Heroic warfare or chivalry.”) Examples: The

epic battles of Achilles and Agamemnon, King Arthur and the Knights of the Round Table, the samurai in medieval Japan.

t a b l e 13-2 Images of the Enemy

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Terrorism 517

Colin Murray Parkes says, “It is not unreasonable to hope that any action to

encourage people to grieve and express their discontent in controlled and

safe ways might reduce the risk of uncontrolled violence.” 101

Terrorism Speaking to the often random nature of terrorist acts, someone said, “It is

not the bullet with my name on it that worries me; it is the one that says, To

whom it may concern.” 102 In a sense, terrorism is like other homicidal acts

that occur between strangers. Yet, many terrorist acts have more in com-

mon with warfare, which is aimed at specifi c targets and goals. The complex

nature of terrorism is apparent in the fact that, although there are more

than one hundred defi nitions of terrorism, no single defi nition is universally accepted.

At Buchenwald, near Weimar, Germany, a few of the dead are piled in a yard awaiting burial following the invasion by the Allies. Starvation and disease due to unsanitary liv- ing conditions, as well as the incessant torture of prisoners, caused an average of two hun- dred deaths each day at this infamous Nazi concentration camp.

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518 c h a p t e r 13 Risks, Perils, and Traumatic Death

Among the common elements of terrorism is the use or threat of vio-

lence to create fear among both its direct victims and a wider audience.

Even when attacks are apparently random, their victims and locations are

often chosen for their shock value. The aim is to destroy the sense of secu-

rity people normally feel in familiar places. Thus, terrorists frequently tar-

get schools, shopping centers, bus stops, restaurants, night clubs, and other

locations where people gather. The defi nition developed by the U.S. State

Department emphasizes the indiscriminate nature of terrorism, describing it

as “premeditated, politically motivated violence perpetrated against noncom-

batant targets by sub-national groups or clandestine agents, usually intended

to infl uence an audience.” 103

Although this defi nition captures key points, it is incomplete for several

reasons. First, many terrorist acts do not target “noncombatants,” or civil-

ians, but rather are aimed against military or police forces. Second, terror-

ist acts may be perpetrated by states as well as “sub-national groups.” Third,

the phrase “politically motivated” is insuffi cient, because much terrorism

has religious or quasi-religious sources. Another criticism is that many such

defi nitions tend to treat terrorism as a type of crime rather than defi ning it as war. 104 The proposal to treat terrorism as war is not universally accepted, how- ever, because war generally has been defi ned as “a state of usually open and

declared armed hostile confl ict between states or nations.” 105 Terrorist acts

do not fi t this defi nition. Furthermore, war is generally viewed as an activity

conducted according to socially recognized rules. In other words, war is a

social construct that is recognized in custom and law. The rules of war are

spelled out in international agreements like the Geneva Convention, which

describes such matters as the appropriate treatment of prisoners of war and

of the sick, wounded, and dead in battle. In contrast, terrorism occurs out-

side the boundaries of social sanctions that regulate conduct between indi-

viduals and between groups. 106

The debate about how to defi ne terrorism, and whether it should be

classifi ed and prosecuted as a criminal act or an act of war, is being shaped

by the methods and manner of terrorist activities. On one hand, the use of

household items like pressure cookers, as were used by the Boston Mara-

thon terrorists, shows that even familiar items can maim and kill indiscrim-

inately. On the other hand, in their desire to attract publicity designed to

generate widespread fear, terrorists engage in dramatic and high-profi le

attacks, including hijackings, hostage takings, kidnappings, car bombings,

and frequently suicide bombings. Terrorism has been called the “weapon of

the weakest,” but, increasingly, terrorists make use of sophisticated weapons

and strategies.

In the Encyclopedia of Terrorism, Cindy Combs and Martin Slann highlight some of the key features of present-day terrorism by observing that it is “a

synthesis of war and theater, a dramatization of the most proscribed kinds

of violence—that which is perpetrated on innocent victims—played before

an audience in the hope of creating a mood of fear.” 107 As one scholar notes,

“The meaning of terrorism is socially constructed.” 108 In achieving their

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Terrorism 519

goals, terrorists often rely on the amplifi cation effect, whereby their actions are broadcast through the media to a much larger audience than merely the one

in the location where the action occurs, thus giving their acts greater signifi -

cance. From this standpoint, the media’s interest in sensational news and the

terrorists’ desire for publicity are linked.

Terrorist attacks often seem to be directed at random targets, but they

are also directed at politically or culturally important targets. Terrorists’

goals are aided by the element of surprise and the pervasive sense of fear

generated among the threatened population. Acts of terrorism threaten our

assumptive world, heightening our awareness of mortality and increasing our

feelings of vulnerability. 109

September 11, 2001 The events that culminated in the bloodiest day on U.S. soil since the

Civil War began shortly before 9:00 a.m. on Tuesday, September 11, 2001,

when terrorists piloted a hijacked jetliner into the North Tower of the World

Trade Center (WTC) in New York City. 110 Roughly fi fteen minutes later, a

second airplane crashed into the South Tower of the WTC, erasing any doubt

about whether the fi rst crash was a horrible accident or an intentional act. As

the nation went on alert and emergency personnel responded to the disas-

ter in New York, a third jet was fl own into the Pentagon, a symbol of U.S.

military power, just outside Washington, D.C., and a fourth jet crashed into

a fi eld near Shanksville, Pennsylvania, a result of passengers on the fl ight

thwarting the terrorists’ apparent intentions to strike the U.S. Capitol or the

White House. It was determined that the hijackings and suicide attacks were

perpetrated by nineteen militants associated with an Islamic extremist group

known as al-Qaeda.

Harold Dow, a correspondent for CBS News, said, “The media were very

much a part of the terrorists’ plan. From the time the fi rst plane went in, they

gave the media time to get down there to record the second plane. These

pictures were shown all over the world; that’s their trophy.” 111

Thousands of people witnessed the attacks fi rsthand, and millions, per-

haps more than two billion worldwide, watched the tragedy unfold on televi-

sion. Because of the time of day, the event “could be seen anywhere, in both

hemispheres, any latitude, any culture, throughout the world, live—something

that we’ve never had happen before.” 112 The events were witnessed in real

time, as the “terrorist moment” took place in a “global public space” created

by extensive media coverage. 113 The most disturbing images were those of

people falling or jumping to their deaths, most from the North Tower, the

fi rst tower to be hit (see Figure 13-3 ). Later analysis of videotapes showed

that at least sixty people died this way. 114 In comparing coverage by print

and television media, David Friend remarks that, whereas “the video would

show mass murder, the still image would hint at split seconds when a man or

woman had been taken from this earth.” 115

The most dramatic and devastating result of the attacks was the collapse

of the 110-story Twin Towers of the WTC, killing more than 2,400 workers

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520 c h a p t e r 13 Risks, Perils, and Traumatic Death

and hundreds of fi refi ghters. Having no way to escape, people trapped in the

buildings or on hijacked airplanes made telephone calls to loved ones or left

poignant messages on answering machines in their last moments.

Besides conventional news media, the Internet was a major medium

for disseminating news of the attacks. People used the Internet to seek

information about what happened, who died, who survived, and the extent

of the damage. Despite the massive death toll caused by the attack on the

Twin Towers, more than fi fteen thousand people managed to escape. 116

An online “survivor registry,” where people could post their names to let

friends and loved ones know they had survived, received more than one

million “hits” on September 11 and the next day, as people turned to the

Internet to exchange information. 117 The Internet also functioned as a vir-

tual space where individuals who died were identifi ed and commemorated.

People from eighty countries around the world, engaged in ordinary life

activities, became victims of a desire to make a point, weaken a govern-

ment, express a grievance. 118

Figure 13-3 Child’s 9/11 Drawing A young child’s portrayal of the terrorist attack on the Twin Towers in New York City shows the towers in fl ames as individuals who were trapped in the devas- tation on the upper fl oors jump to their deaths. At the far left, an airplane is depicted at what appears to be the moment of impact, while a fi re truck and res- cue personnel approach the site from the opposite side. At the top of the draw- ing, the child includes a written affi rmation, “You are the best,” and she signs the drawing with an affectionate “Love, Briana.”

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Terrorism 521

Rescue, Recovery, and Mourning Rescue and recovery operations began immediately, but the initial hope

of fi nding a large number of survivors in the rubble was soon replaced by

the grim realization that efforts would mainly involve retrieving and identi-

fying the dead. Hundreds of photographs of the missing posted by friends

and family members throughout New York City in the days after the attack

became memorials to loved ones. 119 In the end, only eighteen people were

recovered alive from the collapsed Twin Towers. 120

Even though the principle that human remains ought to be treated

with dignity is almost universally accepted, the application of this rule in

extraordinary situations can generate volatile emotions. In Israel, where the

commandment to bury the dead is a basic rule in Jewish law, a volunteer

organization known as ZAK A (an acronym for Zihui Korbanot Ason, Hebrew

for “Identifi cation of Disaster Victims”) responds to terrorist incidents to

collect remains and identify as many parts as they can, including blood, so

that as much of a victim’s body as possible can be buried. Doing this kind of

rescue and “cleanup” work, seeing fi rsthand the gruesome violence done to

human beings, is stressful and can trigger intense grief. To help volunteers

cope with such traumatic experiences, ZAK A regularly schedules counsel-

ing workshops, family days, and other programs where members can discuss

their feelings in an atmosphere of mutual support. 121

Whereas Israelis may be familiar with the stresses of life under terror-

ism, many of the people engaged in recovery at the WTC were much less

accustomed to its grisly effects. Frustrated because of the awesome death toll,

and grieving the deaths of so many individuals both known and unknown,

those who toiled at Ground Zero shared with the wider community a sense

of uncertainty and confusion about how to cope. Problems in recovering and

identifying victims’ remains, as well as the scope and extent of devastation,

were among factors that added to the impact of the terrorism of 9/11.

Just days after the attacks, the New York Times began publishing a special feature, “Portraits of Grief,” which evolved into a kind of shrine that offered

vignettes about people who had died. Unlike formal obituaries, these were

quick sketches that suggested some spark of life that made each person spe-

cial. They served to highlight a person’s unique humanity and interests, not

his or her status or achievements. This new form of reportage represented

what one writer called a “kind of haiku obit”—journalism as tribute, as hom-

age, as witness, and as solace. 122

The Mind of the Terrorist From the moment the second airplane hit the South Tower of the WTC,

confi rming the fact that the events were intentional, people asked what could

motivate human beings to perpetrate such acts of violence against innocent

citizens. Is it even possible to understand the mind of a terrorist? Despite

the unparalleled military arsenal of the United States, a successful attack

on the symbols of power and wealth in the Western world was carried out

by men wielding box cutters, creating the most spectacular terrorist event

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522 c h a p t e r 13 Risks, Perils, and Traumatic Death

in history. 123 Yet, such violence was not unprecedented, nor was it merely a

chance occurrence devised by nineteen amateurs acting on their own. On

the contrary, the attacks were the deliberate result of careful planning by al-

Qaeda, an organization with operations in as many as sixty countries world-

wide. 124 In its use of sophisticated information technology and small cells of

terrorists who operate for long periods independently, al-Qaeda is represen-

tative of a new kind of combat organization, one that operates on a global

scale as a “fi ghting network.” 125

Why do organizations like al-Qaeda exist, and why do individuals become

allied with them to the extent that they are willing to sacrifi ce their lives in

suicide attacks? Much of the terrorism in recent decades has had a religious

or quasi-religious component whereby terrorists combine fanatical hatred of

the secular state with a vision of themselves as defenders of an ancient faith.

The secular world, having betrayed the true faith, is seen as “evil”; therefore,

it is the duty of the “righteous” to engage in a moral and spiritual struggle

between good and evil (see Table 13-3 ).

The idea of martyrdom (from Greek, martys, “witness”) took shape in the early years of the second century CE, when Christians who refused to

sacrifi ce to the Roman emperor were subjected to the extreme penalty, death

by torture or other horrifi c means. 126 Their enthusiasm for a martyr’s death,

arranged by an external agent with the complicity of the victim, was seen in

reports of radiant joy, smiles, and even laughter.

Mark Juergensmeyer says, “Concepts of cosmic war are accompanied by

strong claims of moral justifi cation and an enduring absolutism that trans-

forms worldly struggles into sacred battles.” 127 Such views are adopted by

individuals who seek to impose their own concepts of right and wrong on

those who fail to share their views. Terrorism has tended to develop as part of

revivalist movements that promote a return to fundamentalism in religious

matters. In the mind of the terrorist, it is permissible, even necessary, to kill,

because he or she is doing it for a higher purpose.

Suicide bombings exemplify the terrorist’s belief that he or she is engaged

in a worthy and just struggle, one that makes sacrifi ce not only desirable

but also imperative. The collective—religion, sect, nation—is more impor-

tant than the individual. Suicide missions are usually easy to plan because

no escape route is needed and, once a suicide terrorist heads for the target,

even if he or she does not succeed in reaching it, some damage likely can be

infl icted on the enemy while the terrorist is being apprehended. 128

• Those who practice revolutionary violence and state repression always claim to champion noble causes and values.

• Policies that advocate extreme violence always cite religious goals to justify behav- ior, such as to defend faith or human rights.

• The perpetrators of violent acts maintain that they are freedom fi ghters (in the case of revolutionaries) or the champions of law and social order (in the case of governments).

t a b l e 13-3 Justifi cations for Terrorist Violence

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Horrendous Death 523

Psychologist Aaron Beck describes terrorists as “prisoners of hate.” 129

Harboring a profound sense of being wronged, they call for revenge against

those whom they view as their oppressors. Beck says, “Terrorists who execute

well-planned acts of destruction are not deranged”; rather, they are “pos-

sessed by a cool hatred toward the designated enemy,” which allows them

to be “cold and calculating in carrying out their grand design.” Terrorists of

the “lone wolf ” variety may perpetrate their violent acts in support of some

group, movement, or ideology, but they do so alone, outside of any command

or organizational structure. Timothy McVeigh, convicted of the Oklahoma

City bombing that killed 168 people, is often cited as a classic example of

“lone wolf ” terrorism. Shashi Tharoor says,

Terrorism emerges from blind hatred of an Other, and that in turn is the

product of three factors: fear, rage, and incomprehension. Fear of what the

Other might do to you, rage at what you believe the Other has done to you,

and incomprehension about who or what the Other really is. . . . If terrorism is

to be tackled and ended, we will have to deal with each of these three factors

by attacking the ignorance that sustains them. We will have to learn to see

ourselves as others see us, learn to recognize hatred and deal with its causes,

learn to dispel fear, and, above all, simply learn about each other. 130

Describing the twenty-fi rst century as “the global century,” Tharoor

argues that, as never before, “the tragedies of our time are global in ori-

gin and reach,” and “tackling them is a global responsibility that must be

assumed by us all.”

Horrendous Death Daniel Leviton and William Wendt use the term horrendous death to describe “a form of premature death which is ugly, fashioned by man, without any

trace of grace, totally unnecessary, and, as they say of pornography, lacking

any redeeming social value. It is a category of death that typically affects large

numbers of people.” 131 It is death caused by war, homicide, holocaust, ter-

rorism, starvation, and poisoning of the environment. 132 Horrendous death

typically involves the motivation to kill, maim, injure, torture, or otherwise

destroy another human being. Such acts are often the work of humiliated

individuals who seek to reverse their status from victim to perpetrator. Levi-

ton says, “The horrendous death concept is about preventable death and the

process of prevention. It is about addressing causes as well as symptoms.” 133

The fi rst step in eliminating or at least reducing horrendous deaths involves

confronting the wish to deny their reality. Leviton further says,

It is hypothesized that the more horrible the type or style of dying and/or death

is perceived, the greater the fear; the greater the fear, the greater the denial;

and the greater the denial, the less chance of action to eliminate the very causes

of such torturous deaths. 134

The threat of nuclear destruction would seem to fi t within this category.

Fallout shelters and classroom “duck and cover” trainings are now viewed as

relics of an earlier age. Many people believe the threat of nuclear destruction

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524 c h a p t e r 13 Risks, Perils, and Traumatic Death

disappeared with the end of the Cold War. Stephen Younger points to a rea-

son for such belief:

A signifi cant portion of the U.S. population, including many members of

Congress, came of age after the end of the Cold War. To them, nuclear weapons

are anachronisms, holdovers of a confl ict read about in history books or seen in

movies. 135

Sometimes, as with the nuclear threat, horrendous deaths are treated as

aberrant or anomalous. Yet, they involve enormous costs for present as well as

future generations.

Emerging Infectious Diseases Pestilence derives from the Latin word for plague. It began to be used in the fourteenth century when bubonic and pneumonic plagues ravaged Europe,

and themes of grim terror became common in literature, such as Geoffrey

Chaucer’s “The Pardoner’s Tale.” Today, a similar threat is represented by

emerging infectious diseases. (Whereas epidemic is defi ned as a rapidly spreading disease or condition, pandemic refers to a widespread epidemic.)

The worst infectious disease episode in modern times was the 1918 pan-

demic caused by an infl uenza virus that killed as many as forty million people

worldwide. 136 In the United States, a quarter of the population had the fl u,

and more than half a million people died. Many of the thousands of young

men crammed onto World War I troop ships were just developing the fl u as

they left the United States. After a week’s crossing of the Atlantic, the ships

arrived in France with hundreds of sick servicemen, many of whom died.

In the early twentieth century, infectious diseases predominated among

the main causes of death, and epidemic infections caused global havoc. Sub-

sequent advances in public health and medicine so dramatically altered pat-

terns of morbidity and mortality that many people have become complacent

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Emerging Infectious Diseases 525

about the threat of infectious diseases. Yet, virologists fear that some of the

currently emerging viruses are a bigger threat than the 1918 virus. 137

The World Health Organization defi nes an emerging disease as one that

has appeared in a population for the fi rst time or that may have existed previ-

ously but is rapidly increasing in incidence or geographic range. These emerg-

ing and re-emerging epidemic diseases pose an ongoing threat to global

health security. 138 Among diseases of concern are avian and other forms of

infl uenza, Rift Valley fever, SARS (severe acute respiratory syndrome), coro-

navirus infections, smallpox, and viral hemorrhagic fevers (Ebola, Marburg,

Lassa, Crimean-Congo hemorrhagic fever, etc.).

AIDS (acquired immune defi ciency disease) may be a harbinger of other

emerging diseases that will threaten the health of human beings worldwide

in coming decades. According to a United Nations report, HIV/AIDS is one

of the most destructive epidemics in recorded history. At the end of 2011, an

estimated 34 million people were living with HIV worldwide. 139 Data from

that year shows 1.7 million AIDS-related adult and child deaths, and 2.5 mil-

lion people newly infected. Sub-Saharan Africa remains the most affected

region.

The Response to AIDS For many people, AIDS is synonymous with death: a dread disease, con-

tagious and epidemic, a modern plague. 140 Looking at AIDS in historical per-

spective, Charles Rosenberg says,

Mortality is built into our bodies, into our modes of behavior, and into our

place in the planet’s ecology. Like other epidemics, AIDS has served well to

remind us, fi nally, of these ultimate realities. 141

Robert Kastenbaum says that the symbolism of AIDS embodies the

stigma of earlier forms of catastrophic dying: disfi guration, dementia, and

skeletonization. It conveys multiple meanings about human vanity and pride,

divine punishment, attack by an enemy from within, the terror of life in

death and the despair of death in life, and the romantic exit of brilliant and

beautiful doomed youth. 142 Many survivors—the friends, neighbors, business

associates, and relatives of people who died from AIDS—have experienced

multiple losses.

It is important to distinguish between AIDS and human immunodefi -

ciency virus (HIV), which causes AIDS. Although a blood test can be used to

screen people for HIV infection, people infected with the virus are usually

not aware of it until symptoms become evident years later. The pattern of

progression from HIV infection to AIDS is not entirely clear. However, the

consensus has been that almost all HIV-infected persons eventually develop

AIDS. In recent years, the greatest impact of AIDS in the United States has

been among African Americans and Hispanics.

For some marginalized people, the view of AIDS is quite different from

the view held in society’s mainstream: AIDS appears to be a form of race or

class warfare, “a virus created in a government or CIA laboratory in an attempt

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526 c h a p t e r 13 Risks, Perils, and Traumatic Death

to ‘clean up’ a seemingly dirty population.” 143 The fact that such a view exists

is itself evidence of the gap between the haves and have-nots of society.

AIDS is concentrated in the developing world, where it is wiping out

gains in life expectancy made in recent decades. In the United States, AIDS

mainly affects intravenous (IV) drug users, hemophiliacs, and recipients of

blood transfusions, as well as the sexual partners of individuals infected with

the virus. In other parts of the world, it is transmitted mainly through hetero-

sexual contact.

Zoë Lorenz and her daughter Candice are among the many people affected by AIDS. Zoë saw her father die from AIDS, plagued not only by the disease but by the humiliation and shame so often associated with it. Now affl icted with the virus herself, Zoë says, “I have a beautiful four-year-old daughter who has beat the odds and remains HIV negative. So many people have the attitude that I should go off and die somewhere alone. They don’t see the tragedy of this child losing her mommy. I don’t need to be proud that I have AIDS, but I won’t be ashamed that I do. I don’t want to feel that I have to tell people I’ve got cancer or some other acceptable disease.”

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Emerging Infectious Diseases 527

AIDS reminds us that infectious diseases remain a threat and that human

beings remain uncertain about how to respond to epidemic disease. When

confronted by a new disease with an unknown mode of transmission, people

become anxious and fearful. As the initial panic recedes, more thoughtful

and helpful measures are implemented.

Living with AIDS The prognosis for AIDS patients has much improved, as newer drugs

have become available. Besides new drugs, there are advances in understand-

ing the biology of HIV infectivity and the role of natural chemicals called

chemokines in suppressing HIV’s ability to infect cells. With new treatment

options, the focus is changing from “dying of AIDS” to “living with HIV and

AIDS.” Patients who had depleted their fi nancial resources for care or other

expenses at what had seemed the end of their lives are now confronted by

the need to reappraise their planning for “last days” and to reconstruct their

lives so as to include a future that didn’t seem likely until quite recently (see

Figure 13-4 ). For AIDS patients who lack fi nancial resources to pay for expen-

sive drugs or lack access to sophisticated health care, the future is bleaker.

The Threat of Emerging Diseases If AIDS is a harbinger of things to come, what lessons do we need to

learn? Three of the most important involve (1) early identifi cation of people

who are at risk for disease, (2) a shift to community and public health per-

spectives, and (3) the need to address health problems on a global scale. 144 In

recent decades, localized epidemics of a number of emerging diseases have

occurred, many of them related to hemorrhagic fever viruses, such as the

Marburg, Ebola, Lassa, and hantaviruses, as well as yellow fever, swine fl u (the

pandemic H1N1 virus is an example), Legionnaires’ disease ( Legionella ), and cholera. 145 Bernard Le Guenno of the Pasteur Institute in Paris says,

Hemorrhagic fever viruses are among the most threatening examples of what

are commonly termed emerging pathogens. They are not really new. Mutations

or genetic recombinations between existing viruses can increase virulence,

but what appear to be novel viruses are generally viruses that have existed for

millions of years and merely come to light when environmental conditions

change. The changes allow the virus to multiply and spread in host organisms.

New illnesses may then sometimes become apparent. 146

Patrick Olson, an epidemiologist at the Naval Medical Center in San

Diego, theorizes that the plague that struck the Greek city of Athens in

430 BCE, reported by the Athenian general and historian Thucydides, was

caused by the deadly Ebola virus (named after a river in the Congo). 147 Olson

fi nds parallels between the ancient and modern accounts. Fever, diarrhea,

and severe weakness are prominent symptoms. As with the Athenian plague,

Ebola claims almost all of its victims, and quickly; most infected people die

within two weeks. Ebola outbreaks usually last only a few weeks because its

victims die faster than they are able to spread the virus, which disappears for

a time only to reemerge later.

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528 c h a p t e r 13 Risks, Perils, and Traumatic Death

To better understand the interactions of people and plagues, epidemi-

ologists are gathering data from studying outbreaks caused by “bugs” in the

virtual world of online gaming. When a viruslike epidemic started causing

the deaths of characters in the online game World of Warcraft, epidemiologists studied the risk reactions of players to the inadvertent plague, gaining infor-

mation about human behaviors in the face of threat. 148

In studying how emerging diseases are disseminated in urban societies,

Rodrick and Deborah Wallace conclude that physical and social disruption

intensifi es the pathological behaviors and conditions that promote the rapid

spread of infectious diseases. 149 Abandonment of inner-city areas results in

what the Wallaces term “urban desertifi cation” or “social thanatology.” 150

The devastation and disintegration in some urban areas is characterized as

“unprecedented in a modern industrialized state short of the aftermath of

total war.” 151 Among disadvantaged populations, a lack of crucial municipal

services leads to what Richard Rothenberg of the U.S. Centers for Disease

Control and Prevention calls “the metastasis of dangerous behavior.” 152

Experts believe that many viruses reside harmlessly in birds and occasion-

ally infect pigs, where they are changed into a new form of the virus that can

affect humans. 153 Deprived of their natural hosts, some of these microorgan-

isms have begun to jump to humans, where there is no such equilibrium. “As

we have seen with the Ebola and AIDS viruses,” says William Clark, the results

“can be disastrous.” 154 Since the advent of penicillin, people have become

One year ago today, I told my colleagues that I was dying of AIDS. I had been

fi ghting it for years—the illness and the telling. . . . But now I was gaunt, tired, and

rather sure I was losing the battle.

I was happily dying—and about to go on a Mexican vacation. I felt I had made

my peace with death and, in a way, was looking forward to it. I had blown my mother’s

estate, about $180,000, on living for the moment, eating in the best restaurants and

taking three or four foreign vacations a year. There was no time to lose, and I was

determined to go out in style.

What has happened in the past year, at least for me, is a miracle that couldn’t

have taken place at any other moment. Thanks to the arrival of the new drugs called

protease inhibitors, I am probably more likely to be hit by a truck than to die of AIDS.

I stopped the presses on my obituary. Oddly enough, the return from my near-

death experience was at fi rst very annoying. I had a few adjustments to make. I had to

start thinking again about my bills. . . . We had to start living within our means. . . . I

have had to re-energize myself for the daily grind. I’m even thinking about cleaning

the basement.

But I’m not out of the woods.

Some HIV-negative men are guilt-ridden when they see so many of their friends

dying. I feel guilty that I am getting the best possible medical care, because it is un-

available to most of the world’s AIDS sufferers, and to the poor and uninsured in this

country.

Figure 13-4 Back to a Future

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Further Readings 529

complacent about infectious diseases, believing that epidemics are no longer

a threat. But the pandemic of AIDS shows that complacency is ill advised.

Traumatic Death In its root meaning, trauma is defi ned as a wound, a piercing. In psychologi- cal terms, it refers to a disordered psychic or behavioral state resulting from

severe mental or emotional stress. The human response to trauma, says

Jeffrey Kauffman, is one “in which the cohesion of the self is shattered, pro-

ducing a diversity of symptoms and other life-redefi ning consequences.” 155

Traumatic deaths occur in the context of many topics covered in this chapter,

including disasters, homicide, genocide, combat, terrorism, and epidemics,

as well as in the context of topics discussed in earlier chapters, such as suicide

(Chapter 12).

Traumatic deaths are often characterized by suddenness and lack of

anticipation; preventability and/or randomness; the level of violence, mutila-

tion, and destruction; and the fact of multiple deaths. 156 Such deaths, says Lil-

lian Range, are “out of the ordinary, directly experienced, and perceived as

threatening survival and self-preservation.” In short, they shatter our assump-

tive world. The result, Range says, is that “individuals confront their own

mortality and recognize their fragility as physical creatures.” 157

Risks and perils—accidents, disasters, violence, homicide, war, terrorism,

epidemic diseases—affect us as we go about our daily lives. Sometimes, the

encounter is subtle; at others, it is overt, calling into action our ability to cope.

The failure to fi nd adequate means of coping with these encounters with

death represents a threat to the survival of society as well as the individual.

Further Readings Jonathan Barker. The No-Nonsense Guide to Global Terrorism, 2 nd ed. Oxford: New

Internationalist, 2008.

Mia Bloom. Dying to Kill: The Allure of Suicide Terror. New York: Columbia University Press, 2005.

Feargal Cochrane. Ending Wars. Malden, Mass.: Polity, 2008. Walter Laqueur. No End to War: Terrorism in the Twenty-First Century. New York: Con-

tinuum, 2003.

Gus Martin. Understanding Terrorism: Challenges, Perspectives, and Issues, 3rd ed. Los Angeles: Sage, 2010.

Randolph Roth. American Homicide. Cambridge, Mass.: Harvard University Press, 2009.

Jake Tapper. The Outpost: An Untold Story of American Valor. New York: Little, Brown, 2012.

Trish Wood. What Was Asked of Us: An Oral History of the Iraq War by the Soldiers Who Fought It. New York: Little, Brown, 2006.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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The corpse placed on the funeral pyre, these men prepare to light the cremation fi re. Cremation has been a traditional practice in India, where Hindus believe that “even as the person casts off worn-out clothes and puts on others that are new, so the embodied Self casts off worn-out bodies and enters into others that are new.”

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531

C H A P T E R 1 4

Beyond Death / After Life

D eath—and then what? Some people have a ready answer to this question: “When you’re dead, you’re dead—

that’s it!” or “You go through a transition and take birth in another body,” or “After you die,

you go to heaven.” Each of these responses refl ects a particular understanding of the mean-

ing of human existence. Beliefs about life after death occupy a broad spectrum, from the

notion that death spells the end to the notion that the “soul” or “self ” lives on after death in

some fashion. Answering the question, What happens after I die? has occupied the attention

of human beings since the dawn of consciousness.

Examining the death customs of the ancient Egyptians, we fi nd a culture focused on

preparing for the afterlife. 1 The body was mortal. Yet, within it were immortal elements: the

Ba, a soul or psychic force, and the Ka, a spiritual double representing the creative and sus-

taining power of life. At death, the Ka fl ew to the afterlife, while the Ba lived on in the body.

As the permanent dwelling place of the Ba, the body was preserved by mummifi cation and

protected by a wooden coffi n, sometimes placed within a stone sarcophagus, or limestone

coffi n. Providing a home for the Ba (often depicted in the form of a bird hovering above

the deceased) ensured that the deceased would enjoy the afterlife. However, if the Ba were

destroyed, the deceased would suffer “the second death, the death that really did come as

the end.” Thus, preserving the physical form, as mummy or statue, was necessary for survival.

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532 c h a p t e r 14 Beyond Death / After Life

Concern with immortality—that is, survival after physical death—is cut

from the same cloth as questions about the meaning of life and its corollary

question, How, then, should one live? Responses to these questions refl ect a

person’s values and beliefs about human experience and the nature of real-

ity. Andrew Greeley says, “We are born with two incurable diseases: life, from which we die, and hope, which says maybe death isn’t the end.” 2

Death can be a tricky question for people. Bob Dylan describes how

reviewers of his album Time Out of Mind understood that it dealt with “mor- tality,” but not a single critic applied this recognition to himself; it was,

Dylan said, as if “whoever’s writing about the record has got eternal life and

the singer doesn’t.” 3 Our philosophy of life infl uences our philosophy of

death. Conversely, our understanding of death and its meaning affects the

way we live.

According to Socrates, “The unexamined life is not worth living.” Such

self-investigation includes discovery of what one believes about the conse-

quences of death. Ambivalence about belief in survival after death is aptly

described in an anecdote related by Bertrand Russell: A woman whose daugh-

ter had recently died was asked what she thought had become of her daugh-

ter’s soul. She replied, “Oh, well, I suppose she is enjoying eternal bliss, but I

wish you wouldn’t talk about such unpleasant subjects.” 4

Exploring your beliefs about immortality may not result in an easier

acceptance of death—nor should it necessarily. After all, the prospect of

immortality is not always looked upon favorably. 5 Nevertheless, such an

exploration can lead to a more coherent philosophy of life and death, mak-

ing possible a congruence between hopes and perceptions. Even when we

are settled upon a belief system, exposure to other views can both broaden

our understanding of different responses to death and enhance appreciation

of our own beliefs. In this chapter, we explore the meaning of mortality by

investigating some of the ways that cultures, Eastern and Western, answer the

question, What happens after death? These answers provide grist for the mill

of our own contemplation about this ultimate human concern.

Traditional Concepts About Life After Death The notion that life continues in some form after death is one of the oldest

concepts held by human beings. In some of the earliest graves, archaeologists

have uncovered skeletons that were bound by hands and feet into a fetal posi-

tion, perhaps indicating beliefs about “rebirth” into other forms of existence

following death. (Rebirth, in one form or another, has been characterized

It is wonderful that fi ve thousand years have now elapsed since the creation of the

world, and still it is undecided whether or not there has ever been an instance of

the spirit of any person appearing after death. All argument is against it; but all

belief is for it.

James Boswell, Life of Johnson

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Traditional Concepts About Life After Death 533

as the “most persistent image of afterlife in the history of religion.”) 6 In tra-

ditional societies, death represents a change of status, a transition from the

land of the living to the land of the dead.

Judgment is a key feature of many beliefs about what follows death.

Among the various concepts of afterlife among traditional Hawaiians, for

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The platform burial of a Tahitian chief is depicted in this drawing by William Hodges, made during Captain Cook’s second voyage to the South Pacifi c in the 1770s. In a world populated by unseen spirits who could exert their infl uence for good or evil upon the living, the death of a chief or other important person occasioned a spec- tacular display of grief, which was presided over by a chief mourner (right). Usually a priest or close relative of the deceased, the chief mourner wore an elaborate costume of pearl shells and the feathers of tropic birds. Rattling a pearl shell clapper and brandish- ing a long wooden weapon inset with sharks’ teeth, the chief mourner was accompanied by other weapon-carrying men who could strike anyone in their way, thus helping ensure that funeral rites were carried out in a manner that would offend neither the living nor the dead.

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534 c h a p t e r 14 Beyond Death / After Life

example, was the belief that a person who had offended a god or who had

harmed others would suffer eternal punishment. 7 Such an unworthy soul

became a wandering spirit, “forever homeless, forever hungry.” The ancestor-

gods had the power to punish or reward the released spirit or even to send it

back to the body. Misfortune could result when a person had neither loving

relatives to care for the corpse nor the guardianship of family ancestor-gods,

who help souls fi nd their way to the world of spirits. Those who had lived

worthily were welcomed into eternity, whereas those who had done misdeeds,

without repenting of or correcting them, were punished. The reward for a

good life was reunion with those closest to the family-loving Hawaiians: one’s

own ancestors.

To understand the consciousness from which such a view of immortality

arises, the notion of selfhood in Western cultures must be put aside momen-

tarily. Against an emphasis on individual identity and the self, imagine a

mentality in which group identity is all-encompassing. The family, the clan,

the people—these social groups represent the loci of communal conscious-

ness within which the thoughts and actions of the individual are subsumed.

Thus, traditional beliefs are less concerned with individual survival than with

continuation of the community and its common heritage. Having shared in

the life of the group, the individual is part of its ultimate destiny, a destiny

that transcends death.

Jewish Beliefs About Death and Resurrection Although the Bible takes death seriously, it does not present a systematic “the-

ology of death” or the afterlife. 8 The biblical story describes a people focused

on their communal destiny. Individuals are actors in an unfolding drama, its

fi nal outcome foretold in the promises made by Yahweh (the biblical proper

name for God). The emphasis is on faith—faith in the people of Israel as a

community with a common destiny and faith in Yahweh, whose promises will

be realized in the unfolding of the divine plan. For example, as the patriarch

Abraham lay dying, his last thoughts were hope for the survival of his progeny

so that these promises could be realized. Abraham’s vision is reenacted by

biblical heroes in one circumstance after another as they affi rm Israel’s com-

munal destiny. By contributing to this destiny, the righteous person is part of

the continuing story of the people as a whole. “According to Jewish tradition,

our lives are measured by our deeds and by whether we have lived up to our

full potential.” 9

In the story of Job’s encounter with adversity, the possibility of life beyond

death appears bleak: “As a cloud fades away and disappears, so a person who

goes down to the grave will not come up from it.” 10 Resignation toward death

is echoed in the other wisdom books—including Proverbs, Ecclesiastes, and

some of the Psalms—which present the thought of the ancient Hebrew sages

on the question of human destiny. Righteous conduct is advised because it

leads to harmony in the present life, not because it guarantees future rewards

for the individual.

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Jewish Beliefs About Death and Resurrection 535

Between the time of Job and the later prophets, however, there was a

gradual change from resignation to hopefulness in the face of death. In the

apocalyptic, or visionary, writings of such prophets as Daniel and Ezekiel, we

fi nd the strands of thought that are eventually woven together in ideas about

the resurrection of the body. Daniel envisions a future in which the “sleeping”

dead will awaken, “some to everlasting life, some to everlasting disgrace.” 11

This development in Hebrew thought would greatly infl uence Christian the-

ology. Stated succinctly, it “consists in the belief that, at the end of time, the

bodies of the dead will be resurrected from the grave and reconstituted.” 12

Hints of this change are also evident in the meanings ascribed over time

to the Hebrew word She’ol, which in early usage is generally defi ned as the underworld of all the dead, a shadowy realm of ghostly, disembodied souls

(much like the Hades of Greek mythology). A story gives an account of nec-

romancy in which King Saul requests the witch of Endor to summon the

spirit of the dead prophet Samuel. Asked by Saul to describe what she sees,

the witch replies, “I see a ghost [ elohim   5  superhuman being] rising up from the earth [She’ol].” With further refi nement of these concepts, the shadowy

underworld of She’ol is divided into two distinct realms: Gehinom (hell) and

Pardes (heaven or paradise). 13

In the main, ideas about resurrection of the body found in the writ-

ings of the prophets did not alter the essential understanding of the human

person as an undivided psychophysical entity. Wheeler Robinson says, “The

Hebrew idea of personality is an animated body, and not an incarnated

soul.” 14 In other words, it is not as if the soul takes a body; rather, the body has life. Concepts like body or soul cannot be abstracted from the integrity of the human person.

There is always hope for a tree:

when felled, it can start its life again;

its shoots continue to sprout.

Its roots may be decayed in the earth,

its stump withering in the soil,

but let it scent the water, and it buds,

and puts out branches like a plant new set.

But man? He dies, and lifeless he remains;

man breathes his last, and then where is he?

The waters of the sea may disappear,

all the rivers may run dry or drain away;

but man, once in his resting place, will never rise again.

The heavens will wear away before he wakes,

before he rises from his sleep.

Job 14:7–12, The Jerusalem Bible

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536 c h a p t e r 14 Beyond Death / After Life

The consensus expressed by the biblical writers seems to be, “Our pres-

ent existence is of God; if there is life hereafter, it will also be God’s gift. Why

be anxious about death? What matters is to live righteously.” The faith of

Israel is sustained through customs like the minyan (a quorum or minimum number of individuals required for communal worship) and the reciting of

kaddish (a liturgical expression of praise to God, which functions as a kind of “memorial prayer”), as well as in the practice of shivah (period of formal mourning, traditionally seven days). An Aramaic doxology, kaddish is essen-

tially a pledge from the living to dedicate one’s life to the God of Life. 15 It

is recited by mourners during the fi rst eleven months after death and then

on the anniversary, or yahrzeit, of the death of a loved one. In Judaism, the customary mourning rituals help the bereaved face the reality of death, give

honor to the deceased, and engage in a reaffi rmation of life. 16

Classical Greek Concepts of Immortality The ancient Greeks held a variety of views about what might follow the death

of the body. 17 Generally, however, the afterworld was not an attractive pros-

pect. Hades, the realm of the dead, was typically pictured as a shadowy place

inhabited by bloodless phantoms, an image that evoked despair. The heroes

in Greek drama are often portrayed as raging against death. 18

In the Athenian democracy, what mattered was the survival of the polis, the corporate existence of the city-state. Personal immortality was impor-

tant only to the extent that it affected the survival of the community. A per-

son could achieve social immortality by being a good citizen—that is, by

I knew my former father-in-law from the time I was thirteen. Although I had

divorced many years ago, he remained a second father to me. Kurt was born in

Germany. He left for Holland on the day of Kristallnacht. He arrived here penni-

less and went on to become an extremely successful business man. In coming to

this country, he left his entire family. With the exception of an uncle, they all died

in the Holocaust. He remained an observant Jew and did not talk much about the

Holocaust until the last two years of his life. Since he never knew when his parents,

sisters, and other loved ones died, he observed the yahrzeit (anniversary of their deaths) on Yom Kippur (the day of atonement).

Just before Rosh Hashanah two years ago, he became very ill and was hospital-

ized. Following an old European tradition, in the synagogue on Rosh Hashanah

he was given a new Hebrew name (so that when the angel of death came looking

for him, he wouldn’t fi nd him). I went to visit him in the hospital that day. He was

in and out of consciousness. I doubt that he consciously knew who I was, and I’m

sure was not aware of the day. When he did speak, he was speaking only in Ger-

man. I said my good-bye to him and left. He remained alive for the entire ten-day

period (often referred to as the Days of Awe) and (I believe) went to be with his

loved ones on Yom Kippur.

Barbara J. Paul

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Classical Greek Concepts of Immortality 537

performing actions directed toward the common good. Because the commu-

nity remembers heroic acts, the hero achieves a renown that extends beyond

his or her lifetime.

For those who sought more than symbolic immortality, assurances of

happiness beyond death could be obtained by participating as an initiate

in one of the mystery religions (any of various secret cults that offered reli-

gious experiences not provided by the offi cial public religions). By dedicat-

ing themselves to rites prescribed by the priests of the mystery cult, initiates

exchanged the grim picture of bloodless phantoms in the afterworld for the

more promising one of an idyllic future in paradise.

Among the early Greek philosophers, most thought of life and death as

aspects of an ever-changing, eternal fl ux. They typically believed that the

soul was a vital principle that continued in some fashion after death but did

not imagine it surviving as a distinct entity. If something of the “soul” contin-

ued beyond death, it merged with the stuff of the universe.

Later, Pythagoras taught that conduct during life determined the des-

tiny of the soul after death. Through practicing discipline and purifi cation,

one could infl uence transmigration—that is, migration of the soul from one

body or state to another in successive rounds of births and deaths—resulting

in eventual union with the Divine or Universal Absolute. These beliefs drew

upon the Orphic mystery religions of ancient Greece (dedicated to the hero

Orpheus and emphasizing ideas about purifi cation and the afterlife), which

went back to the cult of Dionysus.

The idea that a person’s conduct in this life somehow could infl uence

existence in the afterlife contrasted with the predominant view of an indis-

tinct immortality in which all human beings participated, regardless of

their actions. Eventually, the beliefs of Pythagoras and his followers would

be adopted in somewhat altered form during the pre-Christian era, and the

relationship between righteous conduct and immortality would be further

refi ned during the early centuries of Christianity.

For the whole world is the sepulchre of famous men, and it is not the epitaph upon

monuments set up in their own land that alone commemorates them, but also in

lands not their own there abides in each breast an unwritten memorial of them,

planted in the heart rather than graven on stone.

Thucydides, The Peloponnesian War

Speak not smoothly of death, I beseech you, O famous Odysseus. Better by far to

remain on earth the thrall of another . . . rather than reign sole king in the realm

of bodyless phantoms.

Homer, The Odyssey

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538 c h a p t e r 14 Beyond Death / After Life

With Socrates, there are further signs of the shift from a social immor-

tality predicated on the life of the community to the possibility of personal

survival after death. Precisely what Socrates believed is unclear, although

he apparently favored the notion that the soul survives the death of the

body. On his deathbed, he describes a sense of anticipation at the prospect

of communion with the spirits of the great in the afterworld. In the Apology, however, he describes death as either eternal bliss or dreamless sleep. In the Phaedo, Plato advanced a number of “proofs” that the soul is eternal and is released from the body at death. The dualism of body and soul is empha-

sized, and their respective fates are distinguished: Because it is mortal, the

body is subject to corruption; the soul is immortal and therefore not subject

to death.

Christian Beliefs About the Afterlife The principal insight of both Jewish and Christian thought has two main

premises: fi rst, “that human beings are creatures, composites of dust and

God’s animating breath,” and second, “that they are created in the image

and likeness of God, with a destiny—a royal dignity—that overtakes their

fi nite status.” 19 In the New Testament, writings about dying and death derive

from Jewish traditions as interpreted in the light of Jesus’ death and resur-

rection. The life, death, and resurrection of Jesus is the model of ultimate

reality for Christians, a model realized through faith. Oscar Cullman wrote

that only a person who takes death seriously as death is able to “comprehend the Easter exultation of the primitive Christian community and understand

that the whole thinking of the New Testament is governed by belief in the

Resurrection.” 20 In using the phrase, “death as death,” Cullman contrasts the

Christian view of Resurrection with belief in immortality, which is “only a

negative assertion: the soul does not die.” Resurrection, however is “a positive assertion,” in which the whole person, “who has really died, is recalled to life

by a new act of creation by God.” 21

Boniface Ramsey expresses a similar view: “No matter how much the early

Christians may have mourned their dead, and no matter how much they may

have experienced some fear of death, nonetheless the basic attitude toward

death was radically different from that of the pagans,” whose views he describes

as fatalistic, joyless, fi lled with despair and an irreparable sense of loss. 22

He who has lived as a true philosopher has reason to be of good cheer when he is

about to die, and that after death he may hope to receive the greatest good in the

other world. . . . For I deem that the true disciple of philosophy . . . is ever pursu-

ing death and dying; and if this is true, why, having had the desire of death all his

life long, should he repine at the arrival of that which he has been always pursuing

and desiring?

Plato, Phaedo

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Christian Beliefs About the Afterlife 539

For early Christians like the Apostle Paul, death was vanquished by

Christ’s resurrection. “As Paul sees it, the Christian certainty of the life to

come comes from the fact that the Christian’s Savior is one who was dead and

is alive again.” 23 Resurrection is presented in Paul’s writings as a special kind

of bodily existence, but it also has a symbolic or spiritual meaning. The prom-

ise of immortality, which was implicit in the Hebrew scriptures, is defi ned in

the Christian view as “personal and bodily resurrection from the dead.” 24

Ignatius, an early father of the Church, called the Eucharist “medicine of

immortality, an antidote against death.” 25

At the same time, the Greek understanding of body and soul was a persis-

tent infl uence on early Christian thought. In this view, the soul is immortal;

it is part of the human person that exists in a disembodied state after death.

This understanding interacted richly with Hebrew thought during the forma-

tive years of Christianity. Milton Gatch says about this period,

The notion of resurrection and of the restoration of an elect people continued

to be prominent. But the idea of a disembodied afterlife for the soul was

also current and led to the conception of some sort of afterlife between

the separation and the reunion of soul and body. From a picture of death

as the inauguration of a sleep which would last until the divinely instituted

resurrection, there emerged a picture of death as the beginning of quiescence

for the body and of a continued life for the soul, the nature of which remained

more or less undefi ned. 26

Gradually, Church doctrine began to accommodate the idea that an

intermediate period of purifi cation between death and resurrection pro-

vided for the removal of obstacles to “the full enjoyment of eternal union

with God.” 27

This intermediate state came to be known as purgatory. 28 In the writings of Dante and Thomas Aquinas, earlier concepts of death, which focused on

eventual resurrection of the body, are subordinated to a more pronounced

emphasis on the soul’s immortality after death. Jerry Walls says, “It is hard to

exaggerate the long-term signifi cance of [Dante’s poem, Purgatorio ] for the fortunes of the doctrine of purgatory.” 29 Jacques Le Goff wrote that Dante

not only “rescued Purgatory from the infernalization to which the Church

Behold, I show you a mystery: We shall not all sleep, but we shall all be changed.

In a moment, in the twinkling of an eye, at the last trump: for the trumpet shall

sound, and the dead shall be raised incorruptible, and we shall be changed. For

this corruptible must put on incorruption, and this mortal must put on immortal-

ity. So when this corruptible shall have put on incorruption, and this mortal shall

have put on immortality, then shall be brought to pass the saying that is written,

Death is swallowed up in victory. O death, where is thy sting? O grave, where is

thy victory?

I Corinthians, 15

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540 c h a p t e r 14 Beyond Death / After Life

subjected it in the thirteenth century,” but also that he “more than anyone

else made Purgatory the intermediate region of the other world.” 30

Anthony Thiselton expresses a prominent view: “The main focus in the

New Testament lies not chiefl y in the experience of the individual, but on the

last great cosmos acts of God, namely, the Return of Christ (often called after

This scene from Dante’s Divine Comedy shows the guide Charon ferrying worthy souls up the River Styx toward Paradise. Unable to reach the heavenly kingdom, the unworthy, immersed in the river, struggle in despair.

F o

to B

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o te

c a A

p o

st o

li c a V

a ti

c a n

a

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Christian Beliefs About the Afterlife 541

Go Down, Death—A Funeral Sermon Weep not, weep not,

She is not dead;

She’s resting in the bosom of Jesus.

Heart-broken husband—weep no more;

Grief-stricken son—weep no more;

Left-lonesome daughter—weep no more;

She’s only just gone home.

James Weldon Johnson

the Greek term the Parousia ), the Last Judgment, and the resurrection of the dead, as well as what follows these “Last Things.” 31 Carol Zaleski says,

The classical Christian view, expressed in countless catechisms and confessions,

is that upon death the souls of the blessed enter immediately into the divine

presence, where they enjoy the unmediated vision of God, join in the angelic

liturgy, and attend to the needs of the living who turn to them for intercession. . . .

They await the return of Christ, the resurrection of the dead, and the renewal

of all creation. Their bliss is perfect after its kind; but until the soul regains

its body, and the whole body of Christ is complete in all its members, this

perfection is, paradoxically, an unfi nished work. 32

The interplay between the concepts of resurrection and immortality is

illustrated by two tombstone inscriptions from the colonial period found

in a cemetery in New Haven, Connecticut. 33 On the fi rst tombstone, the

inscription reads, “Sleeping, but will someday meet her maker.” The second

is inscribed, “Gone to his eternal reward.” Whereas the fi rst inscription sug-

gests an intermediate state of “soul-sleep” followed by resurrection of the

body at some time in the future, the second inscription proposes the immor-

tality of the soul, which continues to exist even though the body dies. The

apparent contrast between these inscriptions is incongruous when you con-

sider that these two individuals were married to each other and are buried

side by side. Yet, one is “sleeping,” while the other is “gone.” In these tomb-

stone inscriptions, we see a curious example of how contrasting ideas about

the afterlife can coexist.

Indeed, both of these ideas about the afterlife can be found today,

although comparatively few Christians believe in the literal “soul-sleep” of the

dead or waiting until the end of the world before experiencing their heavenly

reward. The predominant view is this:

After death and the separation of the soul from the body through death, the

bodiless and intermediate state of the soul follows; after the intermediate

state of the soul, the resurrection and judgment; after the resurrection and

judgment, two-fold eternity: Paradise or Hell. 34

As for the nature of Paradise or Hell, fi gurative phraseology like “the

heavenly Jerusalem” or “the great tribulation” is used to convey ideas about

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542 c h a p t e r 14 Beyond Death / After Life

the conditions of souls after death rather than exact descriptions. As a “pil- grim people” poised between the ascension of Christ and the realization

of the kingdom of God, Christians see themselves as part of a “narrative of

hope” that dawned at the beginning of human history, a journey of faith in

which death can be understood as “coming home.” 35

The Afterlife in Islamic Tradition The third of the great religious traditions stemming from the patriarch Abra-

ham is Islam. Like Judaism and Christianity, Islam shares the Semitic reli-

gious heritage of monotheism, God’s revelation through the prophets, and

accountability for one’s actions at the Day of Judgment. Islam means “peace” or “submission” (peace comes from submission to transcendent reality, the

Divine). A Muslim is an adherent of Islam—that is, a person who has submit- ted to and is at peace with God. The fi ve main duties of Islam are declaration

of faith, prayer fi ve times a day, almsgiving, fasting from dawn to sunset dur-

ing the sacred month of Ramadan, and a pilgrimage to Mecca.

The Islamic message came through Muhammad, who received his call to

be a prophet in 610 CE, when he was about forty. It is recorded in the Qur’an

(meaning “readings,” and more familiarly spelled phonetically as Koran in the West). According to Muslims, the Qur’an “does not abrogate or nullify,

but rather corrects the scriptures preserved by the Jewish and Christian com-

munities.” 36 Frithjof Schuon notes that the doctrine of Islam hangs on two

statements: First, “There is no divinity (or reality) outside the only Divinity

(or Absolute)” and, second, “Muhammad is the Envoy (the mouthpiece, inter-

mediary, or manifestation).” 37

A basic premise of Qur’anic teaching about death is that God determines

the span of a person’s life: “He creates man and also causes him to die.” 38

After death, Allah (God) judges a person’s conduct. The Book of Deeds,

wherein are recorded good and bad actions, will be opened, and each person

will be consigned to either everlasting bliss or everlasting torment. “For the

Muslim, life on earth is the seedbed of an eternal future.” 39

The Islamic vision of the afterlife is both spiritual and physical. 40 “Since

the Last Day will be accompanied by bodily resurrection,” says John Esposito,

“the pleasures of heaven and the pain of hell will be fully experienced.” 41

Heaven is a paradise of “perpetual peace and bliss with fl owing rivers, beau-

tiful gardens, and the enjoyment of one’s spouses (multiple marriage part-

ners are permitted in Islam) and beautiful, dark-eyed female companions

( houris ).” The terrors of hell are described in equally physical terms.

The happiness of the drop is to

die in the river.

Ghazal of Ghalib

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Death and Immortality in Asian Religions 543

Some Muslims believe that, after a person dies, “two black-faced, blue-

eyed angels named Munkar and Nakir visit the grave and interrogate the

deceased about his beliefs and deeds in life.” Depending on the answers, the

deceased is comforted or punished. Thus, “At a Muslim funeral a mourner

may approach a corpse as it is about to be laid in the tomb and whisper

instructions for answering these questions.” 42 It is also believed by some

Muslims that “no one should precede the corpse in the funeral procession

because the angels of death go before it.” 43

When death nears, the dying person may be read passages from the

Qur’an to help ensure a righteous state of mind and facilitate an easy release.

After death, a ritual washing, or ablution, is done—except in the case of a

martyr, in which case washing is not done “in order not to remove traces of

blood which are the hallmark of his martyrdom.” 44 The funeral should be

conducted without elaborate ceremony, with the body wrapped in white cloth

and laid in a simple, unmarked grave. No coffi n comes between the body

and the earth to which it returns. Some Muslims believe the grave should be

deep enough for the dead person to sit up without his or her head appearing

above ground when the time comes to answer questions at the Last Judg-

ment. The grave is laid out on a north-south axis, with the deceased’s face

turned toward the East—that is, toward Mecca—so that it is symbolically in

a state of prayer. Burial follows as soon as possible after death. On hearing

of someone’s death, it is customary to say, “Allah Karim”: From God we came

and to him we shall return. 45

The goal of Muslims is to die in the knowledge that one has submitted to

the transcendent reality and has passed the test of this life. The moment of

death is considered a call to prayer. “The underlying belief is that one should

and can take comfort knowing that life and death are in accord with God’s

will, that the soul returns to God, and that the community is supportive of

the bereaved.” 46

Death and Immortality in Asian Religions Western thought typically makes distinctions, points up contrasts, estab-

lishes differences. Experiences are analyzed as being either this or that. Life is the opposite of death, death is the enemy of life; life is “good”; death,

“evil.” In Asian cultures, by comparison, the characteristic mode of thought

emphasizes the integrity of the whole rather than distinctions between con-

stituent parts. Whereas Western thought distinguishes between “either/or,”

Eastern thought subsumes such distinctions within a holistic “both/and”

approach.

This view of reality is refl ected in sacred texts of the East. In Chinese tra-

dition, for example, the Book of Changes, or I Ching (Yijing), one of the great- est literary works of Asia, postulates the basic circumstance of change in the

universe; life and death are different manifestations of a constantly changing

reality. As depicted in the symbol of the Tao (literally, “the way”; the process

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544 c h a p t e r 14 Beyond Death / After Life

of nature by which all things change), the contrasting aspects of reality inter-

penetrate one another. Thus, death and life are not mutually exclusive oppo-

sites but, rather, complementary facets of an underlying process revealed in

cycles of birth, decay, and death. Like a pendulum swinging through its arc,

the completion of one cycle heralds the beginning of another. Chuang Tzu

expressed the traditional Chinese attitude toward death as follows:

Life and death are fated—constant as the succession of dark and dawn, a matter

of Heaven. I received life because the time had come; I will lose it because the

order of things passes on. 47

Observing this process, the sages of the East developed the concept of

reincarnation, or transmigration (the passing at death from one state of

existence to another, or of the soul from one body to another). Some people

understand this process in a physical way: “I will take birth in another body fol-

lowing the death of my present body.” In other words, reincarnation implies a

continuity of personal identity from incarnation to incarnation. Other people

shun a materialistic understanding, adopting the view that there is, in fact, no

“I” to be reborn. Something may indeed be carried over from one state to the

next, but this “something” is impersonal, formless, and ineffable.

In China, Confucianism dealt with the external world of politics and

social interactions, while Daoism addressed the inner world of spiritual

exploration and transformation. By practicing various spiritual techniques,

advanced practitioners were supposedly able to gradually purify and trans-

mute their bodies, a transformative process that eliminated impurities and

culminated in an immortal body. 48

Hindu Teachings About Death and Rebirth The terms Hindu and Hinduism refer to the beliefs, practices, and socio-

religious institutions that developed from the civilization of the Indo-European-

speaking peoples who settled in India in the last centuries of the second

millennium BCE. In Hinduism, death has been called “the personifi cation of

time ( mahakala ) and the foundation of the cosmo-moral order ( dharma ).” 49 Among the distinguishing features of Hinduism is belief in transmigration of

the soul. This is termed samsara, which refers to “wandering,” “journeying” or “passing through” a series of incarnational experiences. What links these

experiences is karma, which can be roughly defi ned as the moral law of cause and effect. The thoughts and actions of the past determine the present state

of being; and, in turn, present choices infl uence future states. This karmic pro-

cess pertains to the ever-changing fl ow of moment-to-moment experience as

well as to successive rounds of deaths and rebirths. As each moment conditions

the next, karma governs the reincarnational fl ow of being. In the Bhagavad- Gita, Krishna tells Arjuna,

For death is a certainty for him who has been born,

and birth is a certainty for him who has died.

Therefore, for what is unavoidable thou shouldst not grieve.

In a commentary on this passage, Nikhilananda adds, “It is not proper to

grieve for beings which are mere combinations of cause and effect.” 50

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Death and Immortality in Asian Religions 545

The cosmic dance of the Hindu deity Shiva, an ever-changing fl ow of creation and dis- solution, embodies the fundamental equilibrium between life and death, the underlying reality behind appearances. As the Lord of the Dance, Shiva is portrayed with one foot on the demon of ignorance and poised for the next step.

L o

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M u

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546 c h a p t e r 14 Beyond Death / After Life

Behind the apparent separateness of individual beings is a unitary real-

ity. Just as the ocean is composed of innumerable drops of water, undiffer-

entiated being manifests itself in human experience as apparently separate

selves. “Underlying man’s personality and animating it is a reservoir of being

that never dies, is never exhausted, and is without limit in awareness and

bliss. This infi nite center of life, this hidden self or Atman, is no less than Brahman, the Godhead.” 51

Hinduism teaches that it is possible to free ourselves from the illusion of

separate selfhood, with its attendant pain. Attachment to, or identifi cation

with, the concept of “self ” as separate and distinct causes suffering in the

present life and perpetuates the endless wheel of births and deaths, the wheel

of karma. Liberation ( moksha ) from fate and the cycles of history involves the recognition that life and death are beyond such mistaken notions of self-

identity. “The one who has attained moksha can see the eternal in the tempo- ral and the temporal in the eternal.” 52 The Bhagavad-Gita says,

Worn-out garments are shed by the body:

Worn-out bodies are shed by the dweller.

Nikhilananda says, “In the act of giving up the old body or entering into

the new body, the real Self does not undergo any change whatsoever. .  .  .

Brahman, through Its inscrutable maya (illusion), creates a body, identifi es Itself with it, and regards Itself as an individual, or embodied, soul.” 53

Death is inescapable. What is born passes away (see Figure 14-1 ). Yet, for

the person “whose consciousness has become stabilized by the insight that it

is the very nature of things to come-to-be and pass-away,” there is no “occa-

sion either for rejoicing over birth or grieving over death.” 54

Hinduism offers various rites and practices that help in awakening to

truth. For example, one practice involves imagining one’s own death and the

fate of the body, its return to elemental matter in the grave or on the funeral

pyre. Another practice involves paying close attention to the transitory and

ever-changing nature of one’s own being, moment to moment. Other prac-

tices involve meditation in the presence of a dead body or at burial or crema-

tion grounds. By consciously confronting mortality, one becomes reoriented

toward the transcendent dimensions of reality. The aim is to let go of condi-

tioned existence. This is “the death that conquers death.” 55

Day after day

some of those

who live on the earth

go to the house of death

and those who remain

hope to stay the same forever

what could be stranger.

Figure 14-1 Mahābhārata

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Death and Immortality in Asian Religions 547

The Buddhist Understanding of Death Buddhism is named after the historical Buddha (“the awakened one”),

Siddhartha Gautama, who taught in India around the sixth to fourth cen-

turies BCE. Like Hinduism, Buddhist doctrine explains that the universe is

the product of karma, and the goal is escape from the suffering of samsara, the cycle of births and deaths. The aim is nirvana, which means “extinction,” as when a fl ame goes out when deprived of fuel. Nirvana is defi ned as an “unconditioned state beyond birth and death that is reached after all igno-

rance and craving have been extinguished and all karma, which is the cause

of rebirth, has been dissolved.” 56

In this view, there is no “self ” to survive after death or to be reborn.

Everything is transitory and impermanent ( anicca ), in continual unease and unrest ( dukkha ), and substanceless ( anatta ). In the Buddhist view, karma is seen as the universal principle of causality that underlies the stream of “psy-

chophysical” events. Dōgen, founder of the Soto Zen sect of Buddhism, says,

“Life constantly changes, moment by moment, in each of its stages, whether

we want it to or not. Without even a moment’s pause our karma causes us to

transmigrate continuously.” 57

This transmigration can be likened to impressing a seal onto wax, or to

transferring energy in a game of billiards when the cue ball strikes the cluster

of balls, creating new energy events. “Rebirth does not involve the transfer

of a substance, but the continuation of a process.” 58 Carl Becker says Buddha

spoke of “rebirth, as opposed to the notion of reincarnation that might imply

that a single soul was reincarnated in several consecutive bodies. Rebirth, on

the other hand, suggests a causal continuity between one birth and the next

without requiring that the two be identifi ed as the same person.” 59

From the Buddhist perspective, it could be said that there are two kinds

of death: continuous and regular. Continuous death is the “passing show”

of phenomenal experience, constantly arising and passing away, moment by

moment. Regular, or corporeal, death is the physical cessation of vital body

functions at the end of a lifetime. “For the enlightened person, death hap-

pens; that is all. And one is in perfect accord with the event.” 60

Buddhist meditation is described as “in one sense a death rite, although

it is seldom called that. Meditation practice is about sitting attentively on the

abyss between life and death without clinging to life as if it were good or fl ee-

ing death as if it were bad.” 61 Dōgen said, “The thorough clarifi cation of the

meaning of birth and death—this is the most important problem of all for

Buddhists.” 62

Thus shall you think of all this fl eeting world:

A star at dawn, a bubble in a stream;

A fl ash of lightning in a summer cloud.

A phantom, an illusion, a dream.

Buddha, The Diamond Sutra

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548 c h a p t e r 14 Beyond Death / After Life

Like Hinduism, Buddhism teaches that it is necessary to renounce the

desires and cravings that maintain the delusion of a separate self. When all

attachments are dropped, the incessant round of birth-decay-death is given

no further fuel. How does one awaken to this reality, to nirvana? “Zen sects

emphasize the need to prepare for death. Preparation means spiritual readi-

ness, including the recognition that all things are impermanent.” 63 Dōgen

says, “Simply understand that birth and death are in themselves nirvana, there being no birth-death to be hated or nirvana to be desired. Then, for the fi rst time you will be freed from birth and death.” 64

The paradox of Dōgen’s statement about birth-death and the importance

of using death as a means of awakening to truth is echoed in the words of

Hakuin, who is known as the reviver of the Rinzai sect, the other great Zen

Buddhist lineage in Japan. 65 For those who wish to investigate their true

nature, Hakuin advised meditation on the word shi, the character for death. To do this, he suggested a koan (a teaching question): “After you are dead and cremated, where has the main character [the chief actor or one’s “original

face”] gone?” Hakuin wrote,

Among all the teaching and instructions, the word death has the most unpleasant and disgusting connotations. Yet if you once suddenly penetrate

this “death” koan, you will fi nd that there is no more felicitous teaching

than this instruction that serves as the key to the realm in which birth and

death are transcended, where the place in which you stand is the Diamond

indestructible, and where you have become a divine immortal, unaging

and undying. The word death is the vital essential that the warrior must fi rst determine for himself.

Dying well includes values of composure, living in the moment, and cul-

tivating strength to die alone. 66 There is an emphasis on the importance of

a calm and meditative mental state at the time of death, which is signifi cant

Though it will die soon

The voice of the cicada

Shows no sign of this.

Bashō

Skulls and skeletons are a common theme in Zen painting. Often humorous—

sometimes shocking—these images lead both artist and viewer to contemplate

the impermanent nature of material existence. In the Buddhist view, only when

impermanence is directly confronted and deeply understood can freedom, bliss,

and enlightenment become possible.

Bodhidharma Ink

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Death and Immortality in Asian Religions 549

not only because of transmigration of the consciousness but also more simply

in terms of a “good death”: one that is fi lled with peace rather than struggle

and angst. 67

The period immediately after death is considered an especially oppor-

tune time for gaining insight. The priest at a Buddhist funeral, for exam-

ple, speaks directly to the deceased, expounding on the teachings that

can awaken the intermediate being to the true nature of existence. Philip

Kapleau says, “The funeral and subsequent services thus represent literally a

‘once in a lifetime’ opportunity to awaken the deceased and thereby liberate

him from the binding chain of birth-and-death.” 68

It is important to recognize that, like most religions, Buddhism contains

diverse practices and sects. In Japan alone, these include Shingon, founded by

Ku.̄ kai (774–835); Jodo, founded by Hônen (1133–1212); Zen (Rinzai and Sōtō);

Jôdo Shinshu.̄ (aka Shin Buddhism), founded by Shinran (1173–1262); and Nich-

iren (aka Nichirenshu.̄ ), founded by Nichiren (1222–1282). Jôdo Shinshu.̄ (“True Pure Land School”), for example, is a form of Pure Land Buddhism, known as

the “easy path,” in which faith in the power of Amida Buddha and chanting of

the nembutsu (the name of Amida) brings liberation. 69 Despite differences between the various sects, virtually all perform

funeral rites that assume a personal existence that continues after death. In

In the Japanese section of this cemetery on the island of Oahu, graves holding the ashes of deceased members of the community are ornamented with Buddhist symbols of the Wheel of Dharma and the Lotus .

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550 c h a p t e r 14 Beyond Death / After Life

doing so, they diverge from the teachings of Buddha. George Tanabe points

out, “Sākyamuni [one of the titles of Buddha] taught the nonexistence of

souls ( anātman ), and the absence of souls leaves nothing to commemorate after death.” 70 He adds: “Human sentiments make the core elements of Japa-

nese funerals resilient to the persuasions of orthodoxies. In the end, love and

affection hold sway over both theory and practice.” 71

After-Death States in Tibetan Buddhism According to W. Y. Evans-Wentz, “Buddhists and Hindus alike believe

that the last thought at the moment of death determines the character of

the next incarnation.” 72 On this point, the Buddha said, “Rebirth arises

from two causes: the last thought of the previous life as its governing prin-

ciple and the actions of the previous life as its basis. The stopping of the

last thought is known as decease; the appearance of the fi rst thought as

rebirth.” 73 Scriptures like the Bardo Thödol, or The Tibetan Book of the Dead, as it is better known in the West, are meant to infl uence the thoughts of the

dying person during the transitional period of life-death-rebirth. Indeed,

the Bardo Thödol is also known as “The Book of Natural Liberation.” Here is an excerpt:

Listen carefully; be attentive and alert. Death has come to you. It is time for

you to depart this world. While you must face this reality alone, know that you

are not the only one, for death comes to all. Do not cling to life because of

sentiment, and do not fear to go on. You do not have the power to stay. 74

Although bardo is often interpreted as an intermediate or transitional state between death and rebirth, it can be translated as “gap” or “inter-

val of suspension.” In this sense, it refers to a number of “in between” or

transitional conditions. 75 Chögyam Trungpa suggests that the term refers

not only to the interval between death and rebirth but also to “suspension

within the living situation.” 76 The Bardo Thödol and similar texts are com- monly read as a person is dying. (A similar practice occurs in the Hindu tra-

dition, in which the Bhagavad-Gita is read.) Such texts can serve as a guide for the living as well as the dying. Chögyam Trungpa says that the Bardo Thödol deals with “the principle of birth and death recurring constantly in this life.” Indeed, in this view, “The bardo experience is part of our basic

psychological make-up.”

The Bardo Thödol offers counsel about how to use these experiences— some terrifying, some benign—to awaken to a more enlightened incarna-

tion. Although acknowledging that these experiences likely appear quite

real to the bardo traveler, the text emphasizes that the deities or demons

encountered are simply apparitions, the experiencer’s own projections.

They do not represent ultimate or transcendent perfection but, rather,

steps on the way. (Some scholars believe, as Christopher Carr argues, that

modern near-death experiences, or NDEs, “describe, at most, the begin-

ning of death processes, whereas the Tibetan books of the dead describe

entire death processes.”) 77

. ´

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The Consolations of Religion 551

The Consolations of Religion From the foregoing survey of beliefs about death and the afterlife in various

traditions, it is clear that, for many people, if not most, religion offers path-

ways toward understanding and coping with dying and death. In this sense,

the “religious culture of death” provides an interpretative framework within

which to fi nd a positive meaning in an otherwise negative or tragic event. 78

In stressful situations, religion enhances coping resources by fostering self-

esteem and a sense of control through, for example, trust and faith in God. 79

Even in so-called secular societies, religion plays a signifi cant role in attitudes

and behaviors toward death (see Table 14-1 ).

According to Lucy Bregman, the death awareness movement has gained

much from its connection with religion and spirituality. Bregman says,

Spiritual beliefs and practices provide an interpretation of the dying process,

aid in the developmental task of transcendence, and afford comfort to dying

individuals and their family members. 80

For dying patients and their families, religion may offer solace, sug-

gest some meaning in dying, and provide rituals that help ease the pangs

of grief. Vernon Reynolds and Ralph Tanner note that religion is con-

cerned with “ministering to the dying person, preparing him or her for

the world to come, generally being involved with his physical needs and

psychological feelings at this time, and likewise helping those who are

especially close.” 81

A signifi cant theme in the work of W. E. B. Du Bois, a pioneering American

sociologist of religion, is the insight that religious institutions do more than

connect people with God; they connect people to one another. 82

It is useful to distinguish between two related concepts: religiosity and spirituality. Although a partial defi nition of spirituality is “to be concerned with religious values,” it is understood more broadly as a search for ultimate

meaning and purpose in life, which may or may not be directly related to

1. Religion provides a shared set of beliefs, values, and norms around which people can form a common identity. Thus, religion is a unifi er, “the social glue that binds a group together by giving it a common set of values.”

2. Religion provides answers to the “big questions” about human existence and purpose. It addresses issues of life and death, outlines the kind of life people are expected to lead, and explains what happens to them after they die.

3. Religion often provides a foundation for the norms and laws of a society. Laws acquire a moral as well as a legal force when they are embedded in religious values.

4. Religion is a source of emotional and psychological support to people, especially at times of crisis.

t a b l e 14-1 Four Functions of Religion in Societies

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552 c h a p t e r 14 Beyond Death / After Life

a particular religious tradition. “It entails connection to self-chosen and/

or religious beliefs, values, and practices that give meaning to life, thereby

inspiring and motivating individuals to achieve their optimal being.” 83 It

emphasizes “a personal search for connection with a larger sacredness” and

“a bonding with others that cannot be severed, not even by death.” 84

The consolations of a religious or spiritual orientation are likely

to depend on the manner in which that person makes such an orienta-

tion part of his or her life. For instance, the experience of someone who

attends religious services mainly because they create opportunities for

social interaction is likely to be very different from that of someone who

participates because he or she fi nds deep personal meaning in religious

creeds and beliefs. In this sense, religiosity embraces several dimensions,

including these: 85

1. Experiential religiosity (emotional ties to a religion)

2. Ritualistic religiosity (participation in religious ceremonies)

3. Ideological religiosity (religious commitment)

4. Consequential religiosity (degree to which religion is integrated into the

person’s daily life)

5. Intellectual religiosity (knowledge about the religion’s traditions, beliefs,

and practices)

Any or all of these dimensions can have an impact on how a person faces

death and copes with loss. For example, a young Filipino American man

whose father had died talked about the comfort he felt in connection with

a funeral mass held in the church where his family worshipped. Comment-

ing on the language and other symbols present in the service, he said, “You

know, I’ve never thought much about what those prayers are about, but the

soothing rhythms of the chants and the pungent smell of the incense caused

me to feel that my dad is somehow still being cared for, that he’s really okay.”

This young man’s experience includes aspects of experiential, ritualistic, and

consequential religiosity.

Secular Concepts of Immortality “Mortality teaches us a lot about life, if we let it,” says palliative care physician

Ira Byock. “One thing it teaches is that human life is inherently spiritual,

whether or not a person has a religion.” 86

In technology-oriented and economics-driven societies—both East and

West—traditional religious and philosophical beliefs about the purpose

of life or the nature of death no longer enjoy universal acceptance as they

did when societies and communities were more cohesive. For many people,

death has been divorced from religious and mythic connotations. Seculariza- tion is “the process in modern societies whereby religious ideas, practice, and organizations lose their infl uence in the face of scientifi c and other

knowledge.” 87 Traditional beliefs no longer carry the same weight in a social

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Secular Concepts of Immortality 553

milieu that emphasizes rationalism and scientifi c method. Colin Murray

Parkes says, “Secularism is essentially rational; it is the faith that we must

rely on our reason in all matters, and that reason must take precedence

over other ways of perceiving reality.” 88 Theological or philosophical discus-

sions about the afterlife may seem to resemble the famous debate about the

number of dancing angels that will fi t on the head of a pin. Yet, vestiges of

traditional concepts about death and the afterlife remain part of our mod-

ern consciousness.

The Abrahamic religious traditions—Judaism, Christianity, and Islam—

present a linear picture of human history, describing a progression of events

that begins with creation and eventuates in the resolution of the cosmic story

at the end of time. Such an orientation leads to an interest in eschatologies — that is, pictures of the ultimate state, doctrines of last things. From the well-

springs of the Judeo-Christian tradition and Greek thought, people in West-

ern culture have predominantly framed their beliefs about the afterlife in a

historical context oriented toward the future. The predominant viewpoint

in Western culture is that human beings live a single life; that the soul sur-

vives death, perhaps in a disembodied state; that at some future time each

soul will be judged; and that, depending on one’s conduct during earthly

existence, the aftermath will be either hellish torment or heavenly bliss.

This view is challenged by modern ways of thinking about human existence

and death.

Among the most infl uential secular alternatives to religious orienta-

tions are humanism, positivism, and existentialism. Humanism (a doctrine, attitude, or way of life centered on human interests or values) emphasizes

human intellectual and cultural achievements rather than divine interven-

tion and the supernaturalism of religion. 89 It tends to refl ect an antireligious,

even atheistic, stance in which human beings are the measure of all things.

Positivism, a school of thought associated with science, refl ects the belief that religious or metaphysical modes of knowing are imperfect and that “posi-

tive knowledge” is based on what can be directly observed in nature and in

human activities. Existentialism is an intellectual and artistic movement that also infl uences secular attitudes about life and death. In its inquiry into

the meaning of human experience, existentialism disavows the comforting

answers offered by religion or social convention. Instead, it focuses squarely

on our individual responsibility for making choices that defi ne who we are

and what we will become. The “human predicament” is such that we cannot

shirk our responsibility for making diffi cult but crucial choices that shape

our existence. According to Kenneth McLeish,

We are self-creating creatures: we can choose what we want to be, and choose to

be it. The moment of choice, the leap into existence, comes between two fi xed

points: the nothingness from which we come and the nothingness to which we

return after we die. Our glory is the self-defi ning choice; our agony is that we

need to make it. 90

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554 c h a p t e r 14 Beyond Death / After Life

It is not unusual for a person to hold several competing worldviews at the

same time, perhaps combining elements of religious faith carried over from

childhood with elements of the viewpoints and attitudes represented by one

or more of the secular alternatives just discussed.

Secular, or nonreligious, responses to questions about survival after

death often refl ect ideas about some kind of symbolic immortality. 91 These ideas include the biological continuity that results from having children who

sustain a person’s genetic legacy through succeeding generations, thus con-

ferring a kind of personal immortality. Other “children” that symbolically

convey personal immortality include those produced through creative works

of art, contributions to a fi eld of knowledge, and even heroic or helpful deeds.

A person who has arranged for his or her body to be donated after death

for the purpose of medical research gains a kind of “medical immortality”

through training new physicians or advancing medical science. The fact that

we are all members of one human race means that the good things we do and

our contributions to the welfare of others extend beyond our deaths, thereby

conferring a kind of “communal immortality” as our good deeds continue to

resonate with a positive infl uence on humankind.

Today, despite the option of unbelief, most people in the United States

affi rm belief in God. Nearly 80 percent say they believe in life after death. 92

Researchers note that images of what the afterlife might be like generally

involve union with God, peace and tranquility, and reunion with relatives. 93

One study of college undergraduates found that more than 90 percent believe

that “one is reunited with family and friends, that the afterlife is comforting,

that there is Heaven, and that the transition is peaceful.” 94 It is apparent that

religious ideas continue to play a role in both personal and social thought.

Although the assurances of religion can be comforting, Simone Weil

presents a complementary approach:

Not to believe in the immortality of the soul, but to look upon the whole of life

as destined to prepare for the moment of death; not to believe in God, but to

love the universe, always, even in the throes of anguish, as a home—there lies

the road toward faith by way of atheism. This is the same faith as that which

shines resplendent in religious symbols. 95

The Roman Stoic, Marcus Aurelius, who lived in the second century of

the present era, expressed similar thoughts. “The constant recollection of

death,” he said, “is the test of human conduct.” 96

Questions about immortality and “life after death” engage our thoughts.

When religious answers do not suffi ce, a search for scientifi c proof of “some-

thing beyond” ensues. The search for satisfying answers about what lies

beyond death is illustrated by widespread interest in near-death experiences.

Near-Death Experiences: At the Threshold of Death Stories of travel to other worlds can be found in virtually all cultures. The

traveler may be a hero, a shaman, a prophet, a king, or even an ordinary mor-

tal who passes through the gates of death and returns with a message for the

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Near-Death Experiences: At the Threshold of Death 555

living. Examples of such journeys include the heavenly ascent of the prophet

Muhammad and the heavenly visions of Enoch and the Apostle Paul, as well

as Odysseus’s and Gilgamesh’s epic adventures to the underworld, and the

descent of the goddess Inanna.

Carol Zaleski identifi es three forms of the otherworld journey: (1) the jour- ney to the underworld, (2) the ascent to higher worlds, and (3) the fantastic

voyage. 97 The common thread of all such journeys, says Zaleski, is the “story,”

which is shaped not only by what appear to be universal laws of symbolic expe-

rience but also by the experiences of a given culture. Belief in a future life

was historically based on religious experience; today, near-death experiences

are often cited by people as a reason for such belief. 98 Near-death experiences (NDEs) are “profound psychological events with transcendental and mystical elements, typically occurring to individuals close to death or in situations of

intense physical or emotional danger.” 99

The publication in 1975 of Raymond Moody’s Life After Life sparked the current interest in otherworld journeys and, more specifi cally, in near-death

experiences. These accounts by individuals who have come back from the

edge of death provide fascinating glimpses into a paranormal, or scientifi -

cally unexplainable, order of existence that seemingly transcends the limits

of biological life. Some people view NDEs as proof that the human personal-

ity survives death. Others assign psychological or neurophysiological causes

to NDEs, describing them as naturalistic responses to the stress of facing a

life-threatening danger. What are the components of a typical near-death

experience?

NDEs: A Composite Picture Suppose, in a horrifi c accident or acute medical crisis, you fi nd yourself

suddenly faced by an overwhelming encounter with death. Perhaps, almost

beyond awareness, you begin to realize you’re not going to make it; you’re

going to die.

It’s like a dream, yet the experience seems more real than ordinary wak-

ing consciousness. Your vision and hearing are extremely acute. Sensory

perceptions are heightened, and your thought processes are vividly clear,

rational. Somehow, you are no longer bound to your body. Becoming aware

of this feeling of disconnectedness, you realize that you are, in fact, separate

from the body, fl oating free, as you look down at the mangled or suffering

body and recognize it as your own.

You may feel a bit lonely, drifting in space, although there is a pervasive

sense of calm, a serenity that was rarely if ever experienced in the body. The

constraints of time and space seem irrelevant, unreal. As you move away from

the once-familiar world of the now-dead body, you enter a darkness, a tunnel,

a transitional stage in your journey.

Now you notice a light, more brilliant than could have been imagined

during your earthly existence. It beckons, drawing you onward, its golden

hues heralding your approach to the other side. The whole of your life is

experienced in a nearly instantaneous matrix of fl ashbacks, impressions of

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556 c h a p t e r 14 Beyond Death / After Life

your prior life, events, places, people: your life reviewed and projected on the

transparent screen of consciousness.

As you begin to enter the light, you glimpse a world of unimaginable

and unspeakable brilliance and beauty. Someone is greeting you, perhaps a

loved one, or perhaps you become aware of Jesus or Moses or Muhammad or

another being of ineffable grace. But now you realize that you cannot enter

fully into the light, not yet, not this time.

Dimensions of Near-Death Experiences Many people emerge from a near-death experience with a greater appre-

ciation of life, a determination to make better use of the opportunities pre-

sented to them. Often, they are more self-confi dent, more able to cope with

the diffi culties of life. Relationships become more important and material

comforts less important. NDE researcher Kenneth Ring says the typical near-

death experiencer “has achieved a sense of what is important in life and strives

to live in accordance with his understanding of what matters.” 100 Near-death

experiencers report dramatic reductions in death anxiety and fear of death,

which leads to altered life goals and values and to enhanced health, well-

being, tranquility, and zest for life. 101 People who experience NDEs exhibit

many features associated with the “conversion” stories of life-changing reli-

gious experiences.

In outline, our imaginary NDE is typical of reports by those who have

actually had such experiences. Four core elements have been identifi ed as

characteristic of NDEs: The person (1) hears the news of his or her death,

(2) departs from the body, (3) encounters signifi cant others, and (4) returns

to the body. However, this “typical” NDE is experienced variously by differ-

ent individuals. In one sample, only about 33 percent of respondents experi-

enced themselves as separate from their bodies, 23 percent experienced the

entry into a dark tunnel or transitional stage, 16 percent experienced seeing

a bright light, and 10 percent experienced themselves as actually entering the

light (though only for a “peek” into the unearthly surroundings). Ring found

that NDEs resulting from illness were more likely to be complete—to have

all of these characteristic core elements—than were NDEs resulting from

accidents. Over half of the NDEs related to accidents, however, included an

experience of panoramic memory, or life review, compared to only 16 percent of those whose NDE was related to illness or attempted suicide.

Life review, in itself a fascinating feature of NDEs, usually consists of vivid

and almost instantaneous visions of the person’s whole life or “selected high-

lights” of it. 102 The life review may appear in an orderly sequence, or it may

happen “all at once.” Either way, it apparently occurs without any conscious

control or effort on the part of the experiencer. Life “review” may include

visions of the future, with experiencers visualizing their death, the reactions

of friends and relatives, and events at the funeral.

The encounter with a presence—a feature of NDEs typically related to

the “tunnel” experience—usually involves seeing deceased relatives or friends

or sensing a religious fi gure. This presence has often been understood as a

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Near-Death Experiences: At the Threshold of Death 557

In Hieronymus Bosch’s portrayal of the Ascent into the Empyrean—the highest heaven in medieval cosmology—the soul, purged of its impurities, approaches the end of its long journey and union with the Divine.

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558 c h a p t e r 14 Beyond Death / After Life

representation of the “higher self,” but this is not always the case. 103 William

Serdahely describes an eight-year-old boy who was “comforted by two of his

family’s pets who had died prior to the incident.” 104 These encounters with

a presence are sometimes linked to the decision to return, to terminate the

NDE. Some experiencers believe that the decision to return to earthly life is

made for them; others report that they arrived at this decision themselves.

Usually, the decision to return relates in some way to unfi nished business or

to responsibilities that the person must attend to before his or her death.

The majority of NDEs are characterized by feelings of joy, peace, and cos-

mic unity, but some are distressing and frightening. 105 These “hellish” NDEs

may include imagery and sounds of torment, as well as demonic beings. An

initial period of terror is, in some instances, followed by peaceful resolution.

In other cases, the aftermath of the NDE brings a sense of emptiness and

despair. In yet other instances, a benevolent guide accompanies the experi-

encer through the disconcerting experience. Some scholars think that hell-

ish NDEs may be a truncated version of the typically radiant NDE; that is,

hellish NDEs are incomplete NDEs. Another explanation highlights the fact that many saintly persons and mystics—St. Teresa of Avila and St. John of the

Cross, to name two examples—reported frightening visions while engaged

in deep prayer or meditation. A hellish NDE could therefore be a “purifi ca-

tion experience,” a kind of “dark night of the soul,” as St. John of the Cross

described his distressing religious experiences. What are we to make of near-

death experiences? How should they be interpreted?

Interpreting Near-Death Experiences Near-death experiences are fascinating. To some they suggest (or con-

fi rm) hoped-for possibilities of an afterlife or immortality. Others view near-

death experiences as some sort of psychological phenomenon that may tell

us something about the nature of human consciousness. To those who hold

this view, NDEs are not “glimpses into a world beyond, but insights into the

world within the human mind.” 106 To still others, NDEs are related to psycho-

dynamic processes that occur when the self is threatened by annihilation.

NDEs are initiated in the presence of a belief that one is dying—whether or

not one is in fact close to death. 107 Some of the theories devised to explain

near-death experiences are listed in Table 14-2 . 108

For early Hawaiians, observations of apparent death, or persons who had “left the body prematurely,” were interpreted in accordance with their beliefs

about the ancestor-gods. 109 On each island, there was a special promontory

overlooking the sea; this was the leina, or leaping place, of the soul or spirit on its journey to the realm of the ancestors. If, on its way to the leina, a soul

was met by an ancestor-god and sent back, the body would revive. Otherwise,

the ancestor-god would lead it safely to and over the leina; once beyond that

hurdle, the soul was safe with the ancestors.

For various reasons (often, though not always, having to do with a per-

son’s behavior), an ancestor-god might delay a soul’s acceptance into eternity.

For instance, if a person died before his or her earthly work was done, the

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Near-Death Experiences: At the Threshold of Death 559

ancestor-god conducted the soul back to the body. “Sometimes when it is not

yet time to die,” reports Mary Pukui, “the relatives [ancestors] stand in the

road and make you go back. Then the breath returns to the body with a crow-

ing sound, o’o-a-moa. ” 110 Albert Heim, a Swiss geologist and mountain climber, is thought to have

been the fi rst to systematically gather data on NDEs. 111 During the early part

of the twentieth century, Heim interviewed some thirty skiers and climbers

who had been involved in accidents resulting in paranormal experiences.

Heim’s subjects experienced such phenomena as detachment from their bod-

ies and panoramic memory, or life review.

The data compiled by Heim were subsequently reviewed by psychoana-

lytic pioneer Oskar Pfi ster, who explained NDEs as being caused by shock

and depersonalization in the face of impending death. In other words, when

a person’s life is threatened, psychological defense mechanisms may come

into play, giving rise to the phenomena associated with NDEs. Pfi ster’s inter-

pretation continues to be elaborated by present-day researchers who believe

NDEs can be explained without resorting to the hypothesis that they prove

life after death.

According to Russell Noyes and Roy Kletti, when the self is confronted by

mortal danger, defensive reactions may result in a sense of depersonalization. 112

1. Neuropsychological theories: A. Temporal lobe paroxysm, or limbic lobe syndrome: Seizurelike neural discharges

in the temporal lobe or, more generally, in the limbic system. B. Cerebral anoxia, or oxygen deprivation: Shortage of oxygen in the brain. C. Endorphin release: Release of certain neurotransmitters associated with analge-

sic (pain-killing) effects and a sense of psychological well-being. D. Massive cortical disinhibition: Loss of control over the random activity of the cen-

tral nervous system. E. False sight: Hallucinatory imagery arising from structures in the brain and ner-

vous system. F. Drugs: Side effects. G. Sensory deprivation.

2. Psychological theories: A. Depersonalization: Psychological detachment from one’s body; in this case, a

defensive reaction to the perceived threat of death. May be accompanied by hyperalertness.

B. Motivated fantasy: A type of “defensive” fantasy that basically proposes that experiencers have an impression of surviving death because they desire to sur- vive death.

C. Archetypes: Images associated with various elements of the near-death experi- ence are “wired” into the brain as mythological archetypes of our common humanity.

3. Metaphysical theories: A. Soul travel: Transitional journey of the soul or spirit to another mode of exis-

tence or realm of reality (e.g., “heaven”); proof of life after death. B. Psychic vision: Glimpses into another mode of reality, though not necessarily

providing proof of soul-survival after death.

t a b l e 14-2 Theories of the Near-Death Experience

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560 c h a p t e r 14 Beyond Death / After Life

Their model, which may be the most comprehensive psychological explana-

tion of NDEs offered thus far, distinguishes three stages in the typical near-

death experience: (1) resistance, (2) life review, and (3) transcendence. The

fi rst stage, resistance, includes the processes of recognizing the danger, strug- gling against it, and fi nally accepting death as imminent. Such acceptance, or

surrender, marks the beginning of the second stage, which is characterized

by life review. As the self detaches from its bodily representation, panoramic memories occur and appear to encompass a person’s whole life. Life review is

often accompanied by affi rmation of the meaning of one’s existence and its

integration into the universal order of things. The third stage, transcendence, occurs as there is further detachment from one’s individual existence. It is

characterized by an increasingly transcendental, or cosmic, consciousness

that replaces limited ego- or self-identity.

Calm detachment, heightened sensory awareness, life review or pan-

oramic memory, and mystical consciousness are all phenomena associated

with the ego’s protective response to the possibility of its own demise. In

other words, the threat of death stimulates various psychological processes

that allow the ego, or experiencing self, to “escape” the threat. Because these

processes dissociate the experiencing self from the body, death is perceived

as a threat only to the body, not to the perceiving “self.” It is important to notice that a psychological interpretation of NDEs does not necessarily invali-

date any possible spiritual meaning that may be associated with NDEs.

In seeking the meaning of NDEs, some researchers follow the lines of

inquiry founded in the late nineteenth century by parapsychologists. To

adequately understand NDEs, these researchers say, one must go beyond

the usual boundaries of scientifi c inquiry. In short, we must be prepared to

accept the possibility, which is not scientifi cally verifi able, that NDEs are in

fact what they seem to be—that is, valid experiences of states of conscious-

ness that transcend the death of the body. In this view, NDEs teach us that

the appearance of death is not the same as the experience of death. In conduct- ing cross-cultural studies of near-death experiences, Karlis Osis and Erlendur

Haraldsson concluded that the evidence strongly suggests life after death. 113

They reported that “neither medical, nor psychological, nor cultural con-

ditioning can explain away deathbed visions.” Supporting this conclusion

is the observation that some deathbed visions include apparitions con-

trary to the experiencer’s expectations, such as “apparitions of persons the

person thought were still living, but who in fact were dead,” as well as appari-

tions that do not conform to cultural stereotypes, as with dying children who

are “surprised to see ‘angels’ without wings.” The idea that NDEs strongly

suggest, or even prove, that there is life after death seems to resonate with

many people. In national surveys, most adult Americans answer yes to the

question, Do you believe in life after death? 114

In summary, then, two distinct explanations have been offered to explain

near-death experiences. In the fi rst, NDEs offer proof of survival after death.

NDEs are what they appear to be: experiences of life after death. In the

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Near-Death Experiences: At the Threshold of Death 561

second explanation, NDEs are a response to the threat of death and destruc-

tion of the self. This response focuses on the brain or nervous system and

results from an ego-defensive reaction to a life-threatening situation.

Each explanation offers a model, or representation, of “how the world

works.” Louis Appleby, writing in the British Medical Journal, says that the explanations put forward to explain NDEs share one attribute: Each requires

a form of faith. 115 The explanation that best suits your own perception of how

things work is likely to be accepted most readily. There remains, however,

another approach to interpreting the signifi cance of near-death experiences.

Perhaps both of the explanations are valid: There is life after death, and there

is also a psychological phenomenon involving various defense mechanisms

whereby the personality is radically altered as the transition from one state to

the next is negotiated. In Carol Zaleski’s view, “We need to fi nd a middle path

between the extremes of dismissing near-death experience as ‘nothing but’

and embracing it as ‘proof.’ ” 116

Raymond Moody, who coined the term near-death experiences, now pre- fers to characterize NDEs as part of a “paranormal death syndrome,” which

includes apparitions of “death-bed escorts” frequently reported by individuals

who are near death. 117 Concerning the way his fi ndings about NDEs have been

interpreted over the years, Moody is disturbed when people discuss NDEs as

if they provide scientifi c evidence or proof of life after death. The prospect of

fi nding scientifi c proof of life after death is, he says, “unthinkable.” To Moody,

NDEs represent a “wading out collectively into a domain of experience that

has been closed for the most part to us until the past few decades and which is

now opening up due to the developments and techniques of cardiopulmonary

resuscitation.” People who have experienced NDEs and shared their stories

are enabling us all “to move across a frontier of consciousness.”

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562 c h a p t e r 14 Beyond Death / After Life

On the subject of how best to interpret NDEs, Herman Feifel’s remarks

are pertinent:

What is somewhat disquieting is the claim by some that near-death experiences

are evidence for and proof of the existence of an after-life. There may well be life

after death, but jumping to that conclusion from reported near-death experiences

refl ects more a leap of faith than judicious scientifi c assessment. This in no way

minimizes the reality of these occurrences for the people who declare them. I

just think that in weighing the evidence in this area we have less far-fetched and

more parsimonious interpretations within the canons of science that can explain

these phenomena. What strikes me about many of these out-of-body reports is the

hunger for meaning and purpose they suggest in this age of faltering faith. 118

Robert Kastenbaum cautions us to be careful about readily accepting the

“fantastic voyage” implied by most life-after-death accounts. 119 He says,

The happily-ever-after theme threatens to draw attention away from the actual

situations of the dying persons, their loved ones, and their care givers over the

days, weeks, and months preceding death. What happens up to the point of the

fabulous transition from life to death recedes into the background. This could

not be more unfortunate. The background, after all, is where these people are

actually living until death comes.

Finally, we should consider three points expressed by Charles Garfi eld,

who has worked extensively with dying patients: 120

1. Not everyone dies a blissful, accepting death.

2. Context is a powerful variable in altered-state experiences. A supportive

environment for the dying person may be an important factor in deter-

mining whether the outcome is a positive altered-state experience for the

dying.

3. The “happily ever after” stance toward death may represent a form of

denial when what is really needed by the dying person is a demonstration

of real concern and real caring in his or her present experience.

Whatever beliefs one may hold about life after death, Garfi eld says, “Let

us have the courage to realize that death often will be a bitter pill to swallow.”

Death Themes in Dreams and Psychedelic Experiences Fascinating “hints” about afterlife possibilities have also been conveyed

through “death dreams” and experiences with psychedelic or mind-altering

drugs. “Dreams offer a vivid illustration of our lifelong awareness of death,

giving voice to the unconscious fears, wishes, and desires that surround the

brute fact of human fi nitude.” 121

Marie-Louise von Franz says that, compared to near-death experi-

ences, which tend to be schematic and more culture bound, the death

imagery in dreams is richer in graphic detail and more subtle. 122 Among

older people, dreams often appear to be psychically preparing them for

impending death by symbolically indicating “the end of bodily life and

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Death Themes in Dreams and Psychedelic Experiences 563

the explicit continuation of psychic life after death.” Using the medium of

dreams, the unconscious communicates a comforting message—namely,

that there is an afterlife.

All of the dreams of people who are facing death indicate that the

unconscious . . . prepares consciousness not for a defi nite end but for a

profound transformation and for a kind of continuation of the life process

which, however, is unimaginable to everyday consciousness. 123

Death dreams incorporate a great variety of alchemical and mytho-

logical motifs, including themes associated with the growth of vegetation

or fl owering plants; the divine marriage of the soul with the cosmos; travel

through a dark, narrow passageway, or through fi re or water, to new birth;

sacrifi ce or transformation of the old body; shifting ego- or soul-identity; and

resurrection.

The journey through a dark passageway toward “a light at the end of the

tunnel” is a common motif not only in dreams and NDEs but in numerous

mythological traditions. Indeed, many mythologies embody a comparison of

the sun’s path with the mystery of life and death. Among Egyptians, for exam-

ple, the sun was viewed as the goal of the soul’s journey along the pathway of

the dead. The sun symbolizes the source of awareness, of becoming conscious. Franz says, “This also lies behind the widespread custom of lighting candles

The Egyptian papyrus of Hunefer depicts the Hall of Judgment and the Great Balance, where the deceased’s soul is weighed against the feather of truth. Beneath the scales, the Devourer of Souls awaits the unjust while Horus is ready to lead the just to Osiris, the lord of the underworld, and to a pleasurable afterlife.

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564 c h a p t e r 14 Beyond Death / After Life

and letting them burn in mortuary rooms and on tombs and graves,” which

is a form of “analogy magic through which new life and an awakening to new

consciousness is granted to the deceased.” 124

Turning to death imagery in connection with the use of psychedelic

drugs, it is interesting to note that, although LSD (lysergic acid diethylamide)

was fi rst synthesized in 1938 by the Swiss chemist Albert Hoffman, its bio-

chemical action on the brain is still not completely understood. 125 Neverthe-

less, its amplifying and catalyzing effects on the mind are well documented.

From the earliest studies of LSD, researchers noticed that it activates “uncon-

scious material from deep levels of the personality.” 126 It apparently opens up

areas of religious and spiritual experience that are intrinsic to the human

personality but independent of a person’s cultural or religious background.

Most notably, it often leads to a “shattering encounter” with critical aspects of

human existence: birth, decay, and death.

In the early 1960s, Eric Kast of the Chicago Medical School began stud-

ies of the pain-relieving effects of LSD and other psychedelic substances on

patients who were suffering intense pain from a life-threatening illness. 127

Besides relieving the symptoms of physical pain and discomfort, LSD

therapy diminished emotional symptoms, such as depression, anxiety, ten-

sion, insomnia, and psychological withdrawal. LSD seemed to accomplish

these results by altering the patient’s learned response to pain—that is, the

patient’s anticipation of pain based on past experiences. By becoming free

of this conditioning, the patient was more oriented to the present and thus

able to respond to sensations as they were actually experienced rather than

to an image of pain that had grown more and more distressing over time.

Noting that pain is a composite phenomenon that has both a neurophysi-

ological component (the pain sensation) and a psychological component

(the pain affect), Stanislav Grof and Joan Halifax conclude that the primary

infl uence of psychedelic therapy seems to be in modifying the psychologi-

cal component.

Perhaps more signifi cant than diminution of pain was a change of atti-

tude toward death and dying among patients. After the psychedelic session,

patients typically displayed a diminished fear of death and less anxiety about

the life-threatening implications of the illness. According to Grof and Hali-

fax, “Dying persons who had transcendental experiences developed a deep

belief in the ultimate unity of all creation; they often experienced themselves

as integral parts of it, including their disease and the often painful situations

they were facing.” 128

Many patients exhibited a greater responsiveness to their families and

their environment. Self-respect and morale were enhanced, and they showed

greater appreciation of the subtleties of everyday life. The fact that such tran-

scendental experiences were induced in randomly selected subjects was con-

sidered to be strong evidence that “matrices for such experiences exist in the

unconscious as a normal constituent of the human personality.” 129 (Although

the consensus among researchers was that there was enough positive evidence

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Beliefs About Death: A Wall or a Door? 565

to justify continued research with LSD for therapeutic purposes such as pain

relief, the “religious fervor of casual users and their calls for social revolution

evoked a backlash that transformed LSD into a pariah substance and trig-

gered laws that made its use in any context illegal.”) 130

As with the phenomena discussed in connection with NDEs, the psy-

chedelic experience typically includes phenomena that are not scientifi cally

explainable. Grof and Halifax point out that persons “unsophisticated in

anthropology and mythology experience images, episodes, and even entire

thematic sequences that bear a striking resemblance to the descriptions of

the posthumous journey of the soul and the death-rebirth mysteries of var-

ious cultures.” 131 As with NDEs, the result is usually a signifi cantly altered

outlook with respect to the meaning of life and death. The evidence accumu-

lated through reports of near-death experiences, as well as psychedelic expe-

riences, has led some researchers to the view that modern science should

broaden its perspective on the nature of human consciousness. Stanislav Grof

says, “Reality is always larger and more complex than the most elaborate and

encompassing theory.” 132

Beliefs About Death: A Wall or a Door? One writer comments, “Despite myths of an afterlife, the promises of sacred

texts, and the hopes of the faithful, none of us really knows what continues, and if it does, where it goes or how it gets there.” 133 In the last analysis, then, what shall we believe about personal immortality or the afterlife? Can we

anticipate an ultimately fulfi lling experience after death, as seems to be true

from reports of near-death experiences? Or are such experiences merely psy-

chological projections, wish-fulfi lling fantasies that mask the terror of con-

fronting one’s own demise? Furthermore, what shall we say about various

religious understandings? Do their concepts of the afterlife have some basis

in reality? Or should we adopt a strictly scientifi c approach to such questions?

Two basic philosophical views about death and the afterlife can be summa-

rized as follows: Death is either a wall or a door. 134 We can imagine many variations on these two positions regarding what

happens at death. Indeed, the doctrines of the various religions and the

Now Let the Weeping Cease (Hymn) Now let the weeping cease

Let no one mourn again

The love of God will bring you

peace

There is no end

The Gospel at Colonus

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566 c h a p t e r 14 Beyond Death / After Life

explanations offered for paranormal experiences are just such variations. For

example, stating a Christian perspective, we could say that death appears to

be a wall, but at some time in the future—at the Resurrection—it will turn

out to have been a door. The Hindu concept of reincarnation would suggest

that death is a door, not a wall. Buddhists might respond that death is both

a door and a wall, and it is neither. A standard psychological explanation

of NDEs might support the view that death is a wall that is experienced as a

door. Or perhaps the door and the wall are simply alternative ways of experi-

encing the same reality.

In the end, a statement made by the International Work Group on Death,

Dying and Bereavement may be our best guide: “Dying is more than a biologi-

cal occurrence. It is a human, social, and spiritual event, [but] too often the

spiritual dimension of patients is neglected.” 135 A close relationship between

religion and health has existed since ancient times. Caregivers need to recog-

nize and acknowledge the spiritual component of patient care. Appropriate

resources should be offered to those who wish them. Each person’s spiritual

beliefs and preferences are to be respected. 136

What we believe about death and the afterlife can infl uence the actions

taken when we or others near death. If we have a materialist view, seeing

death as a wall, we may insist that life-sustaining efforts be carried out to

the end. Conversely, if we believe in continued existence after death, we may

prefer to spend our fi nal hours on earth in preparation for a transition into

another mode of existence. Similarly, a bereaved person may fi nd solace in

his or her belief about what lies beyond death. The person who views death

as the end may be reassured that the suffering of a loved one truly ends at

death. Another person fi nds comfort in believing that the personality sur-

vives physical death. By understanding our own beliefs about death, we are

able to “care more adequately for each other when death—wall or door—

comes to those we love.” 137

Further Readings John Bowker. The Meanings of Death. New York: Cambridge University Press, 1991. Ben Bradley, Fred Feldman, and Jens Johansson, eds. The Oxford Handbook of Philoso-

phy of Death. New York: Oxford University Press, 2012. David Chidester. Patterns of Transcendence: Religion, Death, and Dying. 2nd ed. Belmont,

Calif.: Wadsworth, 2002.

Kathleen Garces-Foley, ed. Death and Religion in a Changing World. Armonk, N.Y.: M. E. Sharpe, 2006.

Alister E. McGrath. A Brief History of Heaven. Malden, Mass.: Blackwell, 2003. Samuel Scheffl er. Death and the Afterlife. New York: Oxford University Press, 2013. Alan F. Segal. Life After Death: A History of the Afterlife in the Religions of the West. New

York: Doubleday, 2004.

Gregory Shushan. Conceptions of the Afterlife in Early Civilizations: Universalism, Construc- tivism, and Near-Death Experience. New York: Continuum, 2009.

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Further Readings 567

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

Jane Idelman Smith and Yvonne Yazbeck Haddad. The Islamic Understanding of Death and Resurrection. New York: Oxford University Press, 2002.

Jacqueline I. Stone and Mariko Namba Walter, eds. Death and the Afterlife in Japanese Buddhism. Honolulu: University of Hawaii Press, 2008.

Richard P. Taylor. Death and the Afterlife: A Cultural Encyclopedia. Santa Barbara, Calif.: ABC-CLIO, 2000.

Jerry L. Walls. Purgatory: The Logic of Total Transformation. Oxford: Oxford University Press, 2012.

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The path ahead at times may appear to be clearly marked. Looking ahead, however, the fi nal destination is not so evident. What lies in the distance, around the next bend? The personal and social choices about dying and death are like walking a pathway on which our steps into the immediate future may seem obvious, but it is not always clear what choices lie ahead.

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569

C H A P T E R 1 5

The Path Ahead: Personal

and Social Choices

A Chinese folk tale, “The Mortal King,” draws attention to the fact that the desire for immortality has its own pitfalls. 1 Surveying his realm one day, a king is struck by the

awesome thought that someday he will die and lose it all. “I wish we could live forever!”

he says. “That would be wonderful!” Encouraged by his friends, the king fantasizes how

great it would be if they were never to grow old and die. Of all his companions, only one

refrains from delighting in this prospect. Instead, he bows to the king and explains, “If

we all lived forever as you suggest, why, then, all the great heroes of history would still live

among us; compared to them, we would be fi t only to plow the fi elds or be clerks in the

provinces.”

Does this Chinese folk tale have meaning for us? Acknowledging a place for death in our

lives can awaken us to the preciousness of life. In the Japanese classic, The Tale of Genji, the

phrase mono no aware is generally translated as “the sorrow of human existence,” but Donald

Keene points out that it might be better translated as “a sensitivity to things”; that is, as a

recognition of the perishability of beauty and human happiness. 2

In previous chapters, we have seen many different attitudes toward death and dying. In

our relationship with death, we are both survivors and experiencers. One student said, “Con-

fronting death has put me in touch with life.”

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570 c h a p t e r 15 The Path Ahead: Personal and Social Choices

Think about your own relationship to death. What place does death have

in your life? What kinds of meanings does death hold for you? Are death and

dying compartmentalized in a category all their own, or are they woven into

the fabric of your experience?

Refl ecting on the study of death and dying, a student remarked, “The

thought of death had always created a lot of fear; now I fi nd something fasci-

nating about exploring my own feelings about death and the way that society

relates to death.” Another student said, “I see now what a big part denial and

mutual pretense played in my family’s experience of death; the subject of

death has really been taboo.” As you think about the various topics covered in this book, what do you

notice concerning your understanding of death? Has learning about death

and dying changed your attitudes toward death? Has it expanded your per-

spectives? Do the terms death and dying elicit the same thoughts and emotions as when you fi rst began your study?

Death is the ultimate challenge to human vanity or pretension. “In the

last analysis,” says sociologist David Clark, “human societies are merely men

and women banded together in the face of death.” 3 Death may be devalued,

even denied for a time, but it cannot be eluded.

Exploring Death and Dying “When I thought about my own death,” a student remarked, “I slammed the

door, thinking of all the things I still want to do in my lifetime. Now, I’ve

become a bit more calm, a bit more balanced about it.” Another said, “Before

I got involved in studying death, I wasn’t really down with it, especially my

own death, even though I haven’t had many personal encounters with death.

Now I feel that facing my own death is not as diffi cult, really, as being a survi-

vor of other people’s deaths.”

For some, investigation of death and dying allows a more accurate per-

ception of what one can do to protect or to be responsible for another. A par-

ent said, “I’ve learned about letting go where my children are concerned. No

matter how much you might wish it were otherwise, you can never shield your

loved ones from everything.”

Responding to this awareness, another student said, “I learned how

important it is to appreciate people while you’ve got them.” An awareness

of death can focus attention on the importance of taking care of unfi n-

ished business, saying the things that need to be said, and not being anx-

ious about those things that do not. As one student expressed it, her study

of death and dying had impressed upon her a sense of “the precariousness

of life.”

As Thomas Attig points out, coming to terms with our own fi niteness and

mortality can be understood as a grieving process. 4 Such self-mourning is

really a lifelong process of coming to terms with impermanence, uncertainty,

and vulnerability—qualities inherent in being mortal.

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Exploring Death and Dying 571

The close examination of death can bring insights that help dissipate

long-held feelings of guilt or blame about a loved one’s death. The study of

death and dying can help to put previously unsettling experiences into per-

spective. It can open up new and creative possibilities that result in an easier,

more comfortable relationship with others and with life itself.

For one man who had felt frustrated, resentful, and guilty about his

brother’s death twenty-fi ve years earlier, the study of death allowed oppor-

tunities to explore unexpressed and unresolved grief. As the “stored tears”

began to be expressed, he summed up the benefi t of his exploration of death:

“It feels so good to get rid of that ache.”

The study of death and dying can bring benefi ts related to professional

concerns. One nurse said, “When death occurs on the ward, people often

think, ‘Oh, well, you’re a nurse; it shouldn’t bother you.’ But it does. . . . I really

Death can be viewed as a burden or as a blessing. Its meaning changes as circum- stances change and as our understanding evolves toward new recognitions of its place in our lives.

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572 c h a p t e r 15 The Path Ahead: Personal and Social Choices

miss the patient; it’s a real loss.” A clerk in an emergency room described the

new and more helpful choices she could use in relating to survivors:

My desk is in the same area with the survivors of an ER [emergency room]

death. I used to feel a pain right in the pit of my stomach, wondering what to say

to them. I thought I should be able to comfort them in some way, that I should

somehow offer them words of wisdom. But now I don’t feel that way. I’ve learned

how important it is to simply listen, to be supportive just by being there, instead

of trying to fi nd some words that will magically make it all go away.

The study of death and dying can be academically intriguing. Learning

about the meaning of death in feudal Japan, for example, provides an appre-

ciation that goes beyond the aesthetic or historical approach to cross-cultural

understanding. The willingness of a society to engage in activities that pose

risks for the well-being of its citizens reveals something of the social consen-

sus with regard to the value of human life. The attitudes in a culture are

refl ected in programs for care of the dying. Funeral customs refl ect a soci-

ety’s attitudes toward intimate relationships. For the person with an inquir-

ing mind, investigating a society’s relationship with death opens up larger

patterns of belief and behavior.

Cultural Competence Some of the “lessons taught” in death studies are still based on middle-class,

white populations. Darrell Crase asks the rhetorical question, “Black people

do die, don’t they?” 5 In a culturally diverse environment, this question applies

to people from other ethnic backgrounds as well. Among the most insight-

ful research fi ndings and theories in recent decades have been those that

resulted from scholars taking a broad, cross-cultural view of dying, death,

and bereavement.

Stereotypes will trip you up every time. There is no formula or recipe

for understanding a particular cultural group. While generalizations about

beliefs and practices can be helpful guides, it is nonetheless true that the map

is not the territory. Norms can be used only as a guide. You cannot assume

I took your Death and Dying class while trying to cope with the transition from

working full-time to taking care of my dad, a stroke and cancer patient. After

being convinced for ages that he could die any day, he left us at last, more than 2

years later than anyone (including him!) ever expected.

The lessons I learned in your class are helping me immensely. For example,

when I learned that the word bereavement comes from a root word meaning

“shorn off,” I made a resolution at the time to cut off all my hair when he died.

Sure enough, I was then a newly shorn sheep.

Now, my hair is back down below my ears, though not yet to my shoulders.

Hair growth, and grief—both take a while.

A student in a Death and Dying class

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Cultural Competence 573

that all individuals of a particular religion, race, or cultural or national group

share the same beliefs. Each person is unique.

Rather than making an assumption about an individual’s attitudes and

beliefs, it is important to be curious and to listen. Even if the person sitting next to you looks like he or she comes from the same background that you

do, there is no way to learn the similarities and differences without being curi-

ous. Understanding culture requires knowledge of how an individual defi nes

his or her heritage. Skin color, for example, is probably not going to be the

determining factor in matters of death, dying, and bereavement. 6 You must

also consider other factors, including geographic location, rural or urban set-

ting, family infl uences, and the number of generations from immigration to a

particular country. Heritage is best understood by exploring cultural associa-

tions, spirituality, and social class. 7 When it comes to cultural issues, the most

important thing is to approach each individual with openness and curiosity.

Another essential is the ability to gather information about practices, ritu- als, and patterns of belief. Rather than “knowing” the answers, it is best to

suspend assumptions and ask questions about attitudes, beliefs, and rituals.

Ask an open-ended question, such as “How does that help you cope?” (If it

doesn’t, then listen to how or why it doesn’t.) This is where good listening

comes into play.

Various terms have been used to identify the skills that are needed: cul- tural accommodation, cultural diversity, cultural sensitivity, and cultural competence. The last term has been defi ned as “the process by which individuals and sys-

tems respond respectfully and effectively to people of all cultures, languages,

classes, races, ethnic backgrounds, religions, and other diversity factors in a

manner that recognizes, affi rms, and values the worth of individuals, fami-

lies, and communities and protects and preserves the dignity of each.” 8

It can also be helpful to consider the “Iceberg Theory of Culture.”

According to this model, the vast majority of culture is below the surface.

What we see initially are such things as art, clothing, music, literature, food,

and celebrations. Dig a bit deeper and we fi nd “deep culture.” Near sea level,

this arena teaches us about such things as child rearing and socialization,

patterns of decision making, and rules of descent. Dig even deeper, or should

we say, dive deeper, and you’ll fi nd patterns of handling emotions, conver-

sational patterns in various contexts, concepts of status, and the nature of

friendship. There is much else to discover at this deep sea level.

And now a little story: 9

As the television camera was turned off, the interviewer turned and

asked quietly, “Why are Anglo funerals so serious?” Answering this ques-

tion appropriately requires the ability to explore, consider, and respond to

cultural differences. Take our television reporter. Notice that she used the

word Anglo. Considering her word choice, her name, and her appearance, you might guess that her background is Hispanic. Her use of the word serious also deserves attention.

It is best to gather information before responding. Recall the reporter’s

question. What kind of response might help gain a better understanding of

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574 c h a p t e r 15 The Path Ahead: Personal and Social Choices

her heritage? A useful question might be, “What has been your experience

with Anglo funerals?” She probably isn’t asking about a British Anglo-Saxon

funeral. More likely, she is asking about Caucasian funerals in the United

States as contrasted to rituals of her own family or ethnic group. By matching

her language and using the term Anglo in response, she is likely to provide more specifi c information.

She describes two recent deaths, one of a Caucasian colleague and the

other of a family member. The contrasts between the two funeral ceremo-

nies were quite perplexing to this young woman. The Caucasian funeral was

a Protestant service held at a mortuary. The young reporter described her

experience at the visitation and funeral for her colleague. She arrived at

the mortuary to fi nd the deceased’s body in a small, empty room. Walking

through the door, she noticed a condolence book set out for her to sign. She

did so, briefl y viewed the body, and left. During the funeral, the family sat

behind closed curtains, cut off from the view of the casket and the mourners

sitting in the public portion of the funeral chapel.

The funeral for her uncle was held in his parish church (Catholic) in an

area of Miami, Florida, populated mostly by Cuban immigrants. The funeral

itself was preceded by several days and nights of viewing at a funeral home,

where family members, including small children, visited. Cuban music played

in the background, and central to the gathering were jokes, laughter, and

stories about the deceased. Laughing and crying together, the family visited

with other members of the community who came to pay their respects.

As she talks about the differences in the funeral rituals, her use of the

word serious is placed in context. Now, we have more information about the cultural differences that spark her curiosity. As you imagine the con-

trast between these two gatherings, it makes sense that, to the reporter, one

seemed to be more “serious” (solemn and staid) than the other. Attitudes that

we bring from our cultural experiences refl ect the practices that are a famil-

iar part of our heritage. Paying attention to how people use language can

reveal a great deal about personal as well as cultural attitudes toward death. 10

A comparison of bereavement customs among ethnic and other cultural

groups in the United States shows that, “while adapting partly to Western pat-

terns, these groups also adhere to the bereavement procedures of their own

cultures.” 11 Although death is fundamentally a biological fact, socially shaped

ideas and assumptions create its meaning.

New Directions in Thanatology One job of a thanatologist is to provide clients and students with materials

that deepen their understandings about death. A second job is to stimulate

thinking about attitudes concerning issues in the fi eld. These two tasks are

designed to bring about a balance between the affective and the cognitive, or

emotional and intellectual, aspects of thanatology. A further task in thanatol-

ogy is to engage in actions that build toward a better quality of civilized life,

especially with regard to such events and experiences as war and environ-

mental catastrophe.

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New Directions in Thanatology 575

During a cremation ceremony in Bali, young men carry a papier-mâché tiger containing the remains of a villager through the center of town to a temple outside the village, where the actual cremation will take place. On the way, they run, halt abruptly, shout and make noise, and turn the palanquin around and around to confuse the spirit so that it leaves the earthly realm and journeys to the afterworld.

© R

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576 c h a p t e r 15 The Path Ahead: Personal and Social Choices

Thanatology is a diverse, expanding, and maturing fi eld of study and

practice. In this section, we take a brief tour of some tasks and topics that

constitute new directions in thanatology. We focus particularly on efforts

(1) to gain a global perspective and (2) to narrow the gap between theorists

and practitioners so that research fi ndings are better integrated into practice.

Gaining a Global Perspective If you lived in Germany in recent years, you might have received an invi-

tation to participate in an exhibit designed to make people more attentive

and aware of their mortality. As Fritz Roth was packing his bags for another

trip to speak about death, dying, and bereavement—as well as about the phi-

losophy of his unique funeral establishment, Pütz-Roth—he wondered what

different people might pack in a suitcase for their last journey. He invited

more than a hundred individuals from across Germany— some prominent

individuals, some artists, some young people, and some elderly—to partici-

pate by preparing a suitcase sent to them by Pütz-Roth.

What would the suitcases contain? Would the items be similar or vastly dif-

ferent? Sentimental or practical? Memories of life or equipment for the fi nal

journey? The instructions required the suitcases to be arranged so that when

they were opened they would show, without being unpacked, the individual’s

thoughts on the fi niteness of life. It was hoped that the “suitcases for the last

journey” would be as varied as the worldviews of the individuals participat-

ing. And, as the suitcases were returned to Pütz-Roth, so it was. Some people

returned empty cases, explaining that the task was overwhelming. Others

intentionally left the case empty, indicating their rationale on attached plac-

ards. But most of the cases were fi lled, and each person described not only

the contents but also the accompanying philosophy (see Figure 15-1 ).

What began with one man’s curiosity grew into an art exhibit about per-

sonal mortality. From the exhibit came a fi lm by Phillip Engels, titled To The Afterlife and Back, that was shown on German television. A book with images and descriptions of the individuals’ varied choices for the suitcase project was

also published, Einmal Jenseits und Zurück: Ein Koffer für die Letzte Reise (Beyond and Back: A Case for the Last Journey). 12

International programs in thanatology typically have pioneers who

worked to make a difference in attitudes and practices toward death in a vari-

ety of ways: forming organizations, spearheading government programs, and

preparing educational offerings, for example. Some of these efforts mirror

those found in North America; others are unique, such as the German suit-

case project.

From New Zealand, Margaret Agee, a professor at the University of Auck-

land, says that funeral practices are being infl uenced by traditional customs

of the indigenous Maori. For example, pakeha (ethnically European or white) families are choosing to have the body at home prior to the funeral, as the

Maori people do, either at home or in the marae (meeting house) during the tangi (a memorializing process held over several days). Also, celebrants are often facilitators, not ordained clergy. New choices come from exposure to

and adaptation of different customs.

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New Directions in Thanatology 577

Figure 15-1 Suitcase for the Last Journey I am taking . . . Family photo—for the heart. Noodles—for the mood. Nuts—for the brain. Tweezers—what every woman needs. Sudoku books—against bore- dom. Lighter—for more light. Lip gloss—for more glamour. Cigarettes—for something a bit sinful. Susanne Fröhlich, author and TV show host.

In Limerick, Ireland, language and customs from history are used to

describe end-of-life care. Sinéad Donnelly tells how palliative care services

use the term meitheal to describe a multidisciplinary approach. 13 Meitheal is an Irish word that traditionally denotes a group of neighbors in a rural commu-

nity who come together to help in a particular task, such as harvesting or cut-

ting turf. Through this word choice, a sense of the past, and how it informs

the present in relation to community support, is emphasized.

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578 c h a p t e r 15 The Path Ahead: Personal and Social Choices

Dolores Dooley describes how the twenty-six counties that constitute the

Republic of Ireland have been engaged in a “national conversation” about

death and the process of dying. 14 Topics being discussed include how a “good

death” is understood, how hospitals can deliver better end-of-life care, prefer-

ences about being informed of a terminal condition, advance directives, pain

management, life-prolonging technologies, physician-assisted death, and

other aspects of the thanatology enterprise.

In Hong Kong, Amy Chow, a professor at the University of Hong Kong,

says that courses on death and dying, at all levels, are oversubscribed, and

most Chinese are willing to share their bereavement experiences with oth-

ers, including family, friends, and colleagues. 15 Traditions and rituals, such

as ancestor worship, ghost festivals, and elaborate Taoist funeral rites, lend a

sense of mystery to the experience of bereavement.

In Italy, Francesco Campione conducts a master’s program in dying,

death, and bereavement at the University of Bologna, and he edits two

book series. He plans to publish Italian contributions to thanatology as

well as translations of the best of the international literature. Campione

also began an organization, Progetto Rivivere, that uses the Internet to

help children with death and bereavement. Counselors who work online

are psychologists trained to work with families and children. Francesco

says the biggest problem in Italy is overcoming cultural resistance to talk-

ing about death. However, he believes that people are ready to ask for

advice about how to discuss death with children, which is why he began his

program at that level.

In Barbados, Deiann Sobers, Acting Director of the National Assistance

Board and Coordinator of Bereavement Support Services, says that the pro-

gram she directs is a component of a holistic approach to psychological,

social, physical, and spiritual care. Facilitators are social workers, nurses, doc-

tors, clergy, fi re offi cers, police offi cers, educators, and funeral directors who

provide counseling for persons dealing with loss by death, divorce, fi re, and

natural disasters. There are also support groups for parents whose babies are

stillborn or die immediately after birth. Nearly 2300 volunteers have been

trained to provide bereavement care. This program now extends to the hos-

pital, the Ministry of Education Student Services, the Barbados Cancer Soci-

ety, the Cancer Support Services, governmental as well as nongovernmental

employee assistance programs, and the clergy.

Early Australians were portrayed as hardy, resourceful people too busy

colonizing a harsh and unfamiliar landscape to waste time shedding a tear

or grieving. This attitude, still held by some, is slowly changing to more open

acceptance and willingness to acknowledge losses. Rose Cooper reports that,

in recent decades, Australia has been developing education in the fi elds of

loss, grief, and thanatology generally. Despite Australia’s familiarity with nat-

ural disaster, it took a train wreck to kick-start the formalizing of education

and coordinated services. In January 1977, a commuter train derailed and

tore away the piers of a bridge in suburban Sydney, resulting in the deaths of

eighty-three people. The Granville train disaster was the catalyst for forming

the National Association for Loss and Grief (NALAG) later that year. NALAG

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New Directions in Thanatology 579

now operates in all the mainland states of Australia and offers community

education and an accreditation program for counselors.

In Sydney, Australia, Mal and Di McKissock’s Bereavement Care Centre

is engaged in enrolling the fi rst students in a master’s honors program spe-

cializing in bereavement counseling. The Bereavement Care Centre, estab-

lished in 1981, offers bereavement care that includes counseling, educational

courses, books and DVDs, and other information and resources for bereaved

adults and children.

Victoria University of Technology in Melbourne offered its fi rst thanatol-

ogy program in 1995, the Graduate Diploma in Loss and Grief Counseling.

From beginnings in 1996, the Australian Centre for Grief and Bereavement

in Melbourne is the largest provider of grief and bereavement education in

the country, offering a range of counseling training programs, specialist

short courses, and consultation to industry.

Juan Camilo Algarra Pryor, a Bogotá psychologist, describes the contri-

butions of Isa de Jaramillo in his country, calling her the “mother of thanatol-

ogy” in Colombia. In addition to initiating Fundación Omega, Jaramillo has

published extensively, most recently Morir Bien. 16 Professionals and layper- sons from around the country have participated in seminars sponsored by

Fundación Omega. Juan says, “It’s a pity, but in such a violent, war-stricken

country as ours, professionals in the fi eld of psychology turn their backs to

death-related work. In a group of one hundred students in psychology at my

school, I was the only one interested. I had to turn to Fundación Omega and

Isa Jaramillo’s books for instruction.”

Another organization, Fundación Vida por Amor a Ellos, provides indi-

vidual therapy as well as support groups for children, parents, and family

of the terminally ill; suicide survivors; siblings; widows and widowers; and

people who are separated. They have also devised a program to offer grief

counseling and support through mortuaries in Colombia.

Palliative care is being provided at a hospice in Bogotá, and the Univer-

sity del Rosario in Bogotá may soon begin a residency program in palliative

care for medical doctors. As far as is known, the only course offering for uni-

versity students is at Universidad de los Andes, Bogotá.

In Japan, an Association for Death Education and Grief Counseling was

founded in 1982 by Alfons Deeken, a Jesuit priest and philosopher. Before

that, prolonging the life of a patient usually had been the main concern of

doctors, whereas quality of life of the dying was neglected. Today, the changes

in interest and understanding of death and dying, hospice care, bereavement,

and grief in Japanese society are profound. There are currently chapters of

the association in fi fty Japanese cities. 17

It is interesting to consider terms used to describe thanatology in Japanese.

Thanatology is usually translated as shiseigaku. Shi means “death,” sei means “life,” and gaku means “learning” or “study.” Thus, shiseigaku literally means “the study of death and life.” The primary death education organization in

Japan is called Seitoshi wo Kangaeru Kai. That means “the association for think- ing about life and death.” Thus, in this case, life comes fi rst. Deeken uses the

words shi eno jyunbi kyouiku, meaning “preparatory education” for death. Some

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580 c h a p t e r 15 The Path Ahead: Personal and Social Choices

school teachers recently seem to prefer inochi no kyoiku, which is translated “the education of life.” Inochi means “life.” Inochi no kyoiku includes not only topics about death and bereavement but also topics about the preciousness of life, life

stages, and so on. With this phrase, the word death, shi, is omitted from death studies at the elementary and secondary school levels. 18

From this whirlwind global tour, it’s clear that our international col-

leagues are busy initiating unique art explorations, historical and cultural

adaptations, academic and publishing projects, and governmental and non-

governmental programs, as well as bereavement and end-of-life services to

meet the needs of individuals and families in their respective communities. 19

Bridging Research and Practice Do counselors, therapists, other health professionals, and caregivers in gen-

eral use the knowledge and insights derived from thanatological research? Or

is there a cultural split between researchers and clinicians? Examining issues

in thanatology more than two decades ago, Robert Kastenbaum remarked that

there were few signs of practitioners making much use of either research or

theory in their work with patients or with the bereaved. He said it appears “that

many practitioners in the area of terminal care and bereavement have neither

an up-to-date mastery of thanatological research nor a secure grasp of the his-

torical and theoretical dimensions.” Kastenbaum concluded that

at the worst, perhaps, we have sketched a picture of practitioners who fail to

read a literature that wouldn’t help them very much anyway. The academicians

continue to tread their mills . . . with only each other to amuse, while the

practitioners base their services on individual experiences and a grab-bag of

unexamined assumptions and “facts” whose veridicality has seldom been tested,

let alone established. 20

My Death “Death is our eternal companion,”

Don Juan said with a most serious

air. “It is always to our left, at

an arm’s length. . . . It has always been

watching you. It always will until

the day it taps you.”

Carlos Castaneda

My death

looks exactly like me,

She lives to my left,

at exactly an arm’s length.

She has my face, hair, hands;

she ages

as I grow older.

Sometimes, at night,

my death awakens me

or else appears in dreams

I did not write.

Sometimes a sudden wind

blows from nowhere,

& I look left

& see my death.

Alive, I write

with my right hand only.

When I am dead,

I shall write with my left.

But later I will have to write

through others.

I may appear

to future poets

as their deaths.

Erica Jong

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Creating Compassionate Cities 581

Echoing such thoughts, Myra Bluebond-Langner observed, “While the

quantity of research has increased, what more do we actually know? Has

progress in thanatology kept pace with publication? What differences have

our efforts made in the care of dying patients and their families, and in our

own responses to death and impending disasters?” 21

In concluding a book that aimed for a collaboration between researchers

and practitioners, the editors summed up the challenge:

The pairing of coauthors was something of a “blind date,” in the sense that we

suggested collaborations between prominent theorists or scientists on the one

hand and practicing professionals on the other, many of whom had never met

prior to being invited to write together. Not all of these arranged marriages

worked out amicably! Suspicions arose on both sides of the dialogical divide.

[This highlights] the challenge of fostering dialogue across communities that

differ in style, focus, institutional context, and “closeness” to the reality of

human suffering and resilience. 22

Efforts are being made to span the gap between research and practice. 23

John Jordan says, “Theory is the bridge over which empirical fi ndings can

cross into the world of the practitioner.” In building this bridge, he encour-

aged researchers to “explain with more clarity and depth what their fi nd-

ings could mean for clinical practice.” 24 David Balk refers to a “scholarship

of application,” a dynamic exchange between theory and practice, that can

make research “a useful form of gaining knowledge.” 25

Creating Compassionate Cities Communities give individuals roots, a sense of place, and a location within

the broader scheme of human affairs. Allan Kellehear says, “The question

of seamless social support for end-of-life care fi nds its answer, however ambi-

tious and daunting the task, in community care.” 26 In the twenty-fi rst cen-

tury, our “identities will be layered along a continuum from local to global.” 27

National boundaries will mean less as people begin to have enough in com-

mon to share a transnational identity. This identity “involves the ability to

live ethnically and culturally in both the global and local spheres at the

same time.” 28

This has important implications with respect to death and dying and to

the goal of creating compassionate cities, a term coined by Kellehear to denote “a model of public health that encourages community participation in all

types of end-of-life care.” 29 Ira Byock, a palliative care and hospice physician,

echoes Kellehear’s vision in imagining a “Care-Full Society.” 30 This kind of

care is not limited to hospice or palliative care.

Every day people die in road traumas, suicides, and homicides, and disasters

take people in hundreds and thousands at a time. Aside from death from

old age, there are also tolls of death from the political and social plight of

indigenous peoples all over the world. From civil wars to the negative health

effects of dispossession, our current understandings about caring for those

dying and experiencing loss have yet to be inclusive of these people and

contexts. 31

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582 c h a p t e r 15 The Path Ahead: Personal and Social Choices

Culture and individual personality shape our attitudes toward death. What we under- stand of death and what meanings we ascribe to it become signifi cant to the extent that we construct a meaningful relationship with the experience of death and dying in our lives. This grave marker expresses a memorialization that is consonant with the lifestyles of both the deceased and her survivors.

© C

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Kellehear says, “These widespread experiences of endings, and the losses

that inevitably emerge in their wake, are the most important potential basis

of our interpersonal and international connection with one another.” 32

Moreover, they could be a promising basis for an innovative public

health program that recognizes the need for community involvement and

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Creating Compassionate Cities 583

consideration of death as a fact of life. 33 What, then, are some of the defi ning

characteristics of a “compassionate city”? 34

• It meets the special needs of its aged, those living with life-threatening

illness, and those living with loss. • It recognizes and plans to accommodate the economically disadvan-

taged, including rural and remote populations, indigenous people, and

the homeless. • It preserves and promotes a community’s spiritual traditions and

storytellers. • It has a strong commitment to social and cultural differences.

What do we need to start creating compassionate cities? First, death

education for everyone. 35 Early in the twenty-fi rst century, a newspaper

series of fi fteen articles, Finding Our Way: Living with Dying in America, appeared in more than 160 papers and reached millions of people in the

United States. 36 It included articles on palliative care, advance directives,

grief, funerals, elder care, and other topics in thanatology. Perhaps we are

already under way.

Robert Goss and Dennis Klass note that human bonds based in shared

pain “do not fi t easily into the cultural narrative of consumer capitalism in

which happiness is regarded as the normal human condition.” 37

Thus, the ideal of creating compassionate cities remains a challenge for

thanatology and public health. However, two lessons from our past experi-

ence provide encouragement: First, care of the dying has been normal and routine for families and communities; second, past patterns of community care have illustrated the importance of community relationships in that care. With the increase in our dependence on others to care for our dying and

dead, we have lost sight of these lessons. As a result, death knowledge has

become professional knowledge, not personal knowledge. 38

Herman Feifel calls attention to the need to “integrate existing knowl-

edge concerning death and grief into our communal and public institu-

tions.” 39 People who are involved in death education, counseling, and care

must participate in the work of formulating public policies that impinge on

those areas of concern. Acknowledging that the still-young fi eld of thanatol-

ogy (and the so-called death awareness movement) has many tasks facing it,

What will you say right before they put you six feet under?

Will you say?

“I wish I would have. . . .”

“I wish I could have. . . .”

“I wish I should have. . . .”

Or will you say, “I did it all. Thank you and good night.”

Gene Simmons

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584 c h a p t e r 15 The Path Ahead: Personal and Social Choices

Feifel says that it can already be credited with a number of signifi cant contri-

butions to our collective well-being:

The [death] movement has been a major force in broadening our grasp of

the phenomenology of illness, in helping humanize medical relationships

and health care, and in advancing the rights of the dying. It is highpointing

values that undergird the vitality of human response to catastrophe and loss.

Furthermore, it is contributing to reconstituting the integrity of our splintered

wholeness. More important, perhaps, it is sensitizing us to our common

humanity, which is all too eroded in the present world. It may be somewhat

hyperbolic, but I believe that how we regard death and how we treat the dying

and survivors are prime indications of a civilization’s intention and target. 40

In commenting on the message put forward by Elisabeth Kübler-Ross,

Dame Cicely Saunders, and Mother Teresa of Calcutta, Robert Fulton and

Greg Owen note that it was also about “essential religious and spiritual values

that extend beyond the immediate goal of care for the dying.” 41 Death aware-

ness fosters “compassionate acts of service” that are founded on recognition

of the identity and worth of each human being.

Living with Death and Dying As you review the varied perspectives covered in your study of death and

dying, take a moment to assess the areas that seem particularly valuable to

you. What insights did you gain by examining how death is seen in other

cultures? How does your study of children’s responses to death relate to your

own experiences as a child or as an adult? What have you learned about your

risk-taking behaviors? What choices would you now make regarding funeral

ritual, terminal care, life-sustaining medical technologies? In sum, ask your-

self, “What have I learned that can be helpful to me as a survivor of others’

deaths—and in confronting my own death?” Have you become more com-

fortable in thinking about death and discussing it with others?

The media are sometimes playful with images of death (see Figure 15-2 ).

Recently, an advertisement in several high-fashion magazines used death

imagery to showcase the desirable qualities of the product being promoted

(see Figure 15-3 ). However, in “pushing the envelope” of advertising design,

the manufacturer, ad agency, and others involved in the project received

letters from disgruntled readers who found the use of such imagery offen-

sive and tasteless. Do you suppose this reaction might have been different

if the letter writers had been more comfortable with thinking about dying

and death?

In considering the personal value derived from thinking about and

exploring the meanings of death, notice how the study of death and dying

engages both your mental faculties and your emotions. You may also notice

that your exploration of death has a rippling effect, extending outward to

your social circles and relationships with others. Has a greater awareness of

death had an impact on the quality of your relationships with family members

and friends or with the person down the street or at the neighborhood shop?

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Living with Death and Dying 585

Alfred Killilea says, “Rather than threatening to deprive life of all meaning,

death deepens an appreciation of life and the capacity of every person to give

life to others.” 42

Humanizing Death and Dying Many people are encouraged by what appears to be increasing openness

about death in society. There are signs that the circumstances surrounding

death are being brought back into the personal control of the individuals and

Figure 15-2 Death Imagery in the Media “Lifetime Guarantee! Get Rolling Stone forever, or ’til death do us part. Dis- claimer: Non-transferable (without proof of reincarnation).”

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586 c h a p t e r 15 The Path Ahead: Personal and Social Choices

Figure 15-3 Death Imagery in Advertising Design

www.madelineshoes.com Obsessively shoe obsessed

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Living with Death and Dying 587

families who are closest to a particular death. Traditional customs and prac-

tices are being revived in new ways.

The curricula of death education and thanatology are also being refi ned

and new directions explored. There is ongoing discussion about the goals

of death education. Should death education aim to alleviate discomfort and anxiety about dying and death? If acceptance of death is thought to be “supe-

rior” to denial, that notion needs to be investigated and validated. 43

It is appropriate to question whether apparent openness toward death

is sometimes only illusory. When death becomes just another topic of casual

(or sensational) discussion on television talk shows, does it refl ect a kind of

minimizing or devaluing of death? Is “openness” about death always to be

applauded? Or does it sometimes refl ect a nervous effort to achieve “death

without regrets”? Death is not fully known when its description is limited to

rosy projections and fantasies about the good death.

Death is an intensely human experience. We can balance our fears with

openness. We can understand the dynamics of grief. We can make room for

loss and change in our lives and in the lives of others. Death need not always

be seen as something foreign to our nature, a foe to be fought to the bitter

end. In A Pattern Language: Towns, Building, Construction, Christopher Alexan- der and his coauthors suggest, “No people who turn their backs on death can

be alive. The presence of the dead among the living will be a daily fact in any

society which encourages its people to live.” 44

We should beware, however, of becoming merely casual. Otherwise,

we may fi nd we have confronted only our image of death, not death itself. An increased casualness toward death is very evident in modern society.

Consider, for example, the growing number of death notices that bear the

announcement “No services are planned.” Yet, few individuals die without

leaving survivors who are affected by the loss. Is death a solitary or a com-

munal event? Can I truly say that my death is “my own”? Or is death an event

whose signifi cance ripples outward to touch not only the lives of friends and

loved ones but also the lives of casual acquaintances and even strangers in

ways little understood?

Defi ning the Good Death There is no single defi nition of what constitutes a good death. Caregivers

and other individuals who promote palliative care and hospice often defi ne

a good death as a “peaceful death.” 45 In ancient Greece, to die young, in the

fullness of one’s creative energies, was considered exceptional luck. In our

society, death at a young age is considered a misfortune. The death of a young

person just embarking on an independent life or of someone in the prime

of life seems a great tragedy. “There is a widespread fantasy that one might

reach 80 or 90 years in good health and die in one’s sleep. But the epidemio-

logical reality is rather different.” 46

The good death can be defi ned in many different ways. To an anthropol-

ogist interested in how our lives are celebrated in rites of passage, it might be

something like the following: “Dying a good death is a ceremonially stylized

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588 c h a p t e r 15 The Path Ahead: Personal and Social Choices

way of exiting gracefully. By ritualized means, a grim necessity is transformed

into a dignifi ed and exemplary demise.” 47 A religious concept of a good

death, by contrast, might be defi ned as “one in which the person dies in a

properly sanctifi ed state.” 48 How might you defi ne a good death? Consider

all of the factors—age, mode of death, surroundings, and so on—that would

enter into your concept of a good death. Is your defi nition of a good death

the same for yourself and for others? Some may question whether there can

be any such thing as a good death. “Death is never good,” they might say. “It

can only cause pain and sadness.”

Robert Kastenbaum has enumerated some thoughts about what consti-

tutes the good death, and we list them briefl y here: 49

1. People should be spared extreme physical, mental, and spiritual suffer-

ing at the end of their lives.

2. A good death should enact the highest values held by society. “Communal

values are affi rmed when people end their lives in a congruent manner.”

3. The good death affi rms our most signifi cant personal relationships.

4. The good death is transfi guring. “One experiences an epiphany—a pro-

found sense of beauty, love, or understanding. . . . The moment of death

becomes the peak experience of life.”

5. The good death is simply the fi nal phase of the good life. “People should

die as they have lived. . . . Why try to reshape a person’s life at the last

moment?”

6. The good death is coherent. “It is a story, a drama that makes sense, that

satisfi es our need for closure.”

Another effort to defi ne the components of a good death is shown in

Table 15-1 . Notice that this defi nition, which was published in a medical

t a b l e 15-1 Components of a Good Death

Pain and symptom management. Minimizing the likelihood of dying in pain or suffering “break- through pain” by providing adequate analgesia and other forms of pain relief.

Clear decision making. Empowering the dying person by striving for clear communication between the patient, his or her family, and the medical team. Discussing vital end-of-life decisions before crisis occurs and emotional reserves are low.

Preparation for death. Knowing what to expect during the end-stage of illness relative to the physical and psychosocial changes likely to occur as death approaches. Planning for actions to be taken following death. Exploring one’s own feelings about death.

Completion. Acknowledging the importance of spirituality and other avenues of meaning making, including life review, resolving confl icts, spending time with family and friends, enacting sig- nifi cant cultural rituals, and saying goodbye.

Contributing to others. Sharing meaningful aspects of oneself through tangible or intangible gifts, such as gifts of time, concern for others, and understanding gained through personal refl ection.

Affi rmation of the whole person. Seeing the dying person not as a “disease” but in the context of his or her life, values, and preferences.

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Living with Death and Dying 589

journal, focuses as much on the caregiver’s tasks in making a good death possible as it does on the tasks of the dying person. Compare this list with

Kastenbaum’s description. Would combining these lists create a more com-

plete or more comprehensive defi nition?

An alternative way of defi ning a good death has been offered by Stu

Farber and his colleagues. They propose the term respectful death, defi ned as “a nonjudgmental relationship between parties.” It is “a process of respectful

exploration of the goals and values of patients and families at the end of life

rather than a prescription for successfully achieving ‘a good death.’ ” 50 Like

the components given in Table 15-1 , the concept of a respectful death empha-

sizes the mutuality of caregivers and patients.

Another way to think about the defi nition of a good death is to con-

struct it in terms of an appropriate death. What makes some deaths seem more appropriate than others? Our answers are infl uenced by cultural values and

by social context. Avery Weisman describes some of the elements that consti-

tute the defi nition of appropriate death in contemporary societies. 51

First, an appropriate death is relatively pain free; suffering is kept to a

minimum. The social and emotional needs of the dying person are met to

the fullest extent possible. There is no impoverishment of crucial human

resources. Within the limits imposed by disabilities, the dying person is free

to operate effectively as an individual and to enjoy mobility and indepen-

dence. In addition, the dying person is able to recognize and resolve, as far as

possible, any residual personal and social confl icts. The person is allowed to

satisfy his or her wishes in ways that are consistent with the situation and with

his or her self-identity and self-esteem.

As death approaches, the dying person is allowed to freely choose to

relinquish control over various aspects of his or her life, turning over con-

trol to people in whom confi dence and trust have been placed. The dying

person also may choose to seek out or to relinquish relationships with signifi -

cant others. In other words, the person chooses a comfortable level of social

interaction.

Weisman said that to achieve an appropriate death, we must fi rst rid

ourselves of the notion that death is never appropriate. Such a belief acts as a self-fulfi lling prophecy. It stops us from creating the possibility of a more

appropriate death.

For an appropriate death to become possible, the dying person must be

protected from needless, dehumanizing, and demeaning procedures. The

person’s preferences about pain control and consciousness, and about the

extent of solitude or gregarious interaction desired, should be respected. “An

appropriate death,” Weisman says, “is a death that someone might choose for

himself—had he a choice.”

Finally, we turn to the criteria for a good death suggested by Edwin

Shneidman, a respected thanatologist and suicidologist. (See Table 15-2 .) At

the age of eighty-nine, Shneidman’s ideas about the good death represent

the fruits of thoughtful contemplation, refl ecting back on a life well lived. It

is clearly focused on the dying person, though it acknowledges a continuity

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590 c h a p t e r 15 The Path Ahead: Personal and Social Choices

that includes family and younger generations. The good death, in this sense,

involves more than just a civilized deathbed scene; it encompasses the dying

person’s “post-self,” the self left behind in memory and the community. Shneid-

man says, “Have your dying be a courtly death, among the best things that

you ever did.” 52

The death of Charles Lindbergh exemplifi es many of the features of a

good or appropriate death. 53 Lindbergh was diagnosed with lymphoma. Until

he died two years later, he continued living an active life, traveling and pro-

moting the cause of conservation. When chemotherapy became ineffective,

Lindbergh made arrangements for eventual burial on his beloved island of

Maui. As his condition grew worse, he was hospitalized for several months, but

the best efforts of his physicians could not alter the consequences or course

of the disease. Lindbergh then asked that a cabin on Maui be obtained, and

he was fl own “home to Maui,” where, with two nurses, his physician, and his

family, he spent the last eight days of his life in the environment he loved.

During these last days, Lindbergh gave instructions for the construction

of his grave and conduct of his funeral, requesting that people attend in their

work clothes. As Dr. Milton Howell, one of Lindbergh’s physicians, describes

this period, “There was time for reminiscing, time for discussion, and time

for laughter.”

Finally, Lindbergh lapsed into a coma and died twelve hours later. In

accordance with his wishes, there had been no medical heroics. Dr. Howell

says, “Death was another event in his life, as natural as his birth had been in

Minnesota more than seventy-two years before.”

Perhaps a good death presupposes, in some respects, a good life.

Throughout history, philosophers have proposed both religious and secular

Natural. Rather than accident, suicide, or homicide. Mature. Elderly, near the pinnacle of mental functioning but old enough to have

experienced and savored life.

Expected. Neither sudden nor unexpected; some warning of impending death. Honorable. A positive obituary fi lled with honorifi cs (conveying honor). Prepared. Plans made for the legalities surrounding death, such as funeral arrange-

ments, wills, and trusts.

Accepted. “Willing the obligatory”; gracefully accepting the inevitable. Civilized. Loved ones present; the dying scene enlivened by fresh fl owers, beautiful

pictures, and cherished music.

Generative. To have passed down the “wisdom of the tribe” to younger generations; to have shared memories and histories.

Rueful. To experience the contemplative emotions of sadness and regret without collapse; to die with some projects left undone; to “teach the paradigm that no life is completely complete.”

Peaceable. The dying scene be fi lled with amicability and love and with relief from physical pain.

t a b l e 15-2 Ten Criteria for a Good Death

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Death in the Future 591

models that describe the qualities of a good life. In his essays on the tran-

sience of life, the medieval Buddhist monk Kenkō wrote,

When I see the things people do in their struggle to get ahead, it reminds me of

someone building a snowman on a spring day, making ornaments of precious

metals and stones to decorate it, and then erecting a hall to house it. 54

If, as Kastenbaum says, the good death is simply the fi nal phase of the

good life, we ought to contemplate in this very moment our preparations for

a good death.

Death in the Future During the past century, better living conditions and treatments for infec-

tious diseases enabled people to live long enough to be old enough to suf-

fer from cardiovascular disease, cancers, and other degenerative conditions.

The discoveries, inventions, and applications of twenty-fi rst-century medicine

will continue to push death farther into the future for those able to access

the newest treatments. 55 Individuals who live beyond 100 years, centenarians, are healthier because of genetics, common sense, or maybe just luck. In peo-

ple who live the average life span, diseases of old age strike earlier and last

longer. 56 A publication of the National Center for Health Statistics recently

The contemplation of death and its meaning will determine how we and our children think about and behave toward death in the decades ahead.

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592 c h a p t e r 15 The Path Ahead: Personal and Social Choices

noted that the elimination of heart disease as a cause of death would add

almost four years to life expectancy at birth, and elimination of cancer would

add more than three years. 57 What life expectancy might people look for-

ward to in the future? “Our understandings of what is natural about human life, including the ways we respond to illness, grow older, and die, are forever

being remade.” 58

Imagine the social patterns of death and dying fi fty years from now.

Think about the issues discussed in previous chapters, and consider pres-

ent realities and possibilities. What speculations can you make about how

our relationship with death and dying will change by the middle years of the

twenty-fi rst century? Looking into the future, what do you expect will be the

questions about death and dying that will demand attention from individu-

als and societies? Consider the effects of an older population. In the United

The Angel of Death The Angel of Death is always with me—

the hard wild fl owers of his teeth,

his body like cigar smoke

swaying through a small town jail.

He is the wind that scrapes through our months,

the train wheels grinding over our syllables.

He is the footstep continually pacing through our chests,

the small wound in the soul,

the meteor puncturing the atmosphere.

And sometimes he is merely a quiet between the start of an act

and its completion,

a silence so loud

it shakes you like a tree.

It is only then you look up from the wars,

from the kisses,

from the signing of the business agreements;

It is only then you observe the dimensions

housed in the air of each day,

each moment;

only then you hear the old caressing the cold rims of their sleep,

hear the middle-aged women in love with their pillows

weeping into the gray expanse of each dawn,

where young men, dozing in alleys,

envision their loneliness to be a beautiful girl

and do not know they are part of a young girl’s dream,

as she does not know that she is the dream in the sleep

of middle-aged women and old men,

and that all are contained in a gray wind

that scrapes through our months.

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Death in the Future 593

But soon we forget that the dead sleep in buried cities,

that our hearts contain them in ripe vaults,

We forget that beautiful women dry into parchment

and ball players collapse into ash;

that geography wrinkles and smoothes like the expressions on a face,

and that not even children

can pick the white fruit from the night sky.

And how could we laugh while looking at the face that falls apart like wet tobacco?

How could we wake each morning

to hear the muffl ed gong beating inside us,

our mouths full of shadows, our rooms fi lled with a black dust?

Still,

it is humiliating to be born a bottle:

to be fi lled with air, emptied, fi lled again;

to be fi lled with water, emptied, fi lled again;

and, fi nally, to be fi lled with earth.

And yet I am glad that The Angel of Death is always with me:

his footsteps quicken my own,

his silence makes me speak,

his wind freshens the weather of my day.

And it is because of him

I no longer think

that with each beat

my heart

is a planet drowning from within

but an ocean fi lling for the fi rst time.

Morton Marcus

States, it is estimated that the number of people age sixty-fi ve and over will

grow to nearly 64 million by the year 2025 and to more than 88 million by

2050. 59 Stewart Brand says, “The countries that got rich before they got old

are in increasing trouble.” 60 The average birthrate in long-urbanized, devel-

oped countries is down to 1.56 children per female; in some places, it’s below

1.2. Brand calls these “extinction numbers.” Majority populations will be old,

with few or no children to care for them, with a national economy that is

expiring for lack of young workers. Can we imagine that care of the dying

will become “big business,” as corporations expand their role as surrogate

caregivers for the aged and dying?

Think about the kinds of rituals or ceremonies that, decades from now,

will surround the dead. Writing about the rapid pace of social change among

societies in the South Pacifi c, Ron Crocombe comments on the trend of reduc-

ing the time devoted to funerals, marriages, births, and other such occasions

of community celebration. 61 Increasingly, they are being moved from day to

night and weekday to weekend. “Most traditional social rituals took more

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594 c h a p t e r 15 The Path Ahead: Personal and Social Choices

time than can be spared today,” he says, “both because there are many more

things to do, and because each person is doing different things.” 62 Although

our values and judgments play a role in determining how we spend our time,

such decisions are rarely made independently of social norms and practices.

If our work schedule confl icts with a midweek funeral, we may be reluctant

to insist on time off unless the deceased is a close relative. As notions about

community rituals and the use of time change, what kinds of funeral prac-

tices and services might evolve in response to such changes?

How might changing circumstances affect traditional patterns for dis-

position of the dead? Will there be enough land to continue the practice of

burials? Or might we see a substitution of high-rise cemeteries, cities of the

dead towering above the landscape of the living? This is already happening in

Japan, where burial space in large cities like Tokyo is at a premium. Changes

in methods of carrying out last rites will occur as people create new choices.

What types of social services for help in coping with the death of a loved

one will be available in the years to come? Who could have foreseen the

advent of specialized support and advocacy groups like Parents of Murdered

Children and Mothers Against Drunk Driving? In recent years, innovative

forms of social support—as well as resources for learning about death, dying,

and bereavement—have become available on the Internet and the World

Wide Web. 63 What other developments in bereavement, grief, and mourning

may take place in the coming years?

Recent decades have also seen increased emphasis on counseling or

therapy following bereavement. In the future, might there be “grief clinics”

available for emergencies? Would these clinics—much like present health

institutions—send out reminders for individuals to come in for a bereave-

ment checkup before the anniversary date of a signifi cant death? Perhaps the

time is not far off when some kind of professional assistance in coping with

grief is the norm. Would this be a good thing or not?

If such life-threatening illnesses as cancer and heart disease become

matters of routine prevention or cure in the future, what other diseases will

endanger our survival? Given the rapid pace of medical innovation, what

change do you imagine will occur within even as short a time as the next

decade? The prognosis for a given illness may change from very poor to

exceptionally good within the span of a few years. At the same time, diseases

previously unknown present new threats. As a case in point: Who could

have foreseen the implications of AIDS? Yet, it quickly assumed proportions

comparable to the great plagues of the Middle Ages in terms of public fear

and uncertainty. Will new diseases and threats cause similar distress in the

future?

It is diffi cult to imagine a time when no disease or illness will be life threatening. Yet we have lived through many technological advances that now

make it possible to sustain life beyond measures conceivable by earlier gen-

erations. Perhaps “off-the-shelf ” replaceable body parts will sustain life when

conventional methods prove futile. If there is a “bionic” human in our future,

what values should guide the use of such technologies, and who will decide?

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Death in the Future 595

In Damon Knight’s science fi ction story, “Masks,” a man who has suf-

fered physically devastating injuries is repaired with functional artifi cial

body parts. 64 But his mechanically sustained life causes him to question

what constitutes a living human being. Robin Cook’s novel, Coma, describes “surgery patients” who “undergo suspicious anesthesiology mishaps, become

brain dead, and are stockpiled as waiting donors at the mysterious ‘Jefferson

Institute.’ ” 65

Will medical scientists develop techniques to more accurately predict the

time of a person’s death? This theme is explored in Clifford Simak’s “Death

Scene” and in Robert Heinlein’s “Life-Line.” 66 These stories suggest that the

moment of one’s death might be better left unknown. Although such explora-

tions in speculative fi ction are typically located in the future, in a setting different

from our own, and often incorporate elements of fantasy, the themes investi-

gated bear on present possibilities and on current dilemmas of ethical choice.

What changes are likely to occur in the health care system? What will

be the quality of life—and of dying? In the story “Golden Acres,” Kit Reed

envisions a future in which the administrators of an institution for the aged

make life-or-death decisions about the inmates in order to make room for

new arrivals. 67 Golden Acres provides everything for its residents except the

possibility of living out their lives in the way they wish. Reed’s story focuses

on a resident who refuses to accept society’s neglect of its aged members.

As the protagonist describes it, Golden Acres is “a vast boneyard.” Will that

bleak description apply to the prospects facing the aged members of our own

communities?

What about threats of global warming? Or other global disaster? One sci-

entist writes, “Comets are a real problem, and can do nearly as much damage

as asteroids. . . . This is serious business, and the extent to which we all live

on a knife-edge in relation to the devastation from these objects is very unset-

tling to those of us who keep track of these things.” 68 He continues,

On August 10, 1972, a famous daytime “fi reball” skipped across the Grand

Teton Mountains in Wyoming before returning harmlessly back to space over

Canada. This object was estimated to be 200 yards across. If it had landed on

one of thousands of towns or cities, it would have left a crater a half mile across.

Needless to say, the inhabitants would have had absolutely no useful warning,

and nowhere to escape. 69

In learning from our encounters with dying and death that life is pre-

cious and precarious, we must also consider how the insights we’ve gained

can be compassionately applied to the life of the planet as a whole. The poet

Gary Snyder writes,

The extinction of a species, each one a pilgrim of four billion years of evolution,

is an irreversible loss. The ending of the lines of so many creatures with whom

we have traveled this far is an occasion of profound sorrow and grief. Death

can be accepted and to some degree transformed. But the loss of lineages and

all their future young is not something to accept. It must be rigorously and

intelligently resisted. 70

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596 c h a p t e r 15 The Path Ahead: Personal and Social Choices

Postscript and Farewell Death education sometimes has immediate, practical consequences. At the

conclusion of a course on death and dying, a student said, “It has helped me

and my family deal with my mother’s serious illness.” For others, the practi-

cal application may be less immediate. Yet, as one student said, “I’ve gained

a lot of useful information which may not be applicable to my life right now,

but I know now that information and help is available and I didn’t know that

before.”

Many people who complete a course in death and dying fi nd that their

explorations have consequences for their lives that had not been foreseen

when they fi rst signed up for the course. One student said, “To me, this study

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Further Readings 597

has focused on more than just death; it has dealt with living, like a class on

philosophy.” Another student expressed the value of her death explorations

as having “expanded my faith in the resilience of the human spirit.” After

describing how several individuals faced the prospect of dying, Sandra Bert-

man concluded that a common thread was the sense of “connectedness,

affi nity with all mankind: past, present, alive, dead.” 71

The study of death and dying includes components of information and

data, of course, and it also embraces a wisdom arising out of the human

encounter with death. This wisdom involves “a different kind of knowing, an

integrative approach that refuses to look aside from the real human situation

of uncertainty and ultimate death.” 72 To be sure, death education does per-

tain to practical aspects of the individual and psychosocial encounter with

death. But it offers more than that. Awareness of death and dying brings an

added dimension to the experience of living. It brings us into the present and

serves as a reminder of the precious precariousness of life and the value of

compassion through the ordinary as well as extraordinary circumstances of

human experience.

Further Readings Cecilia Lan-wan Chan and others. In Celebration of Life: A Self-Help Journey on Preparing

a Good Death and Living with Loss and Bereavement. Hong Kong: Centre on Behav- ioral Health, University of Hong Kong, 2009.

Allan Kellehear. Compassionate Cities: Public Health and End-of-Life Care. New York: Routledge, 2005.

David K. Meagher and David E. Balk, eds. Handbook of Thanatology, 2nd ed. New York: Routledge, 2013.

Edwin S. Shneidman. A Commonsense Book of Death: Refl ections at Ninety of a Lifelong Thanatologist. Lanham, Md.: Rowman & Littlefi eld, 2008.

Mark C. Taylor. Field Notes from Elsewhere: Refl ections on Dying and Living. New York: Columbia University Press, 2009.

Barry Vincent. Philosophical Thinking About Death and Dying. Belmont, Calif.: Thomson Wadsworth, 2007.

Additional resources for this chapter can be found at www.mhhe.com/despelder10e

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599

It’s late. I wonder what Death will look like. A drooling ogre? Perhaps an unblinking skull, the Grim Reaper? A veiled mistress with beckoning arms? The standard forms. Or maybe Death will be a polished young man in a three-piece suit, all smiles and sin- cerity and confi dence. What a disappointment that would be. No, I prefer the scythe— no ambiguity, no surrender . . . no dickering. What’s that? . . . I hear him. He’s here.

“May I come in?” I nod. It’s the young man who left me two days ago to knock on the doors of his

neighbors’ homes. “Well . . . ?” My breath is shorter than I thought. He smiles, looks down at his hands, then at me. “Well, I did as you said. It didn’t

take long before I realized that I wasn’t going to fi nd a household that hadn’t been touched by death.”

“How many did you go to?” He covers his mouth with his hand a moment, trying to hide his pride, I guess.

“All of them.” “All?” “Every house. . . . I’m very stubborn.” We both smile. My wheezing is worse, and he notices. He shows his concern, and

I can see that he understands what is happening. “You’re dying, aren’t you, old man?” I close my eyes in answer. When I open them again, he is at my side. “Is there someone I should get for you? Your family?” “Gone.” “Some friend?”

E P I L O G U E

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“Gone. All gone . . . except for you.” The young man nods, then pulls his chair over next to my own. He takes my hand. I rest a moment. “There is something you must do for me,” I wheeze. “When I’m dead, burn this house and everything in it, including me.”

“Leave nothing behind?” “This is only a fi lthy old shack. I’m leaving behind the only thing that anyone

really can leave behind . . . the difference I’ve made in the lives of the people I’ve met.” I squeeze his hand as best I can. He squeezes back. “Oh . . . and this.” I try to lift the book in my lap—my book. He sees me struggling and picks it up for me. “You take this. It’s yours.” His eyes widen.

“But I don’t deserve—” “There isn’t time for that now!” He nods and lays the book on his lap. Good, that’s

done. Moments pass. It gets quieter. . . . I must close my eyes. I witness again the glory of ten thousand mornings, ten thousand afternoons, ten thousand nights .  .  . then they, too, fade. All that’s left is the sound of our breathing and the wind. Time slows. Time changes. Where is the scythe? The young man’s hand leaves mine, and I hear his footsteps recede . . . stop . . . return. He sits down, and I feel his hand on mine. He opens my fi ngers and lays something cool and light in my palm, all lace and limbs . . . the ballerina.

Now I can go.

David Gordon

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10. Robert Fulton and Greg Owen, “Death and Soci-

ety in Twentieth Century America,” Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 379–395. See also Dan Nimmo and James E. Combs, Nightly Horrors: Crisis Coverage by Television Network News (Knoxville: University of Tennessee Press, 1985).

11. National Safety Council, 2009. Estimates based on

data from National Center for Health Statistics and

U.S. Census Bureau.

12. J. Sean McCleneghan, “‘Reality Violence’ on TV

News: It Began with Vietnam,” The Social Science Journal 39 (2002): 593–598.

13. McCleneghan, “‘Reality Violence,’” p. 595. The

man referred to was Daniel V. Jones.

14. Allan Kellehear, Compassionate Cities: Public Health and End-of-Life Care (New York: Routledge, 2005), p. 105.

15. Kellehear, Compassionate Cities, p. 106.

16. George Gerbner, “Death in Prime Time: Notes on

the Symbolic Functions of Dying in the Mass Media,”

Annals of the American Academy of Political and Social Science 447 ( January 1980): 64–70.

17. Transcript, “The Mean World Syndrome: Media

Violence & the Cultivation of Fear,” featuring George

Gerbner and Michael Morgan, Media Education Foun-

dation, 2010; www.mediaed.org .

18. Jacque Lynn Foltyn, “Dead Sexy: Post-Disaster/

Terrorism Voyeurism and the Corpse, Pop Culture’s

New Porn Star” (paper presented at the Centre for

Death and Society, Bath, U.K., 2006).

C H A P T E R 1 1. See Philip A. Mellor and Chris Shilling, “Moder-

nity, Self-Identity and the Sequestration of Death,”

Sociology: The Journal of the British Sociological Association 27, no. 3 (1993): 411–431; and Tony Walter, “Modern

Death: Taboo or Not Taboo?” Sociology 25 (May 1991): 293–310.

2. Regis Martin, The Last Things: Death, Judgment, Heaven, Hell (San Francisco: Ignatius Press, 1998), p. 64.

3. Sami Pihlström, “Death—Mine or the Other’s? On

the Possibility of Philosophical Thanatology,” Mortality 6, no. 3 (2001): 265–286; quote, pp. 266, 280.

4. Steve Jobs, “You’ve Got to Find What You Love,”

Stanford Report, June 14, 2005.

5. David Friend, Watching the World Change: The Stories Behind the Images of 9/11 (New York: Farrar, Straus, and Giroux, 2006), p. 32.

6. See Lynne Ann DeSpelder, “September 11, 2001

and the Internet,” Mortality 8, no. 1 (2003): 88–89.

7. Robert Kastenbaum, Death, Society, and Human Experience (St. Louis: Mosby, 1977), p. 93.

8. Marilyn Johnson, The Dead Beat: Lost Souls, Lucky Stiffs, and the Perverse Pleasures of Obituaries (New York: HarperCollins, 2006), pp. 91, 106, 117, 223.

9. Jack Lule, “News Strategies and the Death of

Huey Newton,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland, 33–40 (Mountain View, Calif.: Mayfi eld,

1995).

N O T E S

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34. De Martino is discussed in James S. Amelang,

“Mourning Becomes Eclectic: Ritual Lament and the

Problem of Continuity,” Past & Present, no. 187 (2005): 3–31.

35. Gail Holst-Warhaft, The Cue for Passion: Grief and Its Political Uses (Cambridge, Mass.: Harvard University Press, 2000), p. 200. About this lament, see also Loring

M. Danforth, The Death Ritual of Rural Greece (Prince- ton, N.J.: Princeton University Press, 1982), p. 143.

36. See Amy Clarkson, “Dying in the Opera,” Pallimed, http://arts.pallimed.org/2009/10/dying-in-opera

.html .

37. Bruce L. Plopper and M. Ernest Ness, “Death as

Portrayed to Adolescents Through Top 40 Rock and

Roll Music,” Adolescence 28, no. 112 (Winter 1993): 793–807.

38. David Margolick, Strange Fruit: Billie Holiday, Café Society, and an Early Cry for Civil Rights (Philadelphia: Running Press, 2000), p. 17.

39. Glenn Watkins, Proof Through the Night: Music and the Great War (Berkeley: University of California Press, 2001), pp. 257–259.

40. Graeme Thomson, I Shot a Man in Reno: A History of Death by Murder, Suicide, Fire, Flood, Drugs, Disaster, Disease, and General Misadventure as Related in Popular Song (New York: Continuum, 2008), p. 59.

41. Elijah Wald, Narcocorrido: A Journey into the Music of Drugs, Guns, and Guerrillas (New York: HarperCollins, 2002).

42. Edward Hirsch, How to Read a Poem (San Diego: Harvest, 1999), p. 271.

43. Charles Reagan Wilson, “Digging Up Bones:

Death in Country Music,” in You Wrote My Life: Lyrical Themes in Country Music, ed. Melton A. McLaurin and Richard A. Peterson, 113–129 (Philadelphia: Gordon

and Breach, 1992), p. 115.

44. Wilson, “Digging Up Bones,” p. 126.

45. George S. Kanahele, ed., Hawaiian Music and Musi- cians (Honolulu: University Press of Hawaii, 1979), pp. 53, 56.

46. Marguerite K. Ashford, Bishop Museum, Hono-

lulu, personal communication.

47. See Albert Lee Strickland, “The Healing Power of

Music in Bereavement,” The Forum: Association for Death Education and Counseling 29, no. 2 (2003): 4–5.

48. See Richard A. Pacholski, “Death Themes in

Music: Resources and Research Opportunities for

Death Educators,” Death Studies 10, no. 3 (1986): 239–263.

19. Frederic B. Tate, “Impoverishment of Death Sym-

bolism: The Negative Consequences,” Death Studies 13, no. 3 (1989): 305–317.

20. Dolf Zillmann, “The Psychology of the Appeal of

Portrayals of Violence,” in Why We Watch: The Attrac- tions of Violent Entertainment, ed. J. H. Goldstein, 179–211 (New York: Oxford University Press, 1998).

21. Colin McGinn, The Power of Movies: How Screen and Mind Interact (New York: Pantheon, 2005), p. 14. See also Lynn Schofi eld Clark, From Angels to Aliens: Teenag- ers, the Media, and the Supernatural (New York: Oxford University Press, 2003), p. 13; and Fran McInerny,

“Cinematic Visions of Dying,” in The Study of Dying: From Autonomy to Transformation, ed. Allan Kellehear, 211–232 (New York: Cambridge University Press,

2009).

22. Hannelore Wass, “A Perspective on the Current

State of Death Education,” Death Studies 28, no. 4 (2004): 289–308.

23. Bill Bryson, The Mother Tongue: English and How It Got That Way (New York: Perennial, 2001), p. 189.

24. Marsha McGee, “Faith, Fantasy, and Flowers: A

Content Analysis of the American Sympathy Card,”

Omega: Journal of Death and Dying 11, no. 1 (1980–1981): 27, 29.

25. Lorraine Hedtke and John Winslade, “The Use of

the Subjunctive in Re-Membering Conversations With

Those Who Are Grieving,” Omega: Journal of Death and Dying 50, no. 3 (2004): 197–215.

26. Alynn Day Harvey, “Evidence of a Tense Shift in

Personal Experience Narratives,” Empirical Studies of the Arts 4, no. 2 (1986): 151–162.

27. Lera Boroditsky, “Linguistic Relativity,” in Ency- clopedia of Cognitive Science, ed. Lynn Nadel (London: Macmillan, 2003), pp. 917–921; esp. 920.

28. Joy S. Berger, Music of the Soul: Composing Life Out of Loss (New York: Routledge, 2006), p. 3.

29. Ted Gioia, Healing Songs (Durham: Duke Univer- sity Press, 2006), pp. 24, 32.

30. Robert McDowell, Poetry as Spiritual Practice (New York: Free Press, 2008), p. 216.

31. G. Chew and T. J. Mathiesen, “Thrēnos,” The New Grove Dictionary of Music Online; www.grovemusic.com .

32. Donovan J. Ochs, Consolatory Rhetoric: Grief, Symbol, and Ritual in the Greco-Roman Era (Columbia, S.C.: Uni- versity of South Carolina Press, 1993), p. 50.

33. See Michael Herzfeld, “In Defi ance of Destiny: The

Management of Time and Gender at a Cretan Funeral,”

American Ethnologist 20, no. 2 (1993): 241–255.

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63. Suse Lowenstein, quoted in Ann F. de Jong Hodg-

son, “Interviews and Issues: Dark Elegy,” Illness, Crises and Loss 4, nos. 3–4 (1995): 18–38; quote, p. 21. The sculpture is located in Livingston, New Jersey.

64. Fritz Eichenberg, Dance of Death: A Graphic Com- mentary on the Danse Macabre Through the Centuries (New York: Abbeville, 1983).

65. See Martha V. Pike and Janice Gray Armstrong,

A Time to Mourn: Expressions of Grief in Nineteenth Cen- tury America (Stony Brook, N.Y.: The Museums at Stony Brook, 1980); and Anita Schorsch, Mourning Becomes America: Mourning Art in the New Nation (Philadelphia: Main Street Press, 1976).

66. Cindy Ruskin, The Quilt: Stories from the Names Project (New York: Pocket Books, 1988).

67. Robert E. Goss and Dennis Klass, Dead But Not Lost: Grief Narratives in Religious Traditions (Walnut Creek, Calif.: AltaMira, 2005), p. 276.

68. Maxine Borowsky Junge, “Mourning, Memory and

Life Itself: The AIDS Quilt and the Vietnam Veterans’

Memorial Wall,” Arts in Psychotherapy 26, no. 3 (1999): 195–203. See also Michael Franklin, “AIDS Iconogra-

phy and Cultural Transformation: Visual and Artistic

Responses to the AIDS Crisis,” The Arts in Psychotherapy 20, no. 4 (1993): 299–316. For a minority view regard-

ing the Quilt, see Daniel Harris, “Making Kitsch from

AIDS,” Harper’s Magazine ( July 1994), pp. 55–60.

69. See Jose Cardenas, “Sympathy Crafted by Hand,”

The Los Angeles Times, May 4, 2004; and Michael M. Phil- lips, “Quilters’ Busy Hands Can’t Quite Keep Up with

Deaths in Iraq,” The Wall Street Journal, August 30, 2005.

70. Quoted in Cardenas, “Sympathy Crafted by

Hand.”

71. Holst-Warhaft, The Cue for Passion, p. 189.

72. Andrew Whitmarsh, “‘We Will Remember Them’:

Memory and Commemoration in War Museums,”

Journal of Conservation and Museum Studies, Issue 7 (November 2001): 1–15; quote pp. 1, 11.

73. See John Breen, “The Dead and the Living in the

Land of Peace: Sociology of the Yasukuni Shrine,”

Mortality 9, no. 1 (2004): 77–82; John Breen, “Yasukuni Shrine: Ritual and Memory,” Japan Focus 293 (2005); John Breen, ed., Yasukuni, the War Dead, and the Struggle for Japan’s Past (New York: Columbia University Press, 2008); Andrew M. McGreevy, “Arlington National

Cemetery and Yasukuni Jinja: History, Memory, and

the Sacred,” Japan Focus 293 (2005); and Daiki Shi- buichi, “The Yasukuni Shrine Dispute and the Politics

of Identity in Japan: Why All the Fuss?” Asian Survey 45, no. 2 (March/April 2005): 197–215.

49. For a survey, see Robert F. Weir, ed., Death in Litera- ture (New York: Columbia University Press, 1980).

50. Ted Bowman, “Using Literary Resources in

Bereavement Work: Evoking Words for Grief,” The Forum: Association for Death Education and Counseling 29, no. 2 (2003): 8–9.

51. Jahan Ramazani, Poetry of Mourning: The Modern Elegy from Hardy to Heaney (Chicago: University of Chi- cago Press, 1994), pp. 1, 361.

52. Albert Lee Strickland, “Elegy,” in The A-Z of Death & Dying: Social, Medical, and Cultural Aspects, ed. Michael John Brennan (Santa Barbara, Calif.:

ABC-Clio/Greenwood, 2014).

53. Robert McDowell, Poetry as Spiritual Practice (New York: Free Press, 2008), p. 216.

54. William M. Lamers, Jr., “The Little Sounds of

Grief: Poetry and Grief ” (paper presented at the 21st

International Death, Grief, and Bereavement

Conference, University of Wisconsin, LaCrosse,

May 28, 2003).

55. Hirsch, How to Read a Poem, p. 80.

56. See Terrence Des Pres, The Survivor: An Anatomy of Life in the Death Camps (New York: Oxford University Press, 1976); Lawrence L. Langer,

Versions of Survival: The Holocaust and the Human Spirit (Albany: State University of New York Press, 1982)

and Holocaust Testimonies: The Ruins of Memory (New Haven, Conn.: Yale University Press, 1991); Lawrence

L. Langer, ed., Art from the Ashes: A Holocaust Anthol- ogy (New York: Oxford University Press, 1995); and Alvin H. Rosenfeld, A Double Dying: Refl ections on Holocaust Literature (Bloomington: Indiana University Press, 1980).

57. Lawrence Langer, The Age of Atrocity: Death in Mod- ern Literature (Boston: Beacon Press, 1978).

58. Frederick J. Hoffman, The Mortal No: Death and the Modern Imagination (Princeton, N.J.: Princeton Univer- sity Press, 1964).

59. William Ruehlmann, Saint with a Gun: The Unlaw- ful American Private Eye (New York: New York University Press, 1984), p. 9.

60. Elizabeth D. Samet, “Teaching Poetry to Soldiers

in a Post-Heroic Age,” Armed Forces & Society 29, no. 1 (2002): 109–127.

61. See Richard A. Pacholski, “Death Themes in the

Visual Arts: Resources and Research Opportunities for

Death Educators,” Death Studies 10, no. 1 (1986): 59–74.

62. Kirk Varnedoe, “Dreams of a Summer Night,”

Portfolio (November–December 1982), p. 93.

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87. Ester R. Shapiro, “Culture and Socialization in

Assessment and Intervention,” in Handbook of Thanatol- ogy, 2nd ed., ed. David K. Meagher and David E. Balk, 193–207 (New York: Routledge, 2013), p. 197.

88. Norman Wirzba, Food and Faith: A Theology of Eat- ing (New York: Cambridge University Press, 2011), pp. 1, 2.

89. Tom Arcaro and Ted Cox, “Human Existence as

a Waltz of Eros and Thanatos,” Humanity & Society 12, no. 1 (1988): 75–94.

90. Francesco Campione, Manifesto della Tanatologia [Manifesto of Thanatology] (Bologna: Cooperativa

Libraria Universitaria Editrice Bologna, 2005).

91. International Work Group on Death, Dying, and

Bereavement, “Existential Questions and Their Moral

Implications,” Omega: Journal of Death and Dying 43, no. 1: 1–6; quote p. 1.

92. Robert Kastenbaum, “Reconstructing Death in

Postmodern Society,” in The Path Ahead, ed. DeSpelder and Strickland, 7–18; quote p. 8.

93. Robert Kastenbaum, “Death Writ Large,” Death Studies 28, no. 4 (2004): 375–392; quote p. 390.

94. Herman Feifel, “The Thanatological Movement:

Respice, Adspice, Prospice,” Loss, Grief, and Care 6, no. 1 (1992): 5–16, esp. pp. 11–12.

95. Calvin Conzelus Moore and John B. William-

son, “The Universal Fear of Death and the Cultural

Response,” in Handbook of Death and Dying, ed. Clifton D. Bryant (Thousand Oaks, Calif.: Sage, 2003), pp. 3–13.

96. Bert Hayslip, Jr., “Death Denial: Hiding and Cam-

oufl aging Death,” in Handbook of Death and Dying, ed. Bryant, 34–42; quote p. 35.

97. Hayslip, “Death Denial,” p. 35.

98. Lindsay Prior, “Actuarial Visions of Death: Life,

Death, Chance in the Modern World,” in The Changing Face of Death: Historical Accounts of Death and Disposal, ed. Peter C. Jupp and Glennys Howarth, 177–193 (New

York: St. Martin’s, 1997), p. 189.

99. Thomas McGuane. The Longest Silence: A Life in Fishing. New York: Knopf, 1999, p. x.

100. Avery Weisman, The Realization of Death (New York: Jason Aronson, 1974), p. 5.

101. Talcott Parsons, “Death in American Society: A

Brief Working Paper,” American Behavioral Scientist 6, no. 9 (1963): 61–65.

102. See Robert A. Neimeyer and David Van Brunt,

“Death Anxiety,” in Dying: Facing the Facts, 3rd ed., ed. Hannelore Wass and Robert A. Neimeyer, 49–88

(Washington, D.C.: Taylor & Francis, 1995).

74. Carla Sofka, “History and Healing: Museums as

Healing Spaces,” The International Journal of the Inclu- sive Museum, Volume 2 (Champaign, Ill.: Common Ground, 2009).

75. International Work Group on Death, Dying, and

Bereavement, “The Arts and Humanities in Health

Care and Education,” Death Studies 24, no. 5 (2000): 365–375; quote p. 366.

76. Sandra L. Bertman, “Volts of Connection: The

Arts as Shock Therapy,” Grief Matters: The Australian Journal of Grief and Bereavement 3, no. 3 (2000): 51–53; see also, by Bertman, Facing Death: Images, Insights, and Interventions (Philadelphia: Taylor & Francis, 1991).

77. See James A. Thorson, “Did You Ever See a Hearse

Go By? Some Thoughts on Gallows Humor,” Journal of American Culture 16, no. 2 (1993): 17–24; quote p. 18.

78. David Lester, “Refl ections on Jokes and Cartoons

About Suicide,” Death Studies 36 (2012): 664–674, p. 668.

79. Neil J. Elgee, “Laughing at Death,” The Psychoana- lytic Review 90, no. 4 (2003): 475–497; quote p. 495.

80. Mary N. Hall, “Laughing as We Go” (paper pre-

sented at the annual meeting of the Forum for Death

Education and Counseling, Philadelphia, April 1985);

see also Mary N. Hall and Paula T. Rappe, “Humor

and Critical Incident Stress,” in The Path Ahead, ed. DeSpelder and Strickland, 289–294.

81. John C. Meyer, “Humor as a Double-Edged Sword:

Four Functions of Humor in Communication,” Com- munication Theory 10, no. 3 (2000): 310–331; example from p. 321.

82. Thorson, “Did You Ever See a Hearse Go By,” p. 18.

83. Linda D. Henman, “Humor as a Coping Mecha-

nism: Lessons from POWs,” Humor: International Journal of Humor Research 14, no. 1 (2001): 83–94; quote p. 86.

84. Linda Francis, Kathleen Monahan, and Candyce

Berger, “A Laughing Matter? The Uses of Humor in

Medical Institutions,” Motivation and Emotion 23, no. 2 (1999): 155–174. See also Fabio Sala, Edward Krupat,

and Debra Roter, “Satisfaction and the Use of Humor

by Physicians and Patients,” Psychology and Health 17, no. 3 (2002): 269–280.

85. Vera M. Robinson, Humor and the Health Professions: The Therapeutic Use of Humor in Health Care, 2nd ed. (Thorofare, N.J.: Slack, 1991), pp. 50, 53.

86. Jamie L. Goldenberg, Tom Pyszczynski, Shannon

K. McCoy, Jeff Greenberg, and Sheldon Solomon,

“Death, Sex, Love, and Neuroticism: Why is Sex Such a

Problem?” Journal of Personality and Social Psychology 77, no. 6 (1999): 1173–1187; quote p. 1175.

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in Advances in Experimental Social Psychology 24, ed. M. P. Zanna (New York: Academic Press): 93–159.

114. Sheldon Solomon, Jeff Greenberg, and Tom

Pyszczynski, “Pride and Prejudice: Fear of Death and

Social Behavior,” Current Directions in Psychological Sci- ence 9, no. 6 (2000): 200–204; quote p. 201.

115. Sam Keen, “The Heroics of Everyday Life: A

Theorist of Death Confronts His Own End,” Psychology Today, April 1974. See also Daniel Liechty, “The Denial of Death Revisited,” Death Studies 23, no. 8 (1999): 757– 760; and “Reaction to Mortality: An Interdisciplinary

Organizing Principle for the Human Sciences,” Zygon: Journal of Religion and Science 33, no. 1 (1998): 45–58. See also Jeffrey Kauffmann, Awareness of Mortality (Amityville, N.Y.: Baywood, 1995).

116. Tom Pyszczynski, Jeff Greenberg, and Sheldon

Solomon, “Why Do We Need What We Need? A Ter-

ror Management Perspective on the Roots of Human

Social Motivation,” Psychological Inquiry 8, no. 1 (1997): 1–20.

117. Jeff Greenberg, Sheldon Solomon, and Tom

Pyszczynski, “Terror Management Theory of Self-

Esteem and Cultural Worldviews: Empirical Assess-

ments and Conceptual Refi nements,” Advances in Experimental Social Psychology 29 (1997): 61–139; quote p. 100.

118. Robert Kastenbaum, “Should We Manage

Terror—If We Could?” Omega: Journal of Death and Dying 59, no. 4 (2009): 271–304; esp. pp. 287, 288.

119. Robert Kastenbaum, “Sad to Say: Is It Time

for Sorrow Management Theory?,” Omega: Journal of Death and Dying 62, no. 4 (2010–2011): 305–327; quote p. 323.

120. Robert C. Solomon, “Death Fetishism, Morbid

Solipsism,” in Death and Philosophy, ed. Jeff Malpas and Robert C. Solomon, 152–176 (New York: Routledge,

1998); quote pp. 174–175.

121. F. David Martin, “Facing Death at 80: Memory

and the Holy,” Soundings: An Interdisciplinary Journal 83, no. 2 (Summmer 2000): 301–330.

122. Patrick Vernon Dean, “Is Death Education a

‘Nasty Little Secret’? A Call to Break the Alleged

Silence,” in The Path Ahead, ed. DeSpelder and Strick- land, pp. 323–326.

123. Vanderlyn R. Pine, “A Socio-Historical Portrait

of Death Education,” Death Education 1, no. 1 (1977): 57–84; see also Pine, “The Age of Maturity for Death

Education: A Socio-Historical Portrait of the Era

1976 –1985,” Death Studies 10, no. 3 (1986): 209–231; and Dan Leviton, “The Scope of Death Education,”

Death Education 1, no. 1 (1977): 41–56.

103. Robert A. Neimeyer, Richard P. Moser, and

Joachim Wittkowski, “Assessing Attitudes Toward

Dying and Death: Psychometric Considerations,”

Omega: Journal of Death and Dying 47, no. 1 (2003): 45–76; quote pp. 46 –47. See also Robert A. Neimeyer,

Death Anxiety Handbook: Research, Instrumentation, and Application (Washington, D.C.: Taylor & Francis, 1993).

104. J. A. Beshai and Mohamed A. Naboulsi, “Exis-

tential Perspectives on Death Anxiety,” Psychological Reports 95 (2004): 507–513; quote p. 511.

105. Robert A. Neimeyer, “Death Anxiety Research:

The State of the Art” (paper presented at the annual

meeting of the Association for Death Education and

Counseling, Duluth, Minnesota, April 1991). See also

Neimeyer, “Death Anxiety,” in Encyclopedia of Death and the Human Experience, ed. Clifton D. Bryant and Dennis L. Peck, 296 –299 (Thousand Oaks, Calif.: Sage, 2009).

106. Robert A. Neimeyer, Joachim Wittkowski, and

Richard P. Moser, “Psychological Research on Death

Attitudes: An Overview and Evaluation,” Death Studies 28 (2004): 309–339; quote p. 331.

107. Robert Kastenbaum, “Theory, Research, and

Application: Some Critical Issues for Thanatology,”

Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 397–410.

108. Herman Feifel, “Psychology and Death: Meaning-

ful Rediscovery,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 19–28.

109. Brian L. Burke, Andy Martens, and Erik H. Faucher,

“Two Decades of Terror Management Theory: a

Meta-Analysis of Mortality Salience Research,” Personality & Social Psychology Review 14, no. 2 (2010): 155–195. Study shows MS hypothesis of TMT provides moderate to large

effects.

110. Maxine Sheets-Johnstone, “Size, Power, Death:

Constituents in the Making of Human Morality,” Jour- nal of Consciousness Studies 9, no. 2 (2002): 49–67.

111. Lillian M. Range, “Historical and Contemporary

Perspectives on Traumatic Death,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, p. 293.

112. Tom Pyszczynski, Jeff Greenberg, and Sheldon

Solomon, “Proximal and Distal Defense: A New Per-

spective on Unconscious Motivation,” Current Directions in Psychological Science 9, no. 5 (2000): 156 –160.

113. Sheldon Solomon, Jeff Greenberg, and Tom

Pyszczynski, “Tales from the Crypt: On the Role of

Death in Life,” Zygon: Journal of Religion and Science 33, no. 1 (1998): 9–43; quote, p. 13. See also Sheldon Solo-

mon, Jeff Greenberg, and Tom Pyszczynski, “A Terror

Management Theory of Social Behavior: The Psycho-

logical Functions of Esteem and Cultural Worldview,”

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606 n o t e s

135. The fi rst of these was Encyclopedia of Death, ed. Robert Kastenbaum and Beatrice Kastenbaum (Phoe-

nix: Oryx Press, 1989); see also Encyclopedia of Death and Dying, ed. Glennys Howarth and Oliver Leaman (Lon- don and New York: Routledge, 2001); Macmillan Encyclo- pedia of Death and Dying, ed. Robert Kastenbaum (New York: Macmillan, 2003); Handbook of Death and Dying, ed. Clifton D. Bryant (Thousand Oaks, Calif.: Sage,

2003); Dana K. Cassell, Robert C. Salinas, and Peter A.

S. Winn, The Encyclopedia of Death and Dying (New York: Facts on File, 2005); and Encyclopedia of Death and the Human Experience, ed. Clifton D. Bryant and Dennis L. Peck (Thousand Oaks, Calif.: Sage, 2009).

136. See entry “United States,” by Lynne Ann

DeSpelder and Albert Lee Strickland, in Encyclopedia of Death and Dying, ed. Howarth and Leaman, pp. 460–463.

137. Luciana Mascarenhas Fonseca and Ines Testoni,

“The Emergence of Thanatology and Current Practice in

Death Education,” Omega: Journal of Death and Dying 64, no. 2 (2011–2012): 157–169; quote p. 163. Italics added.

138. Hannelore Wass, “Visions in Death Education,”

in The Path Ahead, ed. DeSpelder and Strickland, pp. 327–334.

139. See, for example, James K. Crissman, Death and Dying in Central Appalachia: Changing Attitudes and Practices (Urbana: University of Illinois Press, 1994); and James

J. Farrell, Inventing the American Way of Death, 1830–1920 (Philadelphia: Temple University Press, 1980).

140. U.S. Census Bureau, “Expectation of Life at Birth,”

Historical Statistics of the United States, Colonial Times to 1970 (Washington, D.C.: Government Printing Offi ce), p. 55; and Arialdi M. Miniño, “Death in the United

States, 2011,” NCHS Data Brief, no. 115 (Hyattsville, Md.: National Center for Health Statistics, 2013), p. 1.

141. “Nation Digest,” The Washington Post, August 20, 2009.

142. Miniño, “Death in the United States, 2011,”

pp. 1–2.

143. Rachel Ehrenberg, “Modern Living Vastly

Extends Life,” Science News (November 17, 2012), p. 10.

144. Miniño, “Death in the United States, 2011,” p. 4.

145. “Deaths and Death Rates,” Historical Statistics of the United States, p. 59; and Miniño, “Death in the United States, 2011,” p. 1.

146. Vincent DiGirolamo, “Newsboy Funerals: Tales

of Sorrow and Solidarity in Urban America,” Journal of Social History 36, no. 1 (2002): 5–20; esp. p. 7.

147. Jennie Benford, “Victorian Mourning at the Frick,”

The Forum: Newsletter of the Association for Death Education and Counseling 22, no. 1 ( January–February 1996): 7–8.

124. Darrell Crase, “Death Education: Its Diversity

and Multidisciplinary Focus,” Death Studies 13, no. 1 (1989): 25–29.

125. Thomas Attig, “Person-Centered Death Educa-

tion,” Death Studies 16, no. 4 (1992): 357–370.

126. Gorer’s essay was originally published in the

journal Encounter in 1955; it was later reprinted in his 1965 book, Death, Grief, and Mourning in Contemporary Britain. For an account of the essay’s infl uence, see Ian Andrews, “Pornography of Death,” in Encyclopedia of Death and Dying, ed. Glennys Howarth and Oliver Leaman, 361–362 (New York: Routledge, 2001).

127. Lindsay Prior, The Social Organization of Death (London: Macmillan, 1989), esp. pp. 4–12. See also

Neil Small, “Theories of Grief: A Critical Review,” in

Grief, Mourning, and Death Ritual, ed. Jenny Hockey, Jeanne Katz, and Neil Small, 19–48 (Buckingham:

Open University Press, 2001); esp. pp. 21–24.

128. The symposium was titled “The Concept of

Death and Its Relation to Behavior.”

129. Herman Feifel, “Psychology and Death: Meaning-

ful Rediscovery,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 19–28.

130. Kenneth J. Doka, E. Neil Hefl in-Wells, Terry L.

Martin, Lula M. Redmon, and Sherry R. Schacter,

“The Organization of Thanatology,” Omega: Journal of Death and Dying 63, no. 2 (2011): 113–124; esp. p. 115.

131. Robert Kastenbaum, “Omega: Pre-History of a

Journal,” Omega: Journal of Death and Dying 48, no. 1 (2003): 69–84.

132. The Foundation of Thanatology, through its sym-

posia and publication, served an important role early in

the development of the fi eld. See also Darrell Crase and

Dan Leviton, “Forum for Death Education and Coun-

seling: Its History, Impact, and Future,” Death Studies 11, no. 5 (1987): 345–359; Kenneth J. Doka, et. al.,

“The Organization of Thanatology,” Omega: Journal of Death and Dying 63, no. 2 (2011): 113–124; John E. Fryer, “The Goose,” Illness, Crisis, and Loss ( January 2003): 65–69; and Judith M. Stillion, “Association for

Death Education and Counseling: An Organization

for Our Times and for Our Future,” Death Studies 13, no. 2 (1989): 191–201.

133. See Lynne Ann DeSpelder and Albert Lee Strick-

land, “The Life of a Death Textbook and Its Authors,”

The Forum: Newsletter of the Association for Death Education and Counseling 30 (First Quarter, 2004): 8–9.

134. Sarah Brabant, DeAnn Kalich, and Brooke O.

Breaux, “The Psychology Today ‘You and Death’ Question- naire Revisited,” Omega: Journal of Death and Dying 58, no. 3 (2008–2009): 193–211; quote from pp. 210–211.

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2nd ed., ed. Meagher and Balk, p. 431. See also Mar-

garet S. Stroebe, Karolijne Van Der Houwen, and

Henk Schut, “Bereavement Support, Intervention, and

Research on the Internet: A Critical Review,” in

Handbook of Bereavement Research and Practice: Advances in Theory and Intervention, ed. Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolfgang

Stroebe (Washington, D.C.: American Psychological

Association, 2008), pp. 551–574.

162. Jocelyn M. DeGroot, “Maintaining Relational

Continuity with the Deceased on Facebook,” Omega: Journal of Death and Dying 65, no. 3 (2012): 195–212.

163. Robert A. Neimeyer, quoted in “Attachment at

a Distance: Grief Therapy in the Virtual World,” in

Dying, Death, and Grief in an Online Universe, 103–118; quote p. 115.

164. Leanne Italie, “Crisis Hotlines Turning to Text to

Reach Teens,” AP Online (March 29, 2013).

165. Raina M. Merchant, Stacy Elmer, and Nicole

Lurie, “Integrating Social Media into Emergency-

Preparedness Efforts,” New England Journal of Medicine 365, no. 4 ( July 28, 2011): 289–291.

166. Sofka, Cupit, and Gilbert, Dying, Death, and Grief in an Online Universe, p. 4.

167. Robert E. Kavanaugh, Facing Death (Los Angeles: Nash, 1972).

168. David E. Stannard, The Puritan Way of Death: A Study in Religion, Culture, and Social Change (New York: Oxford University Press, 1977).

169. Information from exhibit brochure and stories in

The Los Angeles Times by Diane Haithman, January 22, 2005, and Tonya Alanez, January 24, 2005.

170. Paul Duro and others, “Postmodernism,” in Key Ideas in Human Thought, ed. Kenneth McLeish, 584– 585 (New York: Facts on File, 1993). See also William

Simon, C. Allen Haney, and Russell Buenteo, “The

Postmodernization of Death and Dying,” Symbolic Inter- action 16, no. 4 (1993): 411–426.

171. Chris Schilling and Philip A. Mellor, The Sociologi- cal Imagination: Elementary Forms of Social and Moral Life (Thousand Oaks, Calif.: Sage, 2001), p. 195.

172. Schilling and Mellor, The Sociological Imagination, p. 191.

173. Stuart Sim, ed., The Routledge Companion to Post- modernism, 2nd ed. (New York: Routledge, 2005), p. vii.

174. Masa Higo, “Surviving Death Anxieties in Liq-

uid Modern Times: Examining Zygmunt Bauman’s

Cultural Theory of Death and Dying,” Omega: Journal of Death and Dying 65, no. 3 (2012): 221–238; esp. 228, 232.

148. U.S. Census Bureau, “Deaths and Death Rates

by Leading Causes of Death,” Statistical Abstract of the United States, 2009, 128th ed. (Washington, D.C.: Gov- ernment Printing Offi ce, 2008), p. 86. See also Donna

L. Hoyert, “75 Years of Mortality in the United States,

1935–2010,” NCHS Data Brief, no. 88 (March 2012).

149. John Allen Paulos, A Mathematician Reads the Newspaper (New York: Basic, 1995), p. 139.

150. S. Jay Olshansky and A. Brian Ault, “The Fourth

Stage of the Epidemiologic Transition: The Age of

Delayed Degenerative Diseases,” Milbank Quarterly 64, no. 3 (1986): 355–391.

151. “Annual Estimates of the Population by Age,” His- torical Statistics of the United States, p. 10; and U.S. Census Bureau, “Resident Population by Age,” Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011); http://www.census.gov/compendia/statab/ .

152. Charlotte A. Schoenborn and Kathleen M.

Heyman, “Health Characteristics of Adults Aged 55

Years and Over: United States: 2004–2007,” National Health Statistics Reports, no. 16 ( July 8, 2009): 1–32; esp. p. 1.

153. “Resident Population by Age: 1900 to 1997,”

Statistical Abstract of the United States: 1999, p. 869; and Donna L. Hoyert and Jiaquan Xu, “Deaths: Prelimi-

nary Data for 2011,” National Vital Statistics Reports 61, no. 6 (Hyattsville, Md.: National Center for Health

Statistics, 2012), p. 8.

154. Burden S. Lundgren and Clare A. Houseman,

“Banishing Death: The Disappearance of the Appre-

ciation of Mortality,” Omega: Journal of Death and Dying 61, no. 3 (2010): 223–249; esp. p. 241.

155. Lundgren and Houseman, “Banishing Death,”

pp. 241, 245.

156. Chris Shilling, The Body and Social Theory, 2nd ed. (Thousand Oaks, Calif.: Sage, 2003), p. 167.

157. Shilling, Body and Social Theory, p. 165.

158. Anne M. Smith and Corinne Cavuoti, “Thanatol-

ogy in the Digital Age,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, p. 429.

159. Tony Walter et al., “Does the Internet Change

How We Die and Mourn? Overview and Analysis,”

Omega: Journal of Death and Dying 64, no. 4 (2011–2012): 275–302; quote p. 276.

160. Paraphrased from Carla J. Sofka, Illene Noppe

Cupit, and Kathleen R. Gilbert, eds., Dying, Death, and Grief in an Online Universe (New York: Springer, 2012), p. 262.

161. Anne M. Smith and Corinne Cavuoti, “Thanatol-

ogy in the Digital Age,” in Handbook of Thanatology,

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608 n o t e s

2. Mark W. Speece, “Very Young Children’s Experi-

ences with and Reactions to Death” (master’s thesis,

Wayne State University, 1983).

3. Mark W. Speece and Sandor B. Brent, “The Devel-

opment of Children’s Understanding of Death,”

in Handbook of Childhood Death and Bereavement, ed. Charles A. Corr and Donna M. Corr, 29–50 (New York:

Springer, 1996).

4. Brenda L. Kenyon, “Current Research in Children’s

Conceptions of Death: A Critical Review,” Omega: Jour- nal of Death and Dying 43, no. 1 (2001): 63–91; Mark W. Speece and Sandor B. Brent, “Children’s Understand-

ing of Death: A Review of Three Components of a

Death Concept,” Child Development 55, no. 5 (October 1984): 1671–1686; and Speece and Brent, “The Acqui-

sition of a Mature Understanding of Three Compo-

nents of the Concept of Death,” Death Studies 16, no. 3 (1992): 211–229.

5. See Sandor B. Brent and Mark W. Speece, “‘Adult’

Conceptualization of Irreversibility: Implications for

the Development of the Concept of Death,” Death Stud- ies 17, no. 3 (1993): 203–224.

6. Virginia Slaughter and Maya Griffi ths, “Death

Understanding and Fear of Death in Young Children,”

Clinical Child Psychology and Psychiatry 12, no. 4 (2007): 525–535; esp. p. 526.

7. Virginia Slaughter, “Young Children’s Understand-

ing of Death,” Australian Psychologist 40, no. 3 (2005): 179–186; and Virginia Slaughter and Michelle Lyons,

“Learning about Life and Death in Early Childhood,”

Cognitive Psychology 46, no. 1 (2003): 1–30. See also Susan Carey, Conceptual Change in Childhood (Cam- bridge, Mass.: MIT Press, 1985); and, also by Carey,

“On the Origin of Causal Understanding,” in Causal Cognition: A Multidisciplinary Debate, ed. D. Sperber, D. Premack, and A. Premack (New York: Oxford

University Press, 1995).

8. Slaughter and Griffi ths, “Death Understanding and

Fear of Death in Young Children,” pp. 526 –527.

9. Slaughter and Griffi ths, “Death Understanding and

Fear of Death in Young Children,” p. 533.

10. Kenyon, “Current Research in Children’s Concep-

tions of Death,” p. 87.

11. Eric B. Shiraev and David A. Levy, Cross-Cultural Psychology: Critical Thinking and Contemporary Applica- tions, 5th ed. (Boston: Pearson, 2013), p. 19.

12. Kang Lee, “Scientifi c Reasoning: Introduction,” in

Childhood Cognitive Development: The Essential Readings, ed. Lee, 265–266 (Oxford: Blackwell, 2000).

13. Ross D. Parke, Peter A. Ornstein, John J. Rieser,

and Carolyn Zahn-Waxler, “The Past as Prologue: An

175. Ulrich Beck, “The Cosmopolitan Society and Its

Enemies,” Theory, Culture & Society 19, nos. 1–2 (2002): 17–44; quote from p. 17.

176. Anthony Giddens, Runaway World: How Global- ization Is Reshaping Our Lives (New York: Routledge, 2000), p. 23.

177. Daniel Levy and Natan Sznaider, “Memory

Unbound: The Holocaust and the Formation of

Cosmopolitan Memory,” European Journal of Social Theory 51, no. 1 (2002): 87–106.

178. Marina Sozzi, “The Myth of Natural Death”

(paper presented at the meeting of the International

Association of Thanatology and Suicidology, Bologna,

Italy, June 2005).

179. Robert Kastenbaum, “Should We Manage

Terror,” p. 295.

180. Daniel Callahan, “Frustrated Mastery: The

Cultural Context of Death in America—Caring for

Patients at the End of Life,” Western Journal of Medicine 163, no. 3 (1995): 226 –230.

181. “What is Death Café”? http://www.deathcafe

.com/p/what-is-death-cafe.html .

182. Glennys Howarth, Death and Dying: A Sociological Introduction (Malden, Mass.: Polity, 2006), p. 1.

183. Andrew S. Ziner, Department of Sociology, Uni-

versity of North Dakota, personal communication,

May 1994.

184. See Nancy J. Moules, “Postmodernism and the

Sacred: Reclaiming Connection in Our Greater-than-

Human Worlds,” Journal of Marital and Family Therapy 26, no. 2 (2000): 229–240.

185. “The Bright Side of Death: Awareness of

Mortality Can Result in Positive Behaviors,”

http://www.sciencedaily.com/releases/2012/04/

120430164359.htm .

186. Yoshida Kenkō, quoted by Donald Keene, “Kenkō:

Essays in Idleness ( Tsurezureguswa),” in Approaches to the Asian Classics, edited by Wm. Theodore de Bary and Irene Bloom (New York: Columbia University Press,

1990), p. 314.

C H A P T E R 2

1. Sandor B. Brent, “Puns, Metaphors, and Misunder-

standings in a Two-Year-Old’s Conception of Death,”

Omega: Journal of Death and Dying 8, no. 4 (1977–1978): 285–293. The son, now an adult, has no recollection of

this experience. Dr. Brent, a psychologist, believes that

this indicates a successfully managed event. (Personal

communication.)

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Chapter 2 609

29. Robert Kastenbaum, On Our Way: The Final Passage Through Life and Death (Berkeley: University of Califor- nia Press, 2004), p. 367.

30. Slaughter and Griffi ths, “Death Understanding

and Fear of Death in Young Children,” p. 526.

31. Gerald P. Koocher, “Childhood, Death, and

Cognitive Development,” Developmental Psychology 9, no. 3 (1973): 369–375; “Talking with Children About

Death,” American Journal of Orthopsychiatry 44, no. 3 (April 1974): 404–411; and “Conversations with Chil-

dren About Death,” Journal of Clinical Child Psychology (Summer 1974): 19–21.

32. Helen L. Swain, “Childhood Views of Death,”

Death Education 2, no. 4 (1979): 341–358.

33. Quoted in Claudia Kalb and Aku Ammah-Tagoe,

“Generation 9/11: Children Who Watched the Tragedy

Unfold Are Now On the Brink of Adulthood,” News- week, September 8, 2009.

34. See Mary Alice Varga and Robin Paletti, “Life

Span Issues and Dying,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk,

25–31 (New York: Routledge, 2013), p. 28; and David

E. Balk, “Adolescent Development: The Backstory to

Adolescent Encounters with Death and Bereavement,”

in Adolescent Encounters with Death, Bereavement, and Cop- ing, ed. David E. Balk and Charles A. Corr, 3–20 (New York: Springer, 2009), esp. pp. 4–5.

35. Ken Doka, Counseling Individuals with Life-Threaten- ing Illness (New York: Springer, 2009), p. 118.

36. Jay, Defi ning Decade, pp. 107–108.

37. Mary Dixon-Woods, Bridget Young, and David

Heney, Rethinking Experiences of Childhood Cancer: A Multidisciplinary Approach to Chronic Childhood Illness (Berksnire: Open University Press, 2005), p. 17.

38. Lynn Schofi eld Clark, From Angels to Aliens: Teenagers, the Media, and the Supernatural (New York: Oxford University Press, 2003), p. 11.

39. Jay, Defi ning Decade, p. 1407.

40. Mary Alice Varga and Robin Paletti, “Life Span

Issues and Dying,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 25–31 (New

York: Routledge, 2013); quote p. 28.

41. Miller, Theories of Developmental Psychology, p. 155.

42. Illene Cupit Noppe and Lloyd D. Noppe, “Adoles-

cent Experiences with Death: Letting Go of Immortal-

ity,” Journal of Mental Health Counseling 26, no. 2 (2004): 146 –167; quote p. 154.

43. Lloyd D. Noppe and Illene C. Noppe, “Dialectical

Themes in Adolescent Conceptions of Death,” Journal of Adolescent Research 6, no. 1 (1991): 28–42.

Overview of a Century of Developmental Psychology,”

in A Century of Developmental Psychology, ed. Parke et al. (Washington, D.C.: American Psychological Associa-

tion, 1994), p. 12.

14. Paul Schilder and David Wechsler, “The Attitudes

of Children Toward Death,” Journal of Genetic Psychology 45 (1934): 406 –451.

15. Sylvia Anthony, The Discovery of Death in Childhood and After (New York: Basic Books, 1972), revised edi- tion of The Child’s Discovery of Death: A Study in Child Psychology (London: Kegan Paul, 1940).

16. Maria H. Nagy, “The Child’s Theories Concerning

Death,” Journal of Genetic Psychology 73 (1948): 3–27.

17. Slaughter, “Young Children’s Understanding of

Death.”

18. Susan A. Gelman and John E. Opfer, “Develop-

ment of the Animate-Inanimate Distinction,” in Black- well Handbook of Childhood Cognitive Development, ed. Usha Goswami, 151–166 (Oxford: Blackwell, 2004).

19. Jesse M. Bering, Carlos Hernández Blasi, and

David F. Bjorklund, “The Development of ‘Afterlife’

Beliefs in Religiously and Secularly Schooled Chil-

dren,” British Journal of Developmental Psychology 23 (2005): 587–607; quote p. 589.

20. Jesse M. Bering and David F. Bjorklund, “The

Natural Emergence of Reasoning about the Afterlife

as a Development Regularity,” Developmental Psychology 40, no. 2 (2004): 217–233.

21. Erik Erikson, Childhood and Society (New York: Norton, 1950).

22. Jean Piaget, The Child and Reality: Problems of Genetic Psychology, trans. Arnold Rosin (New York: Grossman, 1973), and The Child’s Conception of the World (London: Routledge & Kegan Paul, 1929).

23. Robert Zucker, The Journey Through Grief and Loss: Helping Yourself and Your Child When Grief Is Shared (New York: St. Martin’s, 2009), p. 37.

24. Bruce Bower, “Toddler Worldview Shifts at Age 2,”

Science News (August 16, 2008), p. 12.

25. Patricia Miller, Theories of Developmental Psychology, 4th ed. (New York: Worth, 2002), p. 42.

26. Meg Jay, The Defi ning Decade: Why Your Twenties Matter—And How to Make the Most of Them Now (New York: Twelve, 2012), p. 139.

27. From a conversation with Jean Piaget in Richard I.

Evans, The Making of Psychology: Discussions with Creative Contributors (New York: Knopf, 1976), p. 46.

28. Miller, Theories of Developmental Psychology, p. 153.

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610 n o t e s

59. Richard A. Settersten, Jr., “Socialization and the

Life Course: New Frontiers in Theory and Research,”

in New Frontiers in Socialization, ed. Richard A. Setter- sten, Jr., and Timothy J. Owens, 13–40 (Amsterdam:

JAI, 2002), p. 15.

60. Settersten, “Socialization and the Life Course,” p. 20.

61. Walter R. Heinz, “Self-Socialization and Post-

Traditional Society,” in New Frontiers in Socialization, ed. Settersten and Owens, 41–64; p. 44.

62. Hannelore Wass, “Death Education for Children,”

in Dying, Death, and Bereavement: A Challenge for Living , 2nd ed., ed. Inge Corless, Barbara B. Germino, and

Mary A. Pittman, 25–41 (New York: Springer, 2003);

quote p. 27.

63. Norman Goodman, Introduction to Sociology (New York: HarperCollins, 1992), pp. 84–85.

64. Settersten, “Socialization and the Life Course,”

p. 34.

65. Mark A. Mesler, “Negotiating Life for the Dying:

Hospice and the Strategy of Tactical Socialization,”

Death Studies 19, no. 3 (1995): 235–255.

66. Kathleen R. Gilbert and Colleen I. Murray, “The

Family, Larger Systems, and Death Education,” in

Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 367–377 (New York:

Routledge, 2013), p. 367.

67. Settersten, “Socialization and the Life Course,” p. 30.

68. Iona Opie and Peter Opie, The Lore and Language of Schoolchildren (Oxford: Clarendon, 1959), p. 1.

69. Iona Opie and Peter Opie, Children’s Games in Street and Playground (Oxford: Clarendon, 1969), pp. 62, 75.

70. Meredith Cox, Erin Garrett, and James A. Gra-

ham, “Death in Disney Films: Implications for Chil-

dren’s Understanding of Death,” Omega: Journal of Death and Dying 50, no. 4 (2004–2005): 267–280.

71. Martha Wolfenstein and Gilbert Kliman, eds., Chil- dren and the Death of a President: Multi-Disciplinary Studies (Garden City, N.Y.: Anchor Press/Doubleday, 1965),

esp. pp. 217–239.

72. See Maria Tatar, ed., The Annotated Classic Fairy Tales (New York: Norton, 2002).

73. Terri Windling, “On Tolkien and Fairy-Tales,” in

Meditations on Middle-Earth, ed. Karen Haber (New York: St. Martin’s, 2001), pp. 215–229; quote p. 227.

74. Elizabeth P. Lamers, “Children, Death, and Fairy

Tales,” Omega: Journal of Death and Dying 31, no. 2 (1995): 151–167. See also Joan Acocella, “Once Upon a

Time: The Lure of the Fairy Tale,” The New Yorker ( July 23, 2012): 73–78.

44. Richard A. Settersten, Jr., and Barbara Ray,

“What’s Going On With Young People Today? The

Long and Twisting Path to Adulthood,” Future of Children 20, no. 1 (2010): 19–36; quote p. 36.

45. Jeffrey Jensen Arnett, “Emerging Adulthood: A

Theory of Development from the Late Teens Through

the Twenties,” American Psychologist 55, no. 5 (2000): 469–480; quote p. 475. See also Jeffrey Jensen Arnett

et al., Debating Emerging Adulthood: Stage or Process? (New York: Oxford University Press, 2011).

46. Yoko Yamada, “Models of Life-Span Development

Psychology: A Construction of the Generative Life

Model Including the Concept of Death,” Kyoto University Research Studies in Education 47 (2002): 39–62; esp. p. 46.

47. Kenneth J. Doka, Counseling Individuals with Life- Threatening Illness (New York: Springer, 2009), p. 120.

48. Charles W. Brice, “Mourning Throughout the

Life Cycle,” American Journal of Psychoanalysis 42, no. 4 (1982): 320–321.

49. Patricia H. Miller, Theories of Developmental Psychol- ogy, 4th ed. (New York: Worth, 2002), p. 156.

50. Doka, Counseling Individuals with Life-Threatening Illness, p. 120.

51. Michele A. Paludi, ed., Human Development in Mul- ticultural Contexts (Upper Saddle River, N.J.: Prentice- Hall, 2002), p. 190.

52. Miller, Theories of Developmental Psychology, p. 156.

53. Doka, Counseling Individuals with Life-Threatening Illness, p. 121.

54. Miller, Theories of Developmental Psychology, p. 156.

55. M. Brewster Smith, “The Case of Brew,” Journal of Personality 73, no. 5 (2005): 1111–1140; quote p. 1136.

56. Erik H. Erikson, The Life Cycle Completed: A Review (New York: Norton, 1982), p. 67. See also Paul B. Baltes

and Ursula M. Staudinger, “Wisdom: A Metaheuristic

(Pragmatic) to Orchestrate Mind and Virtue Toward

Excellence,” American Psychologist 55, no. 1 (2000): 122–136; and Christina RŌcke and Katie E. Cherry,

“Death at the End of the 20th Century: Individual

Processes and Developmental Tasks in Old Age,” Inter- national Journal of Aging and Human Development 54, no. 4 (2002): 315–333.

57. Hilary N. Weaver, Explorations in Cultural Compe- tence: Journeys to the Four Directions (Belmont, Calif.: Brooks/Cole, 2005), p. 25.

58. Frederick Erickson, “Culture and Human Develop-

ment,” Human Development 45 (2002): 299–306; quote p. 303.

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88. Lynne Ann DeSpelder and Nathalie Prettyman,

A Guidebook for Teaching Family Living (Boston: Allyn & Bacon, 1980), pp. 130–134.

89. See Mary Anne Sedney, “Children’s Grief

Narratives in Popular Films,” Omega: Journal of Death and Dying 39, no. 4 (1999): 315–324.

90. Ute Carson, “A Child Loses a Pet,” Death Education 3 (1980): 399–404.

91. Kenneth R. Kaufman and Nathaniel D. Kaufman,

“And Then the Dog Died,” Death Studies 30 (2006): 61–76; quote p. 63.

92. Kelly A. McCutcheon and Stephen J. Fleming,

“Grief Resulting from Euthanasia and Natural Death

of Companion Animals,” Omega: Journal of Death and Dying 44, no. 2 (2001–2002): 169–188.

93. Cheri Barton Ross and Jane Baron-Sorensen, Pet Loss and Human Emotion: A Guide to Recovery, 2nd ed. (New York: Routledge, 2007), p. 6.

94. Ross and Baron-Sorensen, Pet Loss and Human Emotion, 2nd ed., p. 122.

95. Barbara Ambros, “Vengeful Spirits or Loving Spir-

itual Companions? Changing Views of Animal Spirits

in Contemporary Japan,” Asian Ethnology 69, no. 1 (2010): 35–67; quotes pp. 36, 60.

96. Michelle Linn-Gust, “From the Backyard to the

Pet Bed: The Changing Role of Animals in Society,”

The Forum 33, no. 11 (April 2007): 1, 3–4.

97. Jane Brody, “When Your Pet Dies,” Honolulu Star- Bulletin & Advertiser, December 8, 1985.

98. See Morris A. Wessel, “Loss of a Pet,” in A Chal- lenge for Living: Dying, Death, and Bereavement, 2nd ed., ed. Inge B. Corless, Barbara B. Germino, and Mary A.

Pittman (New York: Springer, 2003), pp. 303, 305.

99. See Lynn A. Planchon and others, “Death of a

Companion Cat or Dog and Human Bereavement: Psy-

chosocial Variables,” Society & Animals 10, no. 1 (2002): 93–105.

100. Cheri Barton Ross, Pet Loss and Children: Establish- ing a Healthy Foundation (New York: Routledge, 2005), p. 40.

101. Stanley Coren, The Modern Dog: A Joyful Explana- tion of How We Live With Dogs Today (New York: Free Press, 2008), p. 164.

102. Ross and Baron-Sorensen, Pet Loss and Human Emotion, pp. 174–175.

103. Allan Kellehear and Jan Fook, “Lassie Come

Home: A Study of ‘Lost Pet’ Notices,” Omega: Journal of Death and Dying 34, no. 3 (1996 –1997): 191–202; quote p. 192.

75. Carolyn Marvin, “On Violence in Media,” Journal of Communication 50, no. 1 (2000): 142–149.

76. Sheila Hébert-Collins, Petite Rouge: A Cajun Twist to an Old Tale (Gretna, La.: Pelican, 1997); Niki Daly, Pretty Salma: A Little Red Riding Story from Africa (New York: Clarion, 2007).

77. See Eve Morel, ed., Fairy Tales and Fables (New York: Grosset & Dunlap, 1970), pp. 11–13; and Cath-

erine Orenstein, Little Red Riding Hood Uncloaked: Sex, Morality, and the Evolution of a Fairy Tale (New York: Basic Books, 2002).

78. Ed Young, trans., Lon Po Po: A Red-Riding Hood Story from China (New York: Philomel Books, 1989).

79. Kalle Achte and others, “Themes of Death and

Violence in Lullabies of Different Countries,” Omega: Journal of Death and Dying 20, no. 3 (1989–1990): 193–204.

80. Sandra L. Bertman, “Death Education in the Face

of a Taboo,” in Concerning Death: A Practical Guide for the Living, ed. Earl A. Grollman (Boston: Beacon Press, 1974), p. 334.

81. Reported by Richard Lonetto, Children’s Concep- tions of Death (New York: Springer, 1980), p. 9.

82. Davina A. Allen and others, “Religion,” in Key Ideas in Human Thought, ed. Kenneth McLeish (New York: Facts on File, 1993), pp. 626 –627.

83. Robert A. Emmons, “Religion in the Psychology

of Personality: An Introduction,” Journal of Personality 67, no. 6 (1999): 873–888. See also Alfred Kracher,

“The Study of Religion: Conversation Point for Theol-

ogy and Science,” Zygon: Journal of Religion and Science 35, no. 4 (2000): 827–848. See also Kenneth J. Doka,

“Religion, Spirituality, and Assessment and Interven-

tion,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 209–217 (New York:

Routledge, 2013).

84. Justin L. Barrett, “Exploring the Natural Founda-

tions of Religion,” Trends in Cognitive Sciences 4, no. 1 (2000): 29–34.

85. Clark, From Angels to Aliens, p. 9.

86. Michael E. McCullough and others, “Religious

Involvement and Mortality: A Meta-Analytic Review,”

Health Psychology 19, no. 3 (2000): 211–222.

87. Lynne Ann DeSpelder and Albert Lee Strickland,

“Using Life Experiences as a Way of Helping Children

Understand Death,” in Beyond the Innocence of Childhood: Factors Infl uencing Children and Adolescents’ Perceptions and Attitudes Toward Death, ed. David W. Adams and Eleanor J. Deveau, 45–54 (Amityville, N.Y.: Baywood,

1995).

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2. Jeffrey Jensen Arnett, “The Psychology of Global-

ization,” American Psychologist 57, no. 10 (2002): 774 –783. See also Mary Buchholtz, “Youth and

Cultural Practice,” Annual Review of Anthropology 31 (2002): 525–552.

3. Gordon Marshall, ed., The Concise Oxford Diction- ary of Sociology (New York: Oxford University Press, 1994), p. 104. See also Don Brenneis, “Some Cases for

Culture,” Human Development 45, no. 4 (2002): 264– 269; and Frederick Erickson, “Culture and Human

Development,” Human Development 45, no. 4 (2002): 299–306.

4. Norman Goodman, Introduction to Sociology (New York: HarperCollins, 1992), p. 42.

5. Davina A. Allen, “Structure,” in Key Ideas in Human Thought, ed. Kenneth McLeish, 508–509 (New York: Facts on File, 1993), p. 716.

6. Nancy Scheper-Hughes, “Death Without Weeping:

The Violence of Everyday Life in Brazil,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland (Mountain View,

Calif.: Mayfi eld, 1995), pp. 41–58.

7. Kathy Charmaz, “Conceptual Approaches to the

Study of Death,” Death and Identity, 3rd ed., ed. Robert Fulton and Robert Bendiksen (Philadelphia: Charles

Press, 1993), pp. 44–45.

8. Robert Blauner, “Death and Social Structure,” in

Death and Identity, rev. ed., ed. Robert Fulton (Bowie, Md.: Charles Press, 1976), pp. 35–59.

9. Robert Bendiksen, “The Sociology of Death,” in

Death and Identity, rev. ed., ed. Fulton, pp. 59–81.

10. Joseph M. Kaufert and John D. O’Neil, “Cultural

Mediation of Dying and Grieving Among Native Cana-

dian Patients in Urban Hospitals,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 59–74.

11. See Ernest Becker, The Denial of Death (New York: Free Press, 1973).

12. Paul Koudounaris, The Empire of Death: A Cul- tural History of Ossuaries and Charnel Houses (London: Thames & Hudson, 2011), p. 11.

13. Dana K. Cassell, Robert C. Salinas, and Peter A. S.

Winn, The Encyclopedia of Death and Dying (New York: Facts on File, 2005), p. xv.

14. See, for example, Ben Harder, “Evolving in Their

Graves: Early Burials Hold Clues to Human Origins,”

Science News 160 (December 15, 2001): 380–381. On the origin of “religious feeling” in funeral practices,

see Ina Wunn, “Beginning of Religion,” Numen: International Review for the History of Religions 47, no. 4 (2000): 417–452.

104. See www.aspca.org for further information.

105. See Lynn A. Planchon, Donald I. Templer, Shel-

ley Stokes, and Jacqueline Keller, “Death of a Compan-

ion Cat or Dog and Human Bereavement: Psychosocial

Variables,” Society & Animals 10, no. 1 (2002): 93–105.

106. Ross, Pet Loss and Children, p. 98.

107. McCutcheon and Fleming, “Grief Resulting

from Euthanasia and Natural Death of Companion

Animals.”

108. Avery D. Weisman, “Bereavement and Compan-

ion Animals,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland, 276 –280 (Mountain View, Calif.: Mayfi eld,

1995); quote p. 280.

109. Sandor B. Brent and Mark W. Speece, “‘Adult’

Conceptualization of Irreversibility: Implications for

the Development of the Concept of Death,” Death Stud- ies 17, no. 3 (1993): 203–224.

110. Sandor B. Brent and others, “The Development

of the Concept of Death Among Chinese and U.S.

Children 3–17 Years of Age: From Binary to ‘Fuzzy’

Concepts?” Omega: Journal of Death and Dying 33, no. 1 (1996): 67–83. See also Shu Ching Yang and Shih-Fen

Chen, “A Phenomenographic Approach to the Mean-

ing of Death: A Chinese Perspective,” Death Studies 26, no. 2 (2002): 143–175.

111. David W. Plath, “Resistance at Forty-Eight:

Old-Age Brinksmanship and Japanese Life Course

Pathways,” in Aging and Life Course Transitions: An Interdisciplinary Perspective, ed. Tamara K. Hareven and Kathleen J. Adams, 109–125 (New York: Guilford

Press, 1982).

112. Thomas S. Weisner, “Ecocultural Understanding

of Children’s Developmental Pathways,” Human Devel- opment 45, no. 4 (2002): 275–281; quote p. 276.

113. Martin Sokefeld, “Debating Self, Identity, and

Culture in Anthropology,” Current Anthropology 40, no. 4 (1999): 417–447.

114. Linda M. Hunt, “Beyond Cultural Competence:

Applying Humility to Clinical Settings,” The Park Ridge Center Bulletin (November–December 2001): 3–4.

115. Albert Bandura, “Exploration of Fortuitous

Determinants of Life Paths,” Psychological Inquiry 9, no. 2 (1998): 95–115; quote p. 97.

C H A P T E R 3

1. Pittu Laungani, “Death and Bereavement in India

and England: A Comparative Analysis,” Mortality 1, no. 2 (1996): 191–212.

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of Palliative Care 4, no. 3 (1988): 16 –20; and Frederick S. Paxton, Christianizing Death: The Creation of a Ritual Process in Early Medieval Europe (New York: Cornell University Press, 1990). Except where otherwise noted,

quoted material is from Ariès.

26. C. John Sommerville, “Stark’s Age of Faith Argu-

ment and the Secularization of Things: A Commen-

tary,” Sociology of Religion 63, no. 3 (2002): 361–372; esp. p. 362.

27. See Elisabeth Darby and Nicola Smith, The Cult of the Prince Consort (New Haven, Conn.: Yale University Press, 1983); Patricia Jalland, Death in the Victorian Family (New York: Oxford University Press, 1996); and John Morley, Death, Heaven, and the Victorians (Pittsburgh: University of Pittsburgh Press, 1971).

28. Oscar Lenius, A Well-Dressed Gentleman’s Pocket Guide (London: Prion, 1998), p. 209.

29. See, for example, Philip A. Mellor and Chris Schil-

ling, “Modernity, Self-Identity, and the Sequestration

of Death,” Sociology 27, no. 3 (August 1993): 411–431; and Charles O. Jackson, “Death Shall Have No Domin-

ion: The Passing of the World of the Dead in Amer-

ica,” in Death and Dying: Views from Many Cultures, ed. Richard A. Kalish, 47–55 (New York: Baywood, 1980).

30. See Peter Brown, The Cult of the Saints: Its Rise and Function in Latin Christianity (Chicago: University of Chicago Press, 1981); and Geary, Living with the Dead in the Middle Ages.

31. Koudounaris, The Empire of Death, p. 16.

32. Rob Kay, Santa Cruz Sentinel, March 20, 1983. See also “Empire of the Dead,” Smithsonian (April 2000).

33. A. A. Gill, “Where the Dead Don’t Sleep,” National Geographic 215, no. 2 (February 2009): 118–133; quote p. 122.

34. Richard A. Etlin, The Architecture of Death: The Transformation of the Cemetery in Eighteenth-Century Paris (Cambridge, Mass.: MIT Press, 1984).

35. Kenneth T. Jackson and Camilo José Vergara,

Silent Cities: The Evolution of the American Cemetery (New York: Princeton Architectural Press, 1989), pp. 22–23.

36. See David E. Stannard, The Puritan Way of Death: A Study in Religion, Culture, and Social Change (New York: Oxford University Press, 1977) and “Calm Dwellings:

The Brief, Sentimental Age of the Rural Cemetery,”

American Heritage 30, no. 5 (August–September 1979): 42–55, and, edited by Stannard, Death in America (Phil- adelphia: University of Pennsylvania Press, 1975); also

Michael Vovelle, “A Century and One-Half of Ameri-

can Epitaphs: Toward the Study of Collective Attitudes

About Death,” Comparative Studies in Society and History 22, no. 4 (October 1980): 534–547.

15. The use of blood-red oxide to decorate corpses is

possibly the earliest widespread funeral custom. Red

ochre was mined in Africa by the earliest Homo sapiens sapiens; it appeared in Europe in Neanderthal funeral practices and was used in burials throughout Europe,

Africa, Asia, Australia, and the Americas. If we imag-

ine the earth as a living organism, hematite is analo-

gous to the blood of Mother Earth.

16. Mike Parker Pearson, The Archaeology of Death and Burial (College Station: Texas A&M University Press, 2000), p. 3.

17. Giambattista Vico, The First New Science, ed. and trans. Leon Pompa (Cambridge: Cambridge University

Press, 2002), p. 263.

18. J. Peter Brosius, “Father Dead, Mother Dead:

Bereavement and Fictive Death in Penan Geng Soci-

ety,” Omega: Journal of Death and Dying 32, no. 3 (1995–1996): 197–226.

19. E. S. Craighill Handy and Mary Kawena Pukui, The Polynesian Family System in Ka-’u, Hawai’i (Rutland, Vt.: Charles E. Tuttle, 1972), pp. 98–101.

20. Anita J. Glaze, Art and Death in a Senufo Village (Bloomington: Indiana University Press, 1981),

pp. 150–151.

21. Ninian Smart, The Long Search (Boston: Little, Brown, 1977), p. 231.

22. Carol Warren, “Disrupted Death Ceremonies:

Popular Culture and the Ethnography of Bali,” Oceania 64, no. 1 (September 1993): 36 –56.

23. See Neville Drury, The Elements of Shamanism (Dorset, U.K.: Element Books, 1989); David Riches, “Shamanism:

The Key to Religion,” The Journal of the Royal Anthropologi- cal Institute 29, no. 2 (1994): 381–405; and Lyle B. Stead- man and Craig T. Palmer, “Visiting Dead Ancestors:

Shamans as Interpreters of Religious Traditions,” Zygon: Journal of Religion and Science 29, no. 2 (1994): 173–189.

24. Kenneth McLeish, “Necromancy,” in Key Ideas in Human Thought, ed. McLeish, 508–509 (New York: Facts on File, 1993).

25. Important studies include Philippe Ariès, Western Attitudes Toward Death: From the Middle Ages to the Present (Baltimore: Johns Hopkins University Press, 1974) and

The Hour of Our Death (New York: Knopf, 1981); Paul Binsky, Medieval Death: Ritual and Representation (Lon- don: British Museum Press, 1996); T. S. R. Boase, Death in the Middle Ages: Mortality, Judgment and Remembrance (New York: McGraw-Hill, 1972); Jacques Choron, Death and Western Thought (New York: Macmillan, 1963); Patrick J. Geary, Living with the Dead in the Middle Ages (Ithaca, N.Y.: Cornell University Press, 1994); Ian Gen-

tles, “Funeral Customs in Historical Context,” Journal

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49. Theda Perdue and Michael D. Green, North Ameri- can Indians: A Very Short Introduction (New York: Oxford University Press, 2010), pp. 16 –17.

50. http://historicaltrauma.com/ .

51. Andrea C. Walker, “Building Bridges in American

Indian Bereavement Research,” Omega: Journal of Death and Dying 59, no. 4 (2009): 351–367; esp. p. 355.

52. Quoted in Vine Deloria, Jr., God Is Red (New York: Dell, 1973), pp. 176 –177. See also Frank Waters, “Two

Views of Nature: White and Indian,” The South Dakota Review, May 1964, pp. 28–29.

53. Clara Sue Kidwell and Alan Velie, Native American Studies (Lincoln: University of Nebraska Press, 2005), pp. 11, 21.

54. Chief Joseph, “White Takeover of Indian Land: An

Indian’s View,” in Christopher Columbus and His Legacy: Opposing Viewpoints, ed. Mary Ellen Jones, 123–132 (San Diego: Greenhaven, 1992), esp. p. 129.

55. Robson Bonnichsen and Alan L. Schneider, “Bat-

tle of the Bones,” The Sciences 40, no. 4 (2000): 40–46. See also “Human Remains: Contemporary Issues,” in

Death Studies 14, no. 6 (1990), ed. Glen W. Davidson and Larry W. Zimmerman.

56. Louise B. Halfe, “The Circle: Death and Dying

from a Native Perspective,” Journal of Palliative Care 5, no. 1 (1989): 37–41. See also Paul Radin, The Road of Life and Death: A Ritual Drama of the American Indians (Princeton, N.J.: Princeton University Press, 1973).

57. Stephen Levine, A Year to Live: How to Live This Year as If It Were Your Last (New York: Bell Tower, 1997), p. 154.

58. Richard J. Preston and Sarah C. Preston, “Death

and Grieving Among Northern Forest Hunters: An

East Cree Example,” in Coping with the Final Tragedy: Cultural Variation in Dying and Grieving, ed. David R. Counts and Dorothy A. Counts, 135–155 (Amityville,

N.Y.: Baywood, 1991).

59. Jamake Highwater, The Primal Mind: Vision and Reality in Indian America (New York: Harper & Row, 1981), p. 165.

60. Åke Hultkrantz, Native Religions of North America: The Power of Visions and Fertility (New York: Harper & Row, 1987). See also, by Hultkrantz, The Religions of the American Indians (Berkeley: University of Califor- nia Press, 1979), The Study of American Indian Religions (New York: Crossroad, 1983), and Shamanic Healing and Ritual Drama: Health and Medicine in Native North Ameri- can Religious Tradition (New York: Crossroad, 1992).

61. Malcolm Margolin, The Ohlone Way: Indian Life in the San Francisco Monterey Bay Area (Berkeley, Calif.: Heyday Books, 1978), pp. 145–149.

37. Ray S. Anderson, Theology, Death and Dying (New York: Basil Blackwood, 1986), pp. 105–107.

38. James Stevens Curl, A Celebration of Death: An Intro- duction to Some of the Buildings, Monuments, and Settings of Funerary Architecture in the Western European Tradition (New York: Charles Scribner’s Sons, 1980), p. 367.

39. See, for example, John Cohen, “Death and the

Danse Macabre,” History Today (August 1982): 35–40; and Fritz Eichenberg, Dance of Death: A Graphic Com- mentary on the Danse Macabre Through the Centuries (New York: Abbeville, 1983).

40. See, for example, Norman F. Cantor, In the Wake of the Plague: The Black Death and the World It Made (New York: Free Press, 2001); and Colin Platt, King Death: The Black Death and Its Aftermath in Late-Medieval England (London: University College of London Press, 1996).

41. David Herlihy, The Black Death and the Transforma- tion of the West (Cambridge, Mass.: Harvard University Press, 1997), pp. 63, 64.

42. Johan P. Mackenbach, “Dead Body with Mourners:

Medical Refl ections on the Emtombment of Christ,”

British Medical Journal 327 ( July 26, 2003): 215–217; quote p. 217.

43. Frank Gonzalez-Crussi, “Anatomy and Old Lace:

An Eighteenth-Century Attitude Toward Death,” The Sciences ( January–February 1988): 48–49.

44. Discussion based on Albert Lee Strickland, “Death

Masks,” in The A–Z of Death & Dying: Social, Medical, and Cultural Aspects, ed. Michael John Brennan (Santa Barbara, Calif.: ABC-Clio/Greenwood, 2014). See

also Ernst Benkard, Undying Faces: A Collection of Death Masks, trans. Margaret M. Green (New York: Norton, 1929).

45. The ensuing discussion of various cultural view-

points benefi ts from the following important studies:

Miguel A. Pérez and Raffy R. Luquis, eds., Cultural Competence in Health Education and Health Promotion (San Francisco: Jossey-Bass, 2008); Larry D. Pur-

nell, Transcultural Health Care: A Culturally Competent Approach, 4th ed. (Philadelphia: F. A. Davis, 2013); and Hilary N. Weaver, Explorations in Cultural Competence: Journeys to the Four Directions (Belmont, Calif.: Brooks/ Cole, 2005).

46. Charles Wilkinson, Blood Struggle: The Rise of Mod- ern Indian Nations (New York: Norton, 2005), p. 353.

47. Cassell, Salinas, and Winn, The Encyclopedia of Death and Dying, p. xxii.

48. See Donald Bahr, “Bad News: The Predicament

of Native American Mythology,” Ethnohistory 48, no. 4 (2001): 587–612; and Carl Waldman, Atlas of the North American Indian (New York: Facts on File, 1985).

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Extravagant Funerals Among the Yorubas of Western

Nigeria,” Death Studies 25, no. 7 (2001): 609–619; and A. Odasuo Alali, “Management of Death and Grief in Obit-

uary and in Memoriam Pages of Nigerian Newspapers,”

Psychological Reports 73 (1993): 835–842.

76. Ronald Keith Barrett, “Contemporary African-

American Funeral Rites and Traditions,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 80–82; “Psy- chocultural Infl uences on African-American Attitudes

Toward Death, Dying, and Funeral Rites,” in Personal Care in an Impersonal World: A Multidimensional Look at Bereavement, ed. John D. Morgan (Amityville, N.Y.: Bay- wood, 1995), pp. 213–230.

77. Jennifer Hildebrand, “Funerals,” in Greenwood Encyclopedia of African American Folklore, ed. Anand Prahlad (Westport, Conn.: Greenwood, 2005), p. 482.

78. Ronald K. Barrett, personal communication.

79. LaVone V. Hazell, “Cross-Cultural Funeral Rites,”

The Forum: Newsletter of the Association for Death Education and Counseling 24, no. 3 (1998): 1, 10–11; quote p. 10.

80. Kimberly S. Johnson, Katja I. Elbert-Avila, and

James A. Tulsky, “The Infl uence of Spiritual Beliefs

and Practices on the Treatment Preferences of African

Americans: A Review of the Literature,” Journal of the American Geriatrics Society 53 (2005): 711–719.

81. Weaver, Explorations in Cultural Competence, p. 112.

82. David R. Roediger, “And Die in Dixie: Funerals,

Death & Heaven in the Slave Community, 1700–1865,”

The Massachusetts Review 22, no. 1 (Spring 1981): 163–183.

83. Pérez and Luquis, Cultural Competence in Health Education and Health Promotion, p. 13.

84. Ronald K. Barrett, “Death and Dying in the Black

Experience: An Interview with Ronald K. Barrett,”

Innovations in End-of-Life Care 3, no. 5 (2001); www.edu .org.;lastacts .

85. Weaver, Explorations in Cultural Competence, p. 145.

86. Margo Simon Coler and Maria Adriana Felix

Coler, “People of Brazilian Heritage,” http://

resources.fadavis.com/purnell4e/bonus_chapters/

Ch27_001-011.pdf .

87. Tina A. Ellis and Larry D. Purnell, “People of

Guatemalan Heritage,” http://resources.fadavis.com/

purnell4e/bonus_chapters/Ch31_001-014.pdf .

88. Leylha Ahuile, “Ready for Prime Time,” Publishers Weekly (April 1, 2014), p. 3 (special section, “Spanish Language Publishing”).

89. Pérez and Luquis, Cultural Competence in Health Education and Health Promotion, p. 13.

62. Gerry R. Cox, “Native American Spirituality,

Illness, Dying, and Death” (paper presented at the

annual meeting of the Midwest Sociological Society,

Chicago, 1995).

63. David G. Mandelbaum, “Social Uses of Funeral

Rites,” in The Meaning of Death, ed. Herman Feifel, 189–217 (New York: McGraw-Hill, 1959).

64. John E. Reinhardt, Life . . . Afterlife: African Funerary Sculpture (Washington, D.C.: National Museum of Afri- can Art, 1982). On African religious thought, see John

S. Mbiti, African Religions and Philosophy (Garden City, N.Y.: Anchor/Doubleday, 1970); and Dominique Zahan,

The Religion, Spirituality, and Thought of Traditional Africa (Chicago: University of Chicago Press, 1979).

65. Meyer Fortes, “An Introductory Commentary,” in

Ancestors, ed. William Newell (The Hague: Moulton, 1976), p. 5.

66. Steadman and Palmer, “Visiting Dead Ancestors,”

p. 177.

67. Noel Q. King, Religions of Africa: A Pilgrimage into Traditional Religions (New York: Harper & Row, 1970), pp. 13–14; see also, by King, Christian and Muslim in Africa (New York: Harper & Row, 1971), p. 95.

68. Dominique Zahan, “Some Refl ections on African

Spirituality,” in African Spirituality: Forms, Meanings, and Expressions, ed. Jacob K. Olupona, 3–25 (New York: Crossroad, 2000), p. 12.

69. King, Religions of Africa, p. 68. See also Sjaak Van Der Geest, “‘I Want to Go!’ How Older People in

Ghana Look Forward to Death,” Ageing and Society 22 (2002): 7–28.

70. Kofi Asare Opoku, “African Perspectives on Death

and Dying,” in Perspectives on Death and Dying: Cross-Cul- tural and Multidisciplinary Views, ed. Arthur Berger and others, 14–23 (Philadelphia: Charles Press, 1989).

71. Ogbu U. Kalu, “Ancestral Spirituality and Society

in Africa,” in African Spirituality: Forms, Meanings, and Expressions, ed. Jacob K. Olupona, 54–84 (New York: Crossroad, 2000), p. 54.

72. Francis Bebey, African Music: A People’s Art (Brook- lyn, N.Y.: Lawrence Hill, 1975), p. 126.

73. From a story by Robert Dvorchak, The Los Angeles Times, July 8, 1990.

74. Jack Goody, Death, Property, and the Ancestors: A Study of the Mortuary Customs of the LoDagaa of West Africa (Stanford, Calif.: Stanford University Press, 1962).

75. Olatunde Bayo Lawuyi, “Obituary and Ancestral

Worship: Analysis of a Contemporary Cultural Form in

Nigeria,” Sociological Analysis 48, no. 4 (1988): 372–379. See also Kemi Adamolekun, “Survivors’ Motives for

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96. Regina M. Marchi, Day of the Dead in the USA: The Migration and Transformation of a Cultural Phenomenon (New Brunswick, N.J.: Rutgers University Press, 2009),

p. 40.

97. Stanley Brandes, Skulls to the Living, Bread to the Dead: The Day of the Dead in Mexico and Beyond (Malden, Mass.: Blackwell, 2006), pp. 48–50.

98. Paz, Labyrinth of Solitude.

99. Jorge Valadez, “Pre-Columbian and Modern Philo-

sophical Perspectives in Latin America,” in From Africa to Zen: An Invitation to World Philosophy, ed. Robert C. Solomon and Kathleen M. Higgins, 81–124 (Lanham,

Md.: Rowman and Littlefi eld, 1993), p. 107.

100. Davíd Carrasco, “Religions of Mesoamerica: Cos-

movision and Ceremonial Centers,” in Religious Tradi- tions of the World, ed. H. Byron Earhart, 107–253 (San Francisco: HarperCollins, 1992); quote pp. 232–233.

101. Marchi, Day of the Dead in the USA, p. 37.

102. Quoted in Marchi, Day of the Dead in the USA, p. 103.

103. Weaver, Explorations in Cultural Competence, p. 167.

104. Larry Purnell, “People of Hmong Heritage,” in

Transcultural Health Care, ed. Purnell, 310–318; p. 316.

105. Christopher L. Hayes and Richard A. Kalish,

“Death-Related Experiences and Funerary Practices of

the Hmong Refugee in the United States,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 75–79.

106. Jaya Jambunathan, “People of Hindu Heritage,” in

Transcultural Health Care, ed. Purnell, 288–309; p. 302.

107. Shanil Ebrahim, Sheena Bance, and Kerry W.

Bowman, “Sikh Perspectives Towards Death and End-

of-Life Care,” Journal of Palliative Care 27, no. 2 (2011): 170–174.

108. See, for example: H. Byron Earhart, “Religions

of Japan: Many Traditions Within One Sacred Way,” in

Religious Traditions of the World, ed. Earhart, 1075–1186 (San Francisco: HarperCollins, 1992); Dennis Klass,

“Ancestor Worship in Japan: Dependence and the

Resolution of Grief,” Omega: Journal of Death and Dying 33, no. 4 (1996): 279–302; Hajime Nakamura, Ways of Thinking of Eastern Peoples: India, China, Tibet, Japan, trans. and ed. Philip P. Wiener (Honolulu: University

of Hawaii Press, 1964); Sokyo Ono, Shinto: The Kami Way (Rutland, Vt.: Charles E. Tuttle, 1962); Daniel L. Overmyer, “Religions of China: The World as a Living

System,” in Religious Traditions of the World, ed. Earhart, 973–1073; Ian Reader, Religion in Contemporary Japan (Honolulu: University of Hawaii Press, 1991); Robert J.

Smith, Ancestor Worship in Contemporary Japan (Stanford, Calif.: Stanford University Press, 1974); Yamaori Tetsuo,

“The Metamorphosis of Ancestors,” Japan Quarterly 33,

90. Miguel León-Portilla, “Those Made Worthy by

Divine Sacrifi ce: The Faith of Ancient Mexico,” in

South and Meso-American Native Spirituality: From the Cult of the Feathered Serpent to the Theology of Liberation, ed. Gary H. Gossen, 41–64 (New York: Crossroad, 1993),

p. 56.

91. Rich Zoucha and Cecelia A. Zamarripa, “People

of Mexican Heritage,” in Transcultural Health Care, ed. Purnell, 374–390; p. 384.

92. Luis Cardoza y Arogón, quoted in Claudio Lom-

nitz, Death and the Idea of Mexico (Cambridge, Mass.: MIT Press, 2005), p. 23.

93. Quoted in Rafael Jesús González, El Corazón de la Muerte: Altars and Offerings for Days of the Dead (Berke- ley, Calif.: Heyday Books, 2005), p. 26.

94. Octavio Paz, The Labyrinth of Solitude: Life and Thought in Mexico (New York: Grove Press, 1961); quote p. 54.

95. See, by Mary J. Andrade, Through the Eyes of the Soul, Día de Muertos en Mexico: Michoacan, 2nd ed. (San Jose, Calif.: La Oferta, 1999), Through the Eyes of the Soul, Día de Muertos en Mexico: Oaxaca (San Jose, Calif.: La Oferta, 1999), and Through the Eyes of the Soul, Día de Muertos en Mexico: Mexico City, Mixquic, and Morelos (San Jose, Calif.: La Oferta 2000). See also Barbara

Brodman, The Mexican Cult of Death in Myth and Litera- ture (Gainesville: University of Florida Press, 1976); Elizabeth Carmichael and Chloë Sayer, The Skeleton at the Feast: The Day of the Dead in Mexico (London: Brit- ish Museum Press, 1991); Robert Childs and Patricia

B. Altman, Vive tu Recuerdo: Living Traditions of the Mexican Days of the Dead (Los Angeles: Museum of Cultural History, UCLA, 1982); Juanita Garciagodoy,

Digging the Days of the Dead: A Reading of Mexico’s Dias de Muertos (Niwot, Colo.: University Press of Colorado, 1998); Judith Strupp Green, “The Days of the Dead in

Oaxaca, Mexico: An Historical Inquiry,” in Death and Dying: Views from Many Cultures, ed. Kalish, pp. 56 –71; John Greenleigh and Rosalind Rosoff Beimler, The Days of the Dead: Mexico’s Festival of Communion with the Departed (San Francisco: HarperCollins, 1991); Rafael Jesús González, El Corazón de la Muerte: Altars and Offerings for Days of the Dead (Berkeley, Calif.: Heyday Books, 2005); Patricia Fernández Kelly, “Death in

Mexican Folk Culture,” American Quarterly 26, no. 5 (December 1974): 516 –535; Claudio Lomnitz, Death and the Idea of Mexico (Cambridge, Mass.: MIT Press, 2005); Joan Moore, “The Death Culture of Mexico

and Mexican Americans,” in Death and Dying: Views from Many Cultures, ed. Kalish, pp. 72–91; Patricia Osuna and David K. Reynolds, “A Funeral in Mexico:

Description and Analysis,” Omega: Journal of Death and Dying 1, no. 3 (1970): 249–269.

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120. Janet Lee Scott, For Gods, Ghosts and Ancestors: The Chinese Tradition of Paper Offerings (Hong Kong: Hong Kong University Press, 2007), pp. 2, 20, 104, 114.

See also Roderick Cave, Chinese Paper Offerings (Hong Kong: Oxford University Press, 1998).

121. Scott, For Gods, Ghosts and Ancestors, p. 129.

122. Scott, For Gods, Ghosts and Ancestors, pp. 104, 150.

123. Tetsuo, “Metamorphosis of Ancestors,” p. 51.

124. Janice Selekman, “People of Jewish Heritage,” in

Transcultural Health Care, ed. Purnell, 339–356; p. 349.

125. See, for example, Barry Cunliffe, The Ancient Celts (New York: Oxford University Press, 1997); Hilda Ellis Davidson, Myths and Symbols in Pagan Europe: Early Scandinavian and Celtic Religions (Manchester, U.K.: Manchester University Press, 1988), and The Lost Beliefs of Northern Europe (London: Routledge, 1993); Peter Berresford Ellis, The Celtic Empire: The First Millennium of Celtic History 1000 BC–AD 51 (New York: Carroll & Graf, 2001); Ronald Hutton, The Pagan Religions of the Ancient British Isles: Their Nature and Legacy (Malden, Mass.: Blackwell, 1991); Prudence Jones and Nigel Pen-

nick, A History of Pagan Europe (London: Routledge, 1995); J. A. MacCulloch, The Celtic and Scandinavian Religions (London: Hutchinson’s University Library, 1948); Sabatino Moscati, ed., The Celts (New York: Rizzoli, 1991); Dáithé Ó’Hógáin, The Celts: A History (Cork: Boydell, 2020); and Ward Rutherford, Celtic Mythology (London: Thorsons, 1995).

126. Sandra M. Gilbert, Death’s Door: Modern Dying and the Ways We Grieve (New York: Norton, 2006), p. 1.

127. See, for example, Nora K. Chadwick, The Druids (Cardiff: University of Wales Press, 1966); Paul R.

Lonigan, The Druids: Priests of the Ancient Celts (Westport, Conn.: Greenwood, 1996).

128. John Sharkey, Celtic Mysteries: The Ancient Religion (New York: Thames & Hudson, 1975), p. 10.

129. James R. Babb, River Music: A Fly Fisher’s Four Sea- sons (Guilford, Conn.: Lyons Press, 2001), p. 176.

130. Elizabeth Kantor, The Politically Incorrect Guide to English and American Literature (Washington, D.C.: Reg- nery, 2006), p. 15.

131. Jack Santino, The Hallowed Eve: Dimensions of Cul- ture in a Calendar Festival in Northern Ireland (Lexing- ton: University Press of Kentucky, 1998), p. 90.

132. Stephanie Myers Schim, “People of Irish Heri-

tage,” http://resources.fadavis.com/purnell4e/bonus_

chapters/Ch33_001-013.pdf .

133. Humayun Ansari, “Burying the Dead: Making

Muslim Space in Britain,” Historical Research 80, no. 210 (November 2007): 545–566.

no. 1 ( January–March 1986): 50–53; and James L.

Watson and Evelyn S. Rawski, eds., Death Ritual in Late Imperial and Modern China (Berkeley: University of Cali- fornia Press, 1988).

109. Kate Jellema, “Everywhere Incense Burning:

Remembering Ancestors in Dôi Moí Vietnam,” Journal of Southeast Asian Studies 38, no. 3 (2007): 457–492; esp. p. 473.

110. Inge Rösch-Rhomberg, “Hierarchical Opposition

and the Concept of um-yang ( yin - yang ): A Reevaluation of Values in the Light of the Symbolism of Korean

Rituals for the Dead,” Anthropos 89 (1994): 471–491.

111. Satsuki Kawano, “A Sociocultural Analysis of

Death Anxiety Among Older Japanese Urbanites in a

Citizens’ Movement,” Omega: Journal of Death and Dying 62, no. 4 (2010–2011): 369–386.

112. Wanyan Shaoyuan, Exploring Fêng-shui (Singa- pore: McGraw-Hill, 2010), p. 6. See also Ole Bruun,

An Introduction to Feng Shui (Cambridge: Cambridge University Press, 2008); Richard Creightmore, Feng Shui: Secrets of Chinese Geomancy (New York: Walker, 2012), esp. pp. 2, 4, 14; and Derek Walters, The Feng Shui Handbook: A Practical Guide to Chinese Geomancy and Harmony (San Francisco: Aquarian/Thorsons, 1991), esp. p. 165.

113. Yamaori Tetsuo, “The Metamorphosis of Ances-

tors,” Japan Quarterly 33, no. 1 ( January–March 1986): 50–53.

114. Keys to the Japanese Heart and Soul (Tokyo: Kodan- sha, 1996), p. 169.

115. Donald Keene, The Pleasures of Japanese Literature (New York: Columbia University Press, 1988), p. 53.

116. Andy Hau Yan Ho and Cecilia Lai Wan Chan,

“Liberating Dying People and Bereaved Families from

the Oppression of Death and Loss in Chinese Societ-

ies: A Public Health Approach,” in Governing Death and Loss: Empowerment, Involvement and Participation, ed. Steve Conway, 119–128 (New York: Oxford University

Press, 2011), p. 119.

117. Christine Valentine, “Negotiating a Loved One’s

Dying in Contemporary Japanese Society,” Mortality 14, no. 1 (2009): 34–52; esp. pp. 36, 37.

118. Christine Valentine, “Bereavement in Japan:

Contemporary Responses to Traditional Forms,” paper

presented at a conference of the Centre for Death and

Society, Bath, U.K., March 26, 2009.

119. Allan Kellehear and Daisuke Tanaka, “Support-

ing Bereavement in Society: Comparisons Between

Australia and Japan,” Grief Matters: The Australian Journal of Grief and Bereavement 7, no. 1 (Autumn 2004): 4–7.

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146. This discussion of contemporary Chinese funeral

customs in Hawaii is based on interviews by the

authors with Anna Ordenstein and Ken Ordenstein

who, along with their Chinese-Hawaiian-Jewish-

Portuguese forebears, have provided funeral services

to residents of Hawaii over the course of fi ve genera-

tions. We are grateful for their assistance.

147. John F. McDermott, Jr., “Toward an Interethnic

Society,” in People and Cultures of Hawaii, ed. McDer- mott, Tseng, and Maretzki, p. 231; see also Wayne S.

Wooden, What Price Paradise? Changing Social Patterns in Hawaii (Washington, D.C.: University Press of America, 1981).

148. McDermott, “Toward an Interethnic Society,”

pp. 229–230; see also Elvi Whittaker, The Mainland Haole: The White Experience in Hawaii (New York: Columbia University Press, 1986).

149. Mary Kawena Pukui and Samuel H. Elbert,

Hawaiian Dictionary, rev. ed. (Honolulu: University of Hawaii Press, 1986), p. 34.

150. Paul Spickard, quoted in Susan Yim, “Hapa in

Hawai’i,” Honolulu (December 1994), pp. 44–47, 90, 92.

151. Goodman, Introduction to Sociology, p. 37.

152. David H. Olson and John DeFrain, Marriage and Family: Diversity and Strengths (Mountain View, Calif.: Mayfi eld, 1994), p. 37.

153. Katie Algeo, “Teaching Cultural Geography with

‘Bend It Like Beckham,’” Journal of Geography 106, no. 3 (2007): 133–143.

154. See M. Eisenbruch, “Cross-Cultural Aspects

of Bereavement: Ethnic and Cultural Variations in

the Development of Bereavement Practices,” Culture, Medicine, and Psychiatry 8 (1984): 315–347; and Jimy M. Sanders, “Ethnic Boundaries and Identity in Plu-

ral Societies,” Annual Review of Sociology 28 (2002): 327–357.

155. Alvin O. Korte, “ Despedidas as Refl ections of Death in Hispanic New Mexico,” Omega: Journal of Death and Dying 32, no. 4 (1995–1996): 245–267.

156. Robert Pogue Harrison, The Dominion of the Dead (Chicago: University of Chicago Press, 2003), p. 70.

C H A P T E R 4

1. Robert Kastenbaum, “Death System,” in Encyclopedia of Death, ed. Robert Kastenbaum and Beatrice Kasten- baum, 90–93 (Phoenix, Ariz.: Oryx Press, 1989); and

Kenneth J. Doka, “Death System,” in Macmillan Ency- clopedia of Death and Dying, ed. Robert Kastenbaum, 222–223 (New York: Macmillan, 2003).

134. Pérez and Luquis, Cultural Competence in Health Education and Health Promotion, p. 16.

135. Weaver, Explorations in Cultural Competence, p. 191.

136. John F. McDermott, Jr., “Toward an Interethnic

Society,” in People and Cultures of Hawaii, ed. McDer- mott, Tseng, and Maretzki, p. 231.

137. Eleanor C. Nordyke, The Peopling of Hawai’i, 2nd ed. (Honolulu: University of Hawaii Press, 1989), p. 1.

138. Patrick Vinton Kirch, Feathered Gods and Fishhooks: An Introduction to Hawaiian Archeology and Prehistory (Honolulu: University of Hawaii Press, 1985), p. 298.

139. Jonathan Y. Okamura, “Why There Are No Asian

Americans in Hawai’i: The Continuing Signifi cance of

Local Identity,” Social Process in Hawaii 35 (1994): 161–178.

140. See Benjamin B. C. Young, “The Hawaiians,” in

People and Cultures of Hawaii: A Psychocultural Profi le, ed. John F. McDermott, Jr., Wen-Shing Tseng, and Thomas

W. Maretzki, 5–24 (Honolulu: John A. Burns School of

Medicine and University of Hawaii Press, 1980).

141. Mary Kawena Pukui, E. W. Haertig, and Cath-

erine A. Lee, Nana I Ke Kumu (Look to the Source), 2 vols. (Honolulu: Hui Hanai; Queen Lili’uokalani Chil-

dren’s Center, 1972). A study conducted in the 1930s

found families still tracing their lineage from ances-

tors who were viewed as spiritual guardians of their

descendants and who often interceded in very practi-

cal ways. See E. S. Craighill Handy and Mary Kawena

Pukui, The Polynesian Family System in Ka-’u, Hawai’i (Rutland, Vt.: Charles E. Tuttle, 1972).

142. George Hu’eu Sanford Kanahele, Ku Kanaka, Stand Tall: A Search for Hawaiian Values (Honolulu: Uni- versity of Hawaii Press, 1986), p. 182. On the soul after

death and realms of the spirits of the dead, see also

Donald D. Kilolani Mitchell, Resource Units in Hawaiian Culture (Honolulu: Kamehameha Schools Press, 1982), pp. 84–86.

143. Kathryn L. Braun, Noreen Mokuau, G. Haunani

Hunt, Momi Kaanoi, and Carolyn C. Gotay, “Supports

and Obstacles to Cancer Survival for Hawaii’s Native Peo-

ple,” Cancer Practice 10, no. 4 (2002): 192–200; esp. p. 193.

144. Margaret J. Maaka, Kathryn H. Au, Yvonne K.

Lefcourt, and L. Pauahi Bogac, “Raccoon? Wass Dat?

Hawaiian Preservice Teachers Reconceptualize Cul-

ture, Literacy, and Schooling,” in Reconceptualizing Lit- eracy in the New Age of Multiculturalism and Pluralism, ed. R. Schmidt and P. B. Mosenthal, 341–366 (Greenwich,

Conn.: Information Age, 2001), p. 344.

145. Nordyke, The Peopling of Hawai’i, p. 52; see also Walter F. Char and others, “The Chinese,” in People and Cultures of Hawaii, ed. McDermott, Tseng, and Maretzki, pp. 53–72.

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17. Joseph B. Verrengia, “Remains of Columbia Crew

Recovered,” Associated Press Online, February 2, 2003.

18. John D. Lantos, Do We Still Need Doctors? (New York: Routledge, 1997), pp. 129–130.

19. George D. Lundberg, “Low-Tech Autopsies in

the Era of High-Tech Medicine: Continued Value for

Quality Assurance and Patient Safety,” JAMA 280, no. 14 (October 14, 1998): 1273–1274.

20. George D. Lundberg, “Who Does Not Like

Autopsies and Why,” MedPage Today (February 20, 2012); http://www.medpagetoday.com/Columns/

At-Large/31264 .

21. Joe Palazzolo and Rob Barry, “More Killings

Called Self-Defense,” The Wall Street Journal Weekend (March 31–April 1), p. A1.

22. Henry Lundsgaarde, Murder in Space City: A Cul- tural Analysis of Houston Homicide Patterns (New York: Oxford University Press, 1977).

23. Hugo Adam Bedau, “An Abolitionist’s Survey of

the Death Penalty in America,” in Debating the Death Penalty: Should America Have Capital Punishment? ed. Hugo Bedau and Paul Cassell (New York: Oxford Uni-

versity Press, 2004), pp. 26 –27.

24. Ted Rohrlich and Fredric N. Tulsky, “Not All

L.A. Murder Cases Are Equal,” The Los Angeles Times, December 3, 1995.

25. See N. Prabha Unnithan, “The Processing of

Homicide Cases with Child Victims: Systemic and

Situational Contingencies,” Journal of Criminal Justice 22, no. 1 (1994): 41–50, and “Children as Victims of Homi-

cide: Making Claims, Formulating Categories, and

Constructing Social Problems,” Deviant Behavior 15, no. 1 (1994): 63–83.

26. Catharine R. Stimpson, “Do These Deaths Surpass

Understanding? The Literary Figure of the Mother

Who Murders,” Triquarterly 124 (2006): 46 –61; see also George B. Palermo, “Murderous Parents,” International Journal of Offender Therapy and Comparative Criminology 46, no. 2 (2002): 123–143.

27. “Prisoners Executed Under Civil Authority” and

“Prisoners Under Sentence of Death,” Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011); http://www.census.gov/compendia/statab/ .

28. Roman Espejo, ed., Does Capital Punishment Deter Crime? (Farmington Hills, Mich.: Greenhaven, 2003), p. 7.

29. Glenn M. Vernon, Sociology of Death: An Analysis of Death-Related Behavior (New York: Ronald Press, 1970). See also Dennis J. Stevens, “The Death Sentence

and Inmate Attitudes,” Crime & Delinquency 38, no. 2 (1992): 272–279.

2. Carla J. Sofka, Illene Noppe Cupit, and Kathleen R.

Gilbert, eds., Dying, Death, and Grief in an Online Uni- verse (New York: Springer, 2012), p. 6.

3. Bert Hayslip, Jr., “Death Denial: Hiding and Cam-

oufl aging Death,” in Handbook of Death & Dying, ed. Clifton D. Bryant, 34–42 (Thousand Oaks, Calif.:

Sage, 2003); esp. p. 35.

4. Darcy Harris, “Healing the Narcissistic Injury of

Death in the Context of Western Society,” in The Shame of Death, Grief, and Trauma, ed. Jeffrey Kauffman, 75–86 (New York: Routledge, 2010), p. 80. See also

Kenneth J. Doka, Disenfranchised Grief: Recognizing Hid- den Sorrow (Lexington, Mass.: Lexington Books, 1989).

5. Susan Orpett Long, Final Days: Japanese Culture and Choice at the End of Life (Honolulu: University of Hawaii Press, 2005), p. 3.

6. Robert Kastenbaum, “Should We Manage Terror—

If We Could?” Omega: Journal of Death and Dying 59, no. 4 (2009): 271–304; esp. 297.

7. Robert A. Hahn and others, “The Recording of

Demographic Information on Death Certifi cates: A

National Survey of Funeral Directors,” Public Health Reports 117 (January–February 2002): 37–43; quote p. 38.

8. Edwin S. Shneidman, Deaths of Man (New York: Quadrangle Books, 1973), pp. 121–130.

9. Chris Kaiser, “Heart Disease Not as Pervasive

as Reported,” MedPage Today (May 21, 2013);

www.medpagetoday.com/PublicHealthPolicy/

GeneralProfessionalIssues/39303 .

10. Brad Randall, Death Investigation: The Basics (Tuc- son, Ariz.: Galen, 1997), p. 1. On the functioning of a

big-city coroner’s offi ce, see Tony Blanche and Brad

Schreiber, Death in Paradise: An Illustrated History of the Los Angeles County Department of Coroner (Los Angeles: General Publishing Group, 1998).

11. Deborah Noyes, “Forensic Science,” in Encyclopedia of the End: Mysterious Death in Fact, Fancy, Folklore, and More, ed. Deborah Noyes (Boston: Houghton Miffl in, 2008), p. 50.

12. Stefan Timmermans, Postmortem: How Medical Examiners Explain Suspicious Deaths (Chicago: Univer- sity of Chicago Press, 2006), p. viii.

13. Timmermans, Postmortem, p. 43.

14. Quoted in Timmermans, Postmortem, p. 272.

15. Ernest F. Talarico, Jr., “A Change in Paradigm:

Giving Back Identity to Donors in the Anatomy

Laboratory,” Clinical Anatomy 26, no. 2 (2013): 161–172.

16. Jon Yoshishige, “Searching for Answers: Lab Iden-

tifi es Remains of Soldiers, Civilians,” Honolulu Adver- tiser, August 8, 1993.

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45. Press release, “New A AN Guideline for Determin-

ing Brain Death Provides More Clarity and Direction,”

www.aan.com . See also Eelco F. M. Wijdicks et al.,

“Evidence-Based Guideline Update: Determining

Brain Death in Adults,” Neurology 74 ( June 8, 2010): 1911–1918.

46. Kellehear, “Dying as a Social Relationship,”

p. 1534. Kellehear notes that some researchers conclude

that the transplant lobby exerted a powerful infl uence

within the medical community at the time of these

deliberations.

47. See James L. Bernat, “The Biophilosophical Basis

of Whole-Brain Death,” Social Philosophy & Policy 19, no. 2 (2002): 324–342; Gary Greenberg, “As Good as

Dead: Is There Really Such a Thing as Brain Death?,”

The New Yorker, August 13, 2001, pp. 36 –41; K. G. Karakatsanis and J. N. Tsanakas, “A Critique on the

Concept of ‘Brain Death,’” Issues in Law and Medicine 18, no. 2 (2002): 127–141; R. D. Truog, “Is It Time to

Abandon Brain Death?” Hastings Center Report 27, no. 1 (1997): 29–37; and Robert M. Veatch, “The Impend-

ing Collapse of the Whole-Brain Defi nition of Death,”

Hastings Center Report 23, no. 4 (1993): 18–24. See also John P. Lizza, “Persons and Death: What’s Metaphysi-

cally Wrong with Our Current Statutory Defi nition of

Death?” Journal of Medicine and Philosophy 18 (1993): 351–374.

48. Kellehear, “Dying as a Social Relationship,” p. 1536.

49. Shemie, “Clarifying the Paradigm for the Ethics of

Donation and Transplantation,” p. 18.

50. Karen G. Gervais, “Advancing the Defi nition of

Death: A Philosophical Essay,” Medical Humanities Review 3 ( July 1989): 7–19; and, by Gervais, Redefi ning Death (New Haven, Conn.: Yale University Press, 1986).

51. Robert M. Veatch, “What Counts as Basic Health

Care? Private Values and Public Policy,” Hastings Center Report 24, no. 3 (1994): 20–21.

52. President’s Commission for the Study of Ethical

Problems in Medicine and Biomedical and Behavioral

Research, Defi ning Death: A Report on the Medical, Legal and Ethical Issues in the Determination of Death (Washing- ton, D.C.: Government Printing Offi ce, 1981), p. 45.

53. President’s Commission, Defi ning Death.

54. Albert R. Jonsen, The Birth of Bioethics (New York: Oxford University Press, 1998), pp. 238–244.

55. Zamperetti, Bellomo, and Ronco, “Defi ning Death

in Non-Heart Beating Donors,” p. 184.

56. Zamperetti, Bellomo, and Ronco, “Defi ning

Death,” p. 184.

57. Kellehear, “Dying as a Social Relationship,” p. 1541.

30. Hugo A. Bedau, “Capital Punishment,” Academic American Encyclopedia Online, March 1991.

31. Kastenbaum and Aisenberg, The Psychology of Death (New York: Springer, 1972), pp. 284–285.

32. Linda R. Monk, The Words We Live By: Your Anno- tated Constitution (New York: Stonesong, 2003), p. 187. On the risk of innocent deaths occurring in the opera-

tion of the death penalty, see James S. Liebman, “Rates

of Reversible Error and the Risk of Wrongful Execu-

tion,” Judicature 86, no. 2 (2002): 78–82.

33. Lundsgaarde, Murder in Space City, p. 146.

34. Allan Kellehear, “Dying As a Social Relationship:

A Sociological Review of Debates on the Determina-

tion of Death,” Social Science & Medicine 66 (2008): 1533–1544.

35. Douglas N. Walton, On Defi ning Death: An Analytic Study of the Concept of Death in Philosophy and Medical Eth- ics (Montreal: McGill-Queen’s University Press, 1979).

36. Ronald E. Cranford, “The Persistent Vegetative

State: The Medical Reality,” in Medical Ethics: Applying Theories and Principles to the Patient Encounter, ed. Matt Weinberg, 111–120 (Amherst, N.Y.: Prometheus, 2001).

37. D. Alan Shewman, transcript, “Session 5:

Responses to the Council’s White Paper, ‘Controver-

sies in the Determination of Death,’” The President’s

Council on Bioethics (November 9, 2007).

38. Sam D. Shemie, “Clarifying the Paradigm for the

Ethics of Donation and Transplantation: Was ‘Dead’

Really So Clear Before Organ Donation?” Philosophy, Ethics, and Humanities in Medicine 2 (August 24, 2007): 18.

39. William R. Clark, Sex and the Origins of Death (New York: Oxford University Press, 1996), p. 171.

40. Robert M. Veatch, Death, Dying, and the Biologi- cal Revolution: Our Last Quest for Responsibility, rev. ed. (New Haven, Conn.: Yale University Press, 1989).

41. Duncan MacDougall, “Hypothesis Concerning

Soul Substance Together with Experimental Evidence

of the Existence of Such Substance,” Journal of the Amer- ican Society for Psychical Research 1, no. 5 (May 1907): 237–244.

42. Jay F. Rosenberg, Thinking Clearly About Death (Englewood Cliffs, N.J.: Prentice-Hall, 1983), p. 106.

43. “A Defi nition of Irreversible Coma: Report of the

Ad Hoc Committee of the Harvard Medical School

to Examine the Defi nition of Brain Death,” Journal of the American Medical Association 205, no. 6 (August 5, 1968): 337–340.

44. N. Zamperetti, R. Bellomo, and C. Ronco, “Defi n-

ing Death in Non-Heart Beating Donors,” Journal of Medical Ethics 29 (2003): 182–185.

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and Barriers of Asian American and Pacifi c Islander

Adolescents in Hawaii,” Progress in Transplantation 20, no. 4 (2010): 392–400; Elisa J. Gordon, Jillian Rodde,

and Juan Carlos Calcedo, “Quality of Internet Educa-

tion about Living Kidney Donation for Hispanics,”

Progress in Transplantation 22, no. 3 (2012): 294–302.

71. Louis A. Gamino and R. Hal Ritter, Jr., Ethical Practice in Grief Counseling (New York: Springer, 2009), p. 153.

72. Caplan, “Organ Transplantation,” p. 130.

73. John Lauerman and Connie Guglielmo, “Jobs

Travel to Transplant Mecca Shows System Flaws,”

Bloomberg.com .

74. Susan E. Morgan, Michael T. Stephenson, Tyler R.

Harrison, Walid A. Afi fi , and Shawn D. Long, “Facts

versus ‘Feelings’: How Rational Is the Decision to

Become an Organ Donor?” Journal of Health Psychology 13 (2008): 644–658.

75. Felicia Schanche Hodge, Patricia Bellanger, and

Connie Norman, “Organ Donation and Transplanta-

tion: A Dialogue with American Indian Healers and

Western Health-Care Providers,” American Indian Cul- ture and Research Journal 35, no. 3 (2011); 79–90; quote p. 87.

76. Margaret Robbins, “The Donation of Organs for

Transplantation: The Donor Families,” in Contemporary Issues in the Sociology of Death, Dying, and Disposal, ed. Glennys Howarth and Peter C. Jupp, 179–192 (New

York: St. Martin’s, 1996).

77. See Julia D. Mahoney, “The Market for Human

Tissue,” Virginia Law Review 86, no. 2 (2000): 163–223; and Laura A. Siminoff and Mary Beth Mercer, “Public

Policy, Public Opinion, and Consent for Organ Dona-

tion,” Cambridge Quarterly of Healthcare Ethics 10, no. 4 (2001): 377–386.

78. Annie Cheney, Body Brokers: Inside America’s Under- ground Trade in Human Remains (New York: Broadway, 2006), pp. 8–10.

79. Timmermans, Postmortem, pp. 226 –227; see also Chapter 6, “The Organ and Tissue Trade,”

pp. 225–249.

80. Renee C. Fox and Judith P. Swazey, Spare Parts: Organ Replacement in American Society (New York: Oxford University Press, 1992), p. 206.

81. Nancy Scheper-Hughes, “The Global Traffi c in

Human Organs,” Current Anthropology 41, no. 2 (2000): 191–224; quote p. 194. On the way in which a unique

set of social and religious conditions facilitated

acceptance of brain death and organ transplantation

in the United States during the late 1960s, see Wil-

liam R. LaFleur, “From Agape to Organs: Religious

58. Mark H. Beers and Robert Berkow, eds., The Merck Manual of Diagnosis and Therapy, 17th ed. (Whitehouse Station, N.J.: Merck Research Laboratories, 1999),

p. 1067.

59. Leonard L. Bailey, “Organ Transplantation: A

Paradigm of Medical Progress,” Hastings Center Report ( January–February 1990): 24–28; see also Susan L.

Smith, “Progress in Clinical Organ Transplantation,”

www.medscape.com .

60. “First ‘Breathing Lung’ Transplant in United States,”

www.sciencedaily.com/releases/2012/11/121126130928

.htm .

61. Robert Steinbrook, “Organ Donation After Car-

diac Death,” New England Journal of Medicine 357, no. 3 ( July 19, 2007): 209–213; esp. p. 209.

62. Steinbrook, “Organ Donation After Cardiac

Death,” p. 211.

63. Steinbrook, “Organ Donation After Cardiac

Death,” quote p. 211. See also The President’s Council

on Bioethics, Controversies in the Determination of Death (Washington, D.C.: 2008).

64. David K. Meagher, “Ethical and Legal Issues and

Loss, Grief and Mourning,” in Handbook of Thanatol- ogy, 2nd ed., ed. David K. Meagher and David E. Balk, 179–190 (New York: Routledge, 2013), p. 183.

65. Joseph L. Verheijde, Mohamed Y. Rady, and Joan

L. McGregor, “The United States Revised Uniform

Anatomical Gift Act (2006): New Challenges to Bal-

ancing Patient Rights and Physician Responsibilities,”

Philosophy, Ethics, and Humanities in Medicine 2, (September 12, 2007): 19–21.

66. Michael A. DeVita and Arthur L. Caplan, “Caring

for Organs or for Patients? Ethical Concerns about the

Uniform Anatomical Gift Act (2006),” Annals of Inter- nal Medicine 147, no. 12 (2007): 876 –879.

67. Zamperetti, Bellomo, and Ronco, “Defi ning Death

in Non-Heart Beating Donors,” p. 184.

68. Margaret Lock, “Human Body Parts as Therapeu-

tic Tools: Contradictory Discourses and Transformed

Subjectivities,” Qualitative Health Research 12, no. 10 (2002): 1406 –1418; quote p. 1407.

69. Arthur Caplan, “Organ Transplantation,” in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefi ng Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley, 129–132 (Garrison, N.Y.: The Hastings Center, 2008); and United Network for

Organ Sharing ( www.unos.org ).

70. See, for example, Cheryl L. Albright et al.,

“Choosing to be a Designated Organ Donor on Their

First Driver’s License: Actions, Opinions, Intentions,

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6. Joshua Hauser and John Lantos, “Stories of Car-

ing and Connection,” Hastings Center Report 30, no. 2 (2000): 44–47.

7. Paul M. Insel and Walton T. Roth, Connect Core Concepts in Health, 13th ed. (New York: McGraw-Hill, 2013), p. 584.

8. Alastair Gray, “International Patterns of Health

Care, 1960 to the 1990s,” in Caring for Health: History and Diversity, ed. Charles Webster, Health and Disease Series, Book 6 (Buckingham, U.K.: Open University

Press, 1994), p. 174. See also Thomas S. Bodenheimer

and Kevin Grumbach, Understanding Health Policy: A Clinical Approach, 3rd ed. (New York: Lange Medical Books, 2002).

9. Daniel Callahan, Taming the Beloved Beast: How Medi- cal Technology Costs Are Destroying Our Health Care System (Princeton, N.J.: Princeton University Press, 2009), p. 7.

10. Callahan, Taming the Beloved Beast, p. 9.

11. Callahan, Taming the Beloved Beast, pp. 47, 151.

12. Callahan, Taming the Beloved Beast, p. 152.

13. Callahan, Taming the Beloved Beast, p. 177.

14. Howard M. Spiro, “If It Ain’t Broke,” Science & Medicine 3, no. 6 (November–December 1996): 4–5.

15. Clive F. Seale, “Changing Patterns of Death and

Dying,” Social Science and Medicine 51 (2000): 917–930.

16. Callahan, Taming the Beloved Beast, p. 3.

17. Madeline Jacobs, “Ethical and Legal Issues Related

to Dying and End-of-Life Care,” in Handbook of Thana- tology, 2nd ed., ed. David K. Meagher and David E. Balk, 43–49 (New York: Routledge, 2013), p. 43.

18. George D. Lundberg, “How to Rein in Medical

Costs, RIGHT NOW,” http://thehealthcareblog.com/

blog/2009/08/11/how-to-rein-in-medical-costs-

right-now .

19. Daniel Callahan, “Health Care Costs and Medical

Technology,” 79–92, The Hastings Center Bioethics Briefi ng Book (Garrison, N.Y.: The Hastings Center, 2009), p. 80.

20. Callahan, “Health Care Costs and Medical Tech-

nology,” p. 82.

21. Daniel Callahan, “The Limits of Medical Progress:

A Principle of Symmetry,” in The Path Ahead: Read- ings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland, 103–105 (Mountain View,

Calif.: Mayfi eld, 1995), p. 104. See also, by Callahan,

What Kind of Life: The Limits of Medical Progress (New York: Simon & Schuster, 1990).

22. Madeline Jacobs, “Ethical and Legal Issues

Related to Dying and End-of-Life Care,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, p. 47.

Differences Between Japan and America in Judging

the Ethics of the Transplant,” Zygon: Journal of Religion and Science 37, no. 3 (2002): 623–642. For different religious views, see Laurence J. O’Connell, “The Reli-

gious and Spiritual Perspective Toward Human Organ

Donation and Transplantation,” in The Ethics of Organ Transplantation, ed. Wayne Shelton and John Balint, 277–292 (New York: JAI Press, 2001).

82. This case study draws on the following sources:

Albert R. Jonsen, “Ethical Issues in Organ Transplan-

tation,” in Medical Ethics, 2nd ed., ed. Robert M. Veatch (Boston: Jones & Bartlett, 1997), pp. 239–274; Rihito

Kimura, “Organ Transplantation and Brain-Death in

Japan: Cultural, Legal, and Bioethical Background,”

Annals of Transplantation 3, no. 3 (1998): 5–58; Darryl Macer, “Bioethics in and from Asia,” Journal of Medical Ethics 25 (1999): 293–295; Masahiro Morioka, “Bio- ethics and Japanese Culture: Brain Death, Patients’

Rights, and Cultural Factors,” Eubios Journal of Asian and International Bioethics 5 (1995): 87–90; Emiko Ohnuki-Tierney, “Brain Death and Organ Transplan-

tation: Cultural Bases of Medical Technology,” Current Anthropology 35, no. 3 (1994): 233–254; and Mona New- some Wicks, “Brain Death and Transplantation: The

Japanese,” www.medscape.com .

83. Mari Yamaguchi, “Japan Lifts Ban on Children

Donating Organs,” AP News Online, July 13, 2009.

84. Michihiro Matsumoto and Lafayette De Mente

Boyé, Japanese Nuance in Plain English (Tokyo: Kodan- sha, 2007), p. 35.

85. Robert Kastenbaum, Death, Society, and Human Experience, 7th ed. (Needham Heights, Mass.: Allyn & Bacon, 2001), p. 62.

C H A P T E R 5

1. Richard A. Deyo, “Cascade Effects of Medical

Technology,” Annual Review of Public Health 23 (2002): 23–44; quote p. 29.

2. Ira Byock, The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life (New York: Avery Penguin, 2012), p. 3.

3. Stephen R. Connor, Hospice and Palliative Care: The Essential Guide, 2nd ed. (New York: Routledge, 2009), p. 2.

4. Vanessa M. P. Johnson, Joan M. Teno, Meg Bour-

bonniere, and Vincent Mor, “Palliative Care Needs of

Cancer Patients in U.S. Nursing Homes,” Journal of Pal- liative Medicine 8, no. 2 (2005): 273–279.

5. Charles E. Rosenberg, “Institutionalized Ambigu-

ity: Confl ict and Continuity in the American Hospi-

tal,” Second Opinion 12 (November 1989): 63–73.

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Chapter 5 623

Support of the Cancer Patient,” in Psychosocial Care of the Dying Patient, ed. Charles A. Garfi eld, 169–184 (New York: McGraw-Hill, 1978).

34. Candace West, Routine Complications: Troubles with Talk Between Doctors and Patients (Bloomington: Indi- ana University Press, 1984).

35. Sandra L. Bertman, Michael D. Wertheimer, and

H. Brownell Wheeler, “Humanities in Surgery, a Life-

Threatening Situation: Communicating the Diagno-

sis,” Death Studies 10, no. 5 (1986): 431–439.

36. Richard S. Sandor, “On Death and Coding,” in

The Path Ahead, ed. DeSpelder and Strickland, pp. 144 –147.

37. Eugene A. Stead, Jr., A Way of Thinking: A Primer on the Art of Being a Doctor (Durham, N.C.: Carolina Aca- demic Press, 1995), p. 126. See also Susan E. Hickman,

“Improving Communication Near the End of Life,”

American Behavioral Scientist 46, no. 2 (2002): 252–267.

38. Albert Lee Strickland and Lynne Ann DeSpelder,

“Communicating About Death and Dying,” in Dying, Death, and Bereavement: A Challenge for Living, 2nd ed., ed. Inge Corless, Barbara B. Germino, and Mary A.

Pittman, 7–24 (New York: Springer, 2003).

39. S. M. Johnson and M. E. Kurtz, “Name Usage in

Clinical Practice: Ethnic and Gender Disparities,”

Humane Medicine 11, no. 3 (1995): 106 –109. See also Gary L. Brase and Jillian Richmond, “The White-

Coat Effect: Physician Attire and Perceived Authority,

Friendliness, and Attractiveness,” Journal of Applied Social Psychology 34, no. 12 (2004): 2469–2481; Felicity Goodyear-Smith and Stephen Buetow, “Power Issues

in the Doctor-Patient Relationship,” Health Care Analy- sis 9, no. 4 (2001): 449–462; and Robert M. Veatch, “White Coat Ceremonies: A Second Opinion,” Journal of Medical Ethics 28, no. 1 (2002): 5–9.

40. Jeanne Quint Benoliel, “Health Care Providers

and Dying Patients: Critical Issues in Terminal Care,”

Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 341–363; quote p. 345.

41. Anne-Mei The, Tony Hak, Gerard Koëter, and

Gerrit van der Wal, “Collusion in Doctor-Patient Com-

munication about Imminent Death: An Ethnographic

Study,” British Medical Journal 321 (December 2, 2000): 1376 –1381.

42. “Tapping Human Potential: An Interview with

Norman Cousins,” Second Opinion 14 ( July 1990): 57–71.

43. See Balfour Mount, “Whole Person Care: Beyond

Psychosocial and Physical Needs,” American Journal of Hospice and Palliative Care 10, no. 1 ( January–February 1993): 28–37.

23. Arthur W. Frank, “The Painter and the Camera-

man: Boundaries in Clinical Relationships,” Theoretical Medicine 23 (2002): 219–232; quote p. 231.

24. Michael D. Fetters and Howard Brody, “The Epide-

miology of Bioethics,” Journal of Clinical Ethics 10, no. 2 (1999): 107–115.

25. See Dan W. Brock, “The Ideal of Shared Decision

Making Between Physicians and Patients,” Kennedy Institute of Ethics Journal (March 1991): 28–47; and Christine K. Cassel, “The Patient-Physician Covenant:

An Affi rmation of Asklepios,” Annals of Internal Medi- cine 124 (1996): 604–606.

26. Stanley Joel Reiser, “The Era of the Patient: Using

the Experience of Illness in Shaping the Missions of

Health Care,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 106 –115.

27. C. D. Bessinger, “Doctoring: The Philosophic

Milieu,” Southern Medical Journal 81, no. 12 (1988): 1558–1562. See also William Campbell Felch, The Secret(s) of Good Patient Care: Thoughts on Medicine in the 21st Century (Westport, Conn.: Praeger, 1996); and Edmund D. Pellegrino and David C. Thomasma, A Philosophical Basis for Medical Practice: Towards a Phi- losophy and Ethic of the Healing Professions (New York: Oxford University Press, 1981).

28. Stephen R. Connor, “The Family, Larger Systems,

and Dying,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, p. 41. This

phrase is attributed to Avery Weisman, On Dying and Denying (1972).

29. See, for example, Dieter Birnbacher, “Predictive

Medicine: The Right to Know and the Right Not to

Know,” Acta Analytica: Philosophy and Psychology 16 (2001): 35–47; Todd S. Elwyn, Michael D. Fetters,

Hiroki Sasaki, and Tsukada Tsuda, “Responsibil-

ity and Cancer Disclosure in Japan,” Social Science & Medicine 54, no. 2 (2002): 281–293; and Stan A. Kaplowitz, Shelly Campo, and Wai Tat Chiu, “Cancer

Patients’ Desires for Communication of Prognosis

Information,” Health Communication 14, no. 2 (2002): 221–241.

30. Blair Sumner Mynatt and Robyn L. Mowery, “The

Family, Larger Systems, and End-of-Life Decision Mak-

ing,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, p. 99f.

31. Kenneth J. Doka, Counseling Individuals with Life- Threatening Illness (New York: Springer, 2009), pp. 35–36.

32. Thomas J. Smith, “Tell It Like It Is,” Journal of Clini- cal Oncology 18, no. 19 (2000): 3441–3445.

33. For a model of such discussion, see Ernest Rosen-

baum, “Oncology/Hematology and Psychosocial

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58. See F. Ackerman, “Goldilocks and Mrs. Ilych: A

Critical Look at the ‘Philosophy of Hospice,’” Cambridge Quarterly of Healthcare Ethics 6, no. 3 (1997): 314–324.

59. See Katherine Froggatt, “Rites of Passage and the

Hospice Culture,” Mortality 2, no. 2 (1997): 123–136.

60. David S. Greer, Vincent Mor, and Robert Kasten-

baum, “Concepts, Questions, and Research Priorities,”

in The Hospice Experiment, ed. Vincent Mor, David S. Greer, and Robert Kastenbaum (Baltimore: Johns

Hopkins University Press, 1988), p. 249. See also Mar-

cia Lattanzi-Licht, John J. Mahoney, and Galen W.

Miller, The Hospice Choice: In Pursuit of a Peaceful Death (New York: Fireside, 1998).

61. NHPCO Facts and Figures: Hospice Care in America 2012, www.nhpco.org .

62. Stephen R. Connor, Joan Teno, Carol Spench, and

Neal Smith, “Family Evaluation of Hospice Care,” Journal of Pain and Symptom Management 30, no. 1 (2005): 9–17.

63. R. Sean Morrison, Catherine Maroney-Galin,

Peter D. Kravolec, and Diane E. Meier, “The Growth

of Palliative Care Programs in United States Hos-

pitals,” Journal of Palliative Medicine 8, no. 6 (2005): 1127–1134.

64. Ira Byock, “Improving Palliative Care in Intensive

Care Units: Identifying Strategies and Interventions

That Work,” Critical Care Medicine 34, no. 11 (2006): S302–S305; quote p. S303.

65. Stephen R. Connor, “JAMA Article Provides Valu-

able Guidance,” NHPCO Newsline (April 2009): 1–2, 4–5. See also NHPCO, Hospice Care: A Consumer’s Guide to Selecting a Hospice Program, which can be downloaded free from www.caringinfo.org .

66. Ira Byock, “Palliative Care,” in On Our Own Terms: Moyers on Dying, ed. Public Affairs Television (New York: WNET, 2000), pp. 10–11. See also, by Byock,

“End-of-Life Care: A Public Health Crisis and an

Opportunity for Managed Care,” American Journal of Managed Care 7, no. 12 (2001): 1123–1132.

67. See William E. Phipps, “The Origin of Hospices/

Hospitals,” Death Studies 12, no. 2 (1988): 91–99; Susan Lynn Sloan, “The Hospice Movement: A Study in the

Diffusion of Innovative Palliative Care,” American Journal of Hospice and Palliative Care (May–June 1992): 24–31; and Sandol Stoddard, “Hospice in the United

States: An Overview,” Journal of Palliative Care 5, no. 3 (1989): 10–19.

68. James Luther Adams, “Palliative Care in the Light

of Early Christian Concepts,” Journal of Palliative Care 5, no. 3 (1989): 5–8.

69. See Thelma Ingles, “St. Christopher’s Hospice,” in

A Hospice Handbook: A New Way to Care for the Dying, ed.

44. Marilee Ivars Donovan and Sandra Girton Pierce,

Cancer Care Nursing (New York: Appleton-Century- Crofts, 1976), p. 32.

45. Betty Davies and others, Fading Away: The Experi- ence of Transition in Families with Terminal Illness (Amityville, N.Y.: Baywood, 1996).

46. Elisabeth Kübler-Ross, On Death and Dying (New York: Macmillan, 1969), p. 249. For a biographical

account of Kübler-Ross’s experiences, see Elisabeth

Kübler-Ross, The Wheel of Life: A Memoir of Living and Dying (New York: Scribner, 1997).

47. Balfour M. Mount, “Keeping the Mission,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 125–132, quote p. 125.

48. Inge B. Corless, “Settings for Terminal Care,”

Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 319–340.

49. See Rien M. J. P. A. Janssens, Zbigniew Zylicz, and

Henk A. M. J. Ten Have, “Articulating the Concept

of Palliative Care: Philosophical and Theological

Perspectives,” Journal of Palliative Care 15, no. 2 (1999): 38–44; and Allan Kellehear, “Spirituality and Palliative

Care: A Model of Needs,” Palliative Medicine 14 (2000): 149–155.

50. Joan M. Teno and Stephen R. Connor, “Referring

a Patient and Family to High-Quality Palliative Care

at the Close of Life,” JAMA 301, no. 6 (February 11, 2009): 651–659; quote p. 655.

51. Reported in Teno and Connor, “Referring a

Patient and Family to High-Quality Palliative Care at

the Close of Life,” p. 652.

52. Stephen R. Connor, “Palliative Care is a Human

Right,” ADEC Forum 37, no. 3 (2011): 1, 3–4, 10.

53. Study commissioned by the Worldwide Palliative

Care Alliance. See M. Wright et al., “Mapping Levels of

Palliative Care Development,” Journal of Pain and Symp- tom Management 35 (2008): 469–485.

54. Stephen R. Connor, Hospice and Palliative Care: The Essential Guide, 2nd ed., p. 215.

55. Teno and Connor, “Referring a Patient and Family

to High-Quality Palliative Care at the Close of Life,”

p. 654.

56. Mark H. Beers, ed., The Merck Manual of Diagnosis and Therapy, 18th ed. (Whitehouse Station, N.J.: Merck Research Laboratories, 2006), p. 2763. It is noteworthy

that there is no entry for “palliative” in the Manual’s index.

57. Connor, Hospice and Palliative Care: The Essential Guide, p. 8.

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news/2013/Apr/30/sharp-san-diego-hospice-auction/ .

See also press release, “San Diego Hospice and

Scripps Health Joint Statement: San Diego Hospice

Announces Intent to Close,” February 13, 2013.

84. NHPCO Facts and Figures, p. 7; and “Resident Population by Race, Hispanic Origin, and Age: 2009,”

Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011); http://www.census.gov/

compendia/statab/ .

85. Ronald K. Barrett, “Blacks, Death, Dying, and

Funerals: Things You’ve Wondered About but Thought

It Politically Incorrect to Ask” (keynote presentation,

King’s College 15th International Conference on

Death and Bereavement, London, Ontario, May 12,

1997). See also Harold P. Freeman and Richard Payne,

“Racial Injustice in Health Care,” New England Journal of Medicine 342, no. 14 (April 6, 2000): 1045–1047; and Harold P. Freeman, Richard Payne, and Louis W. Sul-

livan, “Racial Injustice in Health Care: How Should It

Be Addressed?” Medical Crossfi re 2, no. 8 (2000): 31–33.

86. David J. Casarett and others, “The Terrible

Choice: Re-Evaluating Hospice Eligibility Criteria for

Cancer,” Journal of Clinical Oncology 27, no. 6 (2009): 953–959; and Jessica Fishman and others, “Race,

Treatment Preferences, and Hospice Enrollment:

Eligibility Criteria May Exclude Patients with Greatest

Needs for Care,” Cancer 115, no. 3 (2009): 689–697. See also Alexander K. Smith, Craig C. Earle, and Ellen

P. McCarthy, “Racial and Ethnic Differences in End-

of-Life Care in Fee-for-Service Medicare Benefi ciaries

with Advanced Cancer,” Journal of the American Geriat- rics Society 57 ( January 2009): 153–158.

87. Sandol Stoddard, quoted in Sloan, “The Hospice

Movement: A Study in the Diffusion of Innovative

Palliative Care,” 24–31.

88. Richard Payne, “At the End of Life, Color Still

Divides,” The Washington Post, February 15, 2000. See also Leslie J. Blackhall and others, “Ethnicity and

Attitudes Towards Life Sustaining Technology,” Social Science & Medicine 48, no. 12 (1999): 1779–1789; Eric L. Krakauer, Christopher Crenner, and Ken Fox, “Barriers

to Optimum End-of-Life Care for Minority Patients,”

Journal of the American Geriatrics Society 50, no. 1 (2002): 182–190; and “Palliative Care in African-American

Communities” (whole issue), Innovations in End-of-Life Care: An International Online Journal 3, no. 5 (September– October 2001) www.2.edu.org/lastacts/crntisue.asp .

89. Carole A. Winston, Paula Leshner, Jennifer

Kramer, and Gillian Allen, “Overcoming Barriers to

Access and Utilization of Hospice and Palliative Care

Services in African-American Communities,” Omega: Journal of Death and Dying 50, no. 2 (2004–2005): 151–163; quote p. 161.

Michael P. Hamilton and Helen F. Reid, 45–56 (Grand

Rapids, Mich.: Eerdmans, 1980). See also Cicely Saun-

ders, “The Evolution of Palliative Care,” Patient Educa- tion and Counseling 41, no. 1 (2000): 7–13.

70. Connor, Hospice and Palliative Care: The Essential Guide, p. 4.

71. Cicely Saunders, personal communication.

72. Quoted in Constance Holden, “Hospices for the

Dying, Relief from Pain and Fear,” in Hospice Handbook, ed. Hamilton and Reid, p. 61.

73. Stephen R. Connor, “The Family, Larger Systems,

and Dying,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 33–41 (New York: Routledge,

2013), p. 37.

74. Ira Byock, “The Ethics of Loving Care,” Health Progress 85, no. 4 (2004): 12–19, 57.

75. International Work Group on Death, Dying, and

Bereavement, Statements on Death, Dying, and Bereave- ment (London, Ont.: IWG, 1994).

76. Kenneth J. Doka, “Historical and Contemporary

Perspectives on Dying,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 17–23 (New York:

Routledge, 2013), p. 19. See also Andrea Fontana and

Jennifer Reid Keene, Death and Dying in America (Malden, Mass.: Polity, 2009), p. 41.

77. William M. Lamers, Jr., “Hospice: Enhancing the

Quality of Life,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 116 –124.

78. For a report compiled by the National Hospice

Work Group, see Bruce Jennings, True Ryndes, Carol

D’Onofrio, and Mary Ann Baily, Access to Hospice Care: Expanding Boundaries, Overcoming Barriers: Hastings Cen- ter Report Special Supplement 33, no. 2 (2003): S3–S59.

79. Paul Glare and others, “A Systematic Review of

Physicians’ Survival Predictions in Terminally Ill

Cancer Patients,” British Medical Journal 327 ( July 26, 2003): 195–198.

80. Quoted in article by Jeff Sharlet, “The Truth Can

Comfort the Dying,” Chronicle of Higher Education 46, no. 21 ( January 28, 2000): A20–A24.

81. Lucette Lagnado, “Medicare Head Tackles Criticism

on Hospice Care,” The Wall Street Journal, September 15, 2000; and Nancy-Ann Min DeParle, Administrator,

Health Care Financing Administration, “Letter to

Medicare Hospices,” September 12, 2000.

82. Code of Federal Regulations, Title 42, Chapter IV,

Part 418, Certifi cation of Terminal Illness (current to

March 1, 2010).

83. Paul Sisson, “Scripps Wins Bidding for Hospice

Property” (April 30, 2013); www.utsandiego.com/

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105. Jon Hendricks and C. Davis Hendricks, Aging in Mass Society: Myths and Realities (Cambridge, Mass.: Winthrop, 1977), pp. 284–285.

106. Hendricks and Hendricks, Aging in Mass Society, p. 282.

107. See Muriel R. Gillick, “Do We Need to Create

Geriatric Hospitals?” Journal of the American Geriatrics Society 50, no. 1 (2002): 174–177.

108. Arthur L. Kellerman and Ricardo Martinez, “The

ER, Fifty Years On,” New England Journal of Medicine 364, no. 24 ( June 15, 2011): 2278–2279.

109. Michael Nurok, “The Death of a Princess and the

Formulation of Medical Competence,” Social Science & Medicine 53 (2001): 1427–1438; quote p. 1436. See also Thomas A. Sancton, “Death of a Princess: Did Princess

Diana Have to Die? A Study in French Emergency

Medicine,” The Internet Journal of Rescue and Disaster Medicine 1, no. 2 (2000).

110. “Deaths and Death Rates by Selected Causes,”

Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011); http://www.census.gov/

compendia/statab/ .

111. See, for example, Mickey Eisenberg, Life in the Bal- ance: Emergency Medicine and the Quest to Reverse Sudden Death (New York: Oxford University Press, 1997).

112. See, for example, Frank Huyler, The Blood of Strangers: Stories from Emergency Medicine (Berkeley: University of California Press, 1999).

113. “Family Presence During Cardiac Resuscitation,”

New England Journal of Medicine 368, no. 11 (March 14, 2013): 1060–1062. This article includes opposing com-

mentary by James Downer and Patricia A. Kritek.

114. Jerome Groopman, “Being There: Should

Patients’ Families See What Happens in the Emer-

gency Room?” The New Yorker (April 3, 2006): 34–39; quote p. 34.

115. James K. Crissman and Mary A. Crissman, “Noti-

fi cations of Death,” in Macmillan Encyclopedia of Death and Dying, ed. Robert Kastenbaum (New York: Macmil- lan, 2003), p. 620.

116. Resources include Kenneth V. Iserson, Grave Words: Notifying Survivors About Sudden, Unexpected Deaths (Tucson, Ariz.: Galen Press, 1999); R. Moroni Leash, Death Notifi cation: A Practical Guide to the Process (Hinesburg, Vt.: Upper Access, 1994); Janice H. Lord,

Breaking the Bad News with Concern for the Professional and Compassion for the Survivor (Washington, D.C.: U.S. Department of Justice, n.d.); C. A. J. McLauchlan,

“Handling Distressed Relatives and Breaking Bad

News,” British Medical Journal 301 (November 17, 1990): 1145–1149; and Alan Stewart and Janice Harris Lord,

90. “The Debate in Hospice Care,” Journal of Oncology Practice 4, no. 3 (2008): 153–157.

91. Stephen R. Connor, Martha Tecca, Judi Lund-

Person, and Joan Teno, “Measuring Hospice Care,”

Journal of Pain and Symptom Management 28, no. 4 (2004): 316 –328; quote p. 325.

92. Inge B. Corless, “Hospice and Hope: An Incompat-

ible Duo,” American Journal of Hospice and Palliative Care (May–June 1992): 10–12.

93. See Nicky James and David Field, “The Routiniza-

tion of Hospice: Charisma and Bureaucratization,”

Social Science & Medicine 34, no. 12 (1992): 1363–1375.

94. Corless, “Settings for Terminal Care,” p. 331.

95. William M. Lamers, Jr., “Hospice Care and Its

Effect on the Grieving Process,” in Living with Grief When Illness Is Prolonged, ed. Kenneth J. Doka and Joyce Davidson, 67–82 (Washington, D.C.: Hospice Founda-

tion of America, 1997). See also, by Lamers, “Defi ning

Hospice and Palliative Care: Some Further Thoughts,”

Journal of Pain & Palliative Care Pharmacotherapy 16, no. 3 (2002): 65–71; and Inge B. Corless, “Palliative

Care: One Does Not Need to Be Terminally Ill,” in The Nursing Profession and Beyond, ed. Norma L. Chasha, 561–573 (Thousand Oaks, Calif.: Sage, 2001).

96. “The Debate in Hospice Care,” p. 155.

97. “The Debate in Hospice Care,” p. 156.

98. Information from www.partners.org .

99. Pam Brown, Betty Davies, and Nola Martens,

“Families in Supportive Care––Part II: Palliative Care

at Home: A Viable Care Setting,” Journal of Palliative Care 6, no. 3 (1990): 21–27. See also Tony Chapman, “There’s No Place Like Home,” Theory, Culture & Society 18, no. 6 (2001): 135–146.

100. Carol Levine, “Family Caregiving,” 63–67, The Hastings Center Bioethics Briefi ng Book (Garrison, N.Y.: The Hastings Center, 2009), p. 63.

101. Sylvia Sherwood, Robert Kastenbaum, John N.

Morris, and Susan M. Wright, “The First Months of

Bereavement,” in The Hospice Experiment, ed. Vincent Mor, David S. Greer, and Robert Kastenbaum (Balti-

more: Johns Hopkins University Press, 1988), p. 150.

102. Frank Ostaseski, “Stories of Lives Lived and Now

Ending,” Inquiring Mind: A Journal of the Vipassana Com- munity 10, no. 2 (Spring 1994): 14–16.

103. Allan Kellehear, “Health-Promoting Palliative

Care: Developing a Social Model for Practice,” Mortal- ity 4, no. 1 (1999): 75–82; quote p. 77.

104. April Dembosky, “Stanford Program Ensures No

One Dies Alone,” The Mercury News; www.mercurynews .com August 21, 2009

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of Palliative Care,” Journal of Palliative Care 18, no. 1 (2002): 15–24.

129. Pallimed: A Hospice and Palliative Medicine Blog

(May 22, 2013). See also David E. Weissman, “Moral

Distress in Palliative Care,” Journal of Palliative Medicine 12, no. 10 (2009): 865–866.

130. Danai Papadatou, In the Face of Death: Profession- als Who Care for the Dying and the Bereaved (New York: Springer, 2009), p. 13.

131. Papadatou, In the Face of Death, p. 172.

132. See Graham Loomes and Lynda McKenzie, “The

Use of QALYs in Health Care Decision Making,” Social Science & Medicine 28 (1989): 299–308; and Erik Nord, “The QALY: A Measure of Social Value Rather Than

Individual Utility?” Health Economics 3 (1993): 89–93, as well as “The Trade-Off Between Severity of Illness

and Treatment Effect in Cost-Value Analysis of Health

Care,” Health Policy 24 (1993): 227–238.

133. Callahan, Taming the Beloved Beast, p. 7.

134. Allan Kellehear, Compassionate Cities: Public Health and End of Life Care (New York: Routledge, 2005), p. x.

C H A P T E R 6

1. Alexander Morgan Capron, “The Burden of Deci-

sion,” Hastings Center Report (May–June 1990): 36 –41.

2. “Introduction to Part 2,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk (New

York: Routledge, 2013), p. 51 .

3. On the history of medical ethics, see Albert R. Jon-

sen, The Birth of Bioethics (New York: Oxford University Press, 1998).

4. Alan Meisel, “End-of-Life Care,” 51–54, The Hastings Center Bioethics Briefi ng Book (Garrison, N.Y.: The Hast- ings Center, 2009).

5. See Karen Bullock, “The Infl uence of Culture on

End-of-Life Decision Making,” Journal of Social Work in End-of-Life & Palliative Care 7, no. 1 (2011): 83–98.

6. Timothy E. Quill and Christine K. Cassel, “Non-

abandonment: A Central Obligation for Physicians,”

Annals of Internal Medicine 122, no. 5 (1995): 368–374.

7. John D. Lantos, Do We Still Need Doctors? (New York: Routledge, 1997), pp. 47–48.

8. The President’s Commission for the Study of Ethi-

cal Problems in Medicine and Biomedical and Behav-

ioral Research, Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient- Practitioner Relationship, vol. 1, Report, and vol. 3, Studies on the Foundations of Informed Consent (Washington, D.C.: Government Printing Offi ce, 1982).

“The Death Notifi cation Process,” in Handbook of Death & Dying, ed. Clifton D. Bryant, 513–522 (Thousand Oaks, Calif.: Sage, 2003).

117. Leash, Death Notifi cation, p. 25. See also Alan E. Stewart, “Complicated Bereavement and Posttrau-

matic Stress Disorder Following Fatal Car Crashes:

Recommendations for Death Notifi cation Practice,”

Death Studies 23 (1999): 289–321.

118. Roger Ray, “Death Notifi cation: A Dreaded Duty,”

The Orlando Sentinel, March 21, 2005.

119. Julian Guthrie, “The Saddest Duty: Informing

Families of Loss,” San Francisco Chronicle, April 6, 2003.

120. “Deaths and Death Rates by Selected Causes,”

Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011); http://www.census.gov/

compendia/statab/ .

121. Leash, Death Notifi cation, p. 48.

122. Peter Rober and Paul C. Rosenblatt, “Selected

Discourse in a First Conversation About a Family

Death in James Agee’s Novel, A Death in the Family, ” Death Studies 37 (2013): 172–194. This novel describes three days in the life of a family confronted with the

husband/father’s death in a road accident.

123. Leash, Death Notifi cation, p. 52.

124. William M. Lamers, Jr., “How Patient Deaths

Affect Health Professionals: A Plea for More Open

Communication,” Journal of Pharmaceutical Care in Pain & Symptom Control 5, no. 3 (1997): 59–71.

125. See Danai Papadatou, “A Proposed Model of

Health Professionals’ Grieving Process,” Omega: Journal of Death and Dying 41, no. 1 (2000): 59–77.

126. See, for example, John D. Sugimoto and Kevin

Ann Oltjenbruns, “The Environment of Death and

Its Infl uence on Police Offi cers in the United States,”

Omega: Journal of Death and Dying 43, no. 2 (2001): 145–155; and Laurence Miller, “Tough Guys: Psycho-

therapeutic Strategies with Law Enforcement and

Emergency Services Personnel,” in Stress Management in Law Enforcement, ed. Leonard Territo and James D. Sewell, 317–332 (Durham, N.C.: Carolina Academic

Press, 1999).

127. Morag B. Harris, Mustafa Baloğlu, and James R.

Stacks, “Mental Health of Trauma-Exposed Firefi ght-

ers and Critical Incident Stress Debriefi ng,” Journal of Loss and Trauma 7 (2002): 223–238.

128. See Patricia Boston, Anna Towers, and David

Barnard, “Embracing Vulnerability: Risk and Empa-

thy in Palliative Care,” Journal of Palliative Care 17, no. 4 (2001): 248–253; and Judi Webster and Linda J.

Kristjanson, “‘But Isn’t It Depressing?’: The Vitality

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21. Sharon R. Kaufman, And a Time to Die: How Ameri- can Hospitals Shape the End of Life (New York: Scribner, 2005), pp. 116 –117.

22. Josh Lakin, “Discussing CPR: What Makes It So

Different?” GeriPal: Geriatrics and Palliative Care Blog (May 24, 2013).

23. Kaufman, And a Time to Die, pp. 49, 74.

24. S. J. Diem and J. D. Lantos, “Cardiopulmonary

Resuscitation on Television: Miracles and Misinfor-

mation,” New England Journal of Medicine 334, no. 24 (1996): 1578–1582.

25. A. Halevy and B. A. Brody, “A Multi-Institutional

Collaborative Policy on Medical Futility,” Journal of the American Medical Association 276, no. 7 (1996): 571–574. See also Donald Joralemon, “Reading Futility: Refl ec-

tions on a Bioethical Concept,” Cambridge Quarterly of Healthcare Ethics 11, no. 2 (2002): 127–133.

26. President’s Commission for the Study of Ethical

Problems in Medicine and Biomedical and Behavioral

Research, Summing Up: Final Report on Studies of the Ethical and Legal Problems in Medicine and Biomedical and Behavioral Research (Washington, D.C.: Government Printing Offi ce, March 1983), p. 31. See also the com-

panion volume, Deciding to Forego Life-Sustaining Treat- ment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions (Washington, D.C.: Government Printing Offi ce, March 1983).

27. Berkow, ed., Merck Manual of Medical Information: Home Edition, p. 16.

28. See, by C. G. Prado, Choosing to Die: Elective Death and Multiculturalism (New York: Cambridge University Press, 2008), which addresses the question of when

and whether it is rational to end one’s life to escape

devastating terminal illness; Coping with Choices to Die (New York: Cambridge University Press, 2011), which

deals with the reasoning that needs to be done by fam-

ily and friends of individuals who choose to die; and

The Last Choice: Preemptive Suicide in Advanced Age, 2nd ed. (Westport, Conn.: Greenwood, 1998), which puts

forth the argument that there are good reasons to end

one’s life as an unforced anticipation of demeaning

and agonizing developments.

29. In the Matter of Karen Quinlan: The Complete Legal Briefs, Court Proceedings and Decisions in the Superior Court of New Jersey (1975) and In the Matter of Karen Quinlan, Volume 2: The Complete Briefs, Oral Arguments, and Opinion in the New Jersey Supreme Court (1976; Arlington, Va.: University Publications of America).

30. Background to the Cruzan case and arguments on

both sides of the issue can be found in Hastings Center Report ( January–February 1990): 38–50. See also Ron

9. Carl B. Becker, “Japan: Challenges of Caring for

the Aging and Dying,” in Buddhist Care for the Dying and Bereaved, ed. Jonathan S. Watts and Yosiharu Tomatsu, 19–36 (Boston: Wisdom, 2012), p. 24.

10. Donald Oken, “What to Tell Cancer Patients: A Study

of Medical Attitudes,” JAMA 175 (1961): 1120–1128.

11. D. H. Novack and others, “Changes in Physicians’

Attitudes Toward Telling the Cancer Patient,” JAMA 241 (March 2, 1979): 897–900.

12. See Daniel J. Klenow and George A. Youngs,

“Changes in Doctor/Patient Communication of a

Terminal Prognosis: A Selective Review and Critique,”

Death Studies 11, no. 4 (1987): 263–277.

13. D. H. Novack and others, “Physicians’ Attitudes

Toward Using Deception to Resolve Diffi cult Ethical

Problems,” JAMA 261 (May 26, 1989): 2980–2985.

14. Robert Berkow, ed., The Merck Manual of Medical Information: Home Edition (Whitehouse Station, N.J.: Merck Research Laboratories, 1997), p. 16.

15. Daniel Callahan, The Troubled Dream of Life: Living with Mortality (New York: Simon & Schuster, 1993), p. 48.

16. Margot L. White and John C. Fletcher, “The Story

of Mr. and Mrs. Doe: ‘You Can’t Tell My Husband He’s

Dying; It Will Kill Him,’” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland (Mountain View, Calif.: Mayfi eld,

1995), pp. 148–153.

17. The SUPPORT Principal Investigators, “A Con-

trolled Trial to Improve Care for Seriously Ill Hospi-

talized Patients: The Study to Understand Prognoses

and Preferences for Outcomes and Risks of Treatment

(SUPPORT),” Journal of the American Medical Association 274, no. 20 (1995): 1591–1598. See also in Journal of the American Geriatrics Society 48, no. 5 (2000): Russell S. Phillips and others, “Findings from SUPPORT and

HELP: An Introduction” (pp. S1–S5); Neil S. Wenger

and others, “Physician Understanding of Patient

Resuscitation Preferences: Insights and Clinical Impli-

cations” (pp. S44–S51); and Carol E. Golin and others,

“A Prospective Study of Patient-Physician Communica-

tion About Resuscitation” (pp. S52–S60).

18. Stephen R. Connor, Hospice and Palliative Care: The Essential Guide, 2nd ed. (New York: Routledge, 2009), p. 39.

19. Madeline Jacobs, “Ethical and Legal Issues Related

to Dying and End-of-Life Care,” in Handbook of Thanatol- ogy, 2nd ed., ed. Meagher and Balk, 43–49; quote p. 49.

20. Stephen R. Connor, Hospice and Palliative Care: The Essential Guide, 2nd ed. (New York: Routledge, 2009), p. 94.

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also, in the same issue of Death Studies, Peter H. Ditto, “What Would Terri Want? On the Psychological Chal-

lenges of Surrogate Decision Making,” pp. 135–148.

39. See Steve Perlmutter, “Physician-Assisted Suicide: A

Medicolegal Inquiry,” Michigan State University Journal of Medicine & Law 15 (Spring 2011): 203–225. See also How- ard Brody, “Assisted Death: A Compassionate Response

to a Medical Failure,” New England Journal of Medicine 327 (November 5, 1992): 1384–1388; Eugenie Anne Gifford,

“ Artes Moriendi: Active Euthanasia and the Art of Dying,” UCLA Law Review 40 (1993): 1545–1585; and Albert R. Jonsen, “Living with Euthanasia: A Futuristic Scenario,”

Journal of Medicine and Philosophy 18 (1993): 241–251.

40. Physician-assisted suicide (PAS) conducted by

Michigan pathologist Jack Kevorkian brought the issue

of hastened deaths of patients to widespread media and

public attention during the 1990s. At the time of his

sentencing in 1999 for the second-degree murder of

Thomas Youk, Dr. Kevorkian had provided aid-in-dying

to more than 100 individuals since he began his active

crusade to legalize physician-assisted suicide in 1990.

41. See Choice in Dying, “Physician-Assisted Suicide:

Vacco v. Quill and Washington v. Glucksberg,” www.choices .org/sctdec.htm ; John Dinan, “Rights and the Political

Process: Physician Assisted Suicide in the Aftermath of

Washington v. Glucksberg,” Publius: The Journal of Federal- ism 31, no. 4 (2001): 1–21; and James L. Werth, Jr., and Judith R. Gordon, “Amicus Curiae Brief for the United

States Supreme Court on Mental Health Issues Associ-

ated with ‘Physician-Assisted Suicide,’” Journal of Coun- seling & Development 80, no. 2 (2002): 160–172.

42. Oregon Health Division, “2008 Summary of

Oregon’s Death with Dignity Act,” http://oregon.gov/

DHS/ph/pas/ar-index.shtml .

43. Timothy E. Quill and Jane Greenlaw, “Physician-

Assisted Death,” in The Hastings Center Bioethics Briefi ng Book, pp. 137–141 (Garrison, N.Y.: The Hastings Cen- ter, 2009); quote p. 138.

44. Ira Byock, “Dying: After the Court Ruling,” The Wall Street Journal, June 25, 1997, p. A14.

45. John A. Pridonoff, “Introduction,” in Hospice and Hemlock: Retaining Dignity, Integrity, and Self-Respect in End-of-Life Decisions, ed. Michele A. Trepkowski (Eugene, Ore.: Hemlock Society, 1993).

46. See P. Rousseau, “Terminal Sedation in the Care

of Dying Patients,” Archives of Internal Medicine 1556, no. 16 (1996): 1785–1786.

47. M. Maltoni and others, “Palliative Sedation Ther-

apy Does Not Hasten Death: Results from a Prospec-

tive Multicenter Study,” Annals of Oncology 20 (2009): 1163–1169.

Hamel, “The Supreme Court’s Decision in the Cru- zan Case: A Synopsis,” Bulletin of the Park Ridge Center (September 1990): 18, 20; and Thane Josef Messinger,

“A Gentle and Easy Death: From Ancient Greece to

Beyond Cruzan Toward a Reasoned Legal Response to

the Societal Dilemma of Euthanasia,” Denver University Law Review 71, no. 1 (1993): 175–251.

31. Lois Shepherd, If That Ever Happens to Me: Making Life and Death Decisions After Terri Schiavo (Chapel Hill: University of North Carolina Press, 2009), p. 67.

32. See Arthur L. Caplan, James J. McCartney, and

Dominic A. Sisti, eds., The Case of Terri Schiavo: Ethics at the End of Life (Amherst, N.Y.: Prometheus, 2006); Ken- neth Goodman, ed., The Case of Terri Schiavo: Ethics, Politics, and Death in the 21st Century (New York: Oxford University Press, 2009); and Shepherd, If That Ever Happens to Me.

33. Jon Eisenberg, Using Terri: The Religious Right’s Con- spiracy to Take Away Our Rights (San Francisco: Harper- Collins, 2005), p. 160. The term persistent vegetative state was coined in 1972 by Scottish neurosurgeon Bryan

Jennett and American neurologist Fred Plum in the

medical journal The Lancet.

34. Madeline Jacobs, “Ethical and Legal Issues in End-

of-Life Decision Making,” pp. 102, 103.

35. William Colby, Unplugged: Reclaiming Our Right to Die in America (New York: Amacom, 2006), p. 95.

36. Kenneth Goodman, “Ethics Schmethics: The Schi-

avo Case and the Culture Wars,” University of Miami Law Review 61, no. 3 (2007): 863–870. See also Ronald E. Cranford, “What is a Minimally Conscious State,”

Western Journal of Medicine 176 (2002): 129–130; Joseph J. Fins, “Brain Injury: The Vegetative and Minimally

Conscious States,” 15–19, The Hastings Center Bioethics Briefi ng Book (Garrison, N.Y.: The Hastings Center, 2009); and J. T. Giacino and others, “The Minimally

Conscious State: Defi nition and Diagnostic Criteria,”

Neurology 58 (2002): 349–353. For a review of the underlying mechanisms and classifi cation of disorders

of consciousness, see Andrew M. Goldfi ne and Nicho-

las D. Schiff, “Consciousness: Its Neurobiology and the

Major Classes of Impairment,” Neurologic Clinics 29, no. 4 (2011): 723–737.

37. Rebecca Dresser, “Schiavo and Contemporary

Myths about Dying,” University of Miami Law Review 61, no. 3 (2007): 821–846.

38. Kathy L. Cerminara, “Tracking the Storm: The

Far-Reaching Power of the Forces Propelling the Schi-

avo Case,” Stetson Law Review 35, no. 1 (2005): 147–178, quote p. 176; and “Theresa Marie Schiavo’s Long Road

to Peace,” Death Studies 30, no. 2 (2006): 101–112. See

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Ethics of Lament,” Linacre Quarterly 56 (August 1989): 64–69; and J. Slomka, “What Do Apple Pie and Moth-

erhood Have to Do with Feeding Tubes and Caring

for the Patient?” Archives of Internal Medicine 155, no. 12 (1995): 1258–1263.

56. Dena S. Davis, “Old and Thin,” Second Opinion 15 (November 1990): 26 –32; see also, in the same issue,

Ronald M. Green, “Old and Thin: A Response,” pp.

34–39. On Japanese attitudes toward withdrawing

nutrition and hydration, see Emiko Konishi, Anne J.

Davis, and Toshiaki Aiba, “The Ethics of Withdrawing

Artifi cial Food and Fluid from Terminally Ill Patients:

An End-of-Life Dilemma for Japanese Nurses and

Families,” Nursing Ethics 9, no. 1 (2002): 7–19.

57. Alan R. Fleishman, “Neonatal Care,” in The Hast- ings Center Bioethics Briefi ng Book, pp. 121–124 (Garri- son, N.Y.: The Hastings Center, 2009); quote p. 121.

58. Fleishman, “Neonatal Care,” p. 122.

59. Quoted in Richard A. McCormick, “To Save or

Let Die: The Dilemma of Modern Medicine,” in Ethical Issues in Death and Dying, ed. Robert F. Weir (New York: Columbia University Press, 1977), pp. 173–184.

60. See, for example, Peter A. Clark, “Medical Futility

in Pediatrics: Is It Time for a Public Policy?” Journal of Public Health Policy 23, no. 1 (2002): 66 –89; and John J. Paris, Jeffrey Ferranti, and Frank Reardon, “From

the Johns Hopkins Baby to Baby Miller: What Have

We Learned from Four Decades of Refl ection on Neo-

natal Cases?” Journal of Clinical Ethics 12, no. 3 (2001): 207–214.

61. Alan R. Fleishman, “Neonatal Care,” p. 124.

62. See Peter H. Ditto and others, “Advance Directives

as Acts of Communication,” Archives of Internal Medicine 161 (2001): 421–430; Angela Fagerlin and others, “Pro-

jection in Surrogate Decisions About Life-Sustaining

Medical Treatments,” Health Psychology 20, no. 3 (2001): 166 –175; and Angela Fagerlin and others, “The Use of

Advance Directives in End-of-Life Decision Making:

Problems and Possibilities,” American Behavioral Scien- tist 46, no. 2 (2002): 268–283.

63. Lisa M. Krieger, “New Survey Sheds Light on Cali-

fornians’ End-of-Life Wishes,” San Jose Mercury News (February 14, 2012), A10.

64. Judi Lund Person, “Regulatory Issues in the Care

of Dying,” in Dying, Death, and Bereavement: A Challenge for Living, 2nd ed., ed. Inge B. Corless, Barbara B. Germino, and Mary A. Pittman (New York: Springer,

2003), p. 205.

65. California Medical Association, “California Natu-

ral Death Act,” www.cmanet.org .

48. Drew Rosielle, “Palliative Sedation and Shortened

Survival,” Pallimed, www.pallimed.org , July 2, 2009.

49. Quoted in Quill and Greenlaw, “Physician-Assisted

Death,” p. 141.

50. Euthanasia can be involuntary, nonvoluntary, or

voluntary. Involuntary euthanasia refers to the death of a patient by a medical practitioner without the patient’s consent. A notorious example was the medicalized kill-

ing done by the Nazi regime. Involuntary euthanasia

is usually considered murder. Nonvoluntary euthanasia occurs when a surrogate decision maker (not the

patient himself or herself) asks a physician for assis-

tance to end another person’s life. This could occur, for

instance, when a family member assumes life-or-death

decisions for an ailing relative. Nonvoluntary euthana-

sia is the category usually applied to child euthanasia

when a seriously ill child is deemed incompetent to

make a decision for himself or herself. Voluntary eutha- nasia is the intentional termination of a patient’s life at

his or her request by someone other than the patient.

In practice, this usually means that a competent patient

requests direct assistance to die, and he or she receives

assistance from a qualifi ed medical practitioner.

51. “It’s Over, Debbie,” Journal of the American Medical Association 259, no. 2 ( January 8, 1988): 272.

52. See Raphael Cohen-Almagor, “Why the Neth-

erlands?” Journal of Law, Medicine & Ethics 30, no. 1 (2002): 95–104, and “‘Culture of Death’ in the Neth-

erlands: Dutch Perspectives,” Issues in Law & Medicine 17, no. 2 (2001): 167–179; Herbert Hendin, “The Dutch

Experience,” Issues in Law & Medicine 17, no. 3 (2002): 223–246; and Herman H. van der Kloot Meijburg,

“How Health Care Institutions in the Netherlands

Approach Physician-Assisted Death,” Omega: Journal of Death and Dying 32, no. 3 (1995–1996): 179–196.

53. Charles J. Dougherty, “The Common Good, Ter-

minal Illness, and Euthanasia,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 154–164.

54. Thomas Attig, “Can We Talk? On the Elusiveness

of Dialogue,” Death Studies 19, no. 1 (1995): 1–19.

55. R. J. Connelly, “The Sentiment Argument for

Artifi cial Feeding of the Dying,” Omega: Journal of Death and Dying 20, no. 3 (1989–1990): 229–237. See also Germain Grisez and Kevin O’Rourke, “Should

Nutrition and Hydration Be Provided to Permanently

Unconscious and Other Mentally Disabled Persons,”

Issues in Law & Medicine 5 (1989): 165–196; James J. McCartney and Jane Mary Trau, “Cessation of the

Artifi cial Delivery of Food and Fluids: Defi ning Ter-

minal Illness and Care,” Death Studies 14, no. 5 (1990): 435–444; Steven H. Miles, “Nourishment and the

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80. Kaja Whitehouse, What Your Lawyer May Not Tell You About Your Family’s Will (New York: Warner, 2006), p. 219.

81. Jackson P. Rainer, “Ethical and Legal Issues in

Assessment and Intervention,” in Handbook of Thana- tology, 2nd ed., ed. Meagher and Balk, pp. 255–261; quote p. 260.

82. See Kenneth J. Doka, “The Monkey’s Paw: The

Role of Inheritance in the Resolution of Grief,” Death Studies 16, no. 1 (1992): 45–58. For a cross-cultural comparison of inheritance practices, see Misa Izuhara,

“Care and Inheritance: Japanese and English Perspec-

tives on the ‘Generational Contract,’” Ageing and Soci- ety 22 (2002): 61–77.

83. Colleen DeBaise, “‘Family Letters’ Go Beyond

Wills,” The Wall Street Journal (November 16, 2005), p. D3.

84. See www.ethicalwill.com ; and Barry K. Baines,

Ethical Wills: Putting Your Values on Paper (New York: Perseus, 2002).

85. Richard Costa, “Challenges of Being an Estate

Executor,” Capitola Soquel Times (May 1, 2006), p. 31.

86. Survey by EZLaw Wills and Estate Planning,

reported in The Week (September 9, 2011), p. 34.

87. See Joseph M. Belth, Life Insurance: A Consumer’s Handbook, 2nd ed. (Bloomington: Indiana University Press, 1985).

88. Karen E. Steinhauser, Nicholas A. Christakis, and

others, “Factors Considered Important at the End of

Life by Patients, Family, Physicians, and Other Care

Providers,” JAMA 284, no. 19 (November 15, 2000): 2476 –2482.

89. Kaufman, And a Time to Die, p. 93.

90. Leon R. Kass, “Practicing Ethics: Where’s the

Action?” Hastings Center Report ( January–February 1990): 5–12.

91. Jitaro Mizuno, “A Caring Heart and Integrated

Knowledge: An Ethics Which Inquires into the Rela-

tionship Between the Self and Others,” Reitaku Uni-

versity, Japan.

92. Jeffrey P. Bishop, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying (Notre Dame, Ind.: University of Notre Dame Press, 2011), p. 7. See also,

by Bishop and others, “Reviving the Conversation

Around CPR/DNR,” American Journal of Bioethics 10, no. 1 (2010): 61–67.

93. Richard B. Gilbert, “End-of-Life Care: Spirituality

and Religion,” in Handbook of Thanatology, 2nd ed., ed. Meagher Balk, pp. 63–71; quote p. 63.

66. Quotes by H. Harrison Sadler, M.D., in “Califor-

nia’s Natural Death Act—Medical Staff Conference,

University of California, San Francisco,” Western Jour- nal of Medicine 128 (1978): 318–330.

67. Angela Fagerlin and Carl E. Schneider, “Enough:

The Failure of the Living Will,” Hastings Center Report 34, no. 2 (2004): 30–42; quote p. 38.

68. Fagerlin and Schneider, “Enough,” pp. 30–42.

69. President’s Council on Bioethics, Ethical Caregiving in Our Aging Society (Washington, D.C.: Government Printing Offi ce, 2005), p. 55.

70. Current information can be found at www.POLST

.org .

71. Marilyn J. Field and Christine K. Cassel, eds.,

Approaching Death: Improving Care at the End of Life (Washington, D.C.: National Academies Press, 1997).

72. Information can be found at www.agingwith-

dignity.org .

73. The authors thank Senator John C. Danforth,

sponsor of this measure, for providing information

about its provisions. See also Elizabeth Leibold McClo-

skey, “The Patient Self-Determination Act,” Kennedy Institute of Ethics Journal 1, no. 2 (1991): 163–169.

74. Madeline Jacobs, “Ethical and Legal Issues in End-

of-Life Decision Making,” p. 104.

75. Information and forms for each state can be

downloaded from Caring Connections at www.caring-

info.org .

76. Susan Dolan and Audrey Vizzard, The End of Life Advisor: Personal, Legal, and Medical Considerations for a Peaceful, Dignifi ed Death (New York: Kaplan, 2009), p. 73.

77. Zelda Foster, “The Struggle to End My Father’s

Life,” in Dying, Death, and Bereavement, 2nd ed., ed. Corless, Germino, and Pittman, pp. 79–85. See also

Reneé Semonin Holleran, “When Is Dead, Dead? The

Ethics of Resuscitation in Emergency Care,” Nursing Clinics of North America 37, no. 1 (2002): 11–18.

78. Christian Sinclair, “Do Not (Attempt) Resuscita-

tion vs. Allow Natural Death,” Pallimed, www.pallimed .org , March 5, 2009.

79. Barton E. Bernstein, “Lawyer and Counselor as

an Interdisciplinary Team: Interfacing for the Termi-

nally Ill,” Death Education 1, no. 3 (Fall 1977): 277–291; “Lawyer and Therapist as an Interdisciplinary Team:

Serving the Terminally Ill,” Death Education 3, no. 1 (Spring 1979): 11–19; and “Lawyer and Therapist as an

Interdisciplinary Team: Serving the Survivors,” Death Education 4, no. 2 (Summer 1980): 179–188.

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15. E. Mansell Pattison, The Experience of Dying (Englewood Cliffs, N.J.: Prentice-Hall, 1977), and “The

Living-Dying Process,” in Psychological Care of the Dying, ed. Charles Garfi eld (New York: McGraw-Hill, 1978),

pp. 163–168. See also Karin L. Olson and others,

“Linking Trajectories of Illness and Dying,” Omega: Journal of Death and Dying 42, no. 4 (2001): 293–308.

16. Avery D. Weisman, On Dying and Denying: A Psychi- atric Study of Terminality (New York: Behavioral Publica- tions, 1972).

17. Elisabeth Kübler-Ross, On Death and Dying (New York: Macmillan, 1969). See also Colin Murray Parkes,

“Classics Revisited: Elisabeth Kübler-Ross, On Death and Dying: A Reappraisal,” Mortality 18, no. 1 (2013): 94–97.

18. Abraham Verghese, “On Death and Dying,” The Wall Street Journal, August 31, 2004.

19. Charles A. Corr and Donna M. Corr, “Culture,

Socialization, and Dying,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 3–8

(New York: Routledge, 2013), p. 8. See also Charles A.

Corr, “Coping with Dying: Lessons That We Should

and Should Not Learn from the Work of Elisabeth

Kübler-Ross,” Death Studies 17 (1993): 69–83.

20. Harold Brodkey, “To My Readers,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland (Mountain View,

Calif.: Mayfi eld, 1995), pp. 295–300; quote p. 298. See

also Robert Connelly, “Living with Death: The Mean-

ing of Acceptance,” Journal of Humanistic Psychology 43, no. 1 (2003): 45–63.

21. Kenneth J. Doka, “Coping with Life-Threatening

Illness: A Task Model,” Omega: Journal of Death and Dying 32, no. 2 (1995–1996): 111–122. See also Doka, Counseling Individuals with Life-Threatening Illness, and Living with Life-Threatening Illness: A Guide for Patients, Their Families, and Caregivers (New York: Lexington, 1993).

22. Doka, “Coping with Life-Threatening Illness,”

p. 120.

23. Herman Feifel, “Psychology and Death: Meaning-

ful Rediscovery,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 19–28; quote p. 23. See also Susan

Folkman and Steven Greer, “Promoting Psychological

Well-Being in the Face of Serious Illness: When Theory,

Research and Practice Inform Each Other,” Psycho- Oncology 9, no. 1 (2000): 11–19. See also Susan Folkman, “Positive Psychological States and Coping with Severe

Stress,” Social Science & Medicine 45, no. 8 (1997): 1207– 1221; and Susan Folkman and Judith Tedlie Moskowitz,

“Positive Affect and the Other Side of Coping,” American Psychologist 55, no. 6 (2000): 647–654.

C H A P T E R 7

1. Lee Lipsenthal, Enjoy Every Sandwich: Living Each Day As If It Were Your Last (New York: Crown Archetype, 2011), p. 110.

2. Paul M. Insel and Walton T. Roth, Connect Core Concepts in Health, 13th ed. (New York: McGraw-Hill, 2013), pp. 414, 428–429, 432.

3. Randall C. Thompson et al., “Atherosclerosis Across

4000 Years of Human History: The Horus Study of

Four Ancient Populations,” The Lancet Early Online Pub- lication (March 11, 2013).

4. Cassandra Lorius, “Taboo,” in Key Ideas in Human Thought, ed. Kenneth McLeish (New York: Facts on File, 1993), p. 731.

5. S. Kay Toombs, “Chronic Illness and the Goals of

Medicine,” Second Opinion 21, no. 1 ( July 1995): 11–19. See also Charles E. Rosenberg, “The Tyranny of Diag-

nosis: Specifi c Entities and Individual Experience,”

Milbank Quarterly 80, no. 2 (2002): 237–260.

6. S. Lochlann Jain, “Survival Odds: Mortality in Cor-

porate Time,” Current Anthropology 52, Supplement 3 (April 2011): S45–S55.

7. Ira Byock, The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life (New York: Avery, 2012), p. 1.

8. Byock, The Best Care Possible, pp. 25, 26.

9. See Maggie Callanan and Patricia Kelley. Final Gifts: Understanding the Special Awareness, Needs, and Communi- cations of the Dying (New York: Bantam, 1997).

10. Arthur W. Frank, “The Pedagogy of Suffering:

Moral Dimensions of Psychological Therapy and

Research with the Ill,” Theory & Psychology 2, no. 4 (1992): 467–485.

11. See Kevin P. Kaut, “Religion, Spirituality, and

Existentialism Near the End of Life: Implications for

Assessment and Application,” American Behavioral Scien- tist 46, no. 2 (2002): 220–234.

12. Charles A. Corr, “A Task-Based Approach to Cop-

ing with Dying,” Omega: Journal of Death and Dying 24, no. 2 (1991–1992): 81–94. See also Charles A. Corr and

Kenneth J. Doka, “Current Models of Death, Dying,

and Bereavement,” Critical Care Nursing Clinics of North America 6, no. 3 (1994): 545–552.

13. Barney G. Glaser and Anselm L. Strauss, Awareness of Dying (Chicago: Aldine, 1965). See also Neil Small and Merryn Gott, “The Contemporary Relevance of

Glaser and Strauss,” Mortality 17, no. 4 (2012): 355–377.

14. Kenneth J. Doka, Counseling Individuals with Life- Threatening Illness (New York: Springer, 2009), p. 206.

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37. Robert L. Wrenn, Dan Levinson, and Danai Papa-

datou, End of Life Decisions: Guidelines for the Health Care Provider (Tucson: University of Arizona Health Sci- ences Center, 1996), p. 20.

38. Byock, The Best Care Possible, p. 244.

39. Anne Hughes, Betty Davies, and Maria Gud-

mundsdottir, “‘Can You Give Me Respect?’: Experi-

ences of the Urban Poor on a Dedicated AIDS Nursing

Home Unit,” Journal of the Association of Nurses in AIDS Care 19, no. 5 (2008): 342–356; and Anne Hughes, Maria Gudmundsdottir, and Betty Davies, “Everyday

Struggling to Survive: Experiences of the Urban Poor

Living with Advanced Cancer,” Oncology Nursing Forum 34, no. 6 (2007): 1113–1118.

40. Anemona Hartocollis and Ford Fessenden,

“In New York City, Two Versions of End-of-Life Care,”

New York Times, May 30, 2008, http://www.nytimes .com/2008/05/30/nyregion/30hospitals.html?_r 5 0# .

See also Kevin Fiscella and Kathleen Holt, “Racial

Disparity in Hypertension Control: Tallying the Death

Toll,” Annals of Family Medicine 6, no. 6 (2008): 497–502.

41. Harvey Max Chochinov, “Dignity-Conserving

Care: A New Model for Palliative Care: Helping the

Patient Feel Valued,” JAMA 287, no. 17 (2002): 2253– 2260; quote p. 2254.

42. Andy Hau Yan Ho et al., “Living and Dying with

Dignity in Chinese Society: Perspectives of Older Pal-

liative Care Patients in Hong Kong,” Age and Ageing 42, no. 4 (2013): 455–461. See also Ho and others, “Dignity

Amidst Liminality: Healing Within Suffering Among

Chinese Terminal Cancer Patients,” Death Studies (2013), in press, as well as Cecilia L. W. Chan and oth-

ers, “The Blessings and Curses of Filial Piety on Dignity

at the End of Life: Lived Experiences of Hong Kong

Chinese Adult Children Caregivers,” Journal of Ethnic and Cultural Diversity in Social Work 21 (2012): 277–296.

43. Insel and Roth, Connect Core Concepts in Health, p. 444.

44. Paolo Venies, “Defi nition and Classifi cation of

Cancer: Monothetic or Polythetic?” Theoretical Medicine 14 (1993): 249–256.

45. Robert Berkow, ed., The Merck Manual of Diagnosis and Therapy, 16th ed. (Rahway, N.J.: Merck Research Laboratories, 1992), p. 1275.

46. Laurence McCahill and Betty Ferrell, “Palliative

Surgery for Cancer Pain,” Western Journal of Medicine 176, no. 2 (2002): 107–110.

47. See Berkow, ed., Merck Manual of Diagnosis and Therapy, 16th ed., pp. 1276–1277; Merck Manual of Medi- cal Information: Home Edition (Whitehouse Station, N.J.: Merck Research Laboratories, 1997), p. 801; and R. A.

Hope and others, Oxford Handbook of Clinical Medicine, 3rd ed. (New York: Oxford University Press, 1994), p. 768.

24. Avery D. Weisman, The Coping Capacity: On the Nature of Being Mortal (New York: Human Sciences Press, 1986).

25. Weisman, On Dying and Denying. See also, by Weis- man, Coping with Cancer (New York: McGraw-Hill, 1979); and “Thanatology,” in Comprehensive Textbook of Psychiatry, ed. O. Kaplan (Baltimore: Williams & Wilkins, 1980).

26. Betsy L. Fife, “The Measurement of Meaning in

Illness,” Social Science & Medicine 40, no. 8 (1995): 1021–1028. See also, by Fife, “The Conceptualization

of Meaning in Illness,” Social Science & Medicine 38, no. 2 (1994): 309–316.

27. See Phoebe Cramer, “Coping and Defense Mecha-

nisms: What’s the Difference?” Journal of Personality 66, no. 6 (1998): 919–946; and “Defense Mechanisms in

Psychology Today: Further Processes for Adaptation,”

American Psychologist 55, no. 6 (2000): 637–646.

28. Russell Noyes, Jr., and others, “Illness Fears in the

General Population,” Psychosomatic Medicine 62, no. 3 (2000): 318–325.

29. Edwin S. Shneidman, Lives and Deaths: Selections from the Works of Edwin S. Shneidman, ed. Antoon A. Leenaars (Philadelphia: Brunner-Mazel, 1999), p. 260.

30. Therese A. Rando, Grief, Dying, and Death: Clinical Interventions for Caregivers (Lexington, Mass.: Lexing- ton, 1993).

31. Richard S. Lazarus, “Toward Better Research

on Stress and Coping,” American Psychologist 55, no. 6 (2000): 665–673.

32. Mark R. Somerfi eld and Robert R. McCrae, “Stress

and Coping Research: Methodological Challenges,

Theoretical Advances, and Clinical Applications,”

American Psychologist 55, no. 6 (2000): 620–625.

33. Folkman and Greer, “Promoting Psychological

Well-Being in the Face of Serious Illness.”

34. On deferred demises, see Bruce Bower, “Death

Waits for No One,” Science News 165, no. 23 (2004): 356; and Judith A. Skala and Kenneth E. Freedland, “Death

Takes a Raincheck,” Psychosomatic Medicine 66 (2004): 382–386.

35. Tone Rustøen and Ingela Wiklund, “Hope in

Newly Diagnosed Patients with Cancer,” Cancer Nurs- ing 23, no. 3 (2000): 214–219. See also Jaklin Eliott and Ian Olver, “The Discursive Properties of ‘Hope’:

A Qualitative Analysis of Cancer Patients’ Speech,”

Qualitative Health Research 12, no. 2 (2002): 173–193.

36. Mary-Jo Del Vecchio Good and others, “Oncology

and Narrative Time,” Social Science & Medicine 38, no. 6 (1994): 855–862.

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62. Gerry Cox, Death and the American Indian (Omaha, Neb.: Grief Illustrated Press, 2010), p. 55. See also

Gerry R. Cox, “The Native American Way of Death,”

in Handbook of Death and Dying, ed. Clifton D. Bryant, 631–639 (Thousand Oaks, Calif.: Sage, 2003).

63. Robert T. Trotter II and Juan Antonio Chavira,

Curanderismo: Mexican-American Folk Healing, 2nd ed. (Athens: University of Georgia Press, 1997).

64. Kaja Finkler, “Sacred Healing and Biomedicine

Compared,” Medical Anthropology Quarterly 8, no. 2 ( June 1994): 178–197.

65. Berkow, ed., Merck Manual of Diagnosis and Therapy, 16th ed., pp. 2593–2596.

66. Lawrence J. Schneiderman, “Alternative Medicine

or Alternatives to Medicine? A Physician’s Perspective,”

Cambridge Quarterly of Healthcare Ethics 9, no. 1 (2000): 83–97.

67. Michael Specter, “The Power of Nothing,” The New Yorker (December 12, 2008), pp. 30–36.

68. Steven B. Perlmutter, “Clinical Use of Placebos:

Medicine, Neuroscience, Ethics, and the Law,” 8 Ten- nessee Journal of Law and Policy 8 (2012).

69. Insel and Roth, Connect Core Concepts in Health, pp. 566 –567.

70. Michael Specter, “The Power of Nothing,” The New Yorker (December 12, 2008), p. 31.

71. Specter, Power of Nothing," p. 31.

72. Perlmutter, “Clinical Use of Placebos.”

73. Perlmutter, “Clinical Use of Placebos.”

74. Rodolfo Passalacqua, Francesco Campione, and

Caterina Caminiti, “Patients’ Opinions, Feelings, and

Attitudes After a Campaign to Promote the Di Bella

Therapy,” The Lancet 353 (April 17, 1999): 1310–1314; quote p. 1313.

75. Doris M. Schoenhoff, The Barefoot Expert: The Inter- face of Computerized Knowledge Systems and Indigenous Knowledge Systems (Westport, Conn.: Greenwood, 1993), pp. 13–14.

76. Insel and Roth, Connect Core Concepts in Health, p. 579.

77. “Medicinal Use of Marijuana,” New England Journal of Medicine 368 (February 28, 2013): 866 –868.

78. Stanley J. Watson, John A. Benson, Jr., and Janet E.

Joy, “Marijuana and Medicine: Assessing the Science

Base,” Archives of General Psychiatry 57 (2000): 547–552. See also Inge B. Corless and others, “Marijuana Effec-

tiveness as an HIV Self-Care Strategy,” Clinical Nursing Research 18, no. 2 (2009): 172–193; Franjo Grotenher- men, “The Medical Use of Cannabis in Germany,”

48. See Berkow, ed., Merck Manual of Diagnosis and Therapy, 16th ed., pp. 55, 1277, 1287; and Merck Man- ual: Home Edition, pp. 799, 802; and Hope and others, Oxford Handbook of Clinical Medicine, 3rd ed., p. 768.

49. Jane C. Weeks et al., “Patients’ Expectations about

Effects of Chemotherapy for Advanced Cancer,” New England Journal of Medicine 367 (October 25, 2012): 1616 –1625.

50. Insel and Roth, Connect Core Concepts in Health, p. 565.

51. Insel and Roth, Connect Core Concepts in Health, p. 566.

52. Roxanne Nelson, “Framework for Experimental

Drug Use in Terminally Ill Patients,” Medscape Medical News, www.medscape.com .

53. Berkow, ed., Merck Manual of Diagnosis and Therapy, 16th ed., p. 1263.

54. The National Center for Complementary and

Alternative Medicine (NCCAM) is the federal gov-

ernment’s lead agency for scientifi c research on

complementary and alternative medicine. It is one of

the twenty-seven institutes and centers that make up

the National Institutes of Health (NIH) within the

U.S. Department of Health and Human Services. See

http://nccam.nih.gov/about/ataglance .

55. Terri A. Winnick, “From Quackery to ‘Comple-

mentary’ Medicine: The American Medical Profession

Confronts Alternative Therapies,” Social Problems 52, no. 1 (2005): 38–61. For critical views on CAM, see the

website Quackwatch ( www.quackwatch.org ).

56. David K. Reynolds, A Thousand Waves: A Sensible Life Style for Sensitive People (New York: Quill/Morrow, 1990).

57. See Josep M. Comelles, “The Role of Local Knowl-

edge in Medical Practice: A Trans-Historical Perspec-

tive,” Culture Medicine and Psychiatry 24, no. 1 (2000): 41–75.

58. Quoted in Anne Fadiman, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doc- tors, and the Collision of Two Cultures (New York: Farrar, Straus and Giroux, 1997), p. 261. See also Arthur

Kleinman, Patients and Healers in the Context of Culture (Berkeley: University of California Press, 1980).

59. Lori Arviso Alvord and Elizabeth Cohen Van

Pelt, The Scalpel and the Silver Bear (New York: Bantam, 1999).

60. Biography, Dr. Lori Arviso Alvord, National

Library of Medicine. www.nlm.nih.gov/changingthefa-

ceofmedicine/physicians/biography_7.html.

61. Biograpy, Dr. Lori Arviso Alvord.

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92. Perry G. Fine and Clarinda Mac Low, “The Last

Chance for Comfort: An Update on Pain Management

at the End of Life,” Medscape, December 26, 2005, www.medscape.com .

93. Berkow, ed., Merck Manual of Diagnosis and Therapy, 16th ed., pp. 1409, 1412. See also Fredrica A. Preston,

Siew Tzuh Tang, and Ruth McCorkle, “Symptom Man-

agement for the Terminally Ill,” in Dying, Death, and Bereavement: A Challenge for Living, 2nd ed., ed. Inge Corless, Barbara B. Germino, and Mary A. Pittman

(New York: Springer, 2003), pp. 145–180.

94. See Fine and Low, “The Last Chance for Comfort.”

95. Ana Blasco, Miguel Berzosa, Vega Iranzo, and

Carlos Camps, “Update in Cancer Pain,” Cancer & Che- motherapy Reviews 4, no. 2 (2009): 95–109.

96. Stephen R. Connor, “Palliative Care is a Human

Right,” ADEC Forum 37, no. 3 (2011): 1, 3–4, 10.

97. Ana Blasco, Miguel Berzosa, Vega Iranzo, and

Carlos Camps, “Update in Cancer Pain,” Medscape Cancer & Chemotherapy Reviews, August 28, 2009, www .medscape.com .

98. See Betty Rolling Ferrell, ed., “Issues in Cancer

Pain Management: Models of Success,” Cancer Practice 10, Supplement 1 (2002): whole issue.

99. See Karen L. Schumacher and others, “Pain Man-

agement Autobiographies and Reluctance to Use Opi-

oids for Cancer Pain Management,” Cancer Nursing 25, no. 2 (2002): 125 –133; and James L. Werth, Jr.,

“Reinterpreting the Controlled Substances Act:

Predictions for the Effect on Pain Relief,” Behavioral Sciences and the Law 20, no. 3 (2002): 287–305.

100. See David Clark, “‘Total Pain’: Disciplinary Power

and the Body in the Work of Cicely Saunders, 1958–1967,”

Social Science & Medicine 49 (1999): 727–736.

101. Robert Kastenbaum and Claude Normand,

“Deathbed Scenes as Imagined by the Young and

Experienced by the Old,” Death Studies 14, no. 3 (1990): 201–217.

102. Barney G. Glaser and Anselm L. Strauss, Time for Dying (Chicago: Aldine, 1968). See also Pattison, The Experience of Dying.

103. Scott A. Murray, Marilyn Kendall, Kirsty Boyd,

and Aziz Sheikh, “Illness Trajectories and Palliative

Care,” British Medical Journal 330 (2005): 1007–1011.

104. Murray and others, “Illness Trajectories and Pal-

liative Care,” p. 1011.

105. Inge B. Corless, “Dying Well: Symptom Control

Within Hospice Care,” in Annual Review of Nursing Research, vol. 12, ed. J. J. Fitzpatrick and J. S. Stevenson (New York: Springer, 1994), pp. 125–146.

Journal of Drug Issues 32, no. 2 (2002): 607–633; and Donald I. Templer, Hiroko Arikawa, and Patrick C.

Gariety, “Psychotropic Drugs in Terminally Ill Patients:

A Review of the Clinical and Research Literature,”

Omega: Journal of Death and Dying 49, no. 3 (2004): 249–274.

79. Gregory T. Carter and Bruce Mirken, “Medical

Marijuana: Politics Trumps Science at the FDA,” Medscape General Medicine, May 24, 2006, www.medscape.com .

80. “Is Marijuana Bad for You? The Week (November 30, 2012), p. 11.

81. Anson Shupe and Jeffrey K. Hadden, “Symbolic

Healing,” Second Opinion 12 (November 1989): 74–97.

82. “Tapping Human Potential: An Interview with

Norman Cousins,” Second Opinion 14 ( July 1990): 57–71. See also Norman Cousins, Anatomy of an Ill- ness as Perceived by the Patient: Refl ections on Healing and Regeneration (New York: Norton, 1979).

83. Kjell Kallenberg and Carl-Rheinhold Braken-

hielm, “Pain and Suffering as Existential Questions in

Palliative Care,” European Journal of Palliative Care 1, no. 1 (1994): 54–56.

84. S. Deandrea, M. Montanari, L. Moja, and G.

Apolone, “Prevalence of Undertreatment in Cancer

Pain: A Review of Published Literature,” Annals of Oncology 19, no. 12 (2008): 1985–1991.

85. Marcia K. Merboth and Susan Barnason, “Managing

Pain: The Fifth Vital Sign,” Nursing Clinics of North America 35, no. 2 (2000): 375–383. See also Marni Jackson,

Pain: The Fifth Vital Sign (New York: Crown, 2002).

86. Alison Twycross, “Education About Pain: A

Neglected Area?” Nurse Education Today 20, no. 3 (2000): 244–253. See also, by Twycross, “Educating

Nurses About Pain Management: The Way Forward,”

Journal of Clinical Nursing 11, no. 6 (2002): 705–714.

87. Berkow, ed., Merck Manual of Diagnosis and Therapy, 16th ed., p. 1409.

88. Dorland’s Illustrated Medical Dictionary, 26th ed. (Philadelphia: Saunders, 1985), p. 954.

89. Yasmin Hawkins and others, “Changes in Sexual-

ity and Intimacy After the Diagnosis and Treatment of

Cancer: The Experience of Partners in a Sexual Rela-

tionship with a Person with Cancer,” Cancer Nursing 32, no. 4 (2009): 271–280.

90. Linda C. Garro, “Culture, Pain and Cancer,” Jour- nal of Palliative Care 6, no. 3 (1990): 34–44. See also David B. Morris, The Culture of Pain (Berkeley: Univer- sity of California Press, 1991).

91. “Interview with Yvette Colón,” Hospice Foundation of America, www.hospicefoundation.org .

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120. Cosh, “Spiritual Care of the Dying,” p. 136.

121. Tenshin Reb Anderson, quoted by Frank Osta-

seski, “Stories of Lives Lived and Now Ending,” Inquir- ing Mind: A Journal of the Vipassana Community 10, no. 2 (Spring 1994), p. 29.

122. Marcia Lattanzi-Licht, “Religion, Spirituality,

and Dying,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 9–16; p. 10.

123. Makoto Ueda, Modern Japanese Writers and the Nature of Literature (Stanford, Calif.: Stanford Univer- sity Press, 1976), p. 193.

124. Jitaro Mizuno, “A Caring Heart and Integrated

Knowledge: An Ethics Which Inquires into the Rela-

tionship Between the Self and Others” (Reitaku

University, Japan, 2005). Unpublished manuscript.

125. Janmarie Silvera, “Crossing the Border,” in

The Path Ahead, ed. DeSpelder and Strickland, pp. 301–302.

C H A P T E R 8

1. Mike Parker Pearson, The Archaeology of Death and Burial (College Station: Texas A&M University Press, 2000), p. 194. See also Robert W. Habenstein and Wil-

liam M. Lamers, Funeral Customs the World Over, rev. ed. (Milwaukee: Bulfi n Printers, 1974).

2. See Lynne Ann DeSpelder and Albert Lee Strick-

land, “Ceremonies,” in Encyclopedia of Death and Dying, ed. Glennys Howarth and Oliver Leaman (New York:

Routledge, 2001), pp. 84–85.

3. Dominic Janes, Romans and Christians (Charleston, S.C.: Tempus, 2002), p. 32.

4. Christopher Hall, “For As Long As It Takes,”

February 22, 2009, www.theage.com.au . See also

Amitai Etzioni, “Toward a Theory of Public Ritual,”

Sociological Theory 18, no. 1 (2000): 44–59.

5. David L. Hall and Roger T. Ames, “Understanding

Order: The Chinese Perspective,” in From Africa to Zen: An Invitation to World Philosophy, ed. Robert S. Solomon and Kathleen M. Higgins, 1–23 (Lanham, Md.: Row-

man and Littlefi eld, 1993), p. 8.

6. Vanderlyn R. Pine, “Funerals: Life’s Final Cer-

emony,” in A Challenge for Living: Dying, Death, and Bereavement, ed. Inge B. Corless, Barbara B. Germino, and Mary A. Pittman (Boston: Jones & Bartlett, 1995),

pp. 159–171. See also Jenny Hockey, “Encountering the

‘Reality of Death’ Through Professional Discourse: The

Matter of Materiality,” Mortality 1, no. 1 (1996): 45–60.

7. Jennifer Hildebrand, “Funerals,” in Greenwood Ency- clopedia of African American Folklore, ed. Anand Prahlad, 478–479 (Westport, Conn.: Greenwood, 2005).

106. See Diane M. Thomas and Brenda Moretta Guer-

rero, “Terminal Restlessness in the Dying: Hospice

Attitudes and Practices,” Omega: Journal of Death and Dying 46, no. 1 (2002–2003): 77–90.

107. Eric J. Cassell, “Dying in a Technological Society,”

in Death Inside Out: The Hastings Center Report, ed. Peter Steinfels and Robert M. Veatch (New York: Harper &

Row, 1974), pp. 43–48; see also, by Cassell, The Nature of Suffering and the Goals of Medicine (New York: Oxford University Press, 1991); Glaser and Strauss, Awareness of Dying; and David Sudnow, Passing On: The Social Organiza- tion of Dying (Englewood Cliffs, N.J.: Prentice-Hall, 1967).

108. Talcott Parsons, The Social System (New York: Free Press, 1951).

109. Marjorie Kagawa-Singer, “Redefi ning Health:

Living with Cancer,” Social Science & Medicine 37, no. 3 (1993): 295–304.

110. See Russell Noyes, Jr., and John Clancy, “The

Dying Role: Its Relevance to Improved Patient Care,”

Psychiatry 40 (February 1977): 41–47.

111. Robert J. Baugher and others, “A Comparison

of Terminally Ill Persons at Various Time Periods to

Death,” Omega: Journal of Death and Dying 20, no. 2 (1989–1990): 103–155.

112. Allan Kellehear and Terry Lewin, “Farewells by

the Dying: A Sociological Study,” Omega: Journal of Death and Dying 19, no. 4 (1988–1989): 275–292.

113. Byock, The Best Care Possible, p. 76.

114. Stephen R. Connor, Hospice and Palliative Care: The Essential Guide, 2nd ed. (New York: Routledge, 2009), p. 12.

115. Arthur W. Frank, “The Pedagogy of Suffering:

Moral Dimensions of Psychological Therapy and

Research with the Ill,” Theory & Psychology 2, no. 4 (1992): 467–485; see also, by Frank, “What Kind of

Phoenix? Illness and Self-Knowledge,” Second Opinion 18, no. 2 (October 1992): 31–41.

116. Thomas Lyons, e-mail message to authors, May

25, 2013.

117. Allan Kellehear, The Inner Life of the Dying Person (New York: Columbia University Press, in press).

118. Ira Byock, “Personal Health and Human Develop-

ment in Life-Threatening Conditions,” in Handbook of Psychiatry in Palliative Medicine, 2nd ed., ed. Harvey Max Chochinov and William Breitbart, 281–299 (New

York: Oxford University Press, 2009). See also Ira

Byock, Dying Well: The Prospect for Growth at the End of Life (New York: Riverhead, 1997).

119. Roderick Cosh, “Spiritual Care of the Dying,” in

Dying, Death, and Bereavement: A Challenge for Living, ed. Corless, Germino, and Pittman, pp. 131–143.

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19. See Ben H. Bagdikian, The Information Machines: Their Impact on Men and the Media (New York: Harper & Row, 1971), pp. 39, 59; and Bradley Greenberg,

“Diffusion of News of the Kennedy Assassination,”

Public Opinion Quarterly 28, no. 2 (Summer 1964): 225–232.

20. See Peter Svensson, “Deaths of Gamers Leave

Their Online Lives in Limbo,” Associated Press (March 14, 2009).

21. Quoted in Daniel Landis, “WoW Gamer Kicked

from Guild, Too Dead To Log In,” Philadelphia Gaming News Examiner (March 15, 2009).

22. J. Z. Young, Programs of the Brain (New York: Oxford University Press, 1978), p. 255.

23. Vernon Reynolds and Ralph Tanner, The Social Ecology of Religion (New York: Oxford University Press, 1995), p. 213.

24. John R. Elliott, “Funerary Artifacts in Contempo-

rary America,” Death Studies 14, no. 6 (1990): 601–612.

25. Federal Trade Commission, Compliance Guide- lines: Trade Regulation Rule on Funeral Industry Practices (Washington, D.C., 1984).

26. See Robert W. Habenstein and William M. Lam-

ers, The History of American Funeral Directing (Milwau- kee: Bulfi n Printers, 1962). See also Gary Laderman,

Rest in Peace: A Cultural History of Death and the Funeral Home in Twentieth-Century America (New York: Oxford University Press, 2003).

27. See Glennys Howarth, Last Rites: The Work of the Modern Funeral Director (Amityville, N.Y.: Baywood, 1996).

28. Benito and Azzaro quotes from Jeanene Harlick,

“Local Undertakers Survive Recession, Stave Off Ste-

reotypes,” Santa Cruz Sentinel, June 2, 2003.

29. Harlick, “Local Undertakers Survive Recession,

Stave Off Stereotypes.”

30. NFDA Funeral Service Facts. http://nfda.org/

about-funeral-service-/trends-and-statistics.html .

31. O. Duane Weeks and Catherine Johnson, “Devel-

oping a Successful Aftercare Program,” The Director 67, no. 12 (December 1995): 12–18.

32. LeRoy Bowman, The American Funeral: A Study in Guilt, Extravagance, and Sublimity (Washington, D.C.: Public Affairs Press, 1959).

33. Jessica Mitford, The American Way of Death (New York: Simon & Schuster, 1963), pp. 16 –19.

34. D. van Vuure, “The Relatives Asked for a Duo-

Committal for Their Parents,” Thanos 22 (1996): 28–30.

8. Michael A. Goldwasser, “Wakes,” in Greenwood Ency- clopedia of African American Folklore, ed. Anand Prahlad, 1359–1361 (Westport, Conn.: Greenwood, 2005); see

also, by Goldwasser, in the same volume, “Nine-Night

Rituals,” pp. 908–909.

9. See Charles Reagan Wilson, “Funerals,” in Folklife, ed. Glenn Hinson and William Ferris, Volume 14 of

Encyclopedia of Southern Culture (Chapel Hill: University of North Carolina Press, 2009), pp. 102–104.

10. Glenys Caswell, “Beyond Words: Some Uses of

Music in the Funeral Setting,” Omega: Journal of Death and Dying 64, no. 4 (2011–2012): 319–334.

11. Sue Adamson and Margaret Holloway, “A Sound

Track of Your Life: Music in Contemporary UK Funer-

als,” Omega: Journal of Death and Dying 65, no. 1 (2012): 33–54; quote p. 49.

12. Deborah Noye, Encyclopedia of the End: Mysterious Death in Fact, Fancy, Folklore, and More (Boston: Hough- ton Miffl in, 2008), p. 93.

13. Alma Williams Freeman, “A Special Love: Spirit of

New Orleans,” The International Review of African Ameri- can Art 17, no. 2 (2002): 14–15.

14. Hilary Mac Austin, “Brass Bands,” in Greenwood Encyclopedia of African American Folklore, ed. Anand Prahlad, 156 (Westport, Conn.: Greenwood, 2005).

See also Tashel C. Bordere, “Second-Lining at Death

in New Orleans,” The Forum: Newsletter of the Association for Death Education and Counseling 31, no. 4 (2005): 1, 3.

15. William G. Hoy, Do Funerals Matter? The Purposes and Practices of Death Rituals in Global Perspective (New York: Routledge, 2013), p. 22.

16. Thomas Lynch, The Undertaking: Life Studies from the Dismal Trade (New York: Norton, 1997), p. 21.

17. David Sudnow, Passing On: The Social Organization of Dying (Englewood Cliffs, N.J.: Prentice-Hall, 1967), pp. 153–168.

18. Ronald K. Barrett, “Contemporary African-American

Funeral Rites and Traditions,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland (Mountain View, Calif.: Mayfi eld, 1995),

pp. 80–92, quote p. 88; and, also by Barrett, “The Legacy

of Traditional African-American Funeral Rites,” Thanos 16 (October 1994): 18–20; “Affi rming and Reclaiming

African-American Funeral Rites,” The Director 66, no. 11 (October 1994): 36–40; and “Psychocultural Infl uences

on African American Attitudes Toward Death, Dying,

and Funeral Rites,” in Personal Care in an Impersonal World, ed. John Morgan (Amityville, N.Y.: Baywood, 1993),

pp. 213–230. See also Elaine Nichols, ed., The Last Miles of the Way: African-American Homegoing Traditions, 1890– Present (Columbia: South Carolina State Museum, 1989).

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638 n o t e s

49. “Other Services––Estimated Revenue,” Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011). http://www.census.gov/compendia/

statab/.

50. NFDA Funeral Service Facts. http://nfda.org/

about-funeral-service-/trends-and-statistics.html .

51. Ronny E. Turner and Charles Edgley, “Death as

Theatre: A Dramaturgical Analysis of the American

Funeral,” Sociology and Social Research 60, no. 4 (1976): 377–392. See also Liam Hyland and Janice M. Morse,

“Orchestrating Comfort: The Role of Funeral Direc-

tors,” Death Studies 19, no. 5 (1995): 453–474.

52. Kenneth V. Iserson, Death to Dust: What Happens to Dead Bodies? 2nd ed. (Tucson, Ariz.: Galen Press, 2001), p. 226; see also pp. 241–257 for a detailed

description of embalming and other body-preparation

procedures.

53. Edward C. Johnson and Melissa Johnson Williams,

“Dr. Charles DeCosta Brown, Civil War Embalming

Surgeon and the Masonic Order,” American Funeral Director 120, no. 9 (September 1997): 74–78.

54. Vanderlyn Pine, “The Care of the Dead: A Histori-

cal Portrait,” in Death and Dying: Challenge and Change, ed. Robert Fulton, Eric Markusen, Greg Owen, and

Jane L. Scheiber (San Francisco: Boyd & Fraser, 1978),

p. 276; see also, by Pine, Caretaker of the Dead: The Ameri- can Funeral Director (New York: Irvington, 1985).

55. Briefl y summarized, exceptions to this require-

ment occur when (1) state or local law requires

embalming or (2) there are “exigent circumstances,”

such as (a) when a family member or other authorized

person cannot be contacted despite diligent efforts,

and (b) there is no reason to believe the family does

not want embalming, and (c) after the body has been

embalmed, the family is notifi ed that no fee will be

charged if they choose a funeral that does not require

embalming.

56. Thanos 24 (1997): 9.

57. Stephen Prothero, Purifi ed by Fire: A History of Cre- mation in America (Berkeley: University of California Press, 2001), p. 2.

58. Reynolds and Tanner, The Social Ecology of Religion, p. 221.

59. Iserson, Death to Dust, p. 390.

60. See Niels Bonde and Arne Emil Christensen,

“Dendrochronological Dating for the Viking Age

Ship Burials at Oseberg, Gokstad, and Tune, Norway,”

Antiquity 67 (1993): 575–583.

61. See Bruce A. Iverson, “Bodies for Science,” Death Studies 14, no. 6 (1990): 577–587; Robert D. Reece

35. Carla Sofka, “Cyberfunerals,” in Encyclopedia of Death and the Human Experience, ed. Clifton D. Bryant and Dennis L. Peak, 249–251 (Thousand Oaks, Calif.:

Sage, 2009), pp. 249–250.

36. See, for example, Andre Van Gemert, “The Digital

Death,” Thanos 21 (1996): 18–21; Lucette Lagnado, “Phone Eulogies, Cybermourners Make Funerals into

Virtual Events,” The Wall Street Journal, August 21, 1996, p. B1.

37. www.Legacy.com/NS/about/ . See also Janice

Hume and Bonnie Bressers, “Obituaries Online: New

Connections with the Living—And the Dead,” Omega: Journal of Death and Dying 60, no. 3 (2009–2010): 255–271.

38. Examples include Virtual Memorial Gardens,

Dearly Departed, Empty Arms, Garden of Remem-

brance, The Virtual Memorial Company, and World

Wide Cemetery. For current Web addresses, an online

search is recommended.

39. Pamela Roberts, “The Living and the Dead: Com-

munity in the Virtual Cemetery,” Omega: Journal of Death and Dying 49, no. 1 (2004): 57–76; quote p. 57.

40. Brochure, Leif Technologies, 1997.

41. Dan Morse, “Shirts for the Dead Are the New Rage

in Some Inner Cities,” The Wall Street Journal, February 4, 1999. For a related version of inner-city memorial-

ization, see Martha Cooper and Joseph Sciorra, R.I.P.: Memorial Wall Art (New York: Henry Holt, 1994).

42. Cooper and Sciorra, R.I.P.: Memorial Wall Art.

43. Charles O. Collins and Charles D. Rhine, “Road-

side Memorials,” Omega: Journal of Death and Dying 47, no. 3 (2003): 221–244. See also Holly Everett, Roadside Crosses in Contemporary Memorial Culture (Denton: Uni- versity of North Texas Press, 2002); and Jon K. Reid

and Cynthia L. Reid, “A Cross Marks the Spot: A Study

of Roadside Death Memorials in Texas and Okla-

homa,” Death Studies 25 (2001): 341–356.

44. Jennifer Clark and Ashley Cheshire, “RIP by the

Roadside: A Comparative Study of Roadside Memori-

als in New South Wales, Australia, and Texas, United

States,” Omega: Journal of Death and Dying 48, no. 3 (2003–2004): 203–222; quote p. 204.

45. Sylvia Grider, “Spontaneous Shrines and Public

Memorialization,” in Death and Religion in a Changing World, ed. Kathleen Garces-Foley, 246 –264 (Armonk, N.Y.: M. E. Sharpe, 2006), p. 255.

46. Grider, “Spontaneous Shrines and Public Memori-

alization,” p. 262.

47. Lynch, The Undertaking, p. 191.

48. Data from the NFDA General Price List Survey.

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76. Angelo B. Henderson, “In Detroit, Blacks Turn the

Staid Obit Into a Glossy Art,” The Wall Street Journal, May 1, 2000.

77. Marion K. Pinsdorf, “Greater Dead Heroes than

Live Husbands: Widows as Image-Makers,” Public Rela- tions Review 28 (2002): 283–299.

78. Kathleen Garces-Foley, “Funerals of the Unaf-

fi liated,” Omega: Journal of Death and Dying 46, no. 4 (2002–2003): 287–302; quote p. 288.

79. Steve Kurutz, “Grave New World,” Details (March 2003), pp. 147–148.

80. Kathleen Garces-Foley and Justin S. Holcomb,

“Contemporary American Funerals: Personalizing Tra-

dition,” in Death and Religion in a Changing World, ed. Kathleen Garces-Foley, 207–227 (Armonk, N.Y.: M. E.

Sharpe, 2006), p. 208.

81. Marilyn Yalom, The American Resting Place: Four Hundred Years of History Through Our Cemeteries and Burial Grounds (Boston: Houghton Miffl in, 2008), p. 274.

82. Garces-Foley and Holcomb, “Contemporary

American Funerals: Personalizing Tradition,” p. 208.

83. Garces-Foley, “Funerals of the Unaffi liated,” p. 295.

84. Douglas J. Davies, “Forms of Disposal,” in Death and Religion in a Changing World, ed. Kathleen Garces- Foley, 228–245 (Armonk, N.Y.: M. E. Sharpe, 2006),

p. 240.

85. Excerpted from Undertaken with Love: A Home Funeral Guide for Congregations and Communities (Oak Ridge, N.C.: Home Funeral Committee Manual Pub-

lishing Group, 2009), p. 5.

86. For information on preplanning a home- or fam-

ily-directed funeral, contact Final Passages, PO Box

1721, Sebastopol, CA 95473, or www.fi nalpassages.org .

87. See, for example, Bob Butz, Going Out Green: One Man’s Adventure Planning His Own Burial (Traverse City, Mich.: Spirituality & Health, 2009).

88. Garces-Foley and Holcomb, “Contemporary

American Funerals: Personalizing Tradition,” p. 221.

89. The Ecopod coffi n, for example, is a recycled

paper coffi n. See www.ecopod.co.uk or www.natural-

burialcompany.com.

90. Eternal Reefs, Inc., www.eternalreefs.com.

91. Katharine Q. Seelye, “Ashes-to-Fireworks Send-Off

for an ‘Outlaw’ Writer,” The New York Times, August 22, 2005.

92. Lou LaGrand, “How to Use Linking Objects as

You Mourn and Continue with Life,” http://ezinearti-

cles.com/?How-to-Use-Linking-Objects-as-You-Mourn-

and-Continue-with-Life&id 5 594394 .

and Jesse H. Ziegler, “How a Medical School (Wright

State University) Takes Leave of Human Remains,”

Death Studies 14, no. 6 (1990): 589–600; and Kathleen A. Schotzinger and Elizabeth Kirkley Best, “Closure

and the Cadaver Experience: A Memorial Service for

Deeded Bodies,” Omega: Journal of Death and Dying 18, no. 3 (1987–1988): 217–227.

62. Honolulu Star-Bulletin & Advertiser, June 3, 1984.

63. Rick Atkinson, “The Nation’s Cemetery,” National Geographic ( June 2007), pp. 121–137.

64. Sir Raymond Firth, “Foreword,” in The Secret Cem- etery, by Doris Frances, Leonie Kellaher, and Georgina Neophytou (Oxford: Berg, 2005), p. xv.

65. Doris Frances, Leonie Kellaher, and Georgina

Neophytou, The Secret Cemetery (Oxford: Berg, 2005), p. 197.

66. Michael Kammen, Digging Up the Dead: A History of Notable American Reburials (Chicago: University of Chi- cago Press, 2010), p. 198.

67. Jack Goody and Cesare Poppi, “Flowers and Bones:

Approaches to the Dead in Anglo-American and Ital-

ian Cemeteries,” Comparative Studies in Society and His- tory 36, no. 1 (1994): 146 –175.

68. See Diane O. Bennett, “Bury Me in Second Class:

Contested Symbols in a Greek Cemetery,” Anthropologi- cal Quarterly 67, no. 3 (1994): 122–134.

69. “L.A.’s Well-to-Do Get Burial Space,” Associated Press, February 10, 2002. http://www.apnewsarchive .com/2002/L-A-s-Well-to-Do-Get-Burial-Space/

id-8b35c5a0d712cd98b74b804bb8c14105 .

70. Douglas Keister, “A Brief History of the Commu-

nity Mausoleum,” American Cemetery 69, no. 9 (Septem- ber 1997): 20–21, 50–52.

71. See Hali J. Weiss, “In the Long Run: Staying Rel-

evant Amidst Cultural Change,” Cemetery Management ( January 1995): 14–16; and, also by Weiss, “Dust to

Dust: Transforming the American Cemetery,” Tikkun 10, no. 5 (1996): 21–25.

72. NFDA, Cremation Facts. Accessed June 22, 2013.

http://nfda.org/about-funeral-service-/trends-and-

statistics.html .

73. Hoy, Do Funerals Matter? p. 125.

74. Sally Gribbin, “The Social Crisis Facing the Cre-

mation Industry,” Cemetery Management ( January 1994), reprint.

75. James Mackay, The Guinness Book of Stamps Facts & Feats (New York: Canopy, 1992), pp. 157–158; see also Charles A. Fricke, “Death and Funeral Notices on U.S.

Postal Cards,” Scott Stamp Monthly 13, no. 7 (1995): 9, 22.

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6. See Lynne Ann DeSpelder and Albert Lee Strick-

land, “Loss,” in Encyclopedia of Death and Dying, ed. Glennys Howarth and Oliver Leaman (New York:

Routledge, 2001), pp. 288–289.

7. Simon Shimson Rubin, Ruth Malkinson, and

Eliezer Wiztum, “On Bereavement Interventions,

Controversy and Consensus,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 263–272; p. 264.

8. See Thomas A. Attig, How We Grieve: Relearning the World (New York: Oxford University Press, 1996); and Jeffrey Kauffman, ed., Loss of the Assumptive World: A Theory of Traumatic Loss (New York: Brunner- Routledge, 2002).

9. Terry Tafoya, “The Widow as Butterfl y: Treatment

of Grief/Depression Among the Sahaptin,” unpub-

lished paper.

10. Philippe Ariès, “The Reversal of Death: Changes

in Attitudes Toward Death in Western Societies,”

in Death in America, ed. David E. Stannard (Phila- delphia: University of Pennsylvania Press, 1975),

pp. 134 –158.

11. J. William Worden, Grief Counseling and Grief Ther- apy: A Handbook for the Mental Health Practitioner, 4th ed. (New York: Springer, 2009), esp. pp. 39–53.

12. Therese A. Rando, Treatment of Complicated Mourn- ing (Champaign, Ill.: Research Press, 1993).

13. See Robert M. Sapolsky, “The Solace of Patterns,”

The Sciences 34, no. 6 (November–December 1994): 14–16.

14. Sigmund Freud, “Mourning and Melancholia,”

Collected Papers, vol. 4 (New York: Basic Books, 1959), pp. 152–170. Originally published in 1917. See also

Lorraine Siggins, “Mourning: A Critical Survey of the

Literature,” International Journal of Psycho-Analysis 47 (1966): 14–25.

15. See John Bowlby’s three-volume work, Attachment and Loss (New York: Basic Books): vol. 1, Attachment (1969); vol. 2, Separation: Anxiety and Anger (1973); and vol. 3, Loss: Sadness and Depression (1982); and The Making and Breaking of Affectional Bonds (London: Tavis- tock, 1979). See also Dale Vincent Hardt, “An Investi-

gation of the Stages of Bereavement,” Omega: Journal of Death and Dying 9, no. 3 (1978–1979): 279–285; and Dennis Klass, “John Bowlby’s Model of Grief and the

Problem of Identifi cation,” Omega: Journal of Death and Dying 18, no. 1 (1987–1988): 13–32.

16. Therese A. Rando, “Grief and Mourning: Accom-

modating to Loss,” in Dying: Facing the Facts, 3rd ed., ed. Hannelore Wass and Robert A. Neimeyer (Wash-

ington, D.C.: Taylor & Francis, 1995), pp. 211–241;

quote p. 212.

93. Nancy C. Reeves and Frederic J. Boersma, “The

Therapeutic Use of Ritual in Maladaptive Grieving,”

Omega: Journal of Death and Dying 20, no. 4 (1989– 1990): 281–291.

94. Onno van der Hart, Coping with Loss: The Thera- peutic Use of Leave-Taking Ritual (New York: Irvington, 1988); and, also by van der Hart, “An Imaginary Leave-

Taking Ritual in Mourning Therapy: A Brief Com-

munication,” The International Journal of Clinical and Experimental Hypnosis 36, no. 2 (1988): 63–69.

95. William Lamers, Sr., quoted in Concerning Death: A Practical Guide for the Living, ed. Earl Grollman (Bos- ton: Beacon Press, 1974), and in Successful Funeral Ser- vice Practice, ed. Howard C. Raether (Englewood Cliffs, N.J.: Prentice-Hall, 1971).

96. William M. Lamers, Jr., “Funerals Are Good for

People: M.D.’s Included,” Medical Economics ( June 23, 1969): 1–4.

97. Alan Wolfelt, “Understanding the Trend Toward

Deritualization of the Funeral,” The Forum: Newsletter of the Association for Death Education and Counseling 20, no. 6 (November–December 1994): 1, 15–17.

98. Sabine Bode and Fritz Roth, Der Trauer Eine Heimat Geben: Für Einen Lebendigen Umgang mit dem Tod [Giving Grief a Home] (Bergisch Gladbach, Ger.: Gustav

Lübbe Verlag, 1998), and Trauer hat Viele Farben [Grief Has Many Colors] (Bergisch Gladbach, Ger.: Ehren-

wirth, 2004).

99. E. S. Craighill Handy and Mary Kawena Pukui,

The Polynesian Family System in Ka-’u, Hawai’i (Rutland, Vt.: Charles E. Tuttle, 1972), p. 157; and Mary Kawena

Pukui, E. W. Haertig, and Catherine A. Lee, Nana I Ke Kumu (Look to the Source), vol. 1 (Honolulu: Hui Hanai; Queen Lili’uokalani Children’s Center, 1972), p. 139.

C H A P T E R 9

1. Georges Bataille, “Sacrifi ce, the Festival, and the

Principles of the Sacred World,” Theory of Religion, trans. Robert Hurley (New York: Zone Books, 1992), p. 48.

2. Simon Shimson Rubin, Ruth Malkinson, and

Eliezer Wiztum, “On Bereavement Interventions:

Controversy and Consensus,” in Handbook of Thanatol- ogy, 2nd ed., ed. David K. Meagher and David E. Balk, 263–272 (New York: Routledge, 2013), p. 265.

3. Personal communication.

4. Bob Krizek, “Goodbye Old Friend: A Son’s Farewell

to Comiskey Park,” Omega: Journal of Death and Dying 25, no. 2 (1992): 87–93.

5. An adaptation of an anonymous reading used in

many funeral and memorial services.

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27. Rando, Treatment of Complicated Mourning, p. 53.

28. See Simon Shimshon Rubin, “Psychodynamic

Therapy with the Bereaved: Listening for Confl ict,

Relationship, and Transference,” Omega: Journal of Death and Dying 39, no. 2 (1999): 83–98; and Paul A. Boelen and others, “Continuing Bonds and Grief: A

Prospective Analysis,” Death Studies 30 (2006): 767–776.

29. Dennis Klass, “Continuing Conversation about

Continuing Bonds,” Death Studies 30 (2006): 843–858; quote p. 851.

30. Lyn H. Lofl and, “Loss and Human Connection:

An Exploration into the Nature of the Social Bond,” in

Personality, Roles, and Social Behavior, ed. William Ickes and Eric S. Knowles (New York: Springer-Verlag, 1982),

pp. 219–242.

31. John D. Kelly, “Grief: Re-forming Life’s Story,”

in The Path Ahead, ed. DeSpelder and Strickland, pp. 242–245.

32. Jerome Bruner, “The Narrative Construction of

Reality,” Critical Inquiry 18 (1991): 1–21; quote p. 4.

33. Carolyn Ellis, “‘There Are Survivors’: Telling a

Story of Sudden Death,” Sociological Quarterly 34, no. 4 (1993): 711–730.

34. Mary Anne Sedney, John E. Baker, and Esther

Gross, “‘The Story’ of a Death: Therapeutic Consider-

ations with Bereaved Families,” Journal of Marital and Family Therapy 20, no. 3 (1994): 287–296. See also Jack J. Bauer and George A. Bonanno, “Continuity amid

Discontinuity: Bridging One’s Past and Present in

Stories of Conjugal Bereavement,” Narrative Inquiry 11, no. 1 (2001): 123–158; Kathleen R. Gilbert, “Taking a

Narrative Approach to Grief Research: Finding Mean-

ing in Stories,” Death Studies 26, no. 3 (2002): 223–239; and Brian Schiff, Chaim Noy, and Bertram J. Cohler,

“Collected Stories in the Life Narratives of Holocaust

Survivors,” Narrative Inquiry 11, no. 1 (2001): 159–193.

35. Jane Harper Chelf and others, “Storytelling: A

Strategy for Living and Coping with Cancer,” Cancer Nursing 23, no. 1 (2000): 1–5.

36. Tony Walter, “A New Model of Grief: Bereavement

and Biography,” Mortality 1, no. 1 (1996): 7–25, quote p. 13; see also James A. Thorson, “Qualitative Thana-

tology,” Mortality 1, no. 2 (1996): 177–190.

37. Quoted in Kathleen Fowler, “So New, So New: Art

and Heart in Women’s Grief Memoirs,” Women’s Studies 36, no. 7 (2007): 525–549.

38. Simon Shimson Rubin, Ruth Malkinson, and

Eliezer Wiztum, “On Bereavement Interventions: Con-

troversy and Consensus,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 263–272; p. 271.

17. Erich Lindemann, “The Symptomatology and

Management of Acute Grief,” American Journal of Psy- chiatry 101 (1944): 141–148.

18. Colin Murray Parkes, “Research: Bereavement,”

Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 365–377; quote p. 366.

19. Colin Murray Parkes, “Complicated Grief in the

DSM-5: Problems and Solutions,” in Beyond Kübler-Ross: New Perspectives on Death, Dying, and Grief, ed. Kenneth J. Doka and Amy S. Tucci, 93–111 (Washington, D.C.:

Hospice Foundation of America, 2011), p. 94.

20. See Dennis Klass, “Developing a Cross-Cultural

Model of Grief: The State of the Field,” Omega: Journal of Death and Dying 39, no. 3 (1999): 153–178.

21. Margaret Stroebe, “Coping with Bereavement: A

Review of the Grief Work Hypothesis,” Omega: Journal of Death and Dying 26, no. 1 (1992–1993): 19–42. See also George A. Bonanno, ed., “New Directions in

Bereavement Research and Theory (special issue),”

American Behavioral Scientist 44, no. 3 (2001); Torill Christine Lindstrøm, “‘It Ain’t Necessarily So’: Chal-

lenging Mainstream Thinking About Bereavement,”

Family & Community Health 25, no. 1 (2002): 11–21; R. J. Russac, Nina S. Steighner, and Angela I. Canto, “Grief

Work Versus Continuing Bonds: A Call for Paradigm

Integration or Replacement?” Death Studies 26, no. 6 (2002): 463–478; and Margaret Stroebe and others,

“Does Disclosure of Emotions Facilitate Recovery

from Bereavement? Evidence from Two Prospective

Studies,” Journal of Consulting and Clinical Psychology 70, no. 1 (2002): 169–178.

22. See Dennis Klass and Robert Goss, “Spiritual

Bonds to the Dead in Cross-Cultural and Historical

Perspective: Comparative Religion and Modern Grief,”

Death Studies 23, no. 6 (1999): 547–567.

23. Simon Shimson Rubin, Ruth Malkinson, and

Eliezer Wiztum, “On Bereavement Interventions: Con-

troversy and Consensus,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 263–272; p. 265.

24. Dennis Klass, “Solace and Immortality: Bereaved

Parents’ Continuing Bond with Their Children,”

in The Path Ahead, ed. DeSpelder and Strickland, pp. 246 –259.

25. Dennis Klass, “The Inner Representation of the

Dead Child and the Worldviews of Bereaved Parents,”

Omega: Journal of Death and Dying 26, no. 4 (1992–1993): 255–272.

26. Phyllis R. Silverman, Steven Nickman, and J. Wil-

liam Worden, “Detachment Revisited: The Child’s

Reconstruction of a Dead Parent,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 260–270.

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Margaret S. Stroebe, Robert O. Hansson, Henk Schut,

and Wolfgang Stroebe, 511–530 (Washington, D.C.:

American Psychological Association, 2008), p. 513. See

also Nadeau, Families Making Sense of Death (Thousand Oaks, Calif.: Sage, 1997).

47. Nancy L. Moos, “An Integrative Model of Grief,”

Death Studies 19, no. 4 (1995): 337–364, quote p. 337. See also Froma Walsh and Monica McGoldrick, eds.,

Living Beyond Loss: Death in the Family, 2nd ed. (New York: Norton, 2004).

48. See Robert A. Neimeyer and John R. Jordan, “His-

torical and Contemporary Perspectives on Assessment

and Intervention,” in Handbook of Thanatology, 2 nd ed., ed. Meagher and Balk, 219–237; p. 224.

49. Stephen J. Fleming and Paul J. Robinson, “The

Application of Cognitive Therapy to the Bereaved,” in

The Challenge of Cognitive Therapy: Applications to Nontra- ditional Populations, ed. T. M. Vallis, J. L. Howes, and P. C. Miller (New York: Plenum Press, 1991), pp. 135–158.

50. Fleming and Robinson, “Application of Cognitive

Therapy to the Bereaved.”

51. Ira Byock, The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life (New York: Avery, 2012), p. 92 .

52. Sandra L. Bertman, Helen K. Sumpter, and Harry

L. Green, “Bereavement and Grief,” in Introduction to Clinical Medicine, ed. Harry L. Green (Philadelphia: B. C. Decker, 1991), p. 682.

53. See Liam Hyland and Janice M. Morse, “Orches-

trating Comfort: The Role of Funeral Directors,” Death Studies 19, no. 5 (1995): 453–474.

54. Bertman, Sumpter, and Green, “Bereavement and

Grief,” p. 682.

55. See Beverly Raphael and Christine Minkov,

“Abnormal Grief,” Current Opinion in Psychiatry 12, no. 1 (1999): 99–102.

56. Sarah Brabant, “Old Pain or New Pain: A Social

Psychological Approach to Recurrent Grief,” Omega: Journal of Death and Dying 20, no. 4 (1989–1990): 273–279.

57. M. A. Bull, S. Clark, and K. Duszynski, “Lessons

from a Community’s Response to the Death of Diana,

Princess of Wales,” Omega: Journal of Death and Dying 46, no. 1 (2002): 35–49.

58. Ira O. Glick, Robert S. Weiss, and Colin Murray

Parkes, The First Year of Bereavement (New York: Wiley, 1974), p. viii; see also Colin Murray Parkes and Robert

S. Weiss, Recovery from Bereavement (New York: Basic Books, 1983); and Robert S. Weiss, “Loss and Recov-

ery,” Journal of Social Issues 44, no. 3 (1988): 37–52.

39. See George A. Bonanno, Anthony Papa, and Kath-

leen O’Neill, “Loss and Human Resilience,” Applied & Preventive Psychology 10, no. 3 (2001): 193–206; Louis A. Gamino, Nancy S. Hogan, and Kenneth W. Sewell,

“Feeling the Absence: A Content Analysis from the

Scott and White Grief Study,” Death Studies 26, no. 10 (2002): 793–813; Judith A. Murray, “Loss as a Universal

Concept: A Review of the Literature to Identify Com-

mon Aspects of Loss in Diverse Situations,” Journal of Loss and Trauma 6, no. 3 (2001): 219–241; and Robert A. Neimeyer, “Reauthoring Life Narratives: Grief Therapy

as Meaning Reconstruction,” Israel Journal of Psychiatry and Related Sciences 38, nos. 3–4 (2001): 171–183.

40. Margaret Stroebe and Henk Schut, “The Dual Pro-

cess Model of Coping with Bereavement” (paper pre-

sented at the Meeting of the International Work Group

on Death, Dying, and Bereavement, Oxford, U.K., June

1995); see also Stroebe and Schut, “The Dual Process

Model of Bereavement: Rationale and Description,”

Death Studies 23, no. 3 (1999): 197–224.

41. Simon Shimshon Rubin, “The Two-Track Model

of Bereavement: Overview, Retrospect, and Prospect,”

Death Studies 23 (1999): 681–714.

42. Simon Shimson Rubin, Ruth Malkinson, and

Eliezer Wiztum, “On Bereavement Interventions: Con-

troversy and Consensus,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 263–272; p. 267.

43. Ruth Malkinson, Simon Shimshon Rubin, and

Eliezer Witztum, “Therapeutic Issues and the Rela-

tionship to the Deceased: Working Clinically with the

Two-Track Model of Bereavement,” Death Studies 30, no. 9 (2006): 797–815; esp. pp. 811–812. See also Ruth

Malkinson, Cognitive Grief Therapy: Constructing a Ratio- nal Meaning to Life Following Loss (New York: Norton, 2007); Ruth Malkinson, Simon Shimshon Rubin, and

Eliezer Witztum, eds., Traumatic and Nontraumatic Loss and Bereavement: Clinical Theory and Practice (Madison, Conn.: Psychosocial Press, 2000); and Rubin, “Two-

Track Model of Bereavement,” pp. 709–710.

44. Colin Murray Parkes, “Bereavement in Adult Life,”

British Medical Journal 316 (1998): 856–859, and “Facing Loss,” British Medical Journal 316 (1998): 1521–1524. See also, by Parkes, “Bereavement Dissected: A Reexamina-

tion of the Basic Components Infl uencing the Reaction

to Loss,” Israel Journal of Psychiatry and Related Sciences 38, nos. 3–4 (2001): 150–156, and “Grief: Lessons from

the Past, Visions for the Future,” Death Studies 26, no. 5 (2002): 367–385.

45. Hannelore Wass, personal communication,

September 15, 2009.

46. Janice Winchester Nadeau, “Meaning-Making in

Bereaved Families,” in Handbook of Bereavement Research and Practice: Advances in Theory and Intervention, ed.

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69. Margaret Stroebe and Henk Schut, “Complicated

Grief: A Conceptual Analysis of the Field,” Omega: Jour- nal of Death and Dying 52, no. 1 (2005–2006): 53–70; quote p. 67.

70. See Jerome F. Fredrick, “Grief as a Disease

Process,” Omega: Journal of Death and Dying 7, no. 4 (1976 –1977): 297–305; and Edgar N. Jackson, “The

Physiology of Crisis,” in his Coping with the Crises of Your Life (New York: Hawthorne Books, 1974), pp. 48–55.

71. Quoted in Jerry E. Bishop, “Secrets of the Heart:

Can It Be ‘Broken’?” The Wall Street Journal, February 14, 1994.

72. Margaret S. Stroebe, “The Broken Heart Phenom-

enon: An Examination of the Mortality of Bereave-

ment,” Journal of Community & Applied Social Psychology 4 (1994): 47–61.

73. W. D. Rees and S. G. Lutkins, “The Mortality of

Bereavement,” British Medical Journal 4 (1967): 13–16.

74. See Nicholas R. Hall and Allan L. Goldstein,

“Thinking Well: The Chemical Links Between Emo-

tions and Health,” The Sciences 26, no. 2 (March/April 1986): 34–40.

75. For a review of these studies, see Colin Murray

Parkes, “Research: Bereavement,” Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 365–377.

76. George L. Engel, “Sudden and Rapid Death Dur-

ing Psychological Stress,” Annals of Internal Medicine 74 (1971); see also, by Engel, “Emotional Stress and Sud-

den Death,” Psychology Today, November 1977.

77. Colin Murray Parkes, “The Broken Heart,” in his

Bereavement: Studies of Grief in Adult Life, 3rd ed. (Phila- delphia: Routledge, 2001), pp. 14–30; quote p. 17.

78. Edgar N. Jackson, Understanding Grief: Its Roots, Dynamics, and Treatment (Nashville: Abingdon Press, 1957), p. 27; see also, by Jackson, The Many Faces of Grief (Nashville: Abingdon Press, 1977). In an inter- view with the authors, Dr. Jackson described how the

death of his young son became the impetus for his

studies of grief, which became a mechanism for cop-

ing with, understanding, and coming to terms with

the loss.

79. Karen S. Pfost, Michael J. Stevens, and Anne B.

Wessels, “Relationship of Purpose in Life to Grief

Experiences in Response to the Death of a Signifi cant

Other,” Death Studies 13, no. 4 (1989): 371–378.

80. See Paul C. Rosenblatt, “Grief: The Social Con-

text of Private Feelings,” Journal of Social Issues 44, no. 3 (1988): 67–78. See also Carolyn Ambler Walter and

Judith L. M. McCoyd, Grief and Loss Across the Lifes- pan: A Biopsychosocial Perspective (New York: Springer, 2009).

59. Stephen Fleming and Paul Robinson, “Grief and

Cognitive-Behavioral Therapy: The Reconstruction of

Meaning,” in Handbook of Bereavement Research: Conse- quences, Coping, and Care, ed. Margaret S. Stroebe, Robert O. Hansson, Wolfgang Stroebe, and Henk Schut,

647–669 (Washington, D.C.: American Psychological

Association, 2001), p. 647.

60. Therese A. Rando, The Treatment of Complicated Mourning (Champaign, Ill.: Research Press, 1993).

61. Robert O. Hansson and Margaret S. Stroebe,

Bereavement in Late Life: Coping, Adaptation, and Develop- mental Infl uences (Washington, D.C.: American Psycho- logical Association, 2007), p. 172.

62. Therese A. Rando, “The Increasing Prevalence

of Complicated Mourning: The Onslaught Is Just

Beginning,” Omega: Journal of Death and Dying 26, no. 1 (1992–1993): 43–59.

63. See Louis A. Gamino and R. Hal Ritter, Jr., Ethical Practice in Grief Counseling (New York: Springer, 2009), pp. 250–252. See also Heather L. Servaty-Seib, “Con-

nections Between Counseling Theories and Current

Theories of Grief and Mourning,” Journal of Mental Health Counseling 26, no. 2 (2004): 125–145; esp. pp. 136 –140.

64. Robert A. Neimeyer, Holly G. Prigerson, and Betty

Davies, “Mourning and Meaning,” American Behavioral Science 46, no. 2 (2002): 235–251.

65. Kenneth J. Doka, “Grief and the DSM: A Brief

Q & A,” Huffpost Healthy Living (May 29, 2013); italics added.

66. Excerpted from the statement developed by a

work group at the meeting of the International Work

Group on Death, Dying and Bereavement (IWG)

in Victoria, British Columbia on April 28–May 3,

2013. This statement represents the opinions of the

authors, not the opinions of the Board or member-

ship of IWG. The full text of the statement can be

found on the European Association of Palliative Care

Blog, http://eapcnet.wordpress.com/2013/05/20/

when-does-a-broken-heart-become-a-mental-disorder.

67. Phyllis R. Silverman, “Dying and Bereavement in

Historical Perspective,” in Living with Dying: A Hand- book for End-of-Life Care Practitioners, ed. Joan Berzoff and Phyllis R. Silverman (New York: Columbia Univer-

sity Press, 2004), pp. 128–149; quote p. 144.

68. Jason M. Holland, Robert A. Neimeyer, Paul A.

Boelen, and Holly G. Prigerson, “The Underlying

Structure of Grief: A Taxometric Investigation of

Prolonged and Normal Reactions to Loss,” Journal of Psychopathology and Behavior Assessment 31, no. 3 (2009): 190–201.

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644 n o t e s

93. Lynne Ann DeSpelder, “Culture and Gender:

Diversity in Dying, Death, and Bereavement” (paper

presented at the VI International Congress of the

International Association of Thanatology and Suici-

dology, Bologna, Italy, June 2005).

94. Arlene Sheskin and Samuel E. Wallace, “Differ-

ing Bereavements: Suicide, Natural, and Accidental

Death,” Omega: Journal of Death and Dying 7, no. 3 (1976): 229–242.

95. See Robert L. Fulton, “Death, Grief, and Social

Recuperation,” Omega: Journal of Death and Dying 1, no. 1 (1970): 23–28; and Bruce J. Horacek, “A Heuristic

Model of Grieving After High-Grief Death,” Death Studies 19, no. 1 (1995): 21–31.

96. See Pauline Boss, Ambiguous Loss: Learning to Live with Unresolved Grief (Cambridge, Mass.: Harvard Uni- versity Press, 1999).

97. Therese A. Rando, Loss and Anticipatory Grief (Lexington, Mass.: Lexington, 1986), p. 24.

98. See Bernard Schoenberg, Arthur C. Carr, Austin

H. Kutscher, David Peretz, and Ivan K. Goldberg,

eds., Anticipatory Grief (New York: Columbia University Press, 1974), p. 4.

99. Yvonne K. Ameche, “A Story of Loss and Survivor-

ship,” Death Studies 14, no. 2 (1990): 185–198.

100. Carol J. Van Dongen, “Social Context of Post-

suicide Bereavement,” Death Studies 17, no. 2 (1993): 125–141; quote p. 130.

101. See Charles P. McDowell, Joseph M. Rothberg,

and Ronald J. Koshes, “Witnessed Suicides,” Suicide and Life-Threatening Behavior 24, no. 3 (1994): 213–223.

102. Francoise M. Reynolds and Peter Cimbolic,

“Attitudes Toward Suicide Survivors as a Function of

Survivors’ Relationship to the Victim,” Omega: Journal of Death and Dying 19, no. 2 (1988–1989): 125–133.

103. Lula M. Redmond, Surviving When Someone You Love Was Murdered: A Professional’s Guide to Group Therapy for Families and Friends of Murder Victims (Clear- water, Fla.: Psychological Consultation and Education

Services, 1989), p. 38.

104. See entry on survivors’ grief, by Lynne Ann

DeSpelder and Albert Lee Strickland, in Encyclopedia of Death and Dying, ed. Howarth and Leaman, pp. 221–223.

105. Terrence Des Pres, The Survivor (New York: Oxford University Press, 1976; Pocket Books, 1977);

and Lawrence L. Langer, Versions of Survival: The Holo- caust and the Human Spirit (Albany: State University of New York Press, 1982). See also Robert Jay Lifton,

Death in Life: Survivors of Hiroshima (New York: Simon & Schuster, 1967).

81. Wolfgang Stroebe and Margaret Stroebe, “Is Grief

Universal? Cultural Variations in the Emotional Reac-

tion to Loss,” in Death and Identity, 3rd ed., ed. Fulton and Bendiksen, p. 197.

82. Daniel Callahan, The Troubled Dream of Life: Living with Mortality (New York: Simon & Schuster, 1993), p. 15.

83. Unni Wikan, “Bereavement and Loss in Two Mus-

lim Communities: Egypt and Bali Compared,” Social Science & Medicine 27, no. 5 (1988): 451–460.

84. Alicia Skinner Cook, “The Family, Larger Sys-

tems, and Loss, Grief, and Mourning,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 171–178; p. 171.

85. Greg Owen, Robert Fulton, and Eric Marcusen,

“Death at a Distance: A Study of Family Bereavement,”

in Death and Identity, 3rd ed., ed. Fulton and Bendik- sen, p. 241.

86. Stephen R. Connor, Hospice and Palliative Care: The Essential Guide, 2nd ed. (New York: Routledge, 2009), p. 88.

87. Fred Sklar and Shirley F. Hartley, “Close Friends

as Survivors: Bereavement Patterns in a ‘Hidden’

Population,” Omega: Journal of Death and Dying 21, no. 2 (1990): 103–112.

88. See entry on “Grief, Vicarious,” by Lynne Ann

DeSpelder and Albert Lee Strickland, in Encyclope- dia of Death and Dying, ed. Howarth and Leaman, pp. 225–226.

89. Larry A. Bugen, “Human Grief: A Model for Pre-

diction and Intervention,” American Journal of Orthopsy- chiatry 47, no. 2 (1977): 196 –206.

90. Robert J. Smith, John H. Lingle, and Timothy C.

Brock, “Reactions to Death as a Function of Perceived

Similarity to the Deceased,” Omega: Journal of Death and Dying 9, no. 2 (1978–1979): 125–138.

91. Richard M. Leliaert, “Spiritual Side of ‘Good

Grief’: What Happened to Holy Saturday?” Death Stud- ies 13, no. 2 (1989): 103–117; quote p. 103.

92. Terry L. Martin and Kenneth J. Doka, Men Don’t Cry . . . Women Do: Transcending Gender Stereotypes of Grief (Philadelphia: Brunner/Mazel, 2000); see also, by

Martin and Doka, “Revisiting Masculine Grief,” in Liv- ing with Grief: Who We Are, How We Grieve, ed. Kenneth J. Doka and Joyce D. Davidson (Washington, D.C.:

Hospice Foundation of America, 1998), pp. 133–142;

and Judith M. Stillion and Susan B. Noviello, “Living

and Dying in Different Worlds: Gender Differences in

Violent Death and Grief,” Illness, Crisis & Loss 9, no. 3 (2001): 247–259.

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118. John R. Jordan and Robert A. Neimeyer, “Does

Grief Counseling Work?” Death Studies 27 (2003): 765–786; quote p. 781.

119. Dale G. Larson and William T. Hoyt, “What Has

Become of Grief Counseling? An Evaluation of the

Empirical Foundations of the New Pessimism,” Profes- sional Psychology: Research and Practice 38, no. 4 (2007): 347–355; quote p. 354. See also Connor, Hospice and Palliative Care: The Essential Guide, 2 nd ed., p. 89.

120. Study by Task Force on Community Preventive

Services, published in American Journal of Preventive Medicine (September 2008) and reported by Bruce Bower, “Study Evaluates Kids’ Therapies,” Science News (September 27, 2008), p. 11.

121. Louis A. Gamino and R. Hal Ritter, Jr., Ethical Practice in Grief Counseling (New York: Springer, 2009), p. 215. See also Margaret S. Stroebe, Karolijne Van

Der Houwen, and Henk Schut, “Bereavement Support,

Intervention, and Research on the Internet: A Critical

Review,” in Handbook of Bereavement Research and Prac- tice: Advances in Theory and Intervention, ed. Stroebe and others, pp. 551–574.

122. Silverman, “Dying and Bereavement in Historical

Perspective,” p. 145.

123. David A. Crenshaw, “Life Span Issues and Assess-

ment and Intervention,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 239–244; p. 242.

124. Louis A. Gamino and R. Hal Ritter, Jr., Ethical Prac- tice in Grief Counseling (New York: Springer, 2009), p. 31.

125. Dennis Klass, “Religion and Spirituality in Loss,

Grief, and Mourning,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 127–134; pp. 128–129, 133.

126. Louis A. Gamino and R. Hal Ritter, Jr., Ethical Practice in Grief Counseling (New York: Springer, 2009), p. 38.

127. Margaret Stroebe, Mary M. Gergen, Kenneth J.

Gergen, and Wolfgang Stroebe, “Broken Hearts or

Broken Bonds: Love and Death in Historical Perspec-

tive,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland

(Mountain View, Calif.: Mayfi eld, 1995), pp. 231–241.

128. Mary Kawena Pukui, E. W. Haertig, and Cath-

erine A. Lee, Nana I Ke Kumu (Look to the Source), vol. 1 (Honolulu: Hui Hanai; Queen Lili’uokalani Chil-

dren’s Center, 1972), pp. 135–136, 141.

129. Quoted in Ari L. Goldman, “Confronting Grief,

Not Burying It,” The New York Times, September 7, 2003.

130. Quoted in Jane E. Brody, “Often, Time Beats

Therapy for Treating Grief,” The New York Times, January 27, 2004.

106. See J. William Worden, “Grieving a Loss from

AIDS,” Hospice Journal 7 (1991): 143–150.

107. Ruben Schindler, “Mourning and Bereavement

Among Jewish Religious Families: A Time for Refl ec-

tion and Recovery,” Omega: Journal of Death and Dying 33, no. 2 (1996): 121–129.

108. See Kenneth J. Doka, “Disenfranchised Grief,”

in The Path Ahead, ed. DeSpelder and Strickland, pp. 271–275; and, edited by Doka, Disenfranchised Grief: Recognizing Hidden Sorrow (Lexington, Mass.: Lexing- ton, 1989); and Disenfranchised Grief: New Directions, Challenges, and Strategies for Practice (Champaign, Ill.: Research Press, 2002).

109. Darlene A. Kloeppel and Sheila Hollins, “Double

Handicap: Mental Retardation and Death in the Fam-

ily,” Death Studies 13, no. 1 (1989): 31–38.

110. Kemi Adamolekun, “In-Laws’ Behavior as a Social

Factor in Subsequent Temporary Upsurges of Grief in

Western Nigeria,” Omega: Journal of Death and Dying 31, no. 1 (1995): 23–34. See also M. A. Sossou, “Widow-

hood Practices in West Africa: The Silent Victims,”

International Journal of Social Welfare 11, no. 3 (2002): 201–209.

111. Phyllis R. Silverman, “Social Support and Mutual

Help for the Bereaved,” in Dying, Death, and Bereave- ment: A Challenge for Living, 2nd ed., ed. Inge Corless, Barbara B. Germino, and Mary A. Pittman (New York:

Springer, 2003), pp. 247–265.

112. Howard R. Winokuer and Darcy L. Harris, Princi- ples and Practice of Grief Counseling (New York: Springer, 2012), p. 15.

113. Glennys Howarth, “Dismantling the Boundaries

Between Life and Death,” Mortality 5, no. 2 (2000): 127–138.

114. Worden, Grief Counseling and Grief Therapy, 4th ed., p. 83.

115. David K. Meagher, “Grief Counseling for the

New Millennium: An Interview with J. William

Worden,” The Thanatology Newsletter 2, no. 4 (2002): 10–12. See also Lawrence G. Calhoun and Richard

G. Tedeshi, eds., Handbook of Posttraumatic Growth: Research and Practice (Mahwah, N.J.: Lawrence Erl- baum, 2006).

116. Henk Schut, Margaret S. Stroebe, Jan Van

Den Bout, and Maaike Terheggen, “The Effi cacy of

Bereavement Interventions: Determining Who Ben-

efi ts,” in Handbook of Bereavement Research: Consequences, Coping, and Care, ed. Stroebe and others, 705–737; p. 731.

117. Jane E. Brody, “Often, Time Beats Therapy for

Treating Grief,” The New York Times, January 27, 2004.

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6. Marilyn J. Field and Richard E. Behrman, eds.,

When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families (Washington, D.C.: National Academies Press, 2003), p. xv.

7. Zlata Filipovic, “Zlata’s Diary: A Child’s Life in Sara-

jevo,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland,

(Mountain View, Calif.: Mayfi eld, 1995); pp. 175–178;

quote p. 178.

8. Dorothy Morgos, J. William Worden, and Leila

Gupta, “Psychosocial Effects of War Experiences Among

Displaced Children in Southern Darfur,” Omega: Journal of Death and Dying 56, no. 3 (2008): 229–253.

9. Marian Tankink, “‘The Moment I Became Born-

Again the Pain Disappeared’: The Healing of Dev-

astating War Memories in Born-Again Churches in

Mbarara District, Southwest Uganda,” Transcultural Psychiatry 44, no. 2 (2007): 203–231.

10. James Garbarino, “Challenges We Face in Under-

standing Children and War: A Personal Essay,” in The Path Ahead, ed. DeSpelder and Strickland, 169–174; quote p. 169.

11. Ice-T, “The Killing Fields,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 179–181.

12. Ronald Keith Barrett and Lynne Ann DeSpelder,

“Ways People Die: The Infl uence of Environment on a

Child’s View of Death” (paper presented at the annual

meeting of the Association for Death Education and

Counseling, Washington, D.C., June 26, 1997).

13. Task Force on Community Preventive Services,

“Recommendations to Reduce Psychological Harm

from Traumatic Events Among Children and Adoles-

cents,” American Journal of Preventive Medicine 35, no. 3 (2008): 314–316.

14. Albert Bandura, “Exploration of Fortuitous Deter-

minants of Life Paths,” Psychological Inquiry 9, no. 2 (1998): 95–115; quote p. 96.

15. Rukmini Callimachi, “Katrina’s Children Struggle

with Fears,” Santa Cruz Sentinel, April 23, 2006.

16. Kevin Ann Oltjenbruns, “Developmental Context

of Childhood: Grief and Regrief Pheonomena,” in

Handbook of Bereavement Research: Consequences, Coping, and Care, ed. Margaret S. Stroebe, Robert O. Hansson, Wolfgang Stroebe, and Henk Schut, 169–197 (Wash-

ington, D.C.: American Psyhological Association,

2001), pp. 176 –177.

17. Kevin Ann Oltjenbruns, “Lifespan Issues and Loss,

Grief, and Mourning: Childhood and Adolescence,”

in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 149–155 (New York: Rout-

ledge, 2013), p. 153.

131. Nissan Rubin, “Social Networks and Mourning:

A Comparative Approach,” Omega: Journal of Death and Dying 21, no. 2 (1990): 113–127. See also Jason Castle, “Grief Rituals: Aspects That Facilitate Adjustment to

Bereavement,” Journal of Loss & Trauma 8, no. 1 (2003): 41–71.

132. For more information, contact T.A.P.S., 2001 S

Street NW, Suite 300, Washington, DC 20009; (800)

959–8277.

133. Stephen J. Fleming and Leslie Balmer, “Bereaved

Families of Ontario: A Mutual-Help Model for Families

Experiencing Death,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 281–288; quote p. 288.

134. John Schneider, Stress, Loss, and Grief: Understand- ing Their Origins and Growth Potential (Baltimore: Uni- versity Park Press, 1984), pp. 66 –76.

135. Julie Fritsch with Sherokee Ilse, The Anguish of Loss (Maple Plain, Minn.: Wintergreen Press, 1988).

136. Simon Shimson Rubin, Ruth Malkinson, and

Eliezer Wiztum, “On Bereavement Interventions:

Controversy and Consensus,” in Handbook of Thanatol- ogy, 2nd ed., ed. Meagher and Balk, 263–272; p. 263. See also Margaret S. Stroebe, Robert O. Hansson, and

Henk Schut, “Bereavement Research: 21st Century

Prospects,” in Handbook of Bereavement Research and Practice: Advances in Theory and Intervention, ed. Stroebe and others, pp. 577–603.

C H A P T E R 1 0

1. See Linda Goldman, Breaking the Silence: A Guide to Helping Children with Complicated Grief—Suicide, Homi- cide, AIDS, Violence, and Abuse, 2nd ed. (New York: Brunner-Routledge, 2001).

2. International Work Group on Death, Dying, and

Bereavement, “Children, Adolescents, and Death:

Myths, Realities, and Challenges,” Death Studies 23 (1999): 443–463.

3. Mary Louise Branch and Sabrina A. Brinson,

“Gone But Not Forgotton: Children’s Experience with

Attachment, Separation, and Loss,” Reclaiming Children and Youth 16, no. 3 (Fall 2007): 41–45.

4. See David W. Adams and Eleanor J. Deveau, eds.,

Beyond the Innocence of Childhood. 3 vols. (Amityville, N.Y.: Baywood, 1995); and Phyllis Rolfe Silverman,

Never Too Young to Know: Death in Children’s Lives (New York: Oxford University Press, 2000).

5. See, for example, Fotini Bonoti, Angeliki Leondari,

and Adelais Mastora, “Exploring Children’s Under-

standing of Death: Through Drawings and the Death

Concept Questionnaire,” Death Studies 37 (2013): 47–60.

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Bereavement, 2nd ed., ed. Corless, Germino, and Pittman, pp. 287–302. See also, by Davies, Shadows in the Sun: The Experience of Sibling Bereavement in Childhood (Washington, D.C.: Taylor & Francis, 1999).

29. Nancy S. Hogan and Lydia DeSantis, “Things That

Help and Hinder Adolescent Sibling Bereavement,”

Western Journal of Nursing Research 16, no. 2 (1994): 132–153.

30. David E. Balk, “Sibling Death, Adolescent Bereave-

ment, and Religion,” Death Studies 15, no. 1 (1991): 1–20.

31. Nancy Hogan and Lydia DeSantis, “Adolescent Sib-

ling Bereavement: An Ongoing Attachment,” Qualita- tive Health Research 2, no. 2 (1992): 159–177.

32. Field and Behrman, eds., When Children Die, p. xv.

33. William G. Bartholome, “Care of the Dying

Child: The Demands of Ethics,” in The Path Ahead, ed. DeSpelder and Strickland, 133 –143; quote p. 136.

See also Judith M. Stillion and Danai Papadatou,

“Suffer the Children: An Examination of Psycho-

social Issues in Children and Adolescents with Ter-

minal Illness,” American Behavioral Scientist 46, no. 2 (2002): 299–315.

34. Marie-Bénédicte Dembour, “The Conscious Death

of a Two-Year-Old,” Omega: Journal of Death and Dying 38, no. 3 (1998–1999): 187–200.

35. Myra Bluebond-Langner, The Private Worlds of Dying Children (Princeton, N.J.: Princeton University Press, 1978).

36. Rebecca R. Kameny and David J. Bearison, “Can-

cer Narratives of Adolescents and Young Adults: A

Quantitative and Qualitative Analysis,” Children’s

Health Care 31, no. 2 (2002): 143–173; quote from

p. 144.

37. See Gregg M. Furth, The Secret World of Drawings: Healing Through Art (Boston: Sigo Press, 1988); and Maare E. Tamm and Anna Granqvist, “The Meaning

of Death for Children and Adolescents: A Phenom-

enographic Study of Drawings,” Death Studies 19, no. 3 (1995): 203–222.

38. Luisa M. Massimo and Daniela A. Zarri, “In

Tribute to Luigi Castagnetta—Drawings: A Narrative

Approach for Children with Cancer,” Annals of the New York Academy of Sciences 1089 (2006): xvi–xxiii.

39. Stan F. Whitsett and others, “Chemotherapy-

Related Fatigue in Childhood Cancer: Correlates,

Consequences, and Coping Strategies,” Journal of Pedi- atric Oncology Nursing 25, no. 2 (2008): 86 –96.

40. Field and Behrman,eds., When Children Die, p. 323.

41. Field and Behrman, eds., When Children Die, p. 180.

18. Illene C. Noppe and Lloyd D. Noppe, “Adolescent

Experiences with Death: Letting Go of Immortality,”

Journal of Mental Health Counseling 26, no. 2 (2004): 146 –167.

19. Illene C. Noppe, Lloyd D. Noppe, and Denise

Bartell, “Terrorism and Resilience: Adolescents’ and

Teachers’ Responses to September 11, 2001,” Death Studies 30 (2006): 41–60.

20. Russell C. Hurd, “A Teenager Revisits Her Father’s

Death During Childhood: A Study in Resilience and

Healthy Mourning,” Adolescence 39, no. 154 (2004): 337–354.

21. Celeste M. Johnson, “African-American Teen Girls

Grieve the Loss of Friends to Homicide: Meaning-

Making and Resilience,” Omega: Journal of Death and Dying 61, no. 2 (2010): 121–143.

22. See, for example, Jeffrey Lancaster, “Developmen-

tal Stages, Grief, and a Child’s Response to Death,”

Pediatric Annals 40, no. 5 (2011): 277–281.

23. See entry on death of parents, by Lynne Ann

DeSpelder and Albert Lee Strickland, in Encyclopedia of Death and Dying, ed. Glennys Howarth and Oliver Leaman, 346 –347 (New York: Routledge, 2001). See also Donna

Schuurman, Never the Same: Coming to Terms with the Death of a Parent (New York: St. Martin’s, 2003); and J. William Worden, Children and Grief: When a Parent Dies (New York: Guilford Press, 1996). Classic studies include Erna Furman, A Child’s Parent Dies: Studies in Childhood Bereavement (New Haven, Conn.: Yale Univer- sity Press, 1974); and Robert A. Furman, “The Child’s

Reaction to Death in the Family,” in Loss and Grief: Psy- chological Management in Medical Practice, ed. Bernard Schoenberg et al., 70–86 (New York: Columbia Univer-

sity Press, 1970).

24. Margo Requarth, After a Parent’s Suicide: Helping Children Heal (Sebastopol, Calif.: Healing Hearts, 2006).

25. Grace H. Christ, Karolynn Siegel, and Adolph E.

Christ, “It Never Really Hit Me . . . Until It Actually

Happened,” JAMA: Journal of the American Medical Asso- ciation 288, no. 10 (September 11, 2002): 1269–1278.

26. Phyllis R. Silverman and Madelyn Kelly, A Par- ent’s Guide to Raising Grieving Children: Rebuilding Your Family After the Death of a Loved One (New York: Oxford University Press, 2009), p. 89.

27. Phyllis R. Silverman, Steven Nickman, and J. Wil-

liam Worden, “Detachment Revisited: The Child’s

Reconstruction of a Dead Parent,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 260–270.

28. Betty Davies, “The Study of Sibling Bereave-

ment: An Historical Perspective,” in Dying, Death, and

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Network on the Social Environment of Children with

Life-Threatening Illnesses,” pp. 47–68; and Ruth T.

Brokstein, Susan O. Cohen, and Gary A. Walco, “Star-

bright World and Psychological Adjustment in Chil-

dren with Cancer: A Clinical Series,” pp. 29–45.

60. Sunshine Foundation, 1041 Mill Creek Drive,

Feasterville, PA 19052, (215) 396 – 4770 or (800) 767–

1976, w w w.sunshinefoundation.org ; Make-A-Wish

Foundation, Suite 400, 4742 24th Street, Phoenix,

A Z 85106, (602) 279 –9474 or (800) 722–9474;

w w w.wish.org .

61. Lori S. Wiener and others, “National Telephone

Support Groups: A New Avenue Toward Psychosocial

Support for HIV-Infected Children and Their Fami-

lies,” Social Work with Groups 16, no. 3 (1993): 55 –71.

62. Heather L. Servaty-Seib, “Death of a Friend Dur-

ing Adolescence,” in Adolescent Encounters with Death, Bereavement, and Coping, ed. David E. Balk and Charles A. Corr, 217–235 (New York: Springer, 2009), p. 218.

63. See the special issue of Omega: Journal of Death and Dying 48, no. 4 (2004) on death-related literature for children, esp. Carol F. Berns, “Bibliotherapy: The Use

of Literature in Working with Bereaved Children,”

pp. 321–336, and Donna Schuurman, “Literature for

Adults to Assist Them in Helping Bereaved Children,”

pp. 415–424.

64. See Myra Bluebond-Langner, In the Shadow of Illness: Parents and Siblings of the Chronically Ill Child (Princeton, N.J.: Princeton University Press, 1996), and

“Worlds of Dying Children and Their Well Siblings,”

Death Studies 13, no. 1 (1989): 1–16.

65. Robert Zucker, The Journey Through Grief and Loss: Helping Yourself and Your Child When Grief Is Shared (New York: St. Martin’s, 2009), p. 2.

66. Nancy L. Malcom, “Images of Heaven and the

Spiritual Afterlife: Qualitative Analysis of Children’s

Storybooks about Death, Dying, Grief, and Bereave-

ment,” Omega: Journal of Death and Dying 62, no. 1 (2010–2011): 51–76; quote p. 69.

67. This and the following anecdote from Jo-Eileen

Gyulay, The Dying Child (New York: McGraw-Hill, 1978), pp. 17–18.

68. See Mary A. Fristad and others, “The Role of Rit-

ual in Children’s Bereavement,” Omega: Journal of Death and Dying 42, no. 4 (2001): 321–339; and Phyllis R. Silverman and J. William Worden, “Children’s Under-

standing of Funeral Ritual,” Omega: Journal of Death and Dying 25, no. 4 (1992): 319–331.

69. Erik Erikson, Childhood and Society (New York: Nor- ton, 1950), p. 233.

42. Betty Davies and others, “Addressing Spirituality

in Pediatric Hospice and Palliative Care,” Journal of Palliative Care 18, no. 1 (2002): 59–67.

43. Field and Behrman, eds., When Children Die, p. 3.

44. Stephen R. Connor, Hospice and Palliative Care: The Essential Guide, 2nd ed. (New York: Routledge, 2009), p. 217.

45. Program Overview ( http://www.dhcs.ca.gov/

services/ppc/Pages/ProgramOverview.aspx#top ). See

also Children’s Hospice and Palliative Care Coalition

( www.childrenshospice.org).

46. Tiffany Hill, “Kid-Size Care,” Honolulu Magazine (November 2011), p. 48.

47. “Children’s Hospice: An Omega Interview [by

Robert Kastenbaum] with Ida M. Martinson,” Omega: Journal of Death and Dying 31, no. 4 (1995): 253–261.

48. Andrea C. Walker, “Life Span Issues and End-of-

Life Decision Making,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 81–89; p. 83.

49. Louis A. Gamino and R. Hal Ritter, Jr., Ethical Practice in Grief Counseling (New York: Springer, 2009), p. 142.

50. Gamino and Ritter, Ethical Practice in Grief Counseling, p. 143.

51. Andrew Newman, “Adolescent Consent to Routine

Medical and Surgical Treatment: A Proposal to Sim-

plify the Law of Teenage Medical Decision-Making,”

Journal of Legal Medicine 22 (2001): 501–532; quote p. 528.

52. Bartholome, “Care of the Dying Child,” p. 133.

53. Bartholome, “Care of the Dying Child,” p. 141.

54. Betty Davies and others, “Living in the Dragon’s

Shadow: Fathers’ Experiences of a Child’s Life-Limit-

ing Illness,” Death Studies 28 (2004): 111–135.

55. Dana Cable, Laurel Cucchi, Faye Lopez, and Terry

Martin, “Camp Jamie,” American Journal of Hospice and Palliative Care 9, no. 5 (1992): 18–21.

56. https://www.moyerfoundation.org/programs/

camperin.aspx .

57. HUGS Fact Sheet. Contact HUGS (Help, Under- standing, and Group Support for Hawaii’s Seriously Ill

Children and Their Families), 3636 Kilauea Avenue,

Honolulu, HI 96816; (808) 732–4846; www.hugslove.org .

58. Starlight Children’s Foundation International,

5900 Wilshire Blvd., Suite 2530, Los Angeles, CA

90036, (323) 634–0080; www.starlight.org .

59. See the following, published in Children’s Health Care 31, no. 1 (2002): Haven B. Battles and Lori S. Wiener, “Starbright World: Effects of an Electronic

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14. Marion Osterweis, Fredric Solomon, and Morris

Green, eds., Bereavement: Reactions, Consequences, and Care (Washington, D.C.: National Academy Press, 1984), p. 85.

15. Miriam S. Moss, Sidney Z. Moss, Robert Rubin-

stein, and Nancy Resch, “Impact of Elderly Mother’s

Death on Middle Aged Daughters,” International Jour- nal of Aging and Human Development 37, no. 1 (1992–1993): 1–22.

16. See Harold Ivan Smith, Grieving the Death of a Mother (Minneapolis: Augsburg, 2003).

17. Debra Umberson and Meichu D. Chen, “Effects

of a Parent’s Death on Adult Children: Relationship

Salience and Reaction to Loss,” American Sociological Review 59, no. 1 (1994): 152–168.

18. Laura R. Umphrey and Joanne Cacciatore, “Cop-

ing with the Ultimate Deprivation: Narrative Themes

in a Parental Bereavement Support Group,” Omega: Journal of Death and Dying 63, no. 2 (2011): 141–160.

19. Laura S. Smart, “Parental Bereavement in Anglo

American History,” Omega: Journal of Death and Dying 28, no. 1 (1993–1994): 49–61.

20. Dennis Klass, “Solace and Immortality: Bereaved

Parents’ Continuing Bond with Their Children,” in

The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland, 246 –259

(Mountain View, Calif.: Mayfi eld, 1995); and Klass, The Spiritual Lives of Bereaved Parents (Philadelphia: Brun- ner/Mazel, 1999).

21. Paul C. Rosenblatt, “Protective Parenting After the

Death of a Child,” Journal of Personal and Interpersonal Loss 5 (2000): 343–360.

22. Exhibition note, “Native Peoples,” Glenbow

Museum, Calgary, Alberta, Canada.

23. See, for example, Harriett Sarnoff Schiff, The Bereaved Parent (New York: Crown, 1977); and Kay Talbot, What Forever Means After the Death of a Child: Transcending the Trauma, Living with the Loss (New York: Brunner-Routledge, 2002).

24. Dorland’s Illustrated Medical Dictionary, 26th ed. (Philadelphia: Saunders, 1985), p. 828.

25. Wendy Simonds and Barbara Katz Rothman,

Centuries of Solace: Expressions of Maternal Grief in Popu- lar Literature (Philadelphia: Temple University Press, 1992), p. 252.

26. Dorland’s Illustrated Medical Dictionary, pp. 664, 1251.

27. Rose Cooper, “Unrecognized Losses in Child Adop-

tion,” in Disenfranchised Grief: New Directions, Challenges, and Strategies for Practice, ed. Kenneth J. Doka, Chapter 17 (Champaign, Ill.: Research Press, 2002).

C H A P T E R 1 1

1. See, for example, Catherine M. Sanders, Grief, the Mourning After: Dealing with Adult Bereavement, 2nd ed. (New York: Wiley, 1989).

2. Peter Marris, “Holding onto Meaning Through

the Life Cycle,” in Challenges of the Third Age: Meaning and Purpose in Later Life, ed. Robert S. Weiss and Scott A. Bass (New York: Oxford University Press, 2002).

Kindle edition.

3. Edwin S. Shneidman, Death and the College Student (New York: Behavioral Publications, 1972).

4. Sara J. Tedrick Parikh and Heather L. Servaty-Seib,

“College Students’ Beliefs about Supporting a Griev-

ing Peer,” Death Studies 37 (2013): 653–669; quote p. 653.

5. Heather L. Servaty-Seib and Lou Ann Hamil-

ton, “Educational Performance and Persistence of

Bereaved College Students,” Journal of College Student Development 47, no. 2 (2006): 225–234; see also Heather L. Servaty-Seib and Deborah J. Taub, “Bereavement

and College Students: The Role of Counseling Psy-

chology,” The Counseling Psychologist 38, no. 7 (2010): 947–975.

6. Leslie Williams Hale, “College Suicide: Second-

Leading Cause of Student Death Hits Home in South-

west Florida,” Naples Daily News ( January 1, 2012).

7. The Spiritual Life of College Students: A National Study of College Students’ Search for Meaning and Purpose (Higher Education Research Institute, University of

California, Los Angeles, n.d.).

8. Harold Ivan Smith, Friendgrief: An Absence Called Presence (Amityville, N.Y.: Baywood, 2000).

9. See Rosemary Blieszner, “‘She’ll Be on My Heart’:

Intimacy Among Friends,” Generations: Journal of the American Society on Aging 25, no. 2 (2001): 48–54.

10. Miriam S. Moss and Sidney Z. Moss, “Meaning

of the Death of an Elderly Father: Two Sisters’ Per-

spectives,” Omega: Journal of Death and Dying 66, no. 3 (2012–2013): 195–213; esp. p. 208.

11. See entry on death of parents, by Lynne Ann

DeSpelder and Albert Lee Strickland, in Encyclopedia of Death and Dying, ed. Glennys Howarth and Oliver Lea- man (New York: Routledge, 2001), pp. 346 –347.

12. Sharon Hines Smith, “‘Fret No More My Child . . .

For I’m All Over Heaven All Day’: Religious Beliefs

in the Bereavement of African American, Middle-

Aged Daughters Coping with the Death of an Elderly

Mother,” Death Studies 26 (2002): 309–323.

13. Smith, “‘Fret No More My Child’ . . . ,” p. 320.

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Johnson and S. Marvin Johnson, with James H.

Cunningham and Irwin J. Weinfeld, A Most Important Picture: A Very Tender Manual for Taking Pictures of Still- born Babies and Infants Who Die (Omaha: Centering Corp., 1985).

42. Joanne Cacciatore, Stephen Schnebly, and J.

Frederik Frøen, “The Effects of Social Support on

Maternal Anxiety and Depression After Stillbirth,”

Health and Social Care in the Community 17, no. 2 (2009): 167–176; quote p. 167.

43. DeFrain and others, “Psychological Effects of a

Stillbirth,” p. 87.

44. Merriam-Webster’s Collegiate Dictionary, 11th ed. (Springfi eld, Mass., 2003), p. 1248. Cf. Mark H. Beers

and others, eds., The Merck Manual of Diagnosis and Therapy, 18th ed. (Whitehouse Station, N.J.: Merck Research Laboratories, 2006), pp. 2402–2403.

45. See J. Rehmeyer, “Abated Breath: Serotonin Prob-

lems May Contribute to SIDS,” Science News 170, no. 19 (November 4, 2006): 294, and “Finding the Cause of

SIDS,” The Week (November 17, 2006), p. 22.

46. Judith A. Savage, Mourning Unlived Lives: A Psycho- logical Study of Childbearing Loss (Wilmette, Ill.: Chiron, 1989).

47. Savage, Mourning Unlived Lives, p. xiii.

48. Beverly Raphael, The Anatomy of Bereavement (New York: Basic Books, 1983), p. 229.

49. “Deaths by Age and Selected Causes: 2007,” Statisti- cal Abstract of the United States: 2012, 131st ed. (Washing- ton, D.C., 2011). http://www.census.gov/compendia/

statab/ .

50. Committee on Trauma Research, National

Research Council, Injury in America: A Continuing Public Health Problem (Washington, D.C.: National Academy Press, 1985).

51. Jerome L. Schulman, Coping with Tragedy: Success- fully Facing the Problem of a Seriously Ill Child (Chicago: Follett, 1976), p. 335. See also Marilyn McCubbin and

others, “Family Resiliency in Childhood Cancer,” Fam- ily Relations 51, no. 2 (2002): 103–111.

52. Kay Talbot, “Mothers Now Childless: Survival

After the Death of an Only Child,” Omega: Journal of Death and Dying 34, no. 3 (1996 –1997): 177–189. See also, by Talbot, What Forever Means After the Death of a Child.

53. Laura S. Smart, “The Marital Helping Relation-

ship Following Pregnancy Loss and Infant Death,”

Journal of Family Issues 13, no. 1 (1992): 81–98.

54. Dennis Klass, Parental Grief: Solace and Resolution (New York: Springer, 1988).

28. Leverett Millen and Samuel Roll, “Solomon’s

Mothers: A Special Case of Pathological Bereavement,”

American Journal of Orthopsychiatry 55, no. 3 (1985): 411–418.

29. Glen W. Davidson, “Death of a Wished-for Child: A

Case Study,” Death Education 1, no. 3 (1977): 265–275. See also Susan Roos, Chronic Sorrow: A Living Loss (New York: Brunner-Routledge, 2002).

30. Paul M. Insel and Walton T. Roth, Connect Core Concepts in Health, 13th ed. (New York: McGraw-Hill, 2013), p. 185.

31. Larry G. Peppers, “Grief and Elective Abortion:

Breaking the Emotional Bond?” Omega: Journal of Death and Dying 18, no. 1 (1987–1988): 1–12.

32. Simonds and Rothman, Centuries of Solace, p. 259.

33. Kenneth J. Doka, “Disenfranchised Grief ” (paper

presented at the annual meeting of the Association

for Death Education and Counseling, Atlanta, Spring

1986); and, edited by Doka, Disenfranchised Grief: New Directions, Challenges, and Strategies for Practice (Cham- paign, Ill.: Research Press, 2002).

34. See William R. LaFleur, Liquid Life: Abortion and Buddhism in Japan (Princeton, N.J.: Princeton Univer- sity Press, 1992). See also Dennis Klass and Amy Olwen

Heath, “Grief and Abortion: Mizuko Kuyo, the Japanese Ritual Resolution,” Omega: Journal of Death and Dying 34, no. 1 (1996 –1997): 1–14; and Takada Yoshihito

and James M. Vardaman, Jr., Talking about Buddhism (Tokyo: Kodansha, 1997), pp. 183–185.

35. Joanne Cacciatore, “The Silent Birth: A Feminist

Perspective,” Social Work 54, no. 1 ( January 2009): 91–95.

36. John DeFrain and others, “The Psychological

Effects of a Stillbirth on Surviving Family Members,”

Omega: Journal of Death and Dying 22, no. 2 (1990–1991): 81–108.

37. Joanne Cacciatore and Suzanne Bushfi eld, “Still-

birth: A Sociopolitical Issue,” Affi lia 23, no. 4 (2008): 378–387.

38. Joanne Cacciatore, Ingela Rådestad, and J.

Frederik Frøen, “Effects of Contact with Stillborn

Babies on Maternal Anxiety and Depression,” Birth 35, no. 4 (December 2008): 313–320; quote p. 313.

39. Irving G. Leon, “Perinatal Loss: Choreographing

Grief on the Obstetric Unit,” American Journal of Ortho- psychiatry 62, no. 1 (1992): 7–8.

40. Cacciatore, Rådestad, and Frøen, “Effects of Con-

tact with Stillborn Babies,” p. 319.

41. Jay Ruby, “Portraying the Dead,” Omega: Journal of Death and Dying 19, no. 1 (1988–1989): 1–20; and Joy

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Evaluation of Activity, Disengagement, and Continuity

Theories,” The Gerontologist 42, no. 4 (2002): 522–533; quote, p. 530.

67. See Karen L. Fingerman, “A Distant Closeness:

Intimacy Between Parents and Their Children in Later

Life,” Generations: Journal of the American Society on Aging 25, no. 2 (2001): 26 –33.

68. See Phyllis R. Silverman, Widow to Widow: How the Bereaved Help One Another, 2nd ed. (New York: Brun- ner-Routledge, 2004); and also by Silverman, “Widow-

hood as the Next Stage in the Life Cycle,” in Widows: North America, ed. Helena Z. Lopata (Durham, N.C.: Duke University Press, 1987), and “The Widow-to-

Widow Program: An Experiment in Preventive Inter-

vention,” Mental Hygiene 53, no. 3 (1969), a landmark report by Silverman on her work at Harvard Medical

School’s Laboratory of Community Psychiatry. See

also Helena Z. Lopata, Widowhood in an American City (Cambridge, Mass.: Schenkman, 1973), Women as Widows: Support Systems (New York: Elsevier, 1979), and Current Widowhood: Myths and Realities (Thousand Oaks, Calif.: Sage, 1996).

69. Joanne Lynn and David M. Anderson, Living Well at the End of Life: Adapting Health Care to Serious Chronic Illness in Old Age, ” Rand Health White Paper (Santa Monica, Calif.: Rand, 2003), p. 4.

70. Lynn and Anderson, Living Well at the End of Life, pp. 4–5.

71. Julia Holmes and others, “Aging Differently:

Physical Limitations Among Adults Aged 50 Years and

Over: United States, 2001–2007,” National Center for Health Statistics Data Brief, no. 20 ( July 2009).

72. R. A. Hope and others, Oxford Handbook of Clinical Medicine, 3rd ed. (Oxford: Oxford University Press, 1994), p. 64.

73. Insel and Roth, Connect Core Concepts in Health, pp.623–626.

74. F. David Martin, “Facing Death at 80: Memory and

the Holy,” Soundings: An Interdisciplinary Journal 83, no. 2 (Summer 2000): 301–330; quote p. 304.

75. Balk, “Life Span Issues and Loss, Grief, and

Mourning: Adulthood,” p. 168.

76. Martin, “Facing Death at 80,” p. 304. See also

Sharon R. Kaufman, The Ageless Self: Sources of Meaning in Later Life (Madison: University of Wisconsin Press, 1995).

77. Stedman’s Medical Dictionary, 26th ed. (Baltimore: Williams & Wilkins, 1995), p. 492; and Insel and Roth,

Connect Core Concepts in Health, p. 630.

78. Beers et al., The Merck Manual of Diagnosis and Therapy, p. 1815.

55. Joanne Cacciatore, John DeFrain, Kara L. C.

Jones, and Hawk Jones, “Stillbirth and the Couple:

A Gender-Based Exploration,” Journal of Family Social Work 11, no. 4 (2008): 351–372; esp. p. 354.

56. Kathleen R. Gilbert, “Interactive Grief and Cop-

ing in the Marital Dyad,” Death Studies 13, no. 6 (1989): 605–626. See also Kathleen R. Gilbert and Laura S.

Smart, Coping with Infant or Fetal Loss: The Couple’s Heal- ing Process (New York: Brunner/Mazel, 1992).

57. When a Child Dies: A Survey of Bereaved Parents (Oak Brook, Ill.: The Compassionate Friends, 2006).

58. Gordon Riches and Pam Dawson, “Communities

of Feeling: The Culture of Bereaved Parents,” Mortality 1, no. 2 (1996): 143–161.

59. Raphael, Anatomy of Bereavement, p. 177.

60. Savine Gross Weizman and Phyllis Kamm, About Mourning: Support and Guidance for the Bereaved (New York: Human Sciences, 1985), p. 130.

61. See Ira O. Glick, Robert S. Weiss, and Colin

Murray Parkes, The First Year of Bereavement (New York: Wiley, 1974), and its follow-up by Colin Murray Parkes

and Robert S. Weiss, Recovery from Bereavement (New York: Basic Books, 1983).

62. David E. Balk, “Life Span Issues and Loss, Grief,

and Mourning: Adulthood,” Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk,

157–169 (New York: Routledge, 2013), p.168.

63. Richard A. Settersten, Jr., “Social Sources of Mean-

ing in Later Life,” in Challenges of the Third Age, ed. Weiss and Bass.

64. Sara Wilcox and others, “The Effects of Widow-

hood on Physical and Mental Health, Health Behav-

iors, and Health Outcomes: The Women’s Health

Initiative,” Health Psychology 22, no. 5 (2003): 1–10.

65. Judith M. Stillion, Death and the Sexes: An Examination of Differential Longevity, Attitudes, Behaviors, and Coping Skills (Washington, D.C.: Hemisphere, 1985). See also Scott Campbell and Phyllis R. Silverman, Widower: When Men Are Left Alone (Amityville, N.Y.: Baywood, 1996); Luann M. Daggett, “Living with Loss: Middle-Aged Men

Face Spousal Bereavement,” Qualitative Health Research 12, no. 5 (2002): 625–639; Geraldine P. Mineau, Ken R.

Smith, and Lee L. Bean, “Historical Trends of Survival

Among Widows and Widowers,” Social Science & Medicine 54, no. 2 (2002): 245–254; and John M. O’Brien, Linda

M. Forrest, and Ann E. Austin, “Death of a Partner: Per-

spectives of Heterosexual and Gay Men,” Journal of Health Psychology 7, no. 3 (2002): 317–328.

66. Rebecca L. Utz and others, “The Effect of Wid-

owhood on Older Adults’ Social Participation: An

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97. Rosenberg, Thinking Clearly About Death, pp. 211–212.

98. Allan Kellehear, “Dying Alone—and Preferably Alone? Agency, Resistance, and Dissent at the End of

Life,” International Journal of Ageing and Later Life 4, no. 1 (2009): 5–21.

99. Jane W. Peterson, “Age of Wisdom: Elderly Black

Women in Family and Church,” in The Cultural Context of Aging: Worldwide Perspectives, ed. Jay Sokolovsky (New York: Bergin & Garvey, 1990), pp. 213–227.

100. See, for example, Cesare Marino, “Honor the

Elders: Symbolic Associations with Old Age in Tradi-

tional Eastern Cherokee Culture,” Journal of Cherokee Studies 13 (1988): 3–18.

101. Robert N. Butler, Why Survive? Being Old in America (New York: Harper & Row, 1975); quote p. 421. See also Robert N. Butler. The Longevity Revolution: The Benefi ts and Challenges of Living a Long Life. New York: Public Affairs, 2008.

102. Butler, Why Survive?, p. 422.

C H A P T E R 1 2

1. Judith M. Stillion, “Premature Exits: Understand-

ing Suicide,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland, 182–197 (Mountain View, Calif.: Mayfi eld,

1995), p. 182.

2. Kay Redfi eld Jamison, Night Falls Fast: Understanding Suicide (New York: Knopf, 1999), p. 292.

3. Mark H. Beers and others, eds., The Merck Manual of Diagnosis and Therapy, 18th ed. (Whitehouse Station, N.J.: Merck Research Laboratories, 2006), p. 1741.

4. Donna L. Hoyert and Jiaquan Xu, “Deaths: Pre-

liminary Data for 2011,” National Vital Statistics Reports 61, no. 6 (Hyattsville, Md.: National Center for Health

Statistics, 2012), p. 4.

5. “Deaths and Death Rates by Leading Causes of

Death and Age: 2007,” Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011). http:// www.census.gov/compendia/statab/ .

6. Beers and others, eds., The Merck Manual of Diagno- sis and Therapy, p. 1741.

7. News Release, Substance Abuse and Mental Health

Services Administration, September 17, 2009, www

.samha.gov .

8. Edwin S. Shneidman, Comprehending Suicide: Land- marks in 20th Century Suicidology (Washington, D.C.: American Psychological Association, 2001), p. 154.

79. Betzaida Tejada-Vera, “Mortality from Alzheimer’s

Disease in the United States: Data for 2000 and 2010,”

NCHS Data Brief, no. 116 (Hyattsville, Md.: National Center for Health Statistics, 2013), p. 1.

80. Stedman’s Medical Dictinoary, p. 492.

81. Leon Kass, Chairman, President’s Council on

Bioethics, “Letter of Transmittal,” Taking Care: Ethical Caregiving in Our Aging Society, September 2005. http:// bioethics.georgetown.edu/pcbe/reports/taking_care/

taking_care.pdf .

82. Gary R. VanderBos, ed., APA Dictionary of Psychol- ogy (Washington, D.C.: American Psychological Asso- ciation, 2007), p. 408.

83. Chris Wilson, “The Century Ahead,” Daedalus 135, no. 1 (Winter 2006): 5–8.

84. James M. Henslin, Sociology: A Down-to-Earth Approach, 9th ed. (Boston: Pearson, 2008), p. 377.

85. See Stanley Brandes, Forty: The Age and the Symbol (Nashville: University of Tennessee Press, 1985).

86. Bernice L. Neugarten, “Growing as Long as We

Live,” Second Opinion 15 (November 1990): 42–51.

87. James F. Fries, Lawrence W. Green, and Sol

Levine, “Health Promotion and the Compression of

Morbidity,” Lancet (March 4, 1989): 481–483; see also, by Fries, “The Compression of Morbidity,” Milbank Memorial Fund Quarterly 61 (1983): 397–419.

88. Insel and Roth, Connect Core Concepts in Health, p. 632.

89. Bert Hayslip, Jr., Julie Hicks Patrick, and Paul E.

Panek, Adult Development and Aging, 5th ed. (Malabar, Fla.: Krieger, 2011), p. 15.

90. Neugarten, “Growing as Long as We Live.”

91. Sandra L. Bertman, “Aging Grace: Treatment of

the Aged in the Arts,” Death Studies 13, no. 6 (1989): 517–535. See also Pamela T. Amoss and Steven

Harrell, eds., Other Ways of Growing Old: Anthropologi- cal Perspectives (Palo Alto, Calif.: Stanford University Press, 1981).

92. Robert C. Atchley, Spirituality and Aging (Balti- more: Johns Hopkins University Press, 2009), p. 4.

93. Diana Athill, Somewhere Towards the End: A Memoir (New York: Norton, 2009), p. 177.

94. Athill, Somewhere Towards the End, p. 180.

95. Daniel Callahan, “Can Old Age Be Given a Public

Meaning?” Second Opinion 15 (November 1990): 12–23.

96. Jay F. Rosenberg, Thinking Clearly About Death (Englewood Cliffs, N.J.: Prentice-Hall, 1983), p. 208.

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Autopsy: Clinical and Legal Perspectives”; and Charles

C. Thompson II, A Glimpse of Hell: The Explosion on the USS Iowa and Its Cover-Up (New York: Norton, 1999).

22. Quoted material from Poythress and others,

“APA’s Expert Panel.”

23. See David A. Brent, “The Psychological Autopsy:

Methodological Considerations for the Study of Ado-

lescent Suicide,” Suicide and Life-Threatening Behavior 19 (Spring 1989): 43–57; and Mohammad Shafi and

others, “Psychological Autopsy of Completed Suicide

in Children and Adolescents,” American Journal of Psy- chiatry 142 (1985): 1061–1064.

24. Heidi Hjelmeland and others, “Psychological

Autopsy Studies as Diagnostic Tools: Are They Meth-

odologically Flawed?” Death Studies 36, no. 7 (2012): 605–626.

25. David Lester, “Theories of Suicide,” in Suicide Among Racial and Ethnic Minority Groups: Theory, Research, and Practice, ed. Frederick T. L. Leong and Mark M. Leach, pp. 39–53 (New York: Routledge);

quote p. 44.

26. Roy F. Baumeister, “Suicide as Escape from Self,”

Psychological Review 97 (1990): 90–113; and Lester, “Theories of Suicide,” p. 51

27. Emile Durkheim, Suicide: A Study in Sociology (New York: Free Press, 1951).

28. Thomas Joiner, Why People Die by Suicide (Cam- bridge, Mass.: Harvard University Press, 2005), p. 34.

29. Norman Farberow, “The History of Suicide,” in

Evans and Farberow, Encyclopedia of Suicide, p. viii.

30. Jack Seward, Hara-Kiri: Japanese Ritual Suicide (Rutland, Vt.: Charles E. Tuttle, 1968). See also Robert

Jay Lifton, Shuichi Kato, and Michael R. Reich, Six Lives, Six Deaths: Portraits from Modern Japan (New Haven, Conn.: Yale University Press, 1979).

31. See Jerome Young, “Morals, Suicide, and Psychia-

try: A View from Japan,” Bioethics 16, no. 5 (2002): 412–424.

32. See Catherine Weinberger-Thomas, Ashes of Immor- tality: Widow-Burning in India (Chicago: University of Chicago Press, 1999).

33. Jeffrey W. Riemer, “Durkheim’s ‘Heroic Suicide’

in Military Combat,” Armed Forces & Society 25, no. 1 (1998): 103–120. See also Albert Axell, “The Kamikaze

Mindset,” History Today 52, no. 9 (2002): 3–4; and Bernard Millot, Divine Thunder: The Life and Death of the Kamikazes (New York: McCall, 1971).

34. Iginia Mancinelli and others, “Mass Suicide: His-

torical and Psychodynamic Considerations,” Suicide and Life-Threatening Behavior 32, no. 1 (2002): 91–100.

9. Jamison, Night Falls Fast, p. 291.

10. Stefan Timmermans, Postmortem: How Medical Examiners Explain Suspicious Deaths (Chicago: Univer- sity of Chicago Press, 2006), p. 92.

11. Quoted in Timmermans, Postmortem, p. 96.

12. Glen Evans and Norman L. Farberow, The Encyclo- pedia of Suicide (New York: Facts on File, 1988), p. 268.

13. See Robert J. Homant and Daniel B. Kennedy,

“Suicide by Police: A Proposed Typology of Law

Enforcement Offi cer-Assisted Suicide,” Policing: An International Journal of Police Strategies & Management 23, no. 3 (2000): 339–355; and Vivian B. Lord, “Law

Enforcement-Assisted Suicide,” Criminal Justice and Behavior 27, no. 3 (2000): 401–419.

14. Julia Dahl, “How to Stop Suicide by Cop,” Miller- McCune (March-April 2011), pp. 66 –73.

15. Katherine Van Wormer and Chuk Odiah, “The

Psychology of the Suicide-Murder and the Death

Penalty,” Journal of Criminal Justice 27, no. 4 (1999): 361–370.

16. Timmermans, Postmortem, p. 185.

17. Edwin S. Shneidman, “Suicide,” in Death: Current Perspectives, 2nd ed., ed. Shneidman (Mountain View, Calif.: Mayfi eld, 1980), p. 432.

18. James R. P. Ogloff and Randy K. Otto, “Psychologi-

cal Autopsy: Clinical and Legal Perspectives,” Saint Louis University Law Journal 37, no. 3 (Spring 1993): 607–646. See also Edwin S. Shneidman, Clues to Suicide (New York: McGraw-Hill, 1957); and, by Avery D. Weisman, The Psychological Autopsy (New York: Human Sciences Press, 1968) and The Realization of Death: A Guide for the Psycho- logical Autopsy (Northvale, N.J.: Aronson, 1974).

19. For an example of the data-gathering approach

used in psychological autopsies, see Tracy L. Cross,

Karyn Gust-Brey, and P. Bonny Ball, “A Psychological

Autopsy of the Suicide of an Academically Gifted Stu-

dent: Researchers’ and Parents’ Perspectives,” Gifted Child Quarterly 46, no. 4 (2002): 247–264.

20. Thomas J. Young, “Procedures and Problems in

Conducting a Psychological Autopsy,” International Journal of Offender Therapy and Comparative Criminology 36, no. 1 (Spring 1992): 43–52.

21. See Norman Poythress and others, “APA’s Expert

Panel in the Congressional Review of the USS ‘Iowa’

Incident,” American Psychologist 48, no. 1 ( January 1993): 8–15; Randy K. Otto and others, “An Empirical

Study of the Reports of APA’s Peer Review Panel in the

Congressional Review of the U.S.S. IOWA Incident,”

Journal of Personality Assessment 61, no. 3 (December 1993): 425–442; Ogloff and Otto, “Psychological

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654 n o t e s

Based Assessment of Suicide Risk,” in Suicidal Behavior: Assessment of People-at-Risk, ed. Updesh Kumar and Manas K. Mandel, 20–41 (Los Angeles: Sage, 2010), p. 25.

51. See, for example, Danny Nugus, “Choosing Life,”

Counseling Children and Young People (March 2009): 32–37.

52. Ronald W. Maris, Pathways to Suicide: A Survey of Self- Destructive Behaviors (Baltimore: Johns Hopkins Univer- sity Press, 1981), and Understanding and Preventing Suicide (New York: Guilford Press, 1988). On the ambiguity

concerning the degree of self-harm intended in suicide

attempts, see Barry M. Wagner, Steven A. Wong, and

David A. Jobes, “Mental Health Professionals’ Determi-

nations of Adolescent Suicide Attempts,” Suicide and Life- Threatening Behavior 32, no. 3 (2002): 284–300.

53. Evans and Farberow, Encyclopedia of Suicide, p. 21.

54. Edwin S. Shneidman, Deaths of Man (New York: Quadrangle Books, 1973), pp. 81–90.

55. Kathleen Erwin, “Interpreting the Evidence: Com-

peting Paradigms and the Emergence of Lesbian and

Gay Suicide as a ‘Social Fact,’” in The Path Ahead, ed. DeSpelder and Strickland, pp. 211–220.

56. Kevin E. Early and Ronald L. Akers, “‘It’s a White

Thing’—An Exploration of Beliefs About Suicide in

the African-American Community,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 198–210. See also

Kevin E. Early, Religion and Suicide in the African-Ameri- can Community (Westport, Conn.: Greenwood, 1992).

57. Brian Barry, “Suicide: The Ultimate Escape,” Death Studies 13, no. 2 (1989): 185–190; quote p. 188.

58. See Alfred Alvarez, The Savage God: A Study of Sui- cide (New York: Random House, 1971).

59. Susan L. Ruth, “Suicide Rates Among Military

Family Members Are On the Rise,” Washington Times ( June 17, 2013).

60. Ann Scott Tyson and Greg Jaffe, “Generals Find

Suicide a Frustrating Enemy,” The Washington Post (May 23, 2009).

61. Committee on the Assessment of Readjustment

Needs of Military Personnel, Veterans, and Their

Families, Returning Home from Iraq and Afghanistan (Washington, D.C.: National Academies Press, 2013),

pp. 110, 120.

62. Committee, Returning Home from Iraq and Afghani- stan, p. 111.

63. Douglas MacArthur, “Duty, Honor, Country”

(speech upon receipt of the Sylvanus Thayer Award for

outstanding service to the nation, United States

Military Academy, West Point, May 12, 1962). http://

www.nationalcenter.org/MacArthurFarewell.html .

35. See David Chidester, Salvation and Suicide: An Inter- pretation of Jim Jones, the Peoples Temple, and Jonestown (Bloomington: Indiana University Press, 1988); Jose I.

Lasaga, “Death in Jonestown: Techniques of Political

Control by a Paranoid Leader,” Suicide and Life-Threat- ening Behavior 10, no. 4 (1980): 210–213; and Richard H. Seiden, “Reverend Jones on Suicide,” Suicide and Life-Threatening Behavior 9, no. 2 (1979): 116 –119. For an overview of mass suicide, see Iginia Manci-

nelli, Anna Comparelli, Paolo Girardi, and Roberto

Tatarelli, “Mass Suicide: Historical and Psychodynamic

Considerations,” Suicide and Life-Threatening Behavior 32, no. 1 (2002): 91–100.

36. Susan Raine, “Reconceptualizing the Human

Body: Heaven’s Gate and the Quest for Divine Trans-

formation,” Religion 35 (2005): 98–117.

37. Andrew Selsky and Jennifer Loven, “3 Gitmo

Inmates Hanged Themselves,” Associated Press Online, June 10, 2006.

38. Edwin S. Shneidman, “Suicide,” Encyclopedia Bri- tannica, vol. 21 (Chicago: William Benton, 1973), p. 385.

39. Erwin Stengel, “A Matter of Communication,” in

On the Nature of Suicide, ed. Edwin S. Shneidman (San Francisco: Jossey-Bass, 1969), pp. 78–79.

40. Sam Silverman, “The Death of Socrates: A Holistic

Re-Examination,” Omega: Journal of Death and Dying 61, no. 1 (2010): 71–84.

41. Edwin S. Shneidman, “Suicide as Psychache,” Jour- nal of Nervous and Mental Disease 181, no. 3 (1993): 147– 149, and “Some Controversies in Suicidology: Toward

a Mentalistic Discipline,” Suicide and Life-Threatening Behavior 23, no. 4 (1993): 292–298.

42. Shneidman, Comprehending Suicide, p. 200.

43. Edwin S. Shneidman, personal communication.

44. Shneidman, Comprehending Suicide, pp. 202–203.

45. Thomas Joiner, Why People Die By Suicide (Cam- bridge, Mass.: Harvard University Press, 2005), p. 201.

46. J. John Mann and others, “The Neurobiology of

Suicide Risk: A Review for the Clinician,” Journal of Clinical Psychiatry 60, Supplement 2 (1999): 7–11.

47. C. G. Prado, The Last Choice: Preemptive Suicide in Advanced Age, 2nd ed. (Westport, Conn.: Greenwood, 1998), p. 6.

48. “Suicide Epidemic,” The Week, August 5, 2005.

49. Roy F. Baumeister, “Suicide as Escape from Self,”

Psychological Review 97 (1990): 90–113.

50. Quoted material from Chad E. Morrow, Craig J.

Bryan, and Kathryn Kanzler Appolonio, “Empirically

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76. Lennings, “A Cognitive Understanding of Adoles-

cent Suicide.”

77. See M. S. Gould, S. Wallenstein, and L. David-

son, “Suicide Clusters: A Critical Review,” Suicide and Life-Threatening Behavior 19 (Spring 1989): 17–29; and James A. Mercy and others, “Is Suicide Contagious?

A Study of the Relation Between Exposure to the Sui-

cidal Behavior of Others and Nearly Lethal Suicide

Attempts,” American Journal of Epidemiology 154, no. 2 (2001): 120–127.

78. Examples from Evans and Farberow, Encyclopedia of Suicide, pp. 26 –27, 72, 254.

79. Bruce L. Danto, Mark L. Taff, and Lauren R.

Boglioli, “Graveside Deaths,” Omega: Journal of Death and Dying 33, no. 4 (1996): 265–278.

80. Ayumi Naito, “Internet Suicide in Japan: Impli-

cations for Child and Adolescent Mental Health,”

Clinical Child Psychology and Psychiatry 12, no. 4 (2007): 583–597.

81. Jason B. Luoma and Jane L. Pearson, “Suicide and

Marital Status in the United States, 1991–1996: Is Wid-

owhood a Risk Factor?” American Journal of Public Health 92, no. 9 (2002): 1518–1522.

82. Benjamin N. Shain and the Committee on Adoles-

cence, “Suicide and Suicide Attempts in Adolescents,”

Pediatrics 120 (2007): 669–676.

83. Y. Conwell and J. L. Pearson, “Suicidal Behaviors

in Older Adults,” American Journal of Geriatric Psychiatry 10, no. 4 (2002): 359–361; and, in the same issue, C. L.

Turvey and others, “Risk Factors for Late-Life Suicide:

A Prospective, Community-Based Study,” pp. 398–406.

84. Susanne S. Carney and others, “Suicide over 60:

The San Diego Study,” Journal of the American Geriatrics Society 42 (1994): 174–180.

85. J. Conrad Glass, Jr., and Susan E. Reed, “To Live

or Die: A Look at Elderly Suicide,” Educational Gerontol- ogy 19 (1993): 767–778.

86. Judith M. Stillion, Eugene E. McDowell, and

Jacque H. May, Suicide Across the Life Span: Premature Exits (New York: Hemisphere, 1989), pp. 180–181.

87. Antoon A. Leenaars and David Lester, “The

Signifi cance of the Method Chosen for Suicide in

Understanding the Psychodynamics of the Suicidal

Individual,” Omega: Journal of Death and Dying 19, no. 4 (1988–1989): 311–314.

88. Edwin S. Shneidman, “Self-Destruction: Suicide

Notes and Tragic Lives,” in Death: Current Perspectives, 2nd ed., ed. Shneidman, p. 467; and, by Shneidman,

“A Bibliography of Suicide Notes: 1856 –1979,” in Sui- cide and Life-Threatening Behavior 9, no. 1 (Spring 1979): 57–59.

64. Tara Bahrampour, “Baby Boomers Are Killing

Themselves at an Alarming Rate, Raising Question:

Why?” Washington Post. http://www.washingtonpost .com/local/baby-boomers-are-killing-themselves-at-

an-alarming-rate-begging-question-why/2013/06/03/

d98acc7a-c41f-11e2-8c3b-0b5e9247e8ca_story.html .

65. See Julie A. Phillips and others, “Understanding

Recent Changes in Suicide Rates Among the Middle-

Aged: Period or Cohort Effects?” Public Health Reports 125, no. 5 (2010): 680–688.

66. Louise B. Andrew, “Physician Suicide,”

eMedicine, July 10, 2008, http://emedicine.medscape. com/article/806779-overview .

67. Donald H. Rubinstein, “Epidemic Suicide Among

Micronesian Adolescents,” Social Science & Medicine 17 (1983): 657–665, and “Suicide in Micronesia,” in Cul- ture, Youth and Suicide in the Pacifi c: Papers from an East- West Center Conference, ed. Francis X. Hezel, Donald H. Rubinstein, and Geoffrey M. White (Honolulu: Pacifi c

Islands Study Program, University of Hawaii, 1985),

pp. 88–111.

68. Thomas Joiner, Lonely at the Top: The High Cost of Men’s Success (New York: Palgrave Macmillan, 2011), p. 45

69. Cynthia R. Pfeffer and others, “Suicidal Children

Grow Up: Suicidal Episodes and Effects of Treatment

During Follow-Up,” Journal of the American Academy of Child and Adolescent Psychiatry 33, no. 2 (1994): 225–230.

70. See Brian L. Mishara, “Conceptions of Death and

Suicide in Children Ages 6 –12 and Their Implications

for Suicide Prevention,” Suicide and Life-Threatening Behavior 29, no. 2 (1999): 105–118.

71. C. J. Lennings, “A Cognitive Understanding of

Adolescent Suicide,” Genetic, Social, and General Psychol- ogy Monographs 120, no. 3 (1994): 289–307.

72. David A. Brent and others, “Stressful Life Events:

Psychopathology and Adolescent Suicide: A Case Con-

trol Study,” Suicide and Life-Threatening Behavior 23, no. 3 (1993): 179–187. See also Stephen Briggs, “Working

with the Risk of Suicide in Young People,” Journal of Social Work Practice 16, no. 2 (2002): 135–148.

73. Kristi Kendrick and others, “Bullying, Cyberbully-

ing, and Teen Suicidality: Results from the 2011 Youth

Risk Behavior Survey,” APA 2013, Abstract NR7-13.

74. Herbert Hendin, “Psychodynamics of Suicide, with

Particular Reference to the Young,” American Journal of Psychiatry 148, no. 9 (1991): 1150–1158.

75. Paulina F. Kernberg, “Psychological Interventions

for the Suicidal Adolescent,” American Journal of Psycho- therapy 48, no. 1 (1994): 52–63.

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656 n o t e s

106. Jack D. Douglas, The Social Meanings of Suicide (Princeton, N.J.: Princeton University Press, 1967),

pp. 324ff.

107. Stillion, McDowell, and May, Suicide Across the Life Span, p. 24.

C H A P T E R 1 3

1. From Letters of E. B. White, collected and edited by Dorothy Lobrano Guth (New York: Harper & Row,

1976), p. 558.

2. Anthony Giddens, Runaway World: How Globalization Is Reshaping Our Lives (New York: Routledge, 2000), p. 52.

3. See Jerome Rosenberg and Dennis L. Peck, “Mega-

deaths,” in Handbook of Death & Dying, 223–235, edited by Clifton D. Bryant (Thousand Oaks, Calif.: Sage,

2003).

4. Paul M. Insel and Walton T. Roth, Connect Core Concepts in Health, 13th ed. (New York: McGraw-Hill, 2013), p. 592.

5. Insel and Roth, Connect Core Concepts in Health, p. 593.

6. Insel and Roth, Connect Core Concepts in Health, p. 259.

7. “Auto Club Analysis Shows that California Teens

15–17 at Fault in 68 Percent of Fatal Crashes,” Santa Cruz Sentinel, January 19, 2006.

8. Louis A. Gamino and R. Hal Ritter, Jr., Ethical Practice in Grief Counseling (New York: Springer, 2009), p. 286.

9. Robert Kastenbaum and Ruth Aisenberg, The Psy- chology of Death: Concise Edition (New York: Springer, 1976), p. 319. See also Alan E. Stewart and Janice

Harris Lord, “Motor Vehicle Crash Versus Accident: A

Change in Terminology Is Necessary,” Journal of Trau- matic Stress 15, no. 4 (2002): 333–335.

10. Giddens, Runaway World, p. 40.

11. Garance Burke, “Hip-Hop Car Stunt Leaves Two

Dead,” Santa Cruz Sentinel, December 29, 2006.

12. Kawahito Hiroshi, “Death and the Corporate War-

rior,” Japan Quarterly 38 (April–June 1991): 149–157.

13. Reinhold Messner, quoted in Caroline Alexander,

“Greatest Mountaineer,” National Geographic 210, no. 5 (November 2006): 44.

14. James A. Thorson and F. C. Powell, “To Laugh in

the Face of Death: The Games That Lethal People

Play,” Omega: Journal of Death and Dying 21, no. 3 (1990): 225–239.

89. Beers and others, eds., The Merck Manual of Diagno- sis and Therapy, p. 1741.

90. Stephen T. Black, “Comparing Genuine and

Simulated Suicide Notes: A New Perspective,” Journal of Consulting and Clinical Psychology 61, no. 4 (1993): 699–702.

91. Shneidman, Comprehending Suicide, pp. 167, 170.

92. Evans and Farberow, Encyclopedia of Suicide, p. 187.

93. Stillion, McDowell, and May, Suicide Across the Life Span, p. 13.

94. Stillion, McDowell, and May, Suicide Across the Life Span, p. 194.

95. D. Lizardi and R. E. Golding, “Religion and Sui-

cide: Buddhism, Native American and African Reli-

gions, Atheism, and Agnosticism,” Journal of Religion and Health 49 (2010): 377–384.

96. Patrick W. O’Carroll, Morton M. Silverman, and

Alan L. Berman, “Community Suicide Prevention:

The Effectiveness of Bridge Barriers,” Suicide and Life- Threatening Behavior 24, no. 1 (Spring 1994): 89–99.

97. Antoon A. Leenaars, “Crisis Intervention with

Highly Lethal Suicidal People,” Death Studies 18, no. 4 (1994): 341–360.

98. Robert A. Neimeyer and Angela M. Pfeiffer, “The

Ten Most Common Errors of Suicide Interventionists,”

in Treatment of Suicidal People, ed. Antoon A. Leenaars, John T. Maltsberger, and Robert A. Neimeyer, 207–224

(Washington, D.C.: Taylor & Francis, 1994), pp. 210, 212.

99. Kenneth J. Doka, Counseling Individuals with Life- Threatening Illness (New York: Springer, 2009), p. 206.

100. Shneidman, Comprehending Suicide, p. 203.

101. See Alison Wertheimer, A Special Scar: The Experi- ences of People Bereaved by Suicide, 2nd ed. (Philadelphia: Brunner-Routledge, 2001).

102. Joan Wickersham, The Suicide Index: Putting My Father’s Death in Order (New York: Harcourt, 2008), p. 158.

103. See Charles P. McDowell, Joseph M. Rothberg,

and Ronald J. Koshes, “Witnessed Suicides,” Suicide and Life-Threatening Behavior 24, no. 3 (1994): 213–223.

104. Evans and Farberow, Encyclopedia of Suicide, pp. 58–59, 63.

105. Adam H. Beasley, David Smiley, and Evan S.

Benn, “Pembroke Pines Teen Broadcasts Suicide on

Webcam,” Miami Herald Online (November 21, 2008); and Fred Tasker, “Teen’s Webcam Suicide Raises Red

Flags for Copycats, Experts Say,” Miami Herald Online (November 22, 2008).

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Christopher Cooper and Robert Block, Disaster: Hur- ricane Katrina and the Failure of Homeland Security (New York: Times Books, 2006).

31. U.S. Senate, Hurricane Katrina, p. 2.

32. Neil Thompson, “The Ontology of Disaster,”

Death Studies 19, no. 5 (1995): 501–510. See also Inter- national Work Group on Death, Dying, and Bereave-

ment, “Assumptions and Principles about Psychosocial

Aspects of Disasters,” Death Studies 26, no. 6 (2002): 449–462.

33. Jennifer L. Matheson, “Assessment and Interven-

tion in the Family and Larger Systems,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 245–254 (New York: Routledge, 2013),

p. 251.

34. Mark Creamer, Director of Australian Center for

Posttraumatic Mental Health, “An Initial Focus on the

Trauma May Damage the Recovery Process,” The Age, http://www.theage.com.au/federal-politics/counsel-

ling-must-hit-the-right-targets-20090209-8287.html .

35. Pan American Health Organization, Management of Dead Bodies in Disaster Situations (Washington, D.C.: PAHO, 2004), p. xi.

36. Fran H. Norris, Matthew J. Friedman, and Patricia

J. Watson, “60,000 Disaster Victims Speak, Parts I and

II,” Psychiatry 65, no. 3 (2002): 207–260.

37. Pan American Health Organization, Management of Dead Bodies in Disaster Situations; see also Oliver Morgan, ed., Management of Dead Bodies After Disasters: A Field Manual for First Responders (Washington, D.C.: PAHO, 2006).

38. Bruce Jennings, “Disaster Planning and Public

Health,” The Hastings Center Bioethics Briefi ng Book, 41–44 (Garrison, N.Y.: The Hastings Center, 2009).

39. David K. Meagher, “Ethical and Legal Issues in

Traumatic Death,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 311–320; p. 315.

40. Beverly McLeod, “In the Wake of Disaster,” Psychol- ogy Today, October 1984, pp. 54–57.

41. “Murder Victims—Circumstances and Weapons

Used or Cause of Death,” Statistical Abstract of the United States: 2012, 131st ed. (Washington, D.C., 2011). http:// www.census.gov/compendia/statab/ .

42. “‘Vietnam Style’ Triage Techniques Used to Treat

Urban Assault Weapon Injuries,” Bulletin of the Park Ridge Center (May 1989): 11–12.

43. See Ronald K. Barrett, “Urban Adolescent Homi-

cidal Violence: An Emerging Public Health Concern,”

Urban League Review 16, no. 2 (1993): 67–75.

15. Baruch Fischhoff and John Kadvany, Risk: A Very Short Introduction (New York: Oxford University Press, 2011), p. 90.

16. Kenneth J. Doka, Eric C. Schwartz, and Catherine

Schwarz, “Risky Business: Observations on the Nature

of Death in Hazardous Sports,” Omega: Journal of Death and Dying 21, no. 3 (1990): 215–223.

17. Highlighting Japan (March 2013), p. 6.

18. National Police Agency of Japan. http://www.npa

.go.jp/archive/keibi/biki/higaijokyo_e.pdf .

19. Lucille Craft, “Japan’s Nuclear Refugees,” National Geographic (December 2011): 92–111

20. “Hot Spots and Blind Spots,” The Economist (December 8, 2011), p. 54. See also Evan Osnos, “The

Fallout,” The New Yorker (October 17, 2011), pp. 46 –61.

21. Compiled from Edward Wong, “China Begins

Burying Its Unknown Quake Victims,” International Herald Tribune, February 12, 2009; and Brian Hen- nessy, “Earthquake in Sichuan, China: The After-

math,” On Line Opinion, http://www.onlineopinion .com.au/view.asp?article 5 8437 .

22. Compiled from Australian news reports provided

by Rose Cooper, who provides grief support services in

Ocean Grove, Australia.

23. Carl Lindahl, “Legends of Hurricane Katrina: The

Right to Be Wrong, Survivor-to-Survivor Storytelling,

and Healing,” Journal of American Folklore 125 (2012): 139–176; esp. p. 171.

24. William Greider, Introduction: “Who Will Protect

the Working Girl,” in The Triangle Fire, by Leon Stein, v–xvi (Ithaca, N.Y.: Cornell University Press, 2001).

25. Charles Perrow, Normal Accidents: Living with High- Risk Technology (New York: Basic Books, 1984).

26. Malcolm Gladwell, “Blowup,” The New Yorker, January 22, 1996, pp. 32–36.

27. John Maurice, “Mitigating Disasters—A Promis-

ing Start,” The Lancet 381, issue 9878 (May 11, 2913): 1611–1613.

28. Robert I. Tilling, U.S. Geological Survey, Eruptions of Mount St. Helens: Past, Present, and Future (Washing- ton, D.C.: Government Printing Offi ce, n.d.).

29. Philip Sarre, “Natural Hazards,” in Key Ideas in Human Thought, ed. Kenneth McLeish, 502–504 (New York: Facts on File, 1993).

30. U.S. Senate, Committee on Homeland Secu-

rity and Governmental Affairs, Hurricane Katrina: A Nation Still Unprepared (Washington, D.C.: Gov- ernment Printing Offi ce, 2006), p. 21. See also

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55. See International Work Group on Death, Dying,

and Bereavement, “Breaking the Cycles of Violence,”

Death Studies 29, no. 7 (2005): 585–600; and “Armed Confl ict: A Model for Understanding and Interven-

tion,” Death Studies 37, no. 1 (2013): 61–88.

56. Robert J. Sampson, Stephen W. Raudenbush, and

Felton Earls, “Neighborhoods and Violent Crime: A

Multilevel Study of Collective Effi cacy,” Science 277 (August 15, 1997): 918–923.

57. Cohen and Swift, “A Public Health Approach to

the Violence Epidemic in the United States.”

58. Arnold Toynbee, “Death in War,” in Death and Dying: Challenge and Change, ed. Robert Fulton and oth- ers (Reading, Mass.: Addison-Wesley, 1978), p. 367.

59. James Lachlan Macleod, “‘Greater Love Hath No

Man Than This’: Scotland’s Confl icting Religious

Reponses to Death in the Great War,” Scottish Historical Review 81, no. 211 (April 2002): 70–96; quote p. 70.

60. Dalton Trumbo, Johnny Got His Gun (New York: Bantam Books, 1970), pp. 214, 224.

61. United Nations Population Fund, “Overview of

Adolescent Life,” State of World Population 2003, http:// www.unfpa.org/swp/2003/english/ch1/index.htm.

62. Sam Keen, Faces of the Enemy: Refl ections of the Hostile Imagination (San Francisco: Harper & Row, 1986), p. 71.

63. Gil Elliot, “Agents of Death,” in Death: Current Per- spectives, 3rd ed., ed. Edwin S. Shneidman (Mountain View, Calif.: Mayfi eld, 1984), pp. 422–440.

64. Gus Martin, Understanding Terrorism: Challenges, Perspectives, and Issues, 3rd ed. (Thousand Oaks, Calif.: Sage, 2010), p. 31.

65. Andrea Fontana and Jennifer Reid Keene, Death and Dying in America (Malden, Mass.: Polity, 2009), p. 131.

66. Elliot, “Agents of Death,” pp. 422–440.

67. Quoted in Shono Naomi, “Mute Reminders

of Hiroshima’s Atomic Bombing,” Japan Quarterly ( July–September 1993): 267–272. See also Robert Jay

Lifton, “Psychological Effects of the Atomic Bomb

in Hiroshima: The Theme of Death,” in The Threat of Impending Disaster: Contributions to the Psychology of Stress, ed. George H. Grosser, Henry Wechsler, and Milton

Greenblatt (Cambridge, Mass.: MIT Press, 1964),

pp. 152–193.

68. Robert Jay Lifton and Eric Olson, Living and Dying (New York: Praeger, 1974), p. 32.

69. Ward Wilson, Five Myths about Nuclear Weapons (Boston: Houghton Miffl in, 2013), p. 32.

44. American Medical Association, Council on Scien-

tifi c Affairs, “Firearms Injuries and Deaths: A Critical

Public Health Issue,” Public Health Reports 104 (1989): 111–120. See also Leland Ropp and others, “Death in

the City: An American Childhood Tragedy,” Journal of the American Medical Association 267, no. 21 (1992): 2905–2910.

45. Ice-T, “The Killing Fields,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland, 178–181 (Mountain View,

Calif.: Mayfi eld, 1995).

46. Mitch Albom, “Random Shooting Paralyzes

Football Player,” Detroit Free Press, December 28, 1994, p. C1.

47. Bruce L. Danto, Mark L. Taff, and Lauren R.

Boglioli, “Graveside Deaths,” Omega: Journal of Death and Dying 33, no. 4 (1996): 265–278.

48. Quoted in Drew Leder, “Guns and Voices,” Second Opinion 20, no. 2 (1994): 83–89.

49. Betsy McAlister Groves and others, “Silent Victims:

Children Who Witness Violence,” Journal of the Ameri- can Medical Association 269, no. 2 (1993): 262–264.

50. Larry Cohen and Susan Swift, “A Public Health

Approach to the Violence Epidemic in the United

States,” Environment and Urbanization 5, no. 2 (1993): 50–66. See also Mary R. Jackman, “Violence in Social

Life,” Annual Review of Sociology 28 (2002): 387–415; and Stephen J. Morewitz, Death Threats and Violence: New Research and Clinical Perspectives (New York: Springer, 2008).

51. Dana D. DeHart and John M. Mahoney, “The

Serial Murderer’s Motivations: An Interdisciplinary

Review,” Omega: Journal of Death and Dying 29, no. 1 (1994): 29–45. See also T. D. Dogra and others, “A

Psychological Profi le of a Serial Killer: A Case Report,”

Omega: Journal of Death and Dying 65, no. 4 (2012): 299–316.

52. Discussion based on Albert Lee Strickland, “Famil-

icide,” in The A-Z of Death & Dying: Social, Medical, and Cultural Aspects, ed. Michael John Brennan (Santa Barbara, Calif.: ABC-Clio/Greenwood, 2014). See also

George B. Palermo, “Murderous Parents,”

International Journal of Offender Therapy and Comparative Criminology 46, no. 2 (2002): 123–143.

53. Kastenbaum and Aisenberg, Psychology of Death, pp. 281–282.

54. Lula M. Redmond, Surviving When Someone You Love Was Murdered: A Professional’s Guide to Group Grief Therapy for Families and Friends of Murder Victims (Clear- water, Fla.: Psychological Consultation and Education

Services, 1989), p. 37.

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article/20130308/BENEFITS05/303080301/

Report-details-fl aws-in-Army-s-handling-of-PTSD .

85. Jessie L. Bonner, “Iraq Veterans Use Fly Fishing

as Therapy, Finding Comfort on the Water,” AP News, October 18, 2009.

86. “A Tough Homecoming,” p. 11.

87. Marian Faye Novak, Lonely Girls with Burning Eyes: A Wife Recalls Her Husband’s Journey Home from Vietnam (Boston: Little, Brown, 1991), p. 3.

88. Lee Woodruff and Bob Woodruff, In an Instant: A Family’s Journey of Love and Healing (New York: Random House, 2007), p. 140.

89. From an account by Barbara Carton, Washington

Park Service, in the Honolulu Star-Bulletin & Advertiser, August 11, 1985.

90. Wilton S. Dillon, “Refl ections on Coping: Then,

Now, and Tomorrow,” Cosmos Journal (Washington, D.C.: The Cosmos Club, 2001).

91. John Horgan, The End of War (San Francisco: McSweeney’s, 2012), p. 102.

92. Keen, Faces of the Enemy, pp. 10–14.

93. Dennis Klass, “Grief, Religion, and Spirituality,”

in Death and Religion in a Changing World, 283–304, edited by Kathleen Garces-Foley (Armonk, N.Y.: M. E.

Sharpe, 2006), p. 301, slightly edited.

94. Debra Umberson and Kristin Henderson, “The

Social Construction of Death in the Gulf War,” Omega: Journal of Death and Dying 25, no. 1 (1992): 1–15.

95. Keen, Faces of the Enemy, pp. 180–181.

96. Horgan, The End of War, p. 165.

97. Keen, Faces of the Enemy, p. 137.

98. Ervin Staub, The Roots of Evil: The Origins of Geno- cide and Other Group Violence (New York: Cambridge University Press, 1989). See also, by Staub, “Genocide

and Mass Killing: Origins, Prevention, Healing, and

Reconciliation,” Political Psychology 21 (2000): 367–382.

99. Robert Kastenbaum, “Grieving in Contemporary

Society,” in Handbook of Bereavement Research and Prac- tice: Advances in Theory and Intervention, ed. Margaret S. Stroebe, Robert O. Hansson, Henk Schut, and Wolf-

gang Stroebe, 67–85 (Washington, D.C.: American

Psychological Association, 2008), p. 79.

100. Paul Rosenblatt, “Grief Across Cultures: A Review

and Research Agenda,” in Handbook of Bereavement Research and Practice, ed. Stroebe and others, 207–222; quote p. 214. See also, in the same volume, Colin Mur-

ray Parkes, “Bereavement Following Disasters,”

pp. 463–484.

70. Gail Holst-Warhaft, The Cue for Passion: Grief and Its Political Uses (Cambridge, Mass.: Harvard University Press, 2000), p. 174.

71. World Campaign for the Protection of Victims

of War, International Red Cross and Red Crescent

Movement. See also James Garbarino, “Challenges We

Face in Understanding Children and War: A Personal

Essay,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 169–174.

72. Glenn M. Vernon, Sociology of Death: An Analysis of Death-Related Behavior (New York: Ronald Press, 1970), p. 46.

73. Toynbee, “Death in War,” p. 367.

74. Anthony Swofford, Jarhead: A Marine’s Chronicle of the Gulf War and Other Battles (New York: Scribner, 2003), p. 7.

75. Joel Baruch, “Combat Death,” in Death: Current Perspectives, ed. Shneidman, pp. 92–93. Reprinted from Suicide and Life-Threatening Behavior 2, no. 3 (1972): 209–216.

76. Interview with military veteran, n.d.

77. Quoted in Trish Wood, What Was Asked of Us: An Oral History of the Iraq War by the Soldiers Who Fought It (New York: Little, Brown, 2006), p. 127.

78. See Robert Jay Lifton, Home from the War: Vietnam Veterans, Neither Victims Nor Executioners (New York: Basic Books, 1985); and Harvey J. Schwartz, “Fear of

the Dead: The Role of Social Ritual in Neutralizing

Fantasies from Combat,” in Psychotherapy of the Combat Veteran, ed. H. J. Schwartz (New York: SP Medical & Scientifi c Books, 1984), pp. 253–267.

79. See Harold A. Widdison and Howard G. Salis-

bury, “The Delayed Stress Syndrome: A Pathological

Delayed Grief Reaction?” Omega: Journal of Death and Dying 20, no. 4 (1989–1990): 293–306.

80. Quoted in Michael Browning, “Homer’s ‘Iliad’

Has Lessons for Vietnam Nightmare,” Honolulu Adver- tiser, February 12, 1995, pp. B1, B4. See also Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (New York: Atheneum, 1994).

81. Paul Recer, “A Different Johnny,” Associated Press

wire story, March 3, 1991.

82. Timothy Kudo, “What War Does to Soldiers,” The Week (February 8, 2013); from a story originally pub- lished in The Washington Post.

83. “A Tough Homecoming,” The Week ( January 27, 2012), p. 11.

84. Gene Johnson, “Report Details Flaws in Army’s

Handling of PTSD,” http://www.armytimes.com/

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660 n o t e s

See also Brian Doyle, “Leap,” The American Scholar 71, no. 1 (2002): 69–70.

115. Friend, Watching the World Change, p. 35.

116. William Langewiesche, American Ground: Unbuild- ing the World Trade Center (New York: North Point, 2002), p. 45.

117. Lynne Ann DeSpelder, “September 11, 2001, and

the Internet,” Mortality 8, no. 1 (2003): 88–89.

118. Craig Calhoun, Paul Price, and Ashley Timmer,

“Introduction,” in Calhoun, Price, and Timmer, Under- standing September 11, p. 4. See also Shashi Tharoor, “The Global Century,” The American Scholar 71, no. 1 (2002): 66 –68.

119. See Marita Sturken, “Memorializing Absence,” in

Calhoun, Price, and Timmer, Understanding September 11, pp. 374–384, esp. 378–381.

120. Langewiesche, American Ground, p. 99.

121. Loolwa Khazzoom, “For ZAK A Rescue Volun-

teers, Grisly Deaths Are a Part of Life.” loolwa.com/

for-zaka-rescue-volunteers-grisly-deaths-are-a-part-of-

life/.

122. Michael Schudson, “What’s Unusual About Cov-

ering Politics as Usual,” in Journalism After September 11, ed. Barbie Zelizer and Stuart Allan (New York: Routledge, 2002), pp. 38–39; see also introduction by

Zelizer and Allan, pp. 8–9.

123. Philip Jenkins, Images of Terror: What We Can and Can’t Know About Terrorism (New York: Aldine de Gruyter, 2003), pp. 82–83.

124. Combs and Slann, Encyclopedia of Terrorism, p. 166.

125. Bruce D. Berkowitz, The New Face of War: How War Will Be Fought in the 21st Century (New York: Free Press, 2003), pp. 16 –17; see also Philip Bobbitt, The Shield of Achilles: War, Peace, and the Course of History (New York: Knopf, 2002), pp. 811, 821.

126. G. W. Bowersock, Martyrdom and Rome (Cam- bridge: Cambridge University Press, 1995), pp. 17–18,

25, 59, 61.

127. Mark Juergensmeyer, “Religious Terror and

Global War,” in Understanding September 11, ed. Calhoun, Price, and Timmer, pp. 27–49; quote p. 29.

See also Kelton Cobb, “Violent Faith,” in 11 September: Religious Perspectives on the Causes and Consequences, ed. Ian Markham and Ibrahim M. Abu-Rabi (Oxford:

OneWorld, 2002), pp. 136 –163; and Bruce Lincoln,

Holy Terrors: Thinking About Religion After September 11 (Chicago: University of Chicago Press, 2003).

128. Laqueur, No End to War, pp. 71, 91.

101. Colin Murray Parkes, “Genocide in Rwanda: Per-

sonal Refl ections,” Mortality 1, no. 1 (1996): 95–110.

102. Anonymous epigraph in Aref M. Al-Kattar, Reli- gion and Terrorism: An Interfaith Perspective (Westport, Conn.: Praeger, 2003), p. 3.

103. See Philip Jenkins, Images of Terror: What We Can and Can’t Know About Terrorism (New York: Aldine de Gruyter, 2003), p. 28; and Walter Laqueur, No End to War: Terrorism in the Twenty-First Century (New York: Continuum, 2003), p. 233.

104. See, for example, Caleb Carr, The Lessons of Terror: A History of Warfare Against Civilians, Why It Has Always Failed and Why It Will Fail Again (New York: Random House, 2002), pp. 7, 9, 12–14.

105. Merriam-Webster’s Collegiate Dictionary, 11th ed. (Springfi eld, Mass.: Merriam-Webster, 2003), p. 1049.

106. Walter Laqueur, The Age of Terrorism (Boston: Little, Brown, 1987), p. 72.

107. Cindy C. Combs and Martin Slann, Encyclopedia of Terrorism (New York: Facts on File, 2002), pp. 208–211.

108. Joseph S. Tuman, Communicating Terror: The Rhetorical Dimensions of Terrorism, 2nd ed. (Thousand Oaks, Calif.: Sage, 210), p. xiii.

109. Tom Pyszczynski, Sheldon Solomon, and Jeff

Greenberg, In the Wake of 9/11: The Psychology of Terror (Washington, D.C.: American Psychological Associa-

tion, 2003), pp. 8, 16, 127.

110. On September 17, 1862, in the Battle of Antie-

tam, 6,000 were killed outright or mortally wounded,

and another 16,000 were wounded and survived. At

least 620,000 died during the course of the Civil War.

See James M. McPherson, “The Lesson of Antietam,”

The American Scholar 71, no. 1 (2002): 64–65.

111. Harold Dow, quoted in Cathy Trost and Alicia

C. Shepard, Running Toward Danger: Stories Behind the Breaking News of 9/11 (Lanham, Md.: Rowman & Little- fi eld, 2002) , p. 247.

112. David Friend, Watching the World Change: The Sto- ries Behind the Images of 9/11 (New York: Farrar, Straus & Giroux, 2006), p. 32.

113. Nilüfer Göle, “Close Encounters, Islam, Moder-

nity, and Violence,” in Understanding September 11, ed. Craig Calhoun, Paul Price, and Ashley Timmer

(New York: New Press, 2002), pp. 332–344. See also

CBS News, What We Saw: The Events of September 11 in Words, Pictures, and Video (New York: Simon & Schuster, 2002).

114. Richard Bernstein and Staff of The New York

Times, Out of the Blue: The Story of September 11, 2001, From Jihad to Ground Zero (New York: Times Books, 2002), p. 3.

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142. Robert Kastenbaum, “Reconstructing Death in

Postmodern Society,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 7–18.

143. Mitchell Duneier, Slim’s Table: Race, Respectability, and Masculinity (Chicago: University of Chicago Press, 1992), p. 75.

144. Margaret A. Chesney, “Health Psychology in the

21st Century: Acquired Immunodefi ciency Syndrome

as a Harbinger of Things to Come,” Health Psychology 12, no. 4 (1993): 259–268.

145. See Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World Out of Balance (New York: Farrar, Straus & Giroux, 1994). See also Robert

Berkow, ed., The Merck Manual of Diagnosis and Therapy, 16th ed. (Rahway, N.J.: Merck Research Laboratories,

1992), pp. 211–220.

146. Bernard Le Guenno, “Emerging Viruses,” Scien- tifi c American (October 1995): 56 –64.

147. See Gunjan Sinha and Burkhard Bilger, “Skeletons in

the Attic: Has the Scourge of Athens Returned to Haunt

Us?” The Sciences 36, no. 5 (September–October 1996): 11; and Matt Crenson, “Researcher: Plague Sparked Ebola,”

Associated Press Online (January 20, 1997).

148. Brian Vastag, “Virtual Worlds, Real Science:

Epidemiologists, Social Scientists Flock to the Online

World,” Science News 172, no. 17 (October 27, 2007): 264–265.

149. Rodrick Wallace and Deborah Wallace, “Inner-

City Disease and the Public Health of the Suburbs:

The Sociogeographical Dispersion of Point-Source

Infection,” Environment and Planning Abstracts 25 (1993): 1707–1723; and “The Coming Crisis of Public

Health in the Suburbs,” Milbank Quarterly 71, no. 4 (1993): 543–564. See also Rodrick Wallace and others,

“Will AIDS Be Contained Within U.S. Minority Urban

Populations?” Social Science & Medicine 39, no. 8 (1994): 1051–1062.

150. Rodrick Wallace and John Pittman, “Recurrence

of Contagious Urban Desertifi cation and the Social

Thanatology of New York City,” Environment and Plan- ning Abstracts 24 ( June 1992): 1–6.

151. Wallace and Pittmann, “Recurrence of Conta-

gious Urban Desertifi cation,” p. 1.

152. Richard Rothenberg, “Chronicle of an Epidemic

Foretold: A Response to the Wallaces,” Milbank Quar- terly 71, no. 4 (1993): 565–574.

153. Paul Recer, “Origin of 1918 Flu Pandemic

Found,” Associated Press Online (March 20, 1997).

154. William R. Clark, Sex and the Origins of Death (New York: Oxford University Press, 1996), p. 177.

129. Aaron T. Beck, “Prisoners of Hate,” Behaviour Research and Therapy 40, no. 3 (2002): 209–216, and Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence (New York: HarperCollins, 1999).

130. Tharoor, “Global Century,” p. 68.

131. Daniel Leviton, “Horrendous Death: Improv-

ing the Quality of Global Health,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 165–168; see also,

edited by Leviton, Horrendous Death, Health, and Well- Being (New York: Hemisphere, 1991), and Horrendous Death and Health: Toward Action (New York: Taylor and Francis, 1991). See also Richard A. Pacholski, “Teach-

ing Nuclear Holocaust, the Basic Thanatological

Topic,” Death Studies 13, no. 2 (1989): 175–183.

132. Daniel Leviton and William Wendt, “Death Edu-

cation: Toward Individual and Global Well-Being,”

Death Education 7, no. 4 (1983): 369–384; quote p. 301.

133. Daniel Leviton, “Horrendous Death,” in Death and the Quest for Meaning: Essays in Honor of Herman Feifel, ed. Stephen Strack (Northvale, N.J.: Jason Aronson, 1997), pp. 301–327; quote p. 303.

134. Leviton, “Horrendous Death,” p. 309.

135. Stephen M. Younger, The Bomb: A New History (New York: HarperCollins, 2009), p. 10.

136. J. Travis, “New Drugs Beat Old Flu,” Science News 162 (September 28, 2002): 196.

137. Travis, “New Drugs Beat Old Flu.” See also

Monica Schoch-Spana, “‘Hospital’s Full-Up’: The 1918

Infl uenza Pandemic,” Public Health Reports 116 (2001): 32–33.

138. UN World Health Organization, Global Alert

and Response (GAR); http://www.who.int/csr/en/ .

139. Joint United Nations Programme on HIV/

AIDS (UNAIDS); www.unaids.org/en/dataanalysis/

datatools/aidsinfo/ .

140. See Mary Catherine Bateson and Richard

Goldsby, Thinking AIDS: The Social Response to the Bio- logical Threat (Reading, Mass.: Addison-Wesley, 1988); Douglas Crimp, ed., AIDS: Cultural Analysis, Cultural Activism (Cambridge, Mass.: MIT Press, 1988); Albert R. Jonsen and Jeff Stryker, eds., The Social Impact of AIDS (Washington, D.C.: National Academy Press, 1993); Eve K. Nichols, Mobilizing Against AIDS, rev. ed. (Cambridge, Mass.: Harvard University Press, 1989);

and Randy Shilts, And the Band Played On: Politics, People, and the AIDS Epidemic (New York: Viking Penguin, 1988).

141. Charles E. Rosenberg, “What Is an Epidemic?

AIDS in Historical Perspective,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 29–32.

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12. Stephen J. Vicchio, “Against Raising Hope of Rais-

ing the Dead: Contra Moody and Kübler-Ross,” Essence: Issues in the Study of Ageing, Dying and Death 3, no. 2 (1979): 63.

13. See Lou H. Silberman in “Death in the Hebrew

Bible and Apocalyptic Literature,” in Perspectives on Death, ed. L. O. Mills (Nashville: Abingdon Press, 1969), pp. 13–32. The “Samuel” story is told in the fi rst

book of Samuel (28:3–25).

14. H. Wheeler Robinson, “Hebrew Psychology,” in

The People and the Book, ed. Arthur S. Peake (London: Oxford University Press, 1925), pp. 353–382.

15. See, for example, Leon Wieseltier, Kaddish (New York: Knopf, 1998).

16. Earl A. Grollman, “The Ritualistic and Theologi-

cal Approach of the Jew,” in Explaining Death to Chil- dren, ed. Grollman (Boston: Beacon Press, 1967), pp. 223–245; and Jonathan Boyarin, “Death and the Min- yan, ” Cultural Anthropology 9, no. 1 (1994): 3–22.

17. See Jasper Griffi n, Homer on Life and Death (Oxford: Clarendon Press, 1980).

18. See C. Fred Alford, “Greek Tragedy and the Place

of Death in Life: A Psychoanalytic Perspective,” Psy- choanalysis and Contemporary Thought 15, no. 2 (1992): 129–159.

19. Carol Zaleski, “In Defense of Immortality,” First Things (August–September 2000): 36 –42; quote p. 40.

20. Oscar Cullman, Immortality of the Soul or Resurrec- tion of the Dead? The Witness of the New Testament (London: Epworth Press, 1958), pp. 26 –27.

21. Cullman, Immortality of the Soul or Resurrection of the Dead?, p. 27.

22. Boniface Ramsey, Beginning to Read the Fathers (New York: Paulist Press, 1985), p. 218.

23. William Barclay, Introducing the Bible (Nashville: Abingdon Press, 1972), p. 123.

24. Anderson, Theology, Death and Dying, p. 59. See also Murray J. Harris, Raised Immortal: Resurrection and Immortality in the New Testament (Grand Rapids, Mich.: Eerdmans, 1985).

25. John D. Zizioulas, “The Early Christian Com-

munity,” in Christian Spirituality: Origins to the Twelfth Century, ed. Bernard McGinn and John Meyendorff, 23–43 (New York: Crossroad, 1992), p. 31.

26. Milton McC. Gatch, Death: Meaning and Mortality in Christian Thought and Contemporary Culture (New York: Seabury Press, 1969), p. 78.

27. Richard P. McBrien, The HarperCollins Encyclopedia of Catholicism (San Francisco: HarperCollins, 1995),

155. Jeffrey Kauffman, “Culture, Socialization, and

Traumatic Death,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 275–284; quote p. 275. See also

Jeffrey Kauffman, Loss of the Assumptive World: A Theory of Traumatic Loss (New York: Routledge, 2002).

156. Lillian M. Range, “Historical and Contemporary

Perspectives on Traumatic Death,” in Handbook of Thanatology, 2nd ed., ed. Meagher and Balk, 291–296; p. 291.

157. Range, “Historical and Contemporary Perspec-

tives on Traumatic Death,” p. 273.

C H A P T E R 1 4

1. This account is based on “Coffi ns and Sarcophagi,”

exhibition note, Metropolitan Museum of Art, New

York; Henri Frankfort, Ancient Egyptian Religion: An Interpretation (New York: Harper & Row, 1948, 1961); Manfred Lurker, The Gods and Symbols of Ancient Egypt (New York: Thames & Hudson, 1980); A. J. Spencer,

Death in Ancient Egypt (New York: Penguin, 1982); and Barbara Watterson, The Gods of Ancient Egypt (New York: Facts on File, 1984).

2. Quoted in Jeffery L. Sheler, “Heaven in the Age of

Reason,” U.S. News & World Report 122, no. 12 (1997): 65–66; italics added.

3. Interview with Mikal Gilmore, Rolling Stone (December 22, 2001).

4. Bertrand Russell, Unpopular Essays (New York: Simon & Schuster, 1950), p. 141.

5. See “The Problem of Immortality,” in Jacques

Choron, Death and Modern Man (New York: Collier, 1964).

6. Geddes MacGregor, Images of Afterlife: Beliefs from Antiquity to Modern Times (New York: Paragon House, 1992), p. 209.

7. Mary Kawena Pukui, E. W. Haertig, and Catherine

A. Lee, Nana I Ke Kumu (Look to the Source), vols. 1 and 2 (Honolulu: Hui Hanai; Queen Lili’uokalani Chil-

dren’s Center, 1972). See also E. S. Craighill Handy

and Mary Kawena Pukui, The Polynesian Family System in Ka-’u, Hawai’i (Rutland, Vt.: Charles E. Tuttle, 1972).

8. Ray S. Anderson, Theology, Death and Dying (New York: Basil Blackwell, 1986), p. 38.

9. Ellen Levine, “Jewish Views and Customs on

Death,” in Death and Bereavement Across Cultures, ed. Colin Murray Parkes, Pitti Laungani, and Bill Young

(New York: Routledge, 1997), pp. 98–130.

10. Job 7:9, The Jerusalem Bible. See also Job 14:7–12.

11. Daniel 12:2, The Jerusalem Bible.

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from the History and Anthropology of Religions, ed. Frank E. Reynolds and Earle H. Waugh (University Park:

Pennsylvania State University Press, 1977), p. 184. See

also Shahzad Bashir, “Deciphering the Cosmos from

Creation to Apocalypse: The Hurufi yya Movement and

Medieval Islamic Esotericism,” in Imagining the End: Visions of Apocalypse from the Ancient Middle East to Modern America, ed. Abbas Amanat and Magnus Bernhardsson (London: I. B. Tauris, 2002),

pp. 168–184; and “Enshrining Divinity: The Death and

Memorialization of Fazlallah Astarabadi in Hurufi

Thought,” Muslim World 90, nos. 3–4 (2000): 289–308.

39. Huston Smith, The Religions of Man (New York: New American Library, 1958), p. 215.

40. See J. I. Smith and Y. Haddad, The Islamic Under- standing of Death and Resurrection (Albany: State Univer- sity of New York Press, 1981).

41. Esposito, Islam: The Straight Path, p. 35.

42. Welch, “Death and Dying in the Qur’an,” p. 193.

43. D. S. Roberts, Islam: A Concise Introduction (San Francisco: Harper and Row, 1981), p. 128.

44. Roberts, Islam, p. 128. See also Suzanne Evans, “The Scent of a Martyr,” Numen: International Review for the History of Religions 49, no. 2 (2002): 193–211.

45. Abdul Latif Al Hoa, Islam (New York: Bookwright Press, 1987), p. 20.

46. Hend Yasien-Esmael and Simon Shimson Rubin,

“The Meaning Structures of Muslim Bereavements

in Israel: Religious Traditions, Mourning Practices,

and Human Experience,” Death Studies 29 (2005): 495–518.

47. Chuang Tzu, Basic Writings, trans. Burton Watson (New York: Columbia University Press, 1964), p. 76.

48. Mario Poceski, Introducing Chinese Religions (New York: Routledge, 2009), p. 76.

49. T. N. Madan, “Dying with Dignity,” Social Science & Medicine 35, no. 4 (1992): 425–432.

50. Bhagavad-Gita II.27, trans. Swami Nikhilananda (New York: Ramakrishna-Vivekananda Center, 1952),

p. 79.

51. Smith, Religions of Man, p. 34.

52. E. M. Jackson, “Moksha,” in Key Ideas in Human Thought, ed. Kenneth McLeish (New York: Facts on File, 1993), pp. 482–483.

53. Bhagavad-Gita II.22, trans. Nikhilananda, p. 77.

54. J. Bruce Long, “Death as a Necessity and a Gift

in Hindu Mythology,” in Religious Encounters with Death, ed. Reynolds and Waugh, p. 92; see also pp. 73 –96.

p. 1070. See also Alan E. Bernstein, The Formation of Hell: Death and Retribution in the Ancient and Early Christian Worlds (Ithaca, N.Y.: Cornell University Press, 1993); Stephen Greenblatt, Hamlet in Purgatory (Princeton, N.J.: Princeton University Press, 2001); and

Jacques Le Goff, The Birth of Purgatory (Chicago: Uni- versity of Chicago Press, 1984).

28. Purgatory is not to be confused with limbo, “a place or state where unbaptized persons enjoy a natural hap-

piness, though they remain excluded from the Beatifi c

Vision.” See McBrien, The HarperCollins Encyclopedia of Catholicism, p. 771.

29. Jerry L. Walls, Purgatory: The Logic of Total Trans- formation (New York: Oxford University Press, 2012), p. 25.

30. Jacques Le Goff, The Birth of Purgatory, trans. Arthur Goldhammer (Chicago: The University of

Chicago Press, 1984), p. 58.

31. Anthony C. Thiselton, The Last Things: A New Approach (London: SPCK, 2012), p. 1.

32. Zaleski, “In Defense of Immortality,” quote p.

41. See also Alister E. McGrath, “Last Things: The

Christian Hope” (Chapter 18), in Christian Theology: An Introduction, 3rd ed. (Malden, Mass.: Blackwell, 2001), pp. 553–577.

33. Vicchio, “Against Raising Hope,” p. 62. See also

Gordon E. Geddes, Welcome Joy: Death in Puritan New England (Ann Arbor, Mich.: UMI Research Press, 1981); and David E. Stannard, The Puritan Way of Death: A Study of Religion, Culture, and Social Change (New York: Oxford University Press, 1977).

34. Constantine Callinicos, Beyond the Grave: An Orthodox Theology of Eschatology, trans. George Dimo- poulos and Leslie Jerome Newville (Scranton, Penn.:

Christian Orthodox Editions, 1969), p. 158. See also

Stanley Samuel Harakas, Health and Medicine in the Eastern Orthodox Tradition: Faith, Liturgy, and Wholeness (New York: Crossroad, 1990), esp. pp. 151–159.

35. Peter C. Phan, Responses to 101 Questions on Death and Eternal Life (New York: Paulist Press, 1997), pp. 18, 129. See also Douglas Connelly, Bible Prophecy for Block- heads: A User-Friendly Look at the End Times (Grand Rapids, Mich.: Zondervan, 2002), pp. 164–166; and

Regis Martin, The Last Things: Death, Judgment, Heaven, Hell (San Francisco: Ignatius, 1998), p. 118.

36. John L. Esposito, Islam: The Straight Path (New York: Oxford University Press, 1988), p. 22.

37. Frithjof Schuon, Understanding Islam (Baltimore: Penguin, 1972), p. 16.

38. Alfred T. Welch, “Death and Dying in the

Qur’an,” in Religious Encounters with Death: Insights

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664 n o t e s

Walter, 325–348 (Honolulu: University of Hawaii

Press, 2008), p. 328.

71. Tanabe, “The Orthodox Heresy of Buddhist

Funerals,” p. 345.

72. W. Y. Evans-Wentz, The Tibetan Book of the Dead: or, the After-Death Experiences on the Bardo Plane, According to Lama Kazi Dawa-Samup’s English Rendering (New York: Oxford University Press, 1960).

73. Quoted in Kapleau, Zen: Dawn in the West, p. 68.

74. Quoted in William R. Clark, Sex and the Origins of Death (New York: Oxford University Press, 1996), p. 159.

75. See Robert E. Goss and Dennis Klass, “Tibetan

Buddhism and the Resolution of Grief: The Bardo-

Thodol for the Dying and Grieving,” Death Studies 21 (1997): 377–395.

76. Francesca Fremantle and Chögyam Trungpa, eds.,

The Tibetan Book of the Dead: The Great Liberation Through Hearing in the Bardo, by Guru Rinpoche According to Karma Lingpa (Boulder, Colo.: Shambhala, 1975).

77. Christopher Carr, “Death and Near-Death: A Com-

parison of Tibetan and Euro-American Experiences,”

Journal of Transpersonal Psychology 25, no. 1 (1993): 59–110. See also Uwe P. Gielen, “A Death on the Roof

of the World,” in Death and Bereavement Across Cultures, pp. 73–97.

78. See Paul Badham and Linda Badham, eds., Death and Immortality in the Religions of the World (New York: Paragon House, 1987).

79. Karolynn Siegel, Stanley J. Anderman, and Eric

W. Schrimshaw, “Religion and Coping with Health-

Related Stress,” Psychology and Health 16 (2001): 631–653.

80. Lucy Bregman, “The Roles of Religions in the

Death Awareness Movement,” The Forum 32, no. 2 (2006): 4–5, quote p. 4.

81. Vernon Reynolds and Ralph Tanner, The Social Ecology of Religion (New York: Oxford University Press, 1995), p. 211.

82. Phil Zuckerman, “The Sociology of Religion of

W. E. B. Du Bois,” Sociology of Religion 63, no. 2 (2002): 239–253.

83. Ruth A. Tanyi, “Towards Clarifi cation of the

Meaning of Spirituality,” Journal of Advanced Nursing 39, no. 5 (2002): 500–509; quote, p. 506.

84. Ralph L. Piedmont, “Does Spirituality Represent

the Sixth Factor of Personality? Spiritual Transcen-

dence and the Five-Factor Model,” Journal of Personality 67, no. 6 (1999): 987–1013; quoted material 988–989.

55. David R. Kinsley in “The ‘Death That Conquers

Death’: Dying to the World in Medieval Hinduism,”

in Religious Encounters with Death, ed. Reynolds and Waugh, pp. 97–108. See also Pittu Laungani, “Death

in a Hindu Family,” in Death and Bereavement Across Cul- tures, pp. 52–72.

56. Philip Kapleau, Zen: Dawn in the West (Garden City, N.Y.: Anchor Press/Doubleday, 1979), p. 296. See also,

ed. Kapleau, The Wheel of Death: A Collection of Writings from Zen Buddhist and Other Sources on Death-Rebirth- Dying (New York: Harper and Row, 1971), and The Wheel of Life and Death: A Practical and Spiritual Guide (New York: Doubleday, 1989).

57. “Awakening to the Bodhi-Mind (Hotsu Bodai-

shin),” from the Shobo-Genzo, in Zen Master Dogen, trans. Yuho Yokoi, p. 109.

58. Kapleau, Zen: Dawn in the West, pp. 67–68.

59. Carl B. Becker, Breaking the Circle: Death and the Afterlife in Buddhism (Carbondale: Southern Illinois University Press, 1993), p. 7.

60. Ronald L. Grimes, Deeply into the Bone: Re-Inventing Rites of Passage (Berkeley: University of California Press, 2000), p. 225.

61. Grimes, Deeply into the Bone , p. 224.

62. “The Meaning of Practice-Enlightenment (Susho-

gi),” in Zen Master Dō gen: An Introduction with Selected Writings, trans. Yuho Yokoi (New York/Tokyo: Weath- erhill, 1976), p. 58.

63. Susan Orpett Long, Final Days: Japanese Culture and Choice at the End of Life (Honolulu: University of Hawaii Press, 2005), p. 69.

64. “The Meaning of Practice-Enlightenment

(Shusho-gi),” p. 58.

65. The Zen Master Hakuin: Selected Writings, trans. Philip B. Yampolsky (New York: Columbia University

Press, 1971), p. 219.

66. Long, Final Days, p. 69.

67. Jonathan S. Watts, “Introduction,” in Buddhist Care for the Dying and Bereaved, 1–17, ed. Jonathan S. Watts and Yosiharu Tomatsu (Boston: Wisdom, 2012),

pp. 4–5.

68. Kapleau, Zen: Dawn in the West, p. 69.

69. For more on Pure Land Buddhism, see “The After-

life in Pure Land Buddhism,” Chapter 3, pp. 46 –62,

in Becker, Breaking the Circle: Death and the Afterlife in Buddhism.

70. George J. Tanabe, Jr., “The Orthodox Heresy of

Buddhist Funerals,” in Death and the Afterlife in Japanese Buddhism, ed. Jacqueline I. Stone and Mariko Namba

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97. Carol Zaleski, Otherworld Journeys: Accounts of Near- Death Experience in Medieval and Modern Times (New York: Oxford University Press, 1987).

98. Paul Badham, “Religious and Near-Death Experi-

ence in Relation to Belief in a Future Life,” Mortality 2, no. 1 (1997): 7–21.

99. Bruce Greyson, “Near-Death Experiences,” in

Varieties of Anomalous Experience: Examining the Scientifi c Evidence, ed. Etzel Cardeña, Steven Jay Lynn, and Stanley Krippner (Washington, D.C.: American Psy-

chological Association, 2000), pp. 315–352; defi nition

pp. 315–316.

100. Kenneth Ring, Life at Death: A Scientifi c Investiga- tion of the Near-Death Experience (New York: Coward, McCann & Geoghegan, 1980), and Heading Toward Omega: In Search of the Meaning of the Near-Death Experi- ence (New York: Morrow, 1984). See also Bruce Greyson, “Varieties of Near-Death Experience,” Psychiatry 56 (1993): 390–399; and Raymond A. Moody, Jr., Life After Life, and its sequel, Refl ections on Life After Life (various editions).

101. Bruce Greyson, “Reduced Death Threat in

Near-Death Experiencers,” in Death Anxiety Handbook: Research, Instrumentation, and Application, ed. Robert A. Neimeyer (Washington, D.C.: Taylor & Francis, 1994),

pp. 169–179, esp. pp. 169, 177.

102. H. J. Irwin, An Introduction to Parapsychology ( Jefferson, N.C.: McFarland, 1989), pp. 188–190.

103. William J. Serdahely, “The Near-Death Experi-

ence: Is the Presence Always the Higher Self?” Omega: Journal of Death and Dying 18, no. 2 (1987–1988): 129–134.

104. William J. Serdahely, “A Pediatric Near-Death

Experience: Tunnel Variants,” Omega: Journal of Death and Dying 20, no. 1 (1989–1990): 55–62. See also William J. Serdahely and Barbara A. Walker, “A Near-

Death Experience at Birth,” Death Studies 14, no. 2 (1990): 177–183.

105. See Bruce Greyson and Nancy Evans Bush, “Dis-

tressing Near-Death Experiences,” Psychiatry 55 (February 1992): 95–110; and P. M. H. Atwater, “Is

There a Hell? Surprising Observations About the

Near-Death Experience,” Journal of Near-Death Studies 10, no. 3 (Spring 1992): 149–160.

106. Brendan I. Koerner, “Is There Life After Death?”

U.S. News & World Report 122, no. 12 (1997): 59–64.

107. Ian Stevenson, Emily W. Cook, and Nicholas

McClean-Rice, “Are Persons Reporting ‘Near-Death

Experiences’ Really Near Death? A Study of Medical

Records,” Omega: Journal of Death and Dying 20, no. 1 (1989–1990): 45–54.

85. Norman Goodman, Introduction to Sociology (New York: HarperCollins, 1992), p. 215.

86. Ira R. Byock, “To Life! Refl ections on Spirituality,

Palliative Practice, and Politics,” American Journal of Hospice & Palliative Medicine 23, no. 6 (2007): 436 –438; quote, p. 436.

87. Davina A. Allen, “Secularization,” in Key Ideas in Human Thought, ed. McLeish, p. 668. See also Charles Taylor, A Secular Age (Cambridge, Mass.: Harvard Uni- versity Press, 2007); and James Turner, Without God, Without Creed: The Origins of Unbelief in America (Baltimore: Johns Hopkins University Press, 1985).

88. Colin Murray Parkes, “Conclusions II: Attach-

ments and Losses in Cross-Cultural Perspective,” in

Death and Bereavement Across Cultures, pp. 233–243; quote p. 234.

89. E. M. Jackson and Kenneth McLeish, “Human-

ism,” in Key Ideas in Human Thought, ed. McLeish, pp. 355–356.

90. Kenneth McLeish, “Existentialism,” in Key Ideas in Human Thought, ed. McLeish, pp. 265–266; quote p. 265. See also William Barrett, Irrational Man: A Study in Existential Philosophy (New York: Doubleday, 1958), and Death of the Soul: From Descartes to the Computer (New York: Anchor/Doubleday, 1986).

91. See Robert J. Lifton, The Future of Immortality and Other Essays for a Nuclear Age (New York: Basic Books, 1987), and The Broken Connection: On Death and the Continuity of Life (New York: Basic Books, 1983; reprint, Washington, D.C.: American Psychiatric

Press, 1996).

92. Sheler, “Heaven in the Age of Reason”; see also Jef-

fery L. Sheler, “Hell’s Sober Comeback,” U.S. News & World Report, March 25, 1991, pp. 56 –57; and Daniel J. Klenow and Robert C. Bolin, “Belief in an Afterlife: A

National Survey,” Omega: Journal of Death and Dying 20, no. 1 (1989–1990): 63–74.

93. Andrew M. Greeley and Michael Hout, “Ameri-

cans’ Increasing Belief in Life After Death: Religious

Competition and Acculturation,” American Sociological Review 64, no. 6 (1999): 813–835.

94. David Lester and others, “What Is the Afterlife

Like? Undergraduate Beliefs about the Afterlife,”

Omega: Journal of Death and Dying 44, no. 2 (2001–2002): 113–126.

95. Quoted in David Cockburn, “Simone Weil on

Death,” Mortality 2, no. 1 (1997): 63–72.

96. The Meditations of Marcus Aurelius, trans. George Long, The Harvard Classics, vol. 2, ed. Charles W. Elliot, pp. 193–301; see especially section II, 5 and 11,

pp. 201–202.

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666 n o t e s

the Age of Reason”; Greeley and Hout, “Americans’

Increasing Belief in Life After Death”; and Klenow

and Bolin, “Belief in an Afterlife: A National Survey.”

115. Louis Appleby, British Medical Journal 298 (April 15, 1989): 976 –977. See also Michael Potts, “Sensory Expe-

riences in Near-Death Experiences and the Thomistic

View of the Soul,” International Journal for Philosophy of Religion 49, no. 2 (2001): 85–100.

116. Zaleski, Otherworld Journeys, p. 182.

117. Raymond A. Moody, Jr., “An Omega Interview

[by Robert Kastenbaum],” Omega: Journal of Death and Dying 31, no. 2 (1995): 87–97.

118. From a conversation between Herman Feifel and

John Morgan, “Humanity Has to Be the Model,” Death Studies 10, no. 1 (1986): 1–9.

119. Robert Kastenbaum, “Happily Ever After,” in

Between Life and Death, ed. Kastenbaum, pp. 17, 19. See also Bruce Greyson, “Near-Death Experiences and

Deathbed Visions,” in The Study of Dying: From Autonomy to Transformation, ed. Allan Kellehear, 253–275 (New York: Cambridge University Press, 2009).

120. Charles A. Garfi eld, “The Dying Patient’s Con-

cern with ‘Life After Death,’” in Between Life and Death, ed. Kastenbaum, pp. 52–57.

121. Kelly Bulkeley and Patricia Bulkley, Dreaming Beyond Death: A Guide to Pre-Death Dreams and Visions (Boston: Beacon Press, 2005), p. 12.

122. Marie-Louise von Franz, On Death and Dreams: A Jungian Interpretation (Boston: Shambhala, 1986), pp. viii–ix.

123. Franz, On Death and Dreams, p. 156.

124. Franz, On Death and Dreams, pp. 66 –67.

125. Some evidence suggests that LSD may interfere

with the transfer of oxygen on the enzymatic level.

Anoxia, or diminished levels of oxygen in the bodily

tissues, is also found in dying patients as well as in

conjunction with certain yogic techniques involving

breath control. Thus, anoxia may activate transper-

sonal matrices in the unconscious, giving rise to

experiences associated with near-death experiences,

certain yogic states, and LSD sessions. See Grof and

Halifax, The Human Encounter with Death, pp. 183ff; and Thomas J. Riedlinger and June R. Riedlinger,

“Psychedelic and Entactogenic Drugs in the Treatment

of Depression,” Journal of Psychoactive Drugs 26, no. 1 (1994): 41–55.

126. Stanislav Grof, Realms of the Human Unconscious: Observations from LSD Research (New York: E. P. Dutton, 1976). See also Robert B. Millman and Ann Bordwine

Beeder, “The New Psychedelic Culture: LSD, Ecstasy,

108. For an introduction to the main points of view,

see Stephen J. Vicchio, “Near-Death Experiences: A

Critical Review of the Literature and Some Questions

for Further Study,” Essence: Issues in the Study of Ageing, Dying and Death 5, no. 1 (1981): 77–89. See also James E. Alcock, “Psychology and Near-Death Experiences,”

The Skeptical Inquirer 3, no. 3 (Spring 1979): 25–41; Michael B. Sabom, Recollections of Death: A Medical Investigation (New York: Harper and Row, 1981); and Stephen J. Vicchio, “Near-Death Experiences: Some

Logical Problems and Questions for Further Study,”

Anabiosis: The Journal of the International Association for Near-Death Studies (1981): 66 –87. The history of research into NDEs is traced in Stanislav Grof and

Joan Halifax, The Human Encounter with Death (New York: E. P. Dutton, 1978), Chapter 7, “Consciousness

and the Threshold of Death,” pp. 131–157.

109. See Handy and Pukui, The Polynesian Family System in Ka-’u, Hawai’i; Donald D. Kilolani Mitchell, Resource Units in Hawaiian Culture (Honolulu: Kamehameha Schools Press, 1982); and Pukui, Haertig, and Lee,

Nana I Ke Kumu (Look to the Source), vols. 1 and 2.

110. Pukui, Haertig, and Lee, Nana I Ke Kumu (Look to the Source), vol. 1, p. 40.

111. See Roy Kletti and Russell Noyes, Jr., “Mental

States in Mortal Danger,” which includes a translation

of Oskar Pfi ster’s 1930 paper commenting on Heim’s

observations, in Essence: Issues in the Study of Ageing, Dying and Death 5, no. 1 (1981): 5–20.

112. See Russell Noyes, Jr., “Dying and Mystical Con-

sciousness,” Journal of Thanatology I (1971): 25–41; Russell Noyes, Jr., and Roy Kletti, “Depersonalization

in the Face of Life-Threatening Danger: An Interpreta-

tion,” Omega: Journal of Death and Dying 7, no. 2 (1976): 103–114, and “Panoramic Memory: A Response to the

Threat of Death,” Omega: Journal of Death and Dying 8, no. 3 (1977): 181–194; Russell Noyes, Jr., “Near-Death

Experiences: Their Interpretation and Signifi cance,”

in Between Life and Death, ed. Robert Kastenbaum (New York: Springer, 1979), pp. 73–78; and Russell Noyes,

Jr., “The Encounter with Life-Threatening Danger: Its

Nature and Impact,” Essence: Issues in the Study of Age- ing, Dying and Death 5, no. 1 (1981): 21–32.

113. Karlis Osis and Erlendur Haraldsson, “Deathbed

Observations of Physicians and Nurses: A Cross-

Cultural Survey,” in The Signet Handbook of Parapsychol- ogy, ed. Martin Ebon (New York: Signet/NAL, 1978); and, by Osis and Haraldsson, At the Hour of Death (New York: Avon Books, 1977). See also, by Haraldsson, “Sur-

vey of Claimed Encounters with the Dead,” Omega: Jour- nal of Death and Dying 19, no. 2 (1988–1989): 103–113.

114. George Gallup, Jr., Adventures in Immortality (New York: McGraw-Hill, 1982). See also Sheler, “Heaven in

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2. Donald Keene, The Pleasures of Japanese Literature (New York: Columbia University Press, 1988), p. 86.

3. David Clark, ed., The Sociology of Death: Theory, Cul- ture, Practice (Cambridge, Mass.: Blackwell, 1993), p. 3.

4. Thomas Attig, “Coping with Mortality: An Essay on

Self-Mourning,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 337–341. See also Herman Feifel and

Steven Strack, “Thanatologists View Death: A 15-Year

Perspective,” Omega: Journal of Death and Dying 43, no. 2 (2001): 97–111; and, in the same issue, Jeanne Quint

Benoliel, “Commentary: Thanatologists View Death”

(117–118).

5. Darrell Crase, “Black People Do Die, Don’t They?”

Death Studies 11, no. 3 (1987): 221–228. The role of gender in shaping attitudes and behaviors relative to

dying and death is similarly underrepresented; see,

for example, Felicity Allen, “Where Are the Women

in End-of-Life Research?” Behaviour Change 19, no. 1 (2002): 39–51.

6. Ronald K. Barrett, “Contemporary African-Ameri-

can Funeral Rites and Traditions,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 80–92.

7. Ronald K. Barrett, “Sociocultural Considerations

for Working with Blacks Experiencing Loss and Grief,”

in Kenneth Doka and Joyce D. Davidson, eds., Living with Grief: Who We Are, How We Grieve, 83–96 (Phila- delphia: Brunner/Mazel, 1998), pp. 88–91; and Lynne

Ann DeSpelder and Ronald K. Barrett, “Developing

Multicultural Competence,” The Director 64 (December 1997): 66 –68; esp. p. 68.

8. Elizabeth J. Clark, “The Future of Social Work in

End-of-Life Care: A Call to Action,” in Joan Berzoff

and Phyllis R. Silverman, Living with Dying: A Handbook for End-of-Life Care Practitioners (New York: Columbia University Press, 2004), pp. 838–847; quote p. 841.

See also Rita Chi-Ying Chung and Fred Bemak,

“The Relationship of Culture and Empathy in Cross-

Cultural Counseling,” Journal of Counseling and Devel- opment 80, no. 2 (2002): 154 –159; Irene Papadopoulos and Shelley Lees, “Developing Culturally Competent

Researchers,” Journal of Advanced Nursing 37, no. 3 (2002): 258–264; and Jeanne-Marie R. Stacciarini,

“Experiencing Cultural Differences: Refl ections on

Cultural Diversity,” Journal of Professional Nursing 18, no. 6 (2002): 346 –349.

9. Lynne Ann DeSpelder and Albert Lee Strickland,

“Culture, Socialization, and Death Education,” in

Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 323–331 (New York:

Routledge, 2013), pp. 323, 324–325, 331.

10. DeSpelder and Barrett, “Developing Multicultural

Competence.”

‘Rave’ Parties, and the Grateful Dead,” Psychiatric Annals 24, no. 3 (1994): 148–150; and Susanna Pre- peliczay, “Socio-Cultural and Psychological Aspects of

Contemporary LSD Use in Germany,” Journal of Drug Issues 32, no. 2 (2002): 431–458.

127. See Stanislav Grof, LSD Psychotherapy (Pomona, Calif.: Hunter House, 1980), pp. 252ff; Grof and

Halifax, The Human Encounter with Death, pp. 16ff; and Peter Stafford, Psychedelics Encyclopedia (Berkeley, Calif.: And/Or Press, 1977), pp. 23–39.

128. Grof and Halifax, The Human Encounter with Death, pp. 120–121.

129. Stanislav Grof and Christina Grof, Beyond Death: The Gates of Consciousness (New York: Thames & Hud- son, 1980), p. 24.

130. David M. Wulff, “Mystical Experience,” in Variet- ies of Anomalous Experience: Examining the Scientifi c Evi- dence, ed. Etzel Cardeña, Steven Jay Lynn, and Stanley Krippner (Washington, D.C.: American Psychological

Association, 2000), pp. 397–440.

131. Stanislav Grof and Joan Halifax, “Psychedelics

and the Experience of Dying,” in Life After Death, ed. Arnold Toynbee and others (New York: McGraw-Hill,

1976), pp. 192–193.

132. Grof, LSD Psychotherapy, p. 294. See also, by Grof, Psychology of the Future: Lessons from Modern Consciousness Research (Albany: State University of New York, 2000).

133. Grimes, Deeply into the Bone, p. 237.

134. Herman Feifel, The Meaning of Death (New York: McGraw-Hill, 1959), p. xiv.

135. International Work Group on Death, Dying, and

Bereavement, “Assumptions and Principles of Spiritual

Care,” Death Studies 14, no. 1 (1990): 75–81.

136. See Thomas Attig, “Respecting the Spiritual

Beliefs of the Dying and the Bereaved,” in Dying, Death, and Bereavement: A Challenge for Living, 2nd ed., ed. Inge Corless, Barbara B. Germino, and Mary A. Pitt-

man (New York: Springer, 2003), pp. 61–75.

137. Clyde M. Nabe, “‘Seeing As’: Death As Door or

Wall,” in Priorities in Death Education and Counseling, ed. Richard A. Pacholski and Charles A. Corr (Arlington,

Va.: Forum for Death Education and Counseling,

1982), pp. 161–169.

C H A P T E R 1 5

1. Allan B. Chinen, “The Mortal King,” in The Path Ahead: Readings in Death and Dying, ed. Lynne Ann DeSpelder and Albert Lee Strickland, 335–336

(Mountain View, Calif.: Mayfi eld, 1995).

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ed. Robert A. Neimeyer, Darcy L. Harris, Howard R.

Winokuer, and Gordon Thornton, 403–418 (New York:

Routledge, 2011), pp. 404–405 (slightly edited).

23. See Bridging Work Group, “Bridging the Gap

Between Research and Practice in Bereavement:

Report from the Center for the Advancement of

Health,” Death Studies 29 (2005): 93–122.

24. John R. Jordan, “Research That Matters: Bridging

the Gap Between Research and Practice in Thanatology,”

Death Studies 24 (2000): 457–467; quote pp. 461, 463.

25. David E. Balk, “Scholarship, Students, and Practi-

tioners: Bringing Scholarship into the Expectations of

Practitioners,” Death Studies 29 (2005): 123–144.

26. Allan Kellehear, Compassionate Cities: Public Health and End of Life Care (New York: Routledge, 2005), p. x.

27. Helen Youngelson-Neal, Arthur G. Neal, and Jacob

Fried, “Global and Local Culture in the 21st Century,”

Journal of American and Comparative Cultures 24, nos. 3–4 (Fall 2001): 31–36, esp. 33–35.

28. Youngelson-Neal, Neal, and Field, “Global and

Local Culture.”

29. Kellehear, Compassionate Cities, p. x.

30. Ira Byock, The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life (New York: Avery, 2012), pp. 250–271.

31. Kellehear, Compassionate Cities, p. 16.

32. Kellehear, Compassionate Cities, p. 162.

33. See Phyllis Silverman and others, “The 2004 Tucson

IWG (International Work Group) Charter for the Nor-

malization of Dying, Death, and Loss,” Omega: Journal of Death and Dying 50 (2004–2005): 331–336, esp. 332.

34. Silverman and others, p. 46.

35. Allan Kellehear, “Public Health Approaches to

Palliative Care: Developments in Australia,” Rikkyo Social Work Review 23 (2003): 27–35; quote p. 32.

36. See http://webpages.scu.edu/ftp/fow/pages/fow-

courseindex.html .

37. Robert E. Goss and Dennis Klass, Dead but Not Lost: Grief Narratives in Religious Traditions (Walnut Creek, Calif.: AltaMira Press, 2005), p. 279.

38. Ronald L. Grimes, Deeply into the Bone: Re-Inventing Rites of Passage (Berkeley: University of California Press, 2000), p. 221.

39. Herman Feifel, “Psychology and Death: Meaning-

ful Rediscovery,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 19–28; quote p. 27.

11. Wolfgang Stroebe and Margaret Stroebe, “Is Grief

Universal? Cultural Variations in the Emotional Reac-

tion to Loss,” in Death and Identity, 3rd ed., ed. Robert Fulton and Robert Bendiksen, 177–209 (Philadelphia:

Charles Press, 1993), p. 201.

12. Fritz Roth, Einmal Jenseits und Zurück: Ein Koffer für die Letzte Reise (Gütersloh: Gütersloher Verlagshaus, 2006).

13. Sinéad Donnelly, “Give Me Your Hands, or

Meitheal, ” Mortality 10 (Suppl., September, 2005): 24.

14. Dolores M. Dooley, “End-of-Life Decision Making:

An Irish Perspective,” in Handbook of Thanatology, 2nd ed., ed. David K. Meagher and David E. Balk, 111–118

(New York: Routledge, 2013), p. 111.

15. Amy Chow, Cecilia Chan, and Samuel Ho, “Social

Sharing of Bereavement Experience by Chinese

Bereaved Persons in Hong Kong,” Death Studies 31, no. 7 (2007): 601–618.

16. Isa Fonnegra de Jaramillo, Morir Bien: Un Compro- miso Personal [Dying Well: A Personal Commitment] (Barcelona: Planeta, 2006).

17. Alfons Deeken, “Evolving Japanese Perspectives on

Death and Dying,” Budhi (1999): 215–232. Published by Offi ce of Research and Publications School of Arts

and Sciences, Ateneo de Manila University, Philip-

pines. See also Lynne Ann DeSpelder, “Desu Edyuke-

syon no Shimei [The Mission of Death Education],”

trans. Keiji Takeuchi, in Otono no Inochi no Kyoiku [The Death Education for Adults], edited by Shigeaki

Hinohara, Alfons Deeken, and Jitaro Mizuno (Tokyo:

Kawadeshobo Shinsha, 2006).

18. K. Takeuchi, Reitaku University, Chiba, personal

communication, January, 2006.

19. Lynne Ann DeSpelder, “A World View: Interna-

tional Thanatology,” The Forum: Newsletter of the Associa- tion for Death Education and Counseling 34, no. 1 (2008): 1, 3–4.

20. Robert Kastenbaum, “Theory, Research, and

Application: Some Critical Issues for Thanatology,”

Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 397–410; quote p. 408.

21. Myra Bluebond-Langner, “Wither Thou Goest?”

Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 257–263. See also James A. Thorson, “Qualitative

Thanatology,” Mortality 1, no. 2 (1996).

22. Robert A. Neimeuyer and Darcy L. Harris, “Build-

ing Bridges in Bereavement Research and Practice:

Some Concluding Refl ections,” in Grief and Bereavement in Contemporary Society: Bridging Research and Practice,

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51. Avery Weisman, On Dying and Denying: A Psychiatric Study of Terminality (New York: Behavioral Publica- tions, 1972), pp. 39–40; see also, by Weisman, The Cop- ing Capacity: On the Nature of Being Mortal (New York: Human Sciences, 1984).

52. Edwin Shneidman, “Criteria for a Good Death,”

Suicide and Life-Threatening Behavior 37, no. 3 (2007): 245–247; quote p. 247.

53. This account of Lindbergh’s death draws from

various sources, including a description by Dr. Milton

H. Howell, one of Lindbergh’s physicians, reported by

Ernest H. Rosenbaum, “The Doctor and the Cancer

Patient,” in A Hospice Handbook, ed. Michael P. Hamilton and Helen F. Reid (Grand Rapids, Mich.:

Eerdmans, 1980), pp. 19–43.

54. Yoshida Kenkō, quoted by Donald Keene, “Kenkō:

Essays in Idleness ( Tsurezureguswa),” in Approaches to the Asian Classics, edited by Wm. Theodore de Bary and Irene Bloom (New York: Columbia University Press,

1990), p. 313.

55. Sharon R. Kaufman, And a Time to Die: How Ameri- can Hospitals Shape the End of Life (New York: Scribner, 2005), p. 323.

56. Stephen S. Hall, “On Beyond 100,” National Geo- graphic 223, no. 5 (May 2013): 28–49; p. 46.

57. Elizabeth Arias, Melonie Heron, and Betzaida

Tejada-Vera, “United States Life Tables Eliminating

Certain Causes of Death, 1999–2001,” National Vital Statistics Report 61, no. 9 (2013).

58. Kaufman, And a Time to Die, p. 324.

59. “Resident Population Projections by Sex and Age:

2010 to 2050,” Statistical Abstract of the United States: 2009, 128th ed. (Washington, D.C.: Government Print- ing Offi ce, 2008), p. 14.

60. Stewart Brand, Whole Earth Discipline: An Ecoprag- matist Manifesto (New York: Viking, 2009), p. 61.

61. Ron Crocombe, The South Pacifi c: An Introduction (Auckland, New Zealand: Longman Paul, 1983).

62. Crocombe, South Pacifi c, p. 73.

63. See Carla J. Sofka, “Social Support ‘Internet-

works,’ Caskets for Sale, and More: Thanatology and

the Information Superhighway,” Death Studies 21, no. 6 (1997): 553–574.

64. Damon Knight, “Masks,” in A Pocketful of Stars, ed. Knight (New York: Doubleday, 1971).

65. Reported in Dick Teresi, The Undead: Organ Har- vesting, the Ice-Water Test, Beating-Heart Cadavers—How Medicine is Blurring the Line Between Life and Death (New York: Pantheon, 2012), p. 173.

40. Feifel, "Psychology and Death: Meaningful Redis-

covery," p. 28.

41. Robert Fulton and Greg Owen, “Death and Soci-

ety in Twentieth-Century America,” Omega: Journal of Death and Dying 18, no. 4 (1987–1988): 390. On the many key contributions by women to both clinical

and academic approaches in the fi eld, see the special

issue focusing on “Women in Thanatology,” edited by

Inge B. Corless, in Illness, Crisis & Loss 9, no. 1 (2001), which includes articles by Jeanne Quint Benoliel,

David Clark (on Cicely Saunders), Thelma Bates, Zelda

Foster, Catherine Sanders, Doris A. Howell, Ida M.

Martinson, Sandra Bertman, Hannelore Wass, Phyllis

R. Silverman, and Mary L. S. Vachon.

42. Alfred G. Killilea, “The Politics of Being Mortal,”

in The Path Ahead, ed. DeSpelder and Strickland, pp. 342–347.

43. J. Eugene Knott and Richard W. Prull, “Death

Education: Accountable to Whom? For What?” Omega: Journal of Death and Dying 7, no. 2 (1976): 178; see also Joseph A. Durlak, “Changing Death Attitudes

Through Death Education,” in Death Anxiety Handbook: Research, Instrumentation, and Application, ed. Robert A. Neimeyer (Washington, D.C.: Taylor & Francis, 1993),

pp. 243–259.

44. Christopher Alexander, Sara Ishikawa, and Mur-

ray Silverstein, A Pattern Language: Towns, Building, Construction (New York: Oxford University Press, 1977), p. 354.

45. See Daniel Callahan, “Defi ning a Peaceful Death,”

in The Troubled Dream of Life: Living with Mortality (New York: Simon & Schuster, 1993), pp. 195–196.

46. Allan Kellehear, A Social History of Dying (New York: Cambridge University Press, 2007), p. 232.

47. Grimes, Deeply into the Bone, p. 223.

48. Vernon Reynolds and Ralph Tanner, The Social Ecology of Religion (New York: Oxford University Press, 1995), p. 204. For an engaging account of how indi-

viduals sustained this concept of a good death despite

distressing and unusual circumstances, see Drew Gilin

Faust, “The Civil War Soldier and the Art of Dying,”

Journal of Southern History 67, no. 1 (2001): 3–38.

49. Robert Kastenbaum, On Our Way: The Final Passage Through Life and Death (Berkeley: University of California Press, 2004), pp. 131–135.

50. Stu Farber, Thomas Egnew, and Annalu Farber,

“What is a Respectful Death?” in Living with Dying: A Handbook for End-of-Life Care Practitioners, ed. Joan Berzoff and Phyllis R. Silverman (New York: Columbia

University Press, 2004), pp. 102–127; quote p. 103.

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69. Odenwald, Back to the Astronomy Cafe, p. 88.

70. Gary Snyder, The Practice of the Wild: Essays (San Francisco: North Point Press, 1990), p. 176.

71. Sandra L. Bertman, “Bearing the Unbearable:

From Loss, the Gain,” in The Path Ahead, ed. DeSpelder and Strickland, pp. 348–354; quote p. 353.

72. Doris M. Schoenhoff, The Barefoot Expert: The Inter- face of Computerized Knowledge Systems and Indigenous Knowledge Systems (Westport, Conn.: Greenwood, 1993), p. 100.

66. Clifford Simak, “Death Scene,” in The Worlds of Clifford Simak (New York: Simon & Schuster, 1960); Robert A. Heinlein, “Life-Line,” in The Man Who Sold the Moon: Harriman and the Escape from the Earth to the Moon! ed. Heinlein (New York: Shasta, 1950).

67. Kit Reed, “Golden Acres,” in Social Problems Through Science Fiction, ed. John W. Miestead and oth- ers (New York: St. Martin’s, 1975).

68. Sten Odenwald, Back to the Astronomy Café (Boulder, Colo.: Westview, 2003), p. 39.

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Credits and Sources

Prologue and Epilogue: Copyright © 1982 by David Gordon. Used by permission.

Pages 4, 101, & 276: Courtesy of the Center for Creative Photography. Used by permission.

Page 10: Language Log Blog, “Kim Jong Il: Did he “die” or “pass away?,” blog entry by Harlow Wilcox, December 20, 2011; http://languagelog. ldc.upenn.edu/nll/?p 5 3643 .

Page 17: From Jean Lipman-Blumen, “Our Existential Vulnerability to Toxic Leaders”; Death and Denial: Interdisciplinary Perspectives on the Legacy of Ernest Becker, ed. Daniel Liechty, 161–172; Praeger, 2002, p. 162. John O’Hara’s Appointment in Samarra was published in 1982.

Page 19: Quote by Suse Lowenstein from Ann F. de Jong Hodgson, “Interviews and Issues: Dark Elegy,” Illness, Crises and Loss 4, nos. 3–4 (1995): 18–38; quote, p. 21.

Pages 21, 24, 79, 169, 202, 254, 294, 325, 329, 343, 349, 427, 429, 443, 549 & 568: Courtesy of Albert Lee Strickland. Used by permission.

Page 25: From The Kitchen Chronicles: 1001 Lunches with J. Krishnamurti by Michael Krohnen; Edwin House, 1997, p. 292.

Pages 30, 52, 193: Courtesy of Nick Downes. Used by permission.

Page 35: From “Death in Cades Cove” by A. Crosby, in Appalachia: When Yesterday Is Today, ed. students at the University of Tennessee, Knoxville, 1965, pp. 1–3; quoted in Death and Dying in Central Appalachia: Changing Attitudes and Practices by James K. Crissman; University of Illinois Press, 1994.

Pages 36 & 37: U.S. Census Bureau, Historical Statistics of the United States, Colonial Times to 1970; Washington, D.C.: Government Printing Offi ce, 1975, pp. 55, 59; and Donna L. Hoyert and Jiaquan Xu, “Deaths: Preliminary Data for 2011,” National Vital Statistics Reports 61, no. 6; Hyattsville, Md.: National Center for Health Statistics, 2012, pp. 1, 26.

Page 38: Donna L. Hoyert and Jiaquan Xu, “Deaths: Preliminary Data for 2011,” National Vital Statistics Reports 61, no. 6; Hyattsville, Md.: National Center for Health Statistics, 2012, p. 4.

Page 40: From the Los Angeles Times (December 21, 1990).

Pages 45, 152 & 304: Courtesy of Edward C. and Gail R. Johnson.

Pages 48, 320 & 575: Courtesy of Robin Van Doren, Open Doors.

Pages 54 & 277: From Mortality by Christopher Hitchens; Twelve, 2012, pp. 6, 101.

Page 55: Based on Erik H. Erikson, Childhood and Society, 2nd ed.; Norton, 1964, pp. 247–274.

Page 58: Tammy Maas, Reader’s Digest ( July 2009), p. 57.

Pages 60, 335, 336 & 398: Used with permission of Joe Allen, Brooks Allen, and Janice Laurent.

Pages 61, 138, 197, 250, 258, 582 & 591: Courtesy of Carol A. Foote. Used by permission.

Page 72: Courtesy of William M. Lamers, Jr., “The Little Sounds of Grief: Poetry and Grief,” a presentation to the 21st International Death, Grief, and Bereavement Conference, Univer- sity of Wisconsin, LaCross, May 28, 2003.

Page 73: From Journeys Through Bookland, Vol. 1, ed. Charles H. Sylvester; Bellows-Reeve Company, Publishers, Chicago, 1922.

Page 74: Courtesy of Christine DeVault. Used by permission.

Page 81: From Shifting Interludes: Selected Essays by Willie Morris, edited by Jack Bales; University Press of Mississippi, 2002, p. 173.

Pages 88, 126, & 136: Courtesy of Patrick Dean. Used by permission.

Page 93: Illustration copyright © 1982 by Eric Mathes. Courtesy of Eric Mathes.

Page 93 (bottom): From Death Customs by E. Bendann; Knopf, 1930.

Page 94: “When Hare Heard of Death” excerpted from pp. 23–24 of The Road of Life and Death: A Ritual Drama of the American Indians by Paul Radin, Bollingen Series V. Copyright © 1945, renewed 1973, by Princeton University Press. Reprinted by permission of Princeton Univer- sity Press and Doris Woodward Radin.

Page 95: Aesop’s “Eros and Death” reworked by Steve Sanfi eld, from Death: An Anthology of Ancient Texts, Songs, Prayers, and Stories, ed. David Meltzer; North Point Press, 1984.

Pages 96–97: Based on A Social History of Dying by Allan Kellehear; Cambridge University Press, 2007. Used with permission.

Page 100: From Strange Facts About Death by Webb Garrison. Copyright © 1978 by Webb Garrison. Used by permission of the publisher, Abingdon Press.

Page 110: Papago song by Juana Manwell. By permission of Smithsonian Institution Press from Papago Music by Frances Densmore;

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Page 162: President’s Commission for the Study of Ethical Problems in Medicine and Biomedi- cal and Behavioral Research, Defi ning Death: A Report on the Medical, Legal, and Ethical Issues in the Determination of Death; Washington, D.C.: Government Printing Offi ce, 1981, p. 73.

Page 170: From Postmortem: How Medical Examiners Explain Suspicious Deaths by Stefan Timmermans; University of Chicago Press, p.103.

Page 177: From Dying and Death: A Clinical Guide for Caregivers, ed. David Barton; Williams & Wilkins, 1977, p. 181.

Page 178: Adapted from Taming the Beloved Beast: How Medical Techinology Costs are Destroying Our Health Care System by Daniel Callahan; Princeton University Press, 2009, pp. 47–48.

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( October 20, 1985). Page 184: From “Dying Words: How Should

Doctors Deliver Bad News?” by Jerome Groop- man; New Yorker (October 28, 2002), p. 62–70; quote, p. 66.

Page 186: Reprinted with permission of Simon & Schuster from To Live Until We Say Good-Bye, text by Elisabeth Kübler-Ross and photographs by Mal Warshaw. Copyright © 1978 by Ross Medical Associates, S.C., and Mal Warshaw. Photograph copyright © 1978 by Mal Warshaw.

Page 187: From “Medicine and the Question of Suffering” by Richard B. Gunderman; Second Opinion: Health, Faith, and Ethics 14 ( July 1990).

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Page 190: Provided courtesy of Maurizio Marinelli by Fondazione Hospice MariaTeresa Chiantore Seràgnoli Onlus, Bologna, Italy.

Pages 199 & 422: From You Don’t Miss Your Water by Cornelius Eady, © 1995 by Cornelius Eady; Henry Holt, 1995; fi rst published in Pequod, no. 35 (1993), p. 114. Reprinted by permission of the author and Henry Holt and Co.

Page 201: Adapted from Our Aging Parents: A Practical Guide to Eldercare, ed. Colette Browne and Roberta Onzuka-Anderson; University of Hawaii Press, 1985, pp. 204–209.

Page 203: From On Fire: A Personal Account of Life and Death and Choices by Larry Brown; Algonquin, 1994, pp. 47–48.

Page 206: From Passing On: The Social Organiza- tion of Dying by David Sudnow; Prentice-Hall, 1967.

Bureau of American Ethnology Bulletin 90; Smithsonian Institution, Washington, D.C. 1929.

Page 110: Dakota song from The Primal Mind: Vision and Reality in Indian America by Jamake Highwater; Harper and Row, 1981.

Page 111: Burial oration (Wintu) from “Wintu Ethnography” by Cora Du Bois, in University of California Publications in American Archaeology and Ethnology 36 (1935). Reprinted by permis- sion of the University of California Press.

Page 113: From Religions of Africa: A Pilgrimage into Traditional Religions by Noel Q. King; Harper and Row, 1970.

Page 121: Courtesy of Shmuel Thaler. Used by permission.

Page 122: Reprinted from Phnom Penh Post ( October 21, 2001). From Under the Dragon: California’s New Culture by Lonny Shavelson and Fred Setterberg; co-published by Heyday Books and the Oakland Museum of California, p. 120.

Page 124: From Chuang Tzu: Basic Writings, trans. Burton Watson; Columbia University Press, 1964, p. 113.

Page 127: From The Four Seasons: Japanese Haiku Second Series, trans. Peter Beilenson. Copyright © 1958 by The Peter Pauper Press.

Page 128: Courtesy of Andy Hau Yan Ho. Used by permission.

Page 145: Courtesy of David Rodriguez. Used by permission.

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Pages 149, 205, 252, 285, 354 & 596: The New Yorker Collection drawings from The Cartoon Bank. All Rights Reserved.

Page 153: Used by permission of Elizabeth Bradbury.

Page 155: From “Clarifying the Paradigm for the Ethics of Donation and Transplantation: Was ‘Dead’ Really So Clear Before Organ Donation?” by Sam D. Shemie; Philosophy, Ethics, and Humanities in Medicine 2 (August 24, 2007), p. 18.

Page 158: From Mystics, Magicians, and Medicine People: Tales of a Wanderer by Doug Boyd. Copy- right © 1989 by Doug Boyd. Reprinted by per- mission of Paragon House.

Page 161: From “Dying As a Social Relationship: A Sociological Review of Debates on the Deter- mination of Death” by Allan Kellehear; Social Science & Medicine 66 (2008), pp. 1533, 1544.

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St. Louis, 1982. Used with permission of The C. V. Mosby Company.

Page 279: From There is a Rainbow Behind Every Dark Cloud, The Center for Attitudinal Healing; Celestial Arts, 1978, p. 71.

Page 283: From “Pain Management on Trial” by Maureen Cushing; American Journal of Nursing 7 (February 1992): 21–22.

Page 287: Adapted from Living Well at the End of Life by Joanne Lynn and David M. Adamson; R AND, 2003, p. 8.

Page 288: Adapted from “Preparing for the Death of a Loved One,” American Journal of Hospice and Palliative Care 9, no. 4 (1992): 14–16; The Merck Manual of Medical Information: Home Edition, ed. Robert Berkow, Merck Research Laboratories, 1997, p. 21; and “The Last Few Days,” by Robert E. Enck, American Journal of Hospice and Palliative Care 9, no. 4 (1992): 11–13.

Page 292: From The End of Life Advisor: Personal, Legal, and Medical Considerations for a Peaceful, Dignifi ed Death by Susan Dolan and Audrey Vizzard; Kaplan, 2009, p. 75.

Page 299 (bottom): From The County Journal, Bayfi eld County, Cable, Wis. (April 25, 1991).

Page 303: Used by permission of Edgar N. Jackson.

Page 306: From “Take Only As Directed” by Wayne Delk; U. S. Gospel News (September 1999). Reprinted by permission of the author.

Page 314: Adapted from General Price List Sur- vey, National Funeral Directors Association.

Page 316: Athenaeum of Philadelphia Collection.

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Page 332 (bottom): Adapted from “Dying to Be Green,” by Neil Shea, National Geographic ( July 2008).

Page 333: From The Secret Cemetery by Doris Fran- cis, Leonie Kellaher, and Georgina Neophytou; Oxford: Berg, 2005, p. 1.

Page 338: Courtesy of Fritz and Inge Roth, Pütz-Roth, Bergisch Gladbach, Germany.

Page 342: From Living Your Dying by Stanley Keleman; Random House, 1974.

Page 344: From Playboy interview by Eric Spitznagel (October 16, 2012).

Page 209: From A Gradual Awakening by Stephen Levine. Copyright © 1979 by Stephen Levine. Reprinted by permission of Doubleday & Company, Inc.

Page 216: President’s Commission for the Study of Ethical Problems in Medicine and Biomedi- cal and Behavioral Research, Making Health Care Decisions, A Report on the Ethical and Legal Implications of the Patient-Practitioner Relation- ship; Washington, D.C.: Government Printing Offi ce, 1982, pp. 64–65.

Page 220: From Care of the Dying by Richard Lamerton; Technomic Publishing, 1976.

Page 223: Adapted from Connect Core Concepts in Health, 13th ed., by Paul M. Insel and Walton T. Roth; McGraw-Hill, 2013, p. 446.

Page 225: From Journeys ( July 2006), Hospice Foundation of America, p. 3.

Page 240: James Scott, e-mail message to authors, July 11, 2013.

Page 241: From To A God Unknown by John Steinbeck; R. O. Ballou, 1933.

Page 245: From News from Native California 4 (August–October 1990).

Pages 246–247: Will of Tomás Antonio Yorba, trans. H. Noya [HM26653]. Reproduced by permission of The Huntington Library, San Marino, California.

Page 255: From the Honolulu Star-Bulletin & Advertiser (August 26, 1990).

Page 262: From Enjoy Every Sandwich: Living Each Day As If It Were Your Last by Lee Lipsenthal; Crown Archetype, 2012, page 14.

Page 263: Adapted from “A Task-Based Approach to Coping with Dying,” by Charles A. Corr; Omega: Journal of Death and Dying 24, no. 2 (1991–1992): 81–94.

Page 265: “But You Look So Good” from No Pain, No Gain. Reprinted by permission of Judith L. Ellsworth.

Page 267: Adapted from “Coping with Life- Threatening Illness: A Task Model,” by Ken- neth J. Doka; Omega: Journal of Death and Dying 32, no. 2 (1995–1996): 111–122.

Page 268: From the Register-Pajaronian, Watsonville, Calif. (March 11, 1981).

Page 270: Used by permission of Joan J. Conn. Page 271: From “Love Bade Me Welcome” by

Christian Wiman in The Best American Spiri- tual Writing 2008; Houghton Miffl in, 2008. Originally published in The American Scholar ( Summer 2007).

Pages 274–275: Adapted from Living with Cancer by Ernest H. Rosenbaum; The Mosby Medical Library series, The C. V. Mosby Company,

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Oxford University Press, 1961. Reprinted by permission of Oxford University Press.

Page 411: Courtesy of Francesco and Sofi a Campione.

Page 414: Caption to cartoon by E. H. Shepard, ©Punch/Rothco. Reprinted by permission of Rothco Cartoons, Inc.

Page 418: From “Scream of Consciousness” by Ruth Kramer Ziony; Neworld (1977).

Page 425: From The Undertaking: Life Studies from the Dismal Trade by Thomas Lynch; W. W.  Norton, 1997, pp. 82–83, 51.

Page 431: From The Journey Through Grief and Loss: Helping Yourself and Your Child When Grief Is Shared by Robert Zucker; St. Martins Griffi n, 2009, p.70.

Page 433: Transcribed by the authors from an inscription at the National Civil Rights Museum in Memphis, Tennessee.

Page 440: From The Warming of Winter by Maxine Dowd Jensen; Abingdon Press, 1977.

Page 441: Adapted from Last Chapters: A Sociol- ogy of Aging and Dying, by Victor W. Marshall; Brooks/Cole, 1980, pp. 169–177.

Page 444: From Chipping Bone: Collected Poems by Maude Meehan; Embers Press, 1985. Courtesy of Maude Meehan.

Page 448: From (a) Merriam-Webster’s Collegiate Dictionary, Eleventh Edition, © 2003 by Merriam-Webster, Inc., publisher of the Merriam-Webster® Dictionaries; used by permission. (b) Pathways to Suicide: A Survey of Self-Destructive Behaviors, by Ronald W. Maris, Johns Hopkins University Press, 1981, p. 290. (c)  Suicide, by Jean Baechler, Basic, 1979, p. 11. (d) Death: Current Perspectives, 2nd ed., ed. Edwin S. Shneidman, Mayfi eld, 1980, p. 416.

Page 451: Adapted from “Procedures and Prob- lems in Conducting a Psychological Autopsy,” by Thomas J. Young; International Journal of Offender Therapy and Comparative Criminology 36, no. 1 (Spring 1992): 43–52.

Page 452: Adapted from “Psychological Autopsy: Clinical and Legal Perspectives,” by James R. P. Ogloff and Randy K. Otto, Saint Louis University Law Journal 37, no. 3 (Spring 1993): 610–614; and “Procedures and Problems in Conducting a Psychological Autopsy,” by Thomas J. Young, International Journal of Offender Therapy and Comparative Criminology 36, no. 1 (Spring 1992): 47–48.

Pages 456, 464, 468, 472 & 480: Suicide notes courtesy of Edwin S. Shneidman.

Page 347: From A Death in the Sanchez Family by Oscar Lewis; Random House, 1969.

Page 349 (left): From Victorian Cemetery Art by Edward V. Gillon, Jr.; Dover, 1972. Reproduced by permission of Edward V. Gillon, Jr.

Page 352: Adapted from “The Two-Track Model of Bereavement: Overview, Retrospect, and Prospect,” by Simon Shimshon Rubin, Death Studies 23 (1999): 681–714, p. 685; and “The Two-Track Model of Bereavement Question- naire (TTBQ): Development and Validation of a Relational Measure,” by Simon Shimson Rubin and others, Death Studies 33 (2009): 305–333, p. 309.

Page 361: Reprinted from “Mourning and Meaning,” by Robert A. Neimeyer, Holly G. Prigerson, and Betty Davies; American Behavioral Scientist 46, no. 2 (October 2002): 235–251, p. 244.

Page 364: From Class: A View from Middle England by Jilly Cooper; Methuen, 1979.

Page 368: From A Harvest Yet to Reap: A History of Prairie Women by Linda Rasmussen and others; Women’s Press, Toronto, Ontario, 1976.

Page 378: From Ethical Practice in Grief Counseling, by Louis A. Gamino and R. Hal Ritter, Jr.; Springer, 2009, p. 213.

Page 382: “Anguish of Loss,” “Sharing the Grief,” and “Collapsing” from The Anguish of Loss, 2nd ed. Copyright © 1992 by Julie Fritsch and Sherokee Ilse. Photographs by Paul Schraub. Reprinted by permission of Wintergreen Press and Julie Fritsch.

Page 389 (bottom): Drawing by Dominic Horath created in Mrs. Bronwyn Luffman’s classroom at Salesian Sisters School and provided by Linda DaValle. Reprinted by permission of Mary and Frank Horath.

Pages 394 & 449: From Never the Same: Coming to Terms with the Death of a Parent by Donna Schuurman; St. Martin’s Press, 2003.

Page 395: Used with permission of Christine and Donovan Longaker.

Page 396: Courtesy of Karen Saltzman. Used by permission.

Page 400: Adapted from Approaching Death: Improvimg Care at the End of Life, ed. Marilyn J. Field and Christine K. Cassel; National Academy Press, 1997, p. 65.

Page 408: “Peanuts” reprinted by permission of United Features Syndicate, Inc.

Page 410: From A Tropical Childhood and Other Poems by Edward Lucie-Smith. Copyright ©

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Page 506: Adapted from The Psychology of Death: Concise Edition, by Robert Kastenbaum and Ruth Aisenberg; Springer, 1976, pp. 291–294.

Page 509: From “Down at the Cross: Letter from a Region in My Mind,” by James Bald- win, in The Fire Next Time, © 1963 James Baldwin, Vintage Press. Reprinted in James Baldwin, Collected Essays; Library of America, 1998, p. 330.

Page 513: From A Journal for Jordan: A Story of Love and Honor by Dana Canedy; Crown, 2008, p. 247.

Page 516: Adapted from Faces of the Enemy: Refl ec- tions of the Hostile Imagination by Sam Keen; Harper and Row, 1986.

Page 520: Courtesy of Carla Sofka, Ph.D., the New York State Museum History Collection, and the World Trade Center Relief Fund. Acquisition number 202.25.184 (cover). All rights reserved.

Page 522: Adapted from Understanding Terrorism: Challenges, Perspectives, and Issues, 3rd ed., by Gus Martin; Sage, 2010, p. 6.

Page 528: From “Back to a Future: One Man’s AIDS Tale Shows How Quickly Epidemic Has Turned” by David Sanford; The Wall Street Jour- nal (November 8, 1996).

Page 536: Courtesy of Barbara J. Paul, Ph.D. All rights reserved.

Page 541: From “Go Down Death—A Funeral Sermon,” in God’s Trombones by James Weldon Johnson. Copyright 1927 by Viking Press, Inc. Copyright renewed 1955 by Grace Nail Johnson. Reprinted by Permission of Viking Penguin Inc.

Page 542: From Religious Encounters with Death: Insights from the History and Anthropology of Religions, ed. Frank E. Reynolds and Earle H. Waugh; Pennsylvania State University Press, 1977.

Page 546: From Mahabharata, 3.314.118, W. S. Merwin’s translation, from J. Moussaieff Masson, “Introduction,” in Sanskrit Love Poetry, trans. W. S. Merwin and J. Moussaieff Masson; Columbia University Press, 1977, p. 20.

Page 547: From Zen Mind, Beginner’s Mind by Shunryu Suzuki; 1970. Reprinted by permis- sion of John Weatherhill, Inc.

Page 548: Courtesy of Bodhidharma Inc. Page 565: From The Gospel at Colonus. Music by

Bob Telson, lyrics by Lee Breuer. Page 577: From Einmal Jenseits und Zurück:

Ein Koffer für die Letzte Reise, by Fritz Roth;

Page 458: Edwin Arlington Robinson, “Richard Cory,” in The Children of the Night; Charles Scribner’s Sons, 1897. Copyright under the Berne Convention. Reprinted with the permission of Charles Scribner’s Sons.

Page 460: Adapted from Death, Society, and Human Experience, 2nd ed., by Robert J. Kasten- baum; The C. V. Mosby Company, St. Louis, 1981. Used with permission of The C. V. Mosby Company and Robert J. Kastenbaum.

Page 462: Kim Bridgeford, Department of En- glish, Fairfi eld University, Fairfi eld, Conn.

Page 465: Adapted from Deaths of Man by Edwin S. Shneidman; Quadrangle Books, 1973, pp, 82–90. Courtesy of Edwin S. Shneidman.

Page 467: Adapted from “Suicide: The Ultimate Escape” by Brian Barry; Death Studies 13, no. 2 (1989): 185–190.

Page 474: From The Savage God: A Study of Suicide by A. Alvarez; Random House, 1972.

Pages 477–478: Courtesy of Magaret Macro. Page 478: “Resume” by Dorothy Parker, from The

Portable Dorothy Parker, revised and enlarged edition, ed. Brendan Gill. Copyright 1926 by Dorothy Parker. Reprinted by permission of Viking Penguin, Inc., and from The Collected Dorothy Parker by permission of Gerald Duck- worth, Ltd.

Page 479: From The Suicide Index: Putting My Father’s Death in Order by Joan Wickersham; Harcourt, 2008, p. 303.

Page 484: Used by permission of Maude Meehan. Page 490: From Life in the Fast Lane: Selected Works

of Stephen St. Croix, by Stephen St. Croix; Mix Books, 2008, p. 210. Originally published in Mix (December 2003), p. 22.

Page 493: From “Groundfall” by William G. Higgins; Sierra (November–December 1979).

Page 497: Drawing by Haruna Sato, age 7. Used by permission of Mie Sato. Reprinted from the book, Tsunami: The Complete Essays by Children from the Disaster Areas edited by Ken Mori. Courtesy of Ken Mori and Bungeis- hunju Ltd., Chiyoda, Tokyo, 2012, published by Yasushi Toriyama (w w w.bunshun, co.jp). With thanks to Makiko Matsumoto and Jitaro Mizuno, as well as to Mie Sato and her daughter Haruna.

Page 499: From Salvage the Bones, by Jesmyn Ward; Bloomsbury, 2011, pp. 216–217.

Page 501: From Life, Sex, and Ideas: The Good Life Without God, by A. C. Grayling; Oxford Univer- sity Press, 2003, p. 125.

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Page 588: Adapted from “In Search of a Good Death: Observations of Patients, Families, and Providers,” by Karen E. Steinhauser and others; Annals of Internal Medicine 132, no. 10 (2002): 825–832.

Page 590: Adapted from “Criteria for a Good Death,” by Edwin Shneidman; Suicide and Life- Threatening Behavior 37, no. 3 (2007): 245–247.

Pages 592–593: From Big Winds, Glass Mornings, Shadows Cast by Stars: Poems 1972–80 by Morton Marcus; Jazz Press, Los Angeles, 1981. Copyright © by Morton Marcus. Used by permission of Morton Marcus.

Gütersloher Verlagshaus, 2006, pp. 84–85. Courtesy of Pütz-Roth.

Page 580: From At the Edge of the Body by Erica Jong. Copyright © 1979 by Erica Mann Jong. Reprinted by permission of the poet.

Page 583: From an advertisement for Sex Money Kiss by Gene Simmons in Publishers Weekly (April 28, 2003).

Page 585: Courtesy of Rolling Stone magazine. Page 586: Reprinted by permission. Advertising

agency: Robaire and Hogshead, Venice, Calif. Photography: Michael Ruppert Studios, Los Angeles, Calif.

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Abraham (patriarch), 534 Achte, Kalle, 611 Ackerman, F., 624 Acocella, Joan, 610 Adagio for Strings (Barber), 296 Adamolekun, Kemi, 375, 645 Adams, David W., 646 Adams, James Luther, 624 Adams, Maurice, 257 Adamson, Sue, 637 Aesculapius (Greco-Roman god

of medicine), 181 Afi fi , Walid A., 621 Agee, Margaret, 576 Aging with Dignity, 237 Ahuile, Leylha, 615 Aiba, Toshiaki, 630 Ainsworth, Mary, 360 Aisenberg, Ruth, 151, 620,

656, 658 Akers, Ronald L., 466, 654 Al Hoa, Abdul Latif, 663 Alali, A. Odasuo, 615 Alanez, Tonya, 607 Albert (prince consort of Queen

Victoria), 99 Albom, Mitch, 658 Albright, Cheryl L., 621 Alcock, Janes E., 666 Alexander, Christopher, 587, 669 Alexander the Great (356 –323

BCE), 295 Alford, C. Fred, 662 Algeo,Katie, 618 Al-Kattar, Aref M., 660 Allah (Islamic deity), 542 Allan, Stuart, 660 Allen, Davina A., 611, 612, 665 Allen, Felicity, 667 Allen, Gillian, 625 al-Qaeda (terrorist network),

519, 522 Altman, Patricia B., 616 Alvarez, Alfred, 474, 654 Alvord, Lori Arviso, 280, 634 Ambros, Barbara, 79, 611 Ameche, Yvonne K., 371, 644 Amelang, James S., 602 American Academy of

Neurology, 160 American Board of Medical

Specialties, 192 American Medical Association,

229, 658 Ames, Roger T., 636 Ammah-Tagoe, Aku, 609

Anderson, David M., 651 Anderson, Ray S., 614, 662 Anderson, Reb, 292, 636 Andrade, Mary J., 616 Andrew, Louise B., 655 Andrews, Ian, 606 Ansari, Humayun, 617 Anthony, Sylvia, 32, 54, 609 Antonius, Marcus Aurelius

(Roman emperor and Stoic philosopher), 554, 665

Apolone, G., 635 Appleby, Louis, 561, 666 Appolonio, Kathryn Kanzler, 654 Aquinas, Thomas, 539 Arcaro, Tom, 604 Arias, Elizabeth, 669 Ariès, Philippe, 99, 100, 102,

103–104, 613, 640 Arikawa, Hiroko, 635 Arlington National Cemetery,

22, 77, 308, 324 Armstrong, Janice Gray, 603 Arnett, Jeffrey Jensen, 610, 612 Arnold, Robert M., 173 Ars Moriendi (thanatology

organization), 33 Ascent into the Empyrean

(Bosch), 557 Ashcroft, John, 228 Ashford, Marguerite K., 602 Association for Death Education

and Counseling (ADEC), 33 Atchley, Robert C., 445, 652 Athill, Diana, 443, 652 Atkinson, Rick, 639 Attig, Thomas A., 231, 382, 570,

606, 630, 640, 667 Atwater, P. M. H., 665 Au, Kathryn H., 618 Ault, A. Brian, 607 Austin, Ann E., 651 Austin, Hilary Mac, 637 Australian Centre for Grief

and Bereavement, 579 Axell, Albert, 653 Azzaro, Vince, 305, 637

Babb, James R., 617 Badham, Linda, 664 Badham, Paul, 664, 665 Baechler, Jean, 448 Bagdikian, Ben H., 637 Bahr, Donald, 614 Bahrampour, Tara, 655 Bailey, Leonard L., 621

Baily, Mary Ann, 625 Baines, Barry K., 631 Baker, John E., 641 Baldwin, James, 509 Balk, David E., 399, 415, 581, 597,

609, 647, 651, 668 Ball, P. Bonnie, 653 Balmer, Leslie, 380, 646 Baloğlu, Mustafa, 627 Bance, Sheena, 616 Bandura, Albert, 82, 612, 646 Banner, Stuart, 173 Barclay, William, 662 Bardo Thödol (Tibetan Book of the

Dead), 550 Barker, Jonathan, 529 Barnard, Christiaan, 165 Barnard, David, 627 Barnason, Susan, 635 Baron-Sorenson, Jane, 611 Barrett, Justin I., 611 Barrett, Ronald Keith, 116, 117,

300, 615, 625, 637, 646, 657, 667 Barrett, William, 665 Barry, Brian, 467, 654 Barry, Rob, 619 Bartell, Denise, 647 Bartholome, William G., 400, 406,

647, 648 Baruch, Joel, 510, 659 Bashir, Shahzad, 663 Bashō, Matsuo ( Japanese

poet), 548 Bataille, Georges, 640 Bates, Thelma, 669 Bateson, Mary Catherine, 661 Battles, Haven B., 648 Bauer, Jack J., 641 Baugher, Robert J., 636 Baumeister, Roy F., 653, 654 Bean, Lee L., 651 Bearison, David J., 647 Beasley, Adam H., 656 Bebey, Francis, 113, 615 Beck, Aaron T., 523, 661 Beck, Ulrich, 44–45, 608 Becker, Carl B., 547, 628, 664 Becker, Ernest, 30, 33, 612 Bedau, Hugo Adam, 619, 620 Beeder, Ann Bordwine, 666 Beers, Mark H., 621, 624, 650, 651,

652, 656 Behrman, Richard E., 415, 646,

647, 648 Beimler, Rosalind Rosoff, 616 Bellanger, Patricia, 621

Name Index

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Bellomo, R., 620, 621 Belth, Joseph M., 631 Bemak, Fred, 667 Bend It Like Beckham (motion

picture), 136 Bendiksen, Robert, 612 Benford, Jennie, 606 Benito, Gary, 305, 637 Benkard, Ernst, 614 Benn, Evan S., 656 Bennett, Diane O., 639 Benoliel, Jeanne Quint, 33, 184,

623, 667, 669 Bensoni, John A., Jr., 634 Bereaved Families of Ontario,

380 Bereavement Care Centre

(Australia), 579 Berger, Candace, 604 Berger, Joy S., 12, 602 Bering, Jesse M., 609 Berkow, Robert, 621, 628, 633,

634, 635, 661 Berkowitz, Bruce D., 660 Berman, Alan L., 656 Bernat, James L., 620 Berns, Carol F., 648 Bernstein, Alan E., 663 Bernstein, Barton E., 631 Bernstein, Richard, 660 Bertman, Sandra L., 23, 597, 604,

611, 623, 642, 652, 669, 670 Berzoff, Joan, 293 Berzosa, Miguel, 635 Beshai, J. A., 605 Bessinger, C. D., 623 Best, Elizabeth Kirkley, 639 Bhagavad-Gita (Hindu religious

text), 546, 550, 663 Bilger, Burkhard, 661 Binsky, Paul, 613 Birnbacher, Dieter, 623 Bishop, Jeffrey P., 256, 631 Bishop, Jerry E., 643 Bjorklund, David F., 609 Black, Stephen T., 656 Black Hills National Cemetery,

254 Blackhall, Leslie J., 625 Blaisdell, William, 201 Blanche, Tony, 619 Blasco, Ana, 635 Blasi, Carol Hernández, 609 Blauner, Robert, 612 Blevins, Dean, 257 Blieszner, Rosemary, 649 Block, Robert, 657 Bloom, Mia, 529 Bluebond-Langner, Myra, 400,

581, 647, 648, 668 Boase, T. S. R., 613

Bobbitt, Philip, 660 Bode, Sabine, 640 Bodenheimer, Thomas S., 622 Body Worlds (exhibition), 44 Boelen, Paul A., 641, 643 Boersma, Frederic J., 640 Bogac, L. Pauahi, 618 Boglioli, Lauren R., 655, 658 Bolin, Robert C., 665, 666 Bonanno, George A., 641, 642 Bonde, Niels, 638 Bonner, Jessie L., 659 Bonnichsen, Robson, 614 Bonoti, Fontini, 646 Book of Changes (Yijing), 543 Bordere, Tashel C., 637 Boroditsky, Lera, 602 Bosch, Hieronymus, 557 Boss, Judith A., 256 Boss, Pauline, 644 Boston, Patricia, 627 Boswell, James, 532 Bourbonniere, Meg, 622 Bower, Bruce, 609, 633, 645 Bowersock, G. W., 660 Bowker, John, 566 Bowlby, John, 347, 360, 640 Bowman, Kerry W., 616 Bowman, LeRoy, 306, 637 Bowman, Pierre, 182 Bowman, Ted, 16, 603 Boyarin, Jonathan, 662 Boyd, Kirsty, 635 Boyé, Lafayeete De Mente, 622 Brabant, Sarah, 606, 642 Bradley, Ben, 566 Brakenhielm, Carl-Rheinhold,

635 Branch, Mary Louise, 646 Branch Davidians (religious

group), 455 Brand, Stewart, 593, 669 Brandes, Stanley, 120, 616, 652 Brannigan, Michael C., 256 Brase, Gary L., 623 Braun, Kathryn I., 618 Breaux, Brooke O., 606 Breen, John, 603 Bregman, Lucy, 551, 664 Brenneis, Don, 612 Brent, David A., 653, 655 Brent, Sandor B., 51, 52–53,

81–82, 608, 612 Bressers, Bonnie, 638 Brice, Charles W., 610 Bridgeford, Kim, 462 Briggs, Stephen, 655 Brinson, Sabrina A., 646 Brock, Dan W., 623 Brock, Timothy C., 644 Brodkey, Harold, 266, 632

Brody, B. A., 628 Brody, Howard, 623 Brody, Jane E., 611, 645 Brokstein, Ruth T., 648 Brosius, J. Peter, 613 Brown, Larry, 203 Brown, Pam, 626 Brown, Peter, 613 Brown & Alexander (funeral

home), 316 Browning, Michael, 659 Bruner, Jerome, 350, 641 Brunn, Ole, 617 Bryan, Craig J., 654 Bryant, Clifton D., 606 Bryson, Bill, 602 Buchholtz, Mary, 612 Buddha, 547, 550 Buenteo, Russell, 607 Buetow, Stephen, 623 Bugen, Larry A., 367, 644 Bulkeley, Kelly, 666 Bulkley, Patricia, 666 Bull, M. A., 642 Bullock, Karen, 627 Burke, Briani L., 605 Burke, Garance, 656 Bush, George W., 224 Bush, Jeb, 224 Bush, Nancy Evans, 665 Bushfi eld, Suzanne, 650 Butler, Robert N., 445, 652 Byock, Ira, 175, 190, 210, 227, 262,

263, 290, 355, 552, 581, 622, 624, 625, 629, 632, 633, 636, 642, 665, 668

Cable, Dana, 648 Cacciatore, Joanne, 649, 650, 651 Calcedo, Juan Carlos, 621 Calhoun, Craig, 660 Calhoun, Lawrence G., 645 Callahan, Daniel, 46, 178, 179,

180, 181, 210, 217, 365, 443, 608, 622, 627, 644, 652, 669

Callahan, Maggie, 632 Callimachi, Rukmini, 646 Callinicos, Constantine, 663 Caminiti, Caterina, 634 Campbell, Scott, 651 Campione, Francesco, 26, 578,

604, 634 Campo, Shelly, 623 Camps, Carlos, 635 Candlelighters Childhood Cancer

Foundation, 435 Canto, Angela I., 641 Canton, Norman F., 614 Canuck Place (pediatric palliative

care program), 403 Capital Caring (hospice), 291

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Caplan, Arthur L., 621, 629 Capron, Alexander Morgan, 627 Cardenas, Jose, 603 Cardoza y Arogón, Luis, 616 Carey, Susan, 608 Carmichael, Elizabeth, 616 Carney, Susanne S., 655 Carr, Arthur C., 644 Carr, Caleb, 660 Carr, Christopher, 550, 664 Carrasco, David, 121, 616 Carson, Ute, 611 Carter, Gregory T., 635 Carton, Barbara, 659 Casarett, David J., 625 Cassel, Christine K., 211, 627, 631 Cassell, Dana K., 606, 612, 614 Cassell, Eric J., 289, 636 Castle, Jason, 646 Caswell, Glenys, 637 Cathedral of Our Lady of the

Angels (Calif.), 325 Cave, Roderick, 617 Cavuoti, Corinne, 607 CBS News, 660 Census Bureau (U.S.), 606, 607 Center for Military History (U.S.

Army), 22 Centers for Disease Control and

Prevention (CDC), 528 Central Identifi cation Laboratory

(U.S. Army), 146 Cerminara, Kathy L., 225, 629 Certifi cate of Death (U.S.), 141 Chadwick, Nora K., 617 Chan, Cecilia Lan Wan, 125, 597,

617, 633, 668 Chapman, Tony, 626 Chapple, Helen, 211 Char, Walter F., 618 Charles C. Carson Center for

Mortuary Affairs, 146 Charmaz, Kathy, 612 Chatterton, Thomas, 468, 473 Chavira, Juan Antonio, 634 Chelf, Jane Harper, 641 Chen, Meichu D., 649 Chen, Pauline W., 293 Chen, Shih-Fen, 612 Cheney, Annie, 621 Cherry, Katie E., 610 Cheshire, Ashley, 638 Chesney, Margaret A., 661 Chew, G., 602 Chidester, David, 566, 654 Childs, Robert, 616 Chinen, Allan B., 667 Chiu, Wai Tat, 623 Chochinov, Harvey Max, 272, 633 Choron, Jacques, 33, 613, 662 Chow, Amy, 578, 668

Christ, Adolph E., 647 Christ, Grace H., 61, 647 Christakis, Nicholas A., 193, 631 Christensen, Arne Emil, 638 Chuang Tzu (Chinese

philosopher), 124, 544, 663 Chung, Rita Chi-Ying, 667 Cimbolic, Peter, 644 Clancy, John, 636 Clark, David, 87, 570, 635,

667, 669 Clark, Elizabeth J., 667 Clark, Jennifer, 638 Clark, Lynn Schofi eld, 87, 602,

609, 611 Clark, Peter A., 630 Clark, S., 642 Clark, William R., 528, 620,

661, 664 Clarkson, Amy, 602 Clausewitz, Karl von, 515 Clifford, Denis, 256 Cobb, Keltoni, 660 Cochrane, Feargal, 529 Cockburn, David, 665 Cohen, John, 614 Cohen, Larry, 502, 658 Cohen, Susan O., 648 Cohen-Almagor, Raphael, 630 Cohler, Bertram J., 641 Colbert, Stephen, 344 Colby, William, 629 Coler, Margo Simon, 615 Coler, Maria Adriana Felix, 615 Collins, Charles O., 638 Colón, Yvette, 283, 284, 635 Colt, George Howe, 487 Combs, Cindy C., 518, 660 Comelles, Josep M., 634 Committee on Homeland

Security (U.S. Senate), 657 Committee on the Assessment of

Readjustment Needs of Military Personnel, Veterans, and Their Families, 654

Committee on Trauma Research, National Research Council, 650

Comparelli, Anna, 654 Compassionate Friends, The,

380, 435 Congress (U.S.), 167, 224, 238 Conn, Joan, 270 Connelly, Douglas, 663 Connelly, R. J., 630 Connelly, Robert, 632 Connor, Stephen R., 187, 188,

211, 291, 365, 403, 622, 623, 624, 625, 626, 628, 636, 644, 645, 648

Controlled Substances Act, 228 Conwell, Y., 655

Cook, Alicia Skinner, 644 Cook, Emily W., 665 Cook, Robin, 595 Cook County Hospital (Chicago),

201 Cooper, Christopher, 657 Cooper, Jilly, 364 Cooper, Martha, 638 Cooper, Rose, 578, 649, 657 Coren, Stanley, 611 Corless, Inge B., 195, 624, 626,

634, 635, 667, 669 Corr, Charles A., 263, 415, 632 Corr, Donna M., 632 Cosh, Roderick, 636 Costa, Richard, 631 Cousins, Norman, 184, 282,

623, 635 Cowley, R. Adams, 201 Cox, Gerry R., 280, 615, 634 Cox, Meredith, 610 Cox, Ted, 604 CPR Annie, 107 Craft, Lucille, 657 Cramer, Phoebe, 633 Cranford, Ronald E., 620, 629 Crase, Darrell, 572, 606, 667 Creamer, Mark, 657 Creightmore, Richard, 617 Crenner, Christopher, 625 Crenshaw, David A., 377, 645 Crenson, Matt, 661 Crimp, Douglas, 661 Crissman, James K., 606, 626 Crissman, Mary A., 626 Crocoombe, Ron, 593–594, 669 Cross, Tracy L., 653 Cruzan, Nancy Beth, 222,

223–224, 240 Cucchi, Laurel, 648 Cullen, Lisa Takaeuchi, 339 Cullman, Oscar, 538, 662 Cunliffe, Barry, 617 Cunningham, James H., 650 Cupit, Illene Noppe, 47, 607, 609,

619, 647 Curl, James Stevens, 104, 614 Cushing, Maureen, 283 Cutter, Fred, 487

Daggett, Luann M., 651 Dahl, Julia, 653 Dance of Life, The (Munch), 18 Danforth, John C., 631 Danforth, Loring M., 602 Daniel (Hebrew prophet), 535 Dante Alighieri, 539, 540 Danto, Bruce L., 655, 658 Darby, Elisabeth, 613 Dark Elegy (Lowenstein), 18, 19 Davenport, Donna S., 445

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Donnelly, Sinéad, 577, 668 D’Onofrio, Carol, 625 Donovan, Marilee Ivar, 624 Dooley, Delores M., 578, 668 Dougherty, Charles J., 230–231,

630 Douglas, Jack D., 656 Dougy Center for Grieving

Children and Their Families (Ore.), 407

Dow, Harold, 660 Doyle, Brian, 660 Dresser, Rebecca, 629 Drug Enforcement Administration

(DEA), 228, 282, 285 Drury, Neville, 613 Du Bois, W. E. B., 551 Duneier, Mitchell, 661 Durkheim, Emile, 453, 455,

456, 653 Durlak, Joseph A., 669 Duro, Paul, 607 Dustin, Christopher, 47 Duszynski, K., 642 Dvorchak, Robert, 615 Dylan, Bob, 532

Eady, Cornelius, 199, 422 Earhart, H. Byron, 616 Earle, Craig C., 625 Earls, Felton, 658 Early, Kevin E., 466, 654 Ebrahim, Shanil, 616 Edgley, Charles, 638 Eggener, Keith, 339 Egnew, Thomas, 669 Ehrenberg, Rachel, 606 Eichenberg, Fritz, 20, 603, 614 Einmal Jenseits und Züruck: Ein

Koffer für die Letzte Reise (Beyond and Back: A Case for the Last Journey), 576, 577

Eisenberg, Jon, 629 Eisenberg, Mickey, 626 Eisenbruch, M., 618 Elbert, Samuel H., 618 Elbert-Avila, Katja I., 615 Elgee, Neil J., 604 Eliason, Grafton T., 47 Eliot, Gil, 658 Eliott, Jaklin, 633 Elliott, John R., 637 Ellis, Carolyn, 350, 641 Ellis, Peter Berresford, 617 Ellis, Tina A., 615 Ellsworth, Judy, 265 Elmer, Stacy, 607 Elwyn, Todd S., 623 Emerson, Ralph Waldo, 251 Emmons, Robert A., 611 Engel, George L., 363, 643

Engels, Phillip, 576 Erickson, Frederick, 610, 612 Erikson, Erik H., 55–56, 57, 58,

60, 62, 65, 415, 609, 610, 648 Erikson, Kai, 173 Erwin, Kathleen, 466, 654 Espejo, Roman, 619 Esposito, John L., 542, 663 Estrada, Fred, 245 Etlin, Richard A., 613 Etzioni, Amitai, 636 Evans, Glen, 485, 653, 654,

655, 656 Evans, Suzanne, 663 Evans-Wentz, W. Y., 550, 664 Everett, Holly, 638

Fabiola (Roman widow and hospice founder), 191

Facebook (online social network), 42, 300

Fadiman, Anne, 634 Fagerlin, Angela, 630, 631 Fahlander, Fredrik, 137 Falk, William, 180 Fancher, Erik H., 605 Farber, Annalu, 669 Farber, Stu, 589, 669 Farberow, Norman L., 451, 481,

487, 653, 654, 655, 656 Farrell, James J., 606 Faust, Drew Gilin, 669 Federal Trade Commission

(FTC), 303, 637. See also Funeral Rule (FTC)

Feifel, Herman, 27–28, 29, 32, 266, 562, 583, 584, 604, 605, 606, 632, 666, 667, 668, 669

Feldman, Fred, 566 Ferranti, Jeffrey, 630 Ferrell, Betty Rolling, 633, 635 Fessenden, Ford, 633 Fetters, Michael D., 623 Field, David, 626 Field, Marilyn J., 211, 415, 631,

646, 647, 648 Fife, Betsy L., 633 Filipovic, Zlata, 388, 646 Finding Our Way: Living and Dying in

America (newspaper series), 583 Fine, Perry G., 635 Fingerman, Karen L., 651 Finkler, Kaja, 634 Fins, Joseph J., 629 Firth, Raymond, 324, 639 Fiscella, Kevin, 633 Fischoff, Baruch, 494, 657 Fishman, Jessica, 625 Five Wishes (advance directive),

237, 238 Fleishman, Alan R., 232, 233, 630

Davidson, Glen W., 614, 650 Davidson, Hilda Ellis, 617 Davidson, L., 655 Davies, Betty, 360, 397, 624, 626,

633, 643, 647, 648 Davies, Douglas J., 339, 639 Davis, Anne J., 630 Davis, Dena S., 231, 630 Dawson, Pam, 651 De Martino, Ernesto, 13 Dean, Patrick Vernon, 31, 605 Deandrea, S., 635 Death with Dignity Act (Ore.),

227, 228 “Debbie” (pseudonymous

patient), 229 DeBlaise, Colleen, 631 Deeken, Alfons, 579, 668 Defoe, Daniel, 489 DeFrain, John, 136, 429, 618,

650, 651 DeGroot, Jocelyn M., 607 DeHart, Dana D., 503, 658 Delk, Wayne, 306 dell’Arca, Niccoli, 343 Deloria, Vine, Jr., 614 Dembosky, April, 626 Dembour, Marie-Bénédicte,

400, 647 DeParle, Nancy-Ann Min, 625 Department of Veterans Affairs

(U.S.), 328 Des Pres, Terrence, 603, 644 DeSantis, Lydia, 647 Descartes, René, 158 DeSpelder, Lynne Ann, 87, 601,

606, 611, 623, 636, 640, 644, 646, 647, 649, 660, 667, 668

Deveau, Eleanor J., 646 DeVita, Michael A., 621 Deyo, Richard A., 622 Diagnostic and Statistical Manual

of Mental Disorders (DSM-5), 361, 362

Diana, Princess of Wales, 202, 359 Dies Irae (Day of Wrath), 13 DiGirolamo, Vincent, 606 Dillon, Wilton S., 513, 659 Dinan, John, 629 Ditto, Peter H., 629, 630 Divine Comedy (Dante), 540 Dixon-Woods, Mary, 415, 609 Dōgen ( Japanese Zen Buddhist

teacher), 547, 548, 664 Dogra, T. D., 658 Doka, Kenneth J., 62, 183, 264,

266, 293, 367, 368, 374, 415, 606, 609, 610, 611, 618, 619, 623, 625, 631, 632, 644, 645, 650, 656, 657

Dolan, Susan, 256, 292, 631

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681

Fleming, Stephen J., 78, 354, 380, 611, 612, 642, 643, 646

Fletcher, John C., 218, 628 Folkman, Susan, 632, 633 Foltyn, Jacque Lynn, 601 Fonseca, Luciana Mascarenhas,

34, 606 Fontana, Andrea, 625, 658 Food and Drug Administration

(FDA), 282 Fook, Jan, 80, 611 Forrest, Linda M., 651 Fortes, Meyer, 615 Foster, Zelda, 239–240, 631, 669 Foundation of Thanatology,

The, 33, 606 Fowler, Kathleen, 641 Fox, Ken, 625 Fox, Renee C., 621 Frances, Doris, 639 Francis, Linda, 604 Frank, Arthur W., 181, 263, 623,

632, 636 Frankfort, Henri, 662 Franklin, Michael, 603 Franz, Marie-Louise von,

562, 666 Fredrick, Jerome F., 643 Freeark, Robert, 201 Freedland, Kenneth E., 633 Freeman, Alma Williams, 637 Freeman, Harold P., 625 Fremantle, Francesca, 664 Freud, Sigmund, 32, 347,

456, 640 Fricke, Charles A., 639 Fried, Jacob, 668 Friedman, Matthew J., 657 Friend, David, 519, 601, 660 Fries, James F., 652 Fristad, Mary A., 648 Fritsch, Julie, 382, 646 Frøen, Frederik, 650 Froggatt, Katherine, 624 Fryer, John E., 606 Fulton, Robert L., 8, 31, 33, 584,

601, 644, 669 Fundación Omega, 579 Fundación Vida por Amor a

Ellos, 579 Funeral Rule (FTC), 303,

313–314, 315, 316 –317, 318, 319, 321, 637

Furman, Erna, 647 Furman, Robert A., 647 Furth, Gregg M., 647

Gallup, George, Jr., 666 Gamino, Louis A., 378, 405, 621,

642, 643, 645, 648, 656 Garbarino, James, 388, 646, 659

Garces-Foley, Kathleen, 330, 566, 639

Garciagodoy, Juanita, 616 Garfi eld, Charles A., 562, 666 Gariety, Patrick C., 635 Garrett, Erin, 610 Garrett, Laurie, 661 Garro, Linda C., 283, 635 Gaslini Children’s Hospital

(Genova), 401 Gatch, Milton McC., 539, 662 Gateway Pet Cemetery (Calif.), 80 Geary, Patrick J., 613 Geddes, Gordon E., 663 Gelfand, Donald E., 256 Gelman, Susan A., 609 Geneva Convention, 518 Gentles, Ian, 613 George Mark Children’s House

(hospice), 403 Gerbner, George, 8, 601 Gergen, Kenneth J., 645 Gergen, Mary A., 645 Gervais, Karen G., 161, 620 Ghalib, Mirza (Persian poet), 542 Giddens, Anthony, 45, 490,

608, 656 Gielen, Uwe P., 664 Gifford, Eugenie Anne, 629 Gilbert, Kathleen R., 47, 351, 607,

610, 619, 641, 651 Gilbert, Richard B., 256, 631 Gilbert, Sandra M., 382, 617 Gill, A. A., 613 Gillick, Muriel R., 626 Gilmore, Mikal, 662 Gioia, Ted, 13, 602 Girardi, Paolo, 654 Gladwell, Malcolm, 657 Glare, Paul, 625 Glaser, Barney G., 33, 263, 264,

632, 635, 636 Glass, J. Conrad, Jr., 655 Glaze, Anita J., 613 Glick, Ira O., 642 Goldberg, Ivan K., 644 Goldenberg, Jamie L., 604 Goldfi ne, Andrew M., 629 Golding, R. E., 656 Goldman, Ari L., 645 Goldsby, Richard, 661 Goldstein, Allan L., 643 Goldwasser, Michael A., 637 GÖle, Nilüfer, 660 Golin, Carol E., 628 Gonzalez, Alberto, 228 González, Rafael Jesús, 616 Gonzalez v. Oregon, 228 Gonzalez-Crussi, Frank, 106, 614 Good, Mary-Jo Del Vecchio, 633 Goodheart, Carol D., 415

Goodman, Kenneth, 629 Goodman, Linda, 646 Goodman, Norman, 610, 612,

618, 665 Goodwin, Michele, 173 Goody, Jack, 615, 639 Goodyear-Smith, Felicity, 623 Gordon, Elisa J., 621 Gorer, Geoffrey, 32, 606 Gospel at Colonus (musical), 565 Goss, Robert E., 382, 583, 603,

641, 664, 668 Gotay, Carolyn C., 618 Gould, M. S., 655 Goya, Francisco José de, 20 Graham, James A., 610 Granqvist, Anna, 647 Gray, Alistair, 622 Grayling, A. C., 501 Great East Japan Earthquake,

494, 495, 497 Great Sichuan Earthquake, 495 Greeley, Andrew M., 665, 666 Green, Harry L., 642 Green, Judith Strupp, 616 Green, Lawrence W., 652 Green, Michael D., 614 Green, Morris, 649 Green, Ronald M., 630 Greenberg, Bradley, 637 Greenberg, Gary, 620 Greenberg, Jeff, 604, 605, 660 Greenblatt, Stephen, 663 Greenlaw, Jane, 227, 629, 630 Greenleigh, John, 616 Greer, David S., 624 Greer, Steven, 632, 633 Greider, William, 657 Greyson, Bruce, 665, 666 Gribbin, Sally, 639 Grider, Sylvia, 311, 638 Griffi n, Jasper, 662 Griffi ths, John, 257 Grifi ths, Maya, 608, 609 Grimes, Ronald L., 137, 664, 667,

668, 669 Grisez, Germain, 630 Grof, Stanislav, 564, 565, 666, 667 Grollman, Earl A., 225, 662 Groopman, Jerome, 184, 204, 626 Gross, Esther, 641 Grotenhermen, Franjo, 634 Groves, Betsy McAlister, 658 Grumbach, Kevin, 622 Gudmundsdottir, Maria, 633 Guerro, Brenda Moretta, 636 Guglielmo, Connie, 621 Gunderman, Richard B., 187 Gupta, Leila, 646 Gust-Brey, Karyn, 653 Gyulay, Jo-Eileen, 648

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682

Habenstein, Robert W., 321, 636, 637

Haddad, Yvonne Yazbeck, 567, 663 Hadden, Jeffrey K., 282, 635 Hadler, Norman M., 445 Haertig, E. W., 618, 640, 645,

662, 666 Hagens, Gunther von, 44 Hahn, Robert A., 619 Haithman, Diane, 607 Hak, Tony, 623 Hakuin ( Japanese Zen Buddhist

teacher), 548, 664 Hale, Leslie Williams, 649 Halevy, A., 628 Halfe, Louise B., 614 Halifax, Joan, 564, 565, 666, 667 Hall, Christopher, 636 Hall, David L., 636 Hall, Mary N., 23, 604 Hall, Nicholas R., 643 Hall, Stephen S., 669 Hamel, Ron, 629 Hamilton, Lou Ann, 649 Handy, E. S. Craighill, 613, 618,

640, 662, 666 Haney, C. Allen, 607 Hansson, Robert O., 360, 383,

445, 642, 643, 646 Harakas, Stanley Samuel, 663 Haraldsson, Erlendur, 560, 666 Harder, Ben, 612 Hardt, Vincent, 640 Harmer, Ruth M., 307 Harris, Daniel, 603 Harris, Darcy L., 376, 383, 619,

645, 668 Harris, Mark, 339 Harris, Morag B., 627 Harris, Murray J., 662 Harrison, Robert Pogue, 137, 618 Harrison, Tyler R., 621 Harrold, Joan, 293 Hart, Onno van der, 640 Hartley, Shirley F., 644 Hartocollis, Anemona, 633 Hartwig, Clayton, 451 Harvard Medical School Ad Hoc

Committee to Examine the Defi nition of Brain Death, 159–160, 163

Harvey, Alynn Day, 602 Hase Temple ( Japan), 427, 428 Hauiser, Joshua, 622 Hawkins, Yasmin, 635 Hawton Keith, 487 Hayes, Christopher I., 616 Hayslip, Bert, Jr., 604, 619, 652 Hazell, LaVone V., 116, 615 Health Care Financing

Administration, 194

“Hearse Song” (The worms crawl in), 72

Heath, Amy Olwen, 650 Heaven’s Gate (Millenarian

group), 455 Hébert-Collins, Sheila, 611 Heeringen, Kees van, 487 Hefl in-Wells, Neil, 606 Heim, Albert, 559, 666 Heinlein, Robert, 595, 670 Heinz, Walter R., 610 Helen House (hospice

program), 403 Help, Understanding, and Group

Support for Hawaii’s Seriously Ill Children and Their Families (HUGS), 407, 648

Hemlock Society, 227 Henderson, Angelo B., 639 Henderson, Kristin, 515, 659 Hendin, Herbert, 630, 655 Hendricks, C. Davis, 626 Hendricks, Jon, 626 Heney, David, 415, 609 Henman, Linda D., 604 Hennessy, Brian, 657 Henslin, James M., 652 Herlihy, David, 614 Herodotus (Greek historian), 306 Heron Melonie, 669 Herzfeld, Michael, 602 Heyman, Kathleen M., 607 Hickman, Susan E., 623 Hiedtke, Lorraine, 602 Higgins, William G., 493 Highwater, Jamake, 614 Higo, Masa, 607 Hildebrand, Jennifer, 615, 636 Hill, Tiffany, 648 Hinton, John, 33 Hippocrates (Greek physician and

father of medicine), 221 Hiroshi, Kawahito, 656 Hirsch, Edward, 602, 603 Hitchens, Christopher, 277, 293 Hjelmeland, Heidi, 653 Ho, Andy Hau Yan, 125, 272,

617, 633 Ho, Samuel, 668 Hockey, Jenny, 636 Hodge, Felicia Schanche, 621 Hodgson, Ann F. de Jong, 603 Hoffman, Albert, 564 Hoffman, Frederick J., 603 Hogan, Nancy S., 642, 647 Holbein, Hans, 105 Holcomb, Justin S., 639 Holden, Constance, 625 Holland, Jason M., 643 Holleran, Reneé Semonin, 631 Hollins, Sheila, 375, 645

Holloway, Margaret, 637 Holmes, Julia, 651 Holocaust Museum (D.C.), 516 Holst-Warhaft, Gail, 602, 603, 659 Holt, Kathleen, 633 Holtkamp, Sue, 173 Homant, Robert J., 653 Homer (Greek epic poet), 537 Hooyman, Nancy R., 383 Hope, R. A., 633, 651 Horacek, Bruce J., 644 Horgan, John, 515, 659 Hospice Hawaii, 403 Hospice MariaTeresa Chiantore

Seràgnoli (Bologna), 190 Hospice of Frederick County

(Md.), 407 Hospice of Marin (Calif.), 192 Hospice of New Haven (Conn.),

192 Houseman, Clare A., 607 Hout, Michael, 665, 666 Howarth, Glennys, 46, 173, 606,

608, 637, 645 Howell, Doris A., 669 Howell, Milton H., 590, 669 Hoy, William G., 298, 326, 339,

637, 639 Hoyert, Donna L., 607, 652 Hoyt, William T., 377, 645 Huffman, L. A., 109 Hughes, Anne, 633 Hultkrantz, Åke, 110, 111, 614 Hume, Janice, 638 Hunt, G. Haunani, 618 Hunt, Linda M., 612 Hurd, Russell C., 647 Hutton, Ronald, 617 Huyler, Frank, 626 Hyland, Liam, 638, 642

I Ching (book of changes), 543 Ice-T, 388, 502, 646, 658 Ilse, Sherokee, 646 Indian Ocean Tsunami, 498 Ingles, Thelma, 624 Insel, Paul M., 178, 277, 490, 622,

632, 633, 634, 650, 651, 652, 656 Institute of Medicine, 387, 399,

402, 469 International Work Group on

Death, Dying, and Bereavement (IWG), 23, 33, 192, 385, 566, 604, 625, 643, 646, 657, 658, 667, 668

Iranzo, Vega, 635 Irwin, H. J., 665 Iserson, Kenneth V., 315, 322, 339,

626, 638 Ishikawa, Sara, 669 Italie, Leanne, 607

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683

Jordan, John R., 581, 642, 645, 668

Joseph (leader of the Nez Percé people), 110, 614

Journal of the Plague Year, A (Defoe), 489

Joy, Janet E., 634 Juergensmeyer, Mark, 522, 660 Junge, Maxine Borowsky, 22, 603

Kaanoi, Momi, 618 Kadvany, John, 494, 657 Kagawa-Singer, Marjorie, 636 Kaiser, Chris, 619 Kaiser Permanente, 196 Kalb, Claudia, 609 Kalich, DeAnn, 606 Kalish, Richard A., 33, 616 Kallenberg, Kjell, 635 Kalu, Ogbu U., 615 Kameny, Rebecca R., 647 Kamm, Phyllis, 651 Kammen, Michael, 324, 639 Kanahele, George Hu’eu Sanford,

133, 602, 618 Kantor, Elizabeth, 617 Kapleau, Philip, 664 Kaplowitz, Stan A., 623 Karakatsanis, K. G., 620 Kass, Leon R., 256, 631, 652 Kast, Eric, 564 Kastenbaum, Beatrice, 606 Kastenbaum, Robert J., 26, 27, 29,

31, 46, 59, 139, 140, 151, 173, 516, 525, 562, 580, 588, 591, 601, 604, 605, 606, 608, 609, 618, 619, 620, 622, 624, 626, 635, 648, 656, 658, 659, 661, 666, 668, 669

Kato, Shuichi, 653 Katrina (hurricane), 80, 392, 496,

498, 500 Kaufert, Joseph M., 612 Kauffman, Jeffrey, 529, 605,

640, 662 Kaufman, Kenneth R., 611 Kaufman, Nathaniel D., 611 Kaufman, Sharon R., 211, 219,

255, 628, 631, 669 Kaut, Kevin P., 632 Kavanaugh, Robert E., 43, 607 Kawabata, Yasunari, 293 Kawano, Satsuki, 617 Keen, Sam, 515, 605, 658, 659 Keene, Donald, 569, 608, 617, 667 Keene, Jennifer Reid, 625, 658 Keister, Douglas, 639 Keleman, Stanley, 342 Kellaher, Leonie, 639 Kellehear, Allan, 8, 47, 80, 95,

127, 137, 160, 161, 163, 198, 291,

293, 581, 582, 597, 601, 611, 617, 620, 624, 626, 627, 636, 652, 668, 669

Keller, Jacqueline, 612 Kellerman, Arthur L., 626 Kelley, Patricia, 632 Kelly, John D., 350, 641 Kelly, Madelyn, 415, 647 Kelly, Patricia Fernández, 616 Kendall, Marilyn, 635 Kendrick, Kristi, 655 Kenkō, Yoshida ( Japanese

Buddhist monk), 591, 608, 669 Kennedy, Daniel B., 653 Kenyon, Brenda L., 608 Kernberg, Paulina F., 473, 655 Kevorkian, Jack, 228, 629 Khazzoom, Loolwa, 660 Kidwell, Clara Sue, 614 Killilea, Alfred G., 585, 669 Kimura, Rihito, 622 King, Noel Q., 615 King, Martin Luther, Sr., 433 Kinsley, David R., 664 Kirk & Nice (funeral home), 316 Kirsch, Patrick Vinton, 618 Klass, Dennis, 349, 350, 378, 382,

515, 583, 603, 616, 640, 641, 645, 649, 650, 659, 664, 668

Kleinman, Arthur, 280, 634 Klenow, Daniel J., 628, 665, 666 Kletti, Roy, 559, 666 Kliman, Gilbert, 610 Kloeppel, Darlene A., 375, 645 Knight, Damon, 595, 669 Knott, J. Eugene, 669 Koerner, Brendan I., 665 Koëter, Gerard, 623 Kollwitz, Käthe, 340, 423, 461 Konishi, Emiko, 630 Koocher, Gerald P., 59, 62, 63–64,

66, 609 Korte, Alvin O., 618 Koshes, Ronald J., 644, 656 Koudounaris, Paul, 92, 137,

612, 613 Kracher, Alfred, 611 Krakauer, Eric L., 625 Kramer, Betty J., 383 Kramer, Jennifer, 625 Kravolec, Peter D., 624 Krieger, Lisa M., 630 Krishna (Hindu deity), 544 Kristjanson, Linda J., 627 Krizek, Bob, 640 Krupat, Edward, 604 Kubasak, Michael, 331 Kübler-Ross, Elisabeth, 33, 185,

186, 192, 264–265, 266, 393, 584, 624, 632

Kudo, Timothy, 659

Iverson, Bruce A., 638 Izuhara, Misa, 631

Jackman, Mary R., 658 Jackson, Charles O., 613 Jackson, E. M., 663, 665 Jackson, Edgar N., 32, 303, 643 Jackson, Kenneth T., 613 Jackson, Marni, 635 Jacobs, Madeline, 181, 219, 224,

622, 628, 629, 631 Jaffe, Greg, 654 Jain, S. Lochlann, 632 Jalland, Patricia, 613 Jambunathan, Jaya, 616 James. Nicky, 626 Jamison, Kay Redfi eld, 448,

652, 653 Janes, Dominic, 636 Janssens, Rien M. J. P. A., 624 Jaramillo, Isa Fonnegra de,

579, 668 Jay, Meg, 58, 609 Jellema, Kate, 617 Jenkins, Philip, 660 Jennett, Bryan, 629 Jennings, Bruce, 625, 657 Jensen, Maxine Dowd, 440 Jesus (central fi gure of

Christianity), 98, 102, 106, 120, 538

Job (Hebrew hero), 534, 535 Jobes, David A., 654 Jobs, Steve, 6, 168, 601 Johansson, Jens, 566 Johnny Got His Gun (Trumbo),

507–508, 509 Johnson, Catherine, 637 Johnson, Celeste M., 392, 647 Johnson, Edward C., 638 Johnson, Gene, 659 Johnson, James Weldon, 541 Johnson, Joy, 650 Johnson, Kimberly S., 615 Johnson, Marilyn, 47, 601 Johnson, S. M., 623 Johnson, S. Marvin, 650 Johnson, Vanessa M. P., 622 Joiner, Thomas, 419, 471, 487,

653, 654, 655 Joint United Nations Programme

on HIV/AIDS, 661 Jones, Hawk, 651 Jones, Jim, 455 Jones, Kara L. C., 651 Jones, Prudence, 617 Jong, Erica, 580 Jonsen, Albert R., 163, 620, 622,

627, 629, 661 Joralemon, Donald, 628 Jordan, Cora, 256

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684

Kumar, Updesh, 487 Kurtz, M. E., 623 Kurutz, Steve, 639 Kutner, Louis, 234 Kutscher, Austin H., 644

Lack, Sylvia, 192 Laderman, Gary, 637 Laerdal, Asmund, 107 LaFleur, William R., 621, 650 Lagnado, Lucette, 625, 638 LaGrand, Lou, 333, 639 Lakin, Josh, 628 Lamentation (dell’Arca), 343 Lamers, Elizabeth P., 73, 610 Lamers, William M., Jr., 192, 195,

331, 603, 625, 626, 627, 640 Lamers, William M., Sr., 321, 334,

636, 637, 640 Lamerton, Richard, 220 Lancaster, Jeffrey, 647 Landis, Daniel, 637 Langer, Lawrence L., 603, 644 Lankgewiesche, William, 660 Lantos, John D., 146, 215, 619,

622, 627 Laquere, Walter, 529, 660 Larson, Dale G., 377, 645 Lasaga, Jose I., 654 Lattanzi-Licht, Marcia, 624, 636 Lauerman, John, 621 Laungani, Pittu, 612, 664 Lawuyi, Olatunde Bayo, 116, 615 Lazarus, Richard S., 633 Le Goff, Jacques, 539, 663 Le Guenno, Bernard, 527, 661 Leaman, Oliver, 606 Leash, R. Moroni, 204, 206,

626, 627 Leder, Drew, 658 Lee, Catherine A., 618, 640, 645,

662, 666 Lee, Kang, 608 Leenaars, Antoon A., 483, 655, 656 Lees, Shirley, 667 Lefcourt, Yvonne K., 618 Legacy.com (memorial Web site),

309, 638 Leichty, Daniel, 47 Leliaert, Richard M., 367, 644 Lenin, Vladimir, 315 Lenius, Oscar, 613 Lennings, C. J., 655 Leon, Irving G., 428, 650 Leondari, Angeliki, 646 León-Portilla, Miguel, 616 Leshner, Paula, 625 Lester, David, 453, 604, 653,

655, 665 Letterman, John (Maj., U.S.

Army), 202

Levine, Carol, 626, 662 Levine, Sol, 652 Levine, Stephen, 110, 209, 614 Levinson, Dan, 633 Leviton, Daniel, 523, 605, 661 Levy, Daniel, 608 Levy, David A., 608 Lewin, Terry, 636 Lewis, C. S., 33 Lewis, Oscar, 347 Liechty, Daniel, 605 Lifton, Robert Jay, 644, 653, 658,

659, 665 Limkin, Raphael, 516 Lin, Maya, 22 Lindahl, Carl, 657 Lindbergh, Charles, 590, 669 Lindemann, Erich, 32, 348, 641 Lindstrøm, Christine, 641 Lingle, John H., 644 Linn-Gust, Michelle, 79, 611 Lipsenthal, Lee, 262, 632 Litman, Robert, 451 Little Red Riding Hood, 73–74 Little Spotted Horse, David, 254 Lizardi, D., 656 Lizza, John P., 620 Lock, Margaret, 166, 621 LoDagaa (ethnic group in

northern Ghana), 114–116, 124 Lofl and, Lyn H., 350, 641 Lomnitz, Claudio, 137, 616 Lon Po Po (Granny Wolf), 74 Lonetto, Richard, 611 Long, J. Bruce, 663 Long, Shawn D., 621 Long, Susan Orpett, 173,

619, 664 Lonigan, Paul R., 617 Loomes, Graham, 627 Lopata, Helena Z., 651 Lopez, Faye, 648 Lord, Janice Harris, 626, 656 Lord Vivian B., 653 Lorius, Cassandra, 632 Los Angeles Suicide Prevention

Center, 481 Loven, Jennifer, 654 Low, Clarinda Mac, 635 Lowenstein, Suse, 18, 19, 23, 603 Lucie-Smith, Edward, 410 Lule, Jack, 7, 601 Lundberg, George D., 147, 179,

619, 622 Lundgren, Burden S., 607 Lundsgaarde, Henry, 151, 619, 620 Luoma, Jason B., 655 Luquis, Raffy R., 614, 615, 618 Lurie, Nicole, 607 Lurker, Manfred, 662 Lutkins, S. G., 643

Lynch, Thomas, 298, 313, 339, 425, 638

Lynn, Joanne, 293, 651 Lyons, Michelle, 608 Lyons, Thomas, 291, 636

Maaka, Margaret J., 618 MacArthur, Douglas, 470, 654 MacCulloch, J. A., 617 MacDougall, Duncan, 620 Macer, Darryl, 622 MacGregor, Geddes, 662 Mackay, James, 639 Mackenbach, Johan P., 106, 614 Macleod, James Lachlan, 658 Madan, T. N., 663 Mahābhārata (Sanskrit epic), 546 Mahoney, John J., 503, 624 Mahoney, John M., 658 Mahoney, Julia D., 621 Make-A-Wish Foundation,

408, 648 Malcom, Nancy L., 648 Malkinson, Ruth, 640, 642, 646 Maltoni, M., 629 Mancinelli, Iginia, 653, 654 Mandal, Manas K., 487 Mandelbaum, David G., 615 Mann, J. John, 654 Marchi, Regina M., 137, 616 Marcus, Morton, 592, 593 Marcus Aurelius, 554, 665 Marcusen, Eric, 644 Margolick, David, 602 Margolin, Malcolm, 111, 614 Margos, Dorothy, 646 Maria Yellow Horse Brave

Heart, 108 Marine Comfort Quilts, 22 Marino, Cesare, 652 Maris, Ronald W., 448, 654 Maroney-Galin, Catherine, 624 Marris, Peter, 417, 649 Marshall, Gordon, 612 Martens, Andy, 605 Martens, Nola, 626 Martin, F. David, 605, 651 Martin, Gus, 529, 658 Martin, Regis, 601, 663 Martin, Terry L., 367, 368, 606,

644, 648 Martinez, Ricardo, 626 Martinson, Ida M., 403, 648, 669 Marvin, Carolyn, 611 Maryland Institute for Emergency

Services, 201–202 Massachusetts General Hospice,

196 Massimo, Luisa M., 647 Mastora, Adelais, 646 Matheson, Jennifer L., 657

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685

Mathiesen, T. J., 602 Matsumoto, Michihiro, 622 Maurice, John, 657 May, Jacque H., 655, 656 Mbiti, John S., 615 McBrien, Richard P., 662, 663 McCahill, Laurence, 633 McCarthy, Ellen P., 625 McCartney, James J., 629, 630 McClean-Rice, Nicholas, 665 McCleneghan, J. Sean, 601 McCorkle, Ruth, 635 McCormick, Richard A., 630 McCoy, Shannon K., 604 McCoyd, Judith L. M., 415, 643 McCrae, Robert R., 633 McCubbin, Marilyn, 650 McCullough, Michael E., 611 McCutcheon, Kelly A., 78,

611, 612 McDermott, John F., Jr., 134, 618 McDowell, Charles P., 644, 656 McDowell, Eugene E., 655, 656 McDowell, Robert, 602, 603 McGee, Marsha, 602 McGinn, Colin, 602 McGoldrick, Monica, 642 McGrath, Alister E., 566, 663 McGreevy, Andrew M., 603 McGregor, Joan L., 621 McGuane, Thomas, 28, 604 McInerny, Fran, 602 McKenzie, Lynda, 627 McKissock, Diane, 579 McKissock, Malcolm, 579 McLauchlan, C. A. J., 626 McLeish, Kenneth, 553, 613, 665 McLeod, Beverly, 657 McPherson, James M., 660 McVeigh, Timothy, 523 Meagher, David K., 597, 621, 645,

651, 657 Meehan, Maude, 444, 484 Meier, Diane E., 624 Meijburg, Herman H. van der

Kloot, 630 Meisel, Alan, 627 Mellor, Philip A., 601, 607, 613 Menninger, Karl, 454 Merboth, Marcia K., 635 Mercer, Mary Beth, 621 Merchant, Raina M., 607 Merck Manual of Diagnosis and

Therapy, 188 Mercy, James A., 655 Mesler, Mark A., 610 Messinger, Thane Josef, 629 Messner, Reinhold, 656 Meyer, John C., 604 Miles, Steven H., 630 Millen, Leverett, 650

Miller, Galen W., 624 Miller, Laurence, 627 Miller, Patricia H., 66, 87, 609, 610 Millman, Robert B., 666 Millot, Bernard, 653 Mineau, Geraldine P., 651 Miniño, Arialdi M., 606 Minkow, Christine, 642 Mirken, Bruce, 635 Mishara, Brian L., 655 Mitchell, Donald D. Kilolani, 618,

666 Mitford, Jessica, 307, 637 Mizuno, Jitaro, 631, 636 Moja, L., 635 Mokuau, Noreen, 618 Monahian, Kathleen, 604 Monk, Linda R., 620 Montanari, M., 635 Moody, Raymond A., Jr., 555, 561,

665, 666 Moore, Calvin Conzelus, 604 Moore, Joan, 616 Moos, Nancy L., 353, 642 Mor, Vincent, 622, 624 Morel, Eve, 611 Morewitz, Stephen J., 658 Morgan, John, 666 Morgan, Oliver, 657 Morgan, Susan E., 621 Morioka, Masahiro, 622 Morley, John, 613 Morning Star Center, 407 Morris, David B., 635 Morris, John N., 626 Morrison, R. Sean, 624 Morrow, Chad E., 654 Morse, Dan, 638 Morse, Janice M., 638, 642 Moscati, Sabatino, 617 Moser, Richard P., 605 Moskowitz, Judith Tedlie, 632 Moss, Miriam S., 421, 649 Moss, Sidney Z., 421, 649 Mothers Against Drunk Driving

(MADD), 369, 435, 594 Moules, Nancy J., 608 Mount, Balfour M., 176, 185,

623, 624 Mount Auburn Cemetery

(Mass.), 104 Mount Pelée (Martinique), 498 Mount St. Helens (Wash.), 498 Mowery, Robyn L., 623 Muhammad (Arab prophet and

founder of Islam), 542 Munch, Edvard, 18, xxi Munkar (Islamic spiritual being),

543 Murray, Colleen I., 610 Murray, Judith A., 642

Murray, Scott A., 635 Mynatt, Blair Sumner, 623

Nabe, Clyde M., 667 Naboulsi, Mohamed A., 605 Nadeau, Janice Winchester, 353, 642 Nagy, Maria H., 54–55, 609 Naito, Ayumi, 655 Nakamura, Hajime, 616 Nakir (Islamic spiritual being), 543 Names Project AIDS Memorial

Quilt, 20–21, 23 Naomi, Shono, 658 National Association for Loss and

Grief (NALAG), 578–579 National Cancer Institute, 408 National Center for

Complementary and Alternative Medicine (NCCAM), 634

National Conference of Commissions on Uniform State Law, 166

National Council on Aging, 442 National Funeral Directors

Association (NFDA), 304–305, 313, 314

National Hospice and Palliative Care Organization (NHPCO), 188, 194

National Organ Transplant Act, 167, 168

National Police Agency of Japan, 657

National Safety Council, 601 Native American Grave Protection

and Repatriation Act, 110, 324 Natural Death Act (Calif.),

234, 630 Navy (U.S.), 451, 452 Neal, Arthur G., 668 Neimeyer, Robert A., 28, 29, 42,

360, 379, 383, 604, 605, 607, 642, 643, 645, 656, 668

Nelson, Roxanne, 634 Neophytou, Georgina, 639 Ness, M. Ernest, 602 Neugarten, Bernice L., 442, 652 New Melleray Abbey, 318 The New York Times, 521 Newman, Andrew, 648 Newton, Huey, 7 Nichols, Elaine, 137, 637 Nick Snow Children’s Hospice and

Palliative Care Act (Calif.), 403 Nickman, Steven, 350, 641, 647 Nikhilananda (founder of

Ramakrishna-Vivekananda Center), 544, 546

No One Dies Alone (palliative care program), 198

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686

Noppe, Illene Cupit, 47, 607, 609, 619, 647

Noppe, Lloyd D., 609, 647 Nordyke, Eleanor C., 618 Norman, Connie, 621 Normand, Claude, 635 Norris, Fran H., 657 Novack, D. H., 628 Novak, Marian Faye, 513, 659 Noviello, Susan B., 644 Noy, Chaim, 641 Noyes, Deborah, 619, 637 Noyes, Russell, Jr., 559, 633,

636, 666 Nugus, Danny, 654 Nurok, Michael, 626

O’Brien, John M., 651 O’Carroll, Patrick W., 656 Ochs, Donovan J., 602 O’Connell, Laurence J., 622 Odenwald, Sten, 670 Odiah, Chuck, 653 Oestigaard, Terje, 137 Ogloff, James R. P., 653 Ohnuki-Tierney, Emiko, 622 O’Hógáin, Dáithé, 617 Okamuira, Jonathan Y., 618 Oken, Donald, 628 Old Age Assistance Act, 200 Oliver, Ian, 633 Olshansky, S. Jay, 607 Olson, David H., 136, 618 Olson, Eric, 658 Olson, Karin L., 632 Olson, Patrick, 527 Oltjenbruns, Kevin Ann, 627, 646 O’Neil, John D., 612 O’Neill, Kathleen, 642 Ono, Sokyo, 616 Operation Gold Star Flag, 22 Operation Homemade Quilts, 22 Opfer, John E., 609 Opie, Iona, 610 Opie, Peter, 610 Opoku, Kofi Asare, 113, 615 Oppenheimer, Stephen, 363 Ordenstein, Anna, 618 Ordenstein, Ken, 618 Organ Procurement and

Transplantation Network (OPTN), 167

Organ Transplant Law ( Japan), 171

Ornstein, Peter A., 608 O’Rourke, Kevin, 630 Osis, Karlis, 560, 666 Osnos, Evan, 657 Ostaseki, Frank, 198, 626 Osterweis, Marion, 649

Osuna, Patricia, 616 Otto, Randy K., 653 Overmyer, Daniel L., 616 Owen, Greg, 8, 584, 601, 644, 669

Pacholski, Richard A., 602, 603, 661

Palazzolo, Joe, 619 Palermo, George B., 619, 658 Paletti, Robin, 63, 609 Palliative Care Project, 196 Palmer, Craig T., 613, 615 Paludi, Michele A., 610 Pan American fl ight 103, 18 Pan American Health

Organization, 657 Panek, Paul E., 652 Papa, Anthony, 642 Papadatou, Danai, 209, 627,

633, 647 Papadoupolos, Irene, 667 Parents of Murdered Children

(POMC), 435, 594 Parikh, Sara J. Tedrick, 649 Paris, J., 630 Parke, Ross D., 608 Parker, Dorothy, 478 Parkes, Colin Murray, 192, 348,

353, 363, 383, 517, 553, 632, 641, 642, 643, 651, 659, 660, 665

Parsons, Talcott, 28, 33, 289, 604, 636

Partners HealthCare (Mass.), 196 Passalacqua, Rudolfo, 634 Patient Self-Determination Act

(PSDA), 238 Patrick, Julie Hicks, 652 Pattison, E. Mansell, 632 Paul (Christian apostle and

missionary), 539 Paul, Barbara J., 536 Paulos, John Allen, 607 Paxton, Frederick S., 613 Payne, Richard, 194, 625 Paz, Octavio, 118, 616 Peale, Charles Willson, 18 Pearson, Jane L., 655 Pearson, Mike Parker, 137,

613, 636 Peck, Dennis L., 606, 656 Pellegrino, Edmund D., 623 Pennick, Nigel, 617 Peppers, Larry G., 650 Perdue, Theda, 614 Pére Lachaise Cemetery

(Paris), 104 Peretz, David, 644 Pérez, Miguel A., 614, 615, 618 Perlmutter, Steven B., 280, 281,

629, 634

Perrow, Charles, 497, 657 Person, Judi Lund, 626, 630 Peter Bent Brigham Hospital

(Mass.), 165, 196 Peterson, Jane W., 652 Pfeffer, Cynthia R., 655 Pfeiffer, Angela M., 656 Pfi ster, Oskar, 559, 666 Pfost, Karen S., 643 Phan, Peter C., 663 Phillips, Julie A., 655 Phillips, Michael M., 603 Phillips, Russell S., 628 Phipps, William E., 624 Physician Orders for Life-

Sustaining Treatment (POLST), 235, 236, 241

Piaget, Jean, 56, 57–58, 59, 61, 63, 609

Piedmont, Ralph L., 664 Pierce, Sandra Girton, 624 Pihlström, Sami, 601 Pike, Martha V., 603 Pine, Vanderlyn R., 296, 605,

636, 638 Pinsdorf, Marion K., 328, 639 Pittman, John, 661 Planchon, Lynn A., 611, 612 Plath, David W., 82, 612 Plath, Sylvia, 468 Plato (Greek philosopher), 538 Platt, Colin, 614 Plopper, Bruce L., 602 Plum, Fred, 629 Poceski, Mario, 663 Poppi, Cesare, 639 “Portraits of Grief,” 521 Posada, José Guadalupe, 20,

105, 118 Potts, Michael, 666 Powell, F. C., 656 Poythress, Norman, 653 Prado, C. G., 628, 654 Prepeliczay, Susanna, 667 Presbyterian Synod of

Phiiladelphia, 253 President’s Commission for the

Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 162, 163, 216, 221, 620, 627

President’s Council on Bioethics, 154, 441, 631

Preston, Fredrica A., 635 Preston, Richard J., 614 Preston, Sarah C., 614 Prettyman, Nathalie, 611 Price, Paul, 660 Pridonoff, John A., 227, 629 Prigerson, Holly G., 360, 383, 643

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687

Prior, Lindsay, 604, 606 Progetto Revivere (Italy), 578 Program in Placebo Studies and

the Therapeutic Encounter (Harvard), 280

Project COPE, 501 Promessa (ecological burial

company), 331 Prothero, Stephen, 638 Prull, Richard W., 669 Pryor, Juan Camilo Algarra, 579 Puckle, Bertram, 306 Pukui, Mary Kawena, 559, 613,

618, 640, 645, 662, 666 Purnell, Larry D., 614,

615, 616 Pütz-Roth (funeral home), 337,

338, 576 Pyszcznski, Tom, 604, 605, 660 Pythagoras (Greek philosopher

and mathematician), 537

Queen of Heaven Mausoleum (Ill.), 325

Quill, Timothy E., 227, 627, 629, 630

Quinlan, Karen Anne, 222 Qur’an (central religious text of

Islam), 542, 543

Rachel Weeping (Peale), 18 Rådestad, Ingela, 650 Radin, Paul, 614 Rady, Mohamed Y., 621 Raine, Susan, 654 Rainer, Jackson P., 242, 631 Ramazani, Jahan, 16, 603 Ramsey, Boniface, 538, 662 Randall, Brad, 619 Rando, Therese A., 268, 346, 347,

350, 359–360, 445, 633, 640, 641, 643, 644

Range, Lillian M., 529, 605, 662 Raphael, Beverly, 436, 642,

650, 651 Rappe, Paula T., 604 Raudenbush, Stephen W., 658 Rawski, Evelyn S., 617 Ray, Barbara, 610 Ray, Roger, 627 Reader, Ian, 616 Reardon, Frank, 630 Recer, Paul, 659, 661 Redmond, Lula M., 372, 606,

644, 658 Reece, Robert D., 638 Reed, Kit, 595, 670 Reed, Susan E., 655 Rees, W. D., 643 Reeves, Nancy C., 640

Regale Funeral Store (London), 319

Rehmeyer, J., 650 Reich, Michael R., 653 Reid, Cynthia L., 638 Reid, Jon K., 638 Reinhardt, John E., 615 Reiser, Stanley Joel, 211, 623 Rembrandt van Rijn, 20 Renzenbrink, Irene, 211 Requarth, Margo, 647 Resch, Nancy, 649 Reynolds, David K., 33, 616,

634, 669 Reynolds, Francoise M., 644 Reynolds, Vernon, 302, 322, 551,

637, 638, 664 Rhine, Charles D., 638 Riches, David, 613 Riches, Gordon, 651 Richmond, Jillian, 623 Riedlinger, June R., 666 Riedlinger, Thomas J., 666 Riemer, Jeffrey W., 653 Rieser, John J., 608 Ring, Kenneth, 556, 665 Ritter, R. Hal, Jr., 378, 405, 621,

643, 645, 648, 656 Robbins, Margaret, 621 Rober, Peter, 206, 627 Roberts, D. S., 663 Roberts, Pamela, 309, 638 Robinson, Edwin Arlington, 458 Robinson, H. Wheeler, 535, 662 Robinson, Paul J., 354, 642, 643 Robinson, Vera M., 604 “Rockabye Baby” (lullaby), 75 Röcke, Christina, 610 Rodde, Jillian, 621 Roediger, David R., 615 Rohrlich, Ted, 619 Roll, Samuel, 650 Rolling Thunder (Cherokee

shaman), 158 Ronco, C., 620, 621 Roos, Susan, 650 Ropp, Leland, 658 Rösch-Rhomberg, Inge, 617 Rosenbaum, Ernest H., 293, 623 Rosenbaum, Isadora, 293 Rosenberg, Charles E., 176 –177,

525, 622, 632, 661 Rosenberg, Jay F., 444, 620, 652 Rosenberg, Jerome, 656 Rosenblatt, Paul C., 206, 424, 445,

516, 627, 643, 649, 659 Rosenfeld, Alvin H., 603 Rosielle, Drew, 229 Ross, Cheri Barton, 81, 611, 612 Roter, Debra, 604

Roth, Fritz, 576, 640, 668 Roth, Randolph, 529 Roth, Walton T., 178, 277, 490,

622, 632, 633, 634, 650, 651, 652, 656

Rothberg, Joseph M., 644, 656 Rothenberg, Richard, 528, 661 Rothman, Barbara Katz,

649, 650 Rousseau, P., 629 Rubin, Nissan, 646 Rubin, Simon Shimson, 352, 353,

640, 642, 646, 663 Rubinstein, Donald H., 655 Rubinstein, Robert, 649 Ruby, Jay, 650 Ruehlmann, William, 603 Ruskin, Cindy, 603 Russac, R. J., 641 Russell, Bertrand, 532, 662 Rustøen, Tone, 633 Rususci Anne (CPR manikin), 107 Ruth, Susan L., 654 Rutherford, Ward, 617 Ryndes, True, 625

Sabom, Michael B., 666 Sadler, H. Harrison, 631 Safer, Peter, 107 Sala, Fabio, 604 Salinas, Robert C., 606, 612, 614 Salisbury, Howard G., 659 Samaritans (telephone support

program), 408, 481 Samet, Elisabeth D., 603 Sampson, Robert J., 658 Samuel (Hebrew judge and

prophet), 535 San Diego Hospice (Calif.), 194 San Francisco Columbarium

(Calif.), 330 San Francisco General Hospital,

201 Sancton, Thomas A., 626 Sanders, Catherine M., 649, 669 Sanders, Jimy M., 618 Sandor, Richard S., 183, 623 Sandy Hook Elementary School

(Conn.), 503 Santino, Jack, 617 Sapolsky, Robert M., 640 Sarre, Philip, 657 Sasaki, Hiroki, 623 Saul (Hebrew king), 535 Saunders, Cicely, 33, 191, 192,

584, 625 Savage, Judith A., 431, 650 Sayer, Chloē, 616 Schacter, Sherry R., 606 Schapiro, Renie, 173

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688

Scheffl er, Samuel, 566 Scheper-Hughes, Nancy, 170, 612,

621 Schiavo, Michael, 224 Schiavo, Terri, 224 Schiff, Brian, 641 Schiff, Harriett Sarnoff, 649 Schiff, Nicholas D., 629 Schilder, Paul, 54, 609 Schim, Stephanie Myers, 617 Schindler, Ruben, 645 Schnebly, Stephen, 650 Schneider, Alan L., 614 Schneider, Carl E., 631 Schneider, John, 381, 646 Schneiderman, Lawrence J., 634 Schoenberg, Bernard, 644 Schoenborn, Charlotte A., 607 Schoenhoff, Doris M., 634, 670 Schorsch, Anita, 603 Schotzinger, Kathleen A., 639 Schreiber, Brad, 619 Schudson, Michael, 660 Schulman, Jerome L., 433, 650 Schumacher, Karen L., 635 Schuon, Frithjof, 542, 663 Schuster, Janice Lynch, 293 Schut, Henk, 351, 362, 383, 607,

642, 643, 645, 646 Schuurman, Donna, 394, 449,

647, 648 Schwartz, Catherine, 657 Schwartz, Eric C., 657 Schwartz, Harvey J., 659 Sciorra, Joseph, 638 Scott, Janet Lee, 617 Seale, Clive F., 87, 622 Seattle (leader of Suquamish

people), 109 Sedney, Mary Anne, 351, 611, 641 Seelye, Katherine Q., 639 Segal, Alan F., 566 Selekman, Janice, 129, 617 Self-Portrait with Dr. Arrieta (Goya),

20 Selsky, Andrew, 654 Senate (Vt.), 227 Serdahely, William J., 558, 665 Servaty-Seib, Heather, 409, 418,

643, 648, 649 Settersten, Richard A., Jr., 68, 438,

610, 651 Seward, Jack, 653 Sewell, Kenneth W., 642 Shafi , Mohammad, 653 Shain, Benjamin N., 655 Shaoyuan, Wanyan, 617 Shapiro, Ester R., 604 Sharkey, John, 617 Sharlet, Jeff, 625 Shaw, Richard, 20

Shay, Jonathan, 511, 512, 659 Sheets-Johnstone, Maxine, 605 Sheikh, Aziz, 635 Sheler, Jeffery L., 662, 665, 666 Shemie, Sam D., 620 Shepherd, Lois, 629 Sherwood, Sylvia, 626 Sheskin, Arlene, 644 Shewman, D. Alan, 154, 620 Shibata Hospital ( Japan), 279 Shibuichi, Daiki, 603 Shilling, Chris, 41, 601, 607, 613 Shilts, Randy, 661 Shiraev, Eric B., 608 Shiun Jizo Temple ( Japan), 427 Shiva (Hindu deity of destruction

and regeneration), 545 Shneidman, Edwin S., 141, 268,

418, 448, 449, 450, 451, 457–458, 464, 481, 487, 589, 597, 619, 633, 649, 652, 653, 654, 655, 656, 669

Shumway, Norman, 164 Shupe, Anson, 282, 635 Shushan, Gregory, 566 Siddhartha Gautama (Indian

philosopher and founder of Buddhism), 547, 550

Siegel, Karolynn, 647 Siggins, Lorraine, 640 Silberman, Lou H., 662 Silvera, Janmarie, 293, 636 Silverman, Morton M., 656 Silverman, Phyllis R., 293, 350,

362, 375, 377, 393, 415, 439, 445, 641, 643, 645, 646, 647, 648, 651, 668, 669

Silverman, Sam, 457, 654 Silverstein, Murray, 669 Sim, Stuart, 607 Simak, Clifford, 595, 670 Siminoff, Laura A., 621 Simmons, Gene, 583 Simon, William, 607 Simonds, Wendy, 649, 650 Sinclair, Christian, 631 Sinha, Gunjan, 661 Sisson, Paul, 625 Sisti, Dominic A., 629 Skala, Judith A., 633 Sklar, Fred, 644 Slann, Martin, 518, 660 Slaughter, Virginia, 608, 609 Sloan, Susan Lynn, 624 Slomka, J., 630 Smart, Laura S., 649, 650, 651 Smart, Ninian, 613 Smiley, David, 656 Smith, Alexander K., 625 Smith, Anne M., 607 Smith, Harold Ivan, 649

Smith, Huston, 663 Smith, Jane Idelman, 567, 663 Smith, Ken R., 651 Smith, M. Brewster, 66, 610 Smith, Neal, 624 Smith, Nicola, 613 Smith, Robert J., 616, 644 Smith, Sharon Hines, 649 Smith, Thomas J., 623 Smithsonian Institution, 22 Snyder, Gary, 595, 670 Sobers, Deiann, 578 Social Security Act, 199–200 Socrates (Greek philosopher),

457, 532, 538 Sofka, Carla J., 23, 47, 309, 604,

607, 619, 638, 669 Sokan ( Japanese poet), 127 Sokefeld, Martin, 612 Solomon, Fredric, 649 Solomon, Robert, 31 Solomon, Sheldon, 604,

605, 660 Somerfi eld, Mark R., 633 Sommerville, C. John, 613 Sorrows of Young Werther, The

(Goethe), 466 –467 Sossou, M. A., 645 Sozzi, Marina, 45, 608 Specter, Michael, 634 Speece, Mark W., 51, 52–53,

81–82, 608, 612 Spencer, A. J., 662 Spench, Carol, 624 Spickard, Paul, 618 Spiro, Howard M., 622 Spring Grove Cemetery

(Cincinnati), 104 St. Anthony’s Hospital (Denver),

202 St. Christopher’s Hospice

(England), 191–192 St. Croix, Stephen, 490 St. Luke’s Hospice (New York),

192 Stacciarini, Jeanne-Marie R., 667 Stacks, James R., 627 Stafford, Peter, 667 Stanford University Hospital

(Calif.), 198 Stannard, David E., 43, 607,

613, 663 Starlight Children’s Foundation,

408, 648 State Department (U.S.), 518 Staub, Ervin, 659 Stead, Eugene A., Jr., 623 Steadman, Lyle B., 613, 615 Steighner, Nina S., 641 Steinbeck, John, 241 Steinbrook, Robert, 621

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689

Steinhauser, Karen E., 631 Stengel, Erwin, 654 Stephenson, Michael T., 621 Stevens, Dennis J., 619 Stevens, Michael J., 643 Stevenson, Ian, 665 Stewart, Alan E., 626, 656 Stillion, Judith M., 438, 447, 606,

644, 647, 651, 652, 655, 656 Stimpson, Catherine R., 619 Stoddard, Sandol, 624, 625 Stokes, Shelley, 612 Stone, Jacqueline I., 567 Strack, Steven, 667 Strauss, Anselm L., 33, 263, 264,

632, 635, 636 Strickland, Albert Lee, 87, 602,

603, 606, 611, 614, 623, 636, 640, 644, 647, 649, 658, 667

Stroebe, Margaret S., 348, 351, 360, 362, 363, 365, 379, 384, 445, 607, 641, 642, 643, 644, 645, 646, 668

Stroebe, Wolfgang, 365, 383, 642, 644, 645, 668

Stryker, Jeff, 661 Study to Understand Prognoses

and Preferences for Outcomes and Risks of Treatment (SUPPORT), 219, 238, 628

Sturken, Marita, 660 Suárez, Constancio S., 118 Sudnow, David, 206, 298, 637 Sugimoto, John D., 627 Suicide of Lucretia, The

(Rembrandt), 20 Sullivan, Louis W., 625 Sumpter, Helen K., 642 Sunshine Foundation, 408, 648 Supreme Court (Fla.), 224 Supreme Court (Mo.), 222 Supreme Court (N.J.), 222 Supreme Court (U.S.), 222–223,

226, 227, 228, 240 Svensson, Peter, 637 Swain, Helen L., 60, 609 Swazey, Judith P., 621 Swift, Susan, 502, 658 Swofford, Anthony, 659 Sznaider, Natan, 608

Taff, Mark L., 655, 658 Tafoya, Terry, 640 Takeuchi, K., 668 Talarico, Ernest F., Jr., 619 Talbot, Kay, 649, 650 Tamm, Maare E., 647 Tanabe, George J., Jr., 664 Tanaka, Daisuke, 127, 617 Tang, Siew Tzuh, 635 Tankink, Marian, 646

Tanner, Ralph, 302, 322, 551, 637, 638, 664, 669

Tanyi, Ruth A., 664 Tapper, Jake, 529 Tasker, Fred, 656 Tasma, David, 191 Tatar, Maria, 610 Tatarelli, Roberto, 654 Tate, Frederic B., 602 Taub, Deborah J., 649 Taylor, Mark C., 597 Taylor, Richard P., 567 Tecca, Martha, 626 Tedeshi, Richard G., 645 Tejada-Vera, Betzaida, 652, 669 Templer, Donald I., 612, 635 Ten Have, Henk A. M. J., 624 Teno, Joan M., 188, 622, 624 Teresa (Albanian religious in

India), 584 Teresi, Dick, 669 Terheggen, Maaike, 645 Testoni, Ines, 34, 606 Tetsuo, Yamaori, 616, 617 Thanatos (Greco-Roman

personifi cation of death), 6 Tharoor, Shashi, 523, 660, 661 The, Anne-Mei, 623 Thich Quang Duc (Buddhist

monk), 454 Thiselton, Anthony C., 540, 663 Thomas, Diane M., 636 Thomas, L. Eugene, 293 Thomasma, David C., 623 Thompson, Charles C., II, 653 Thompson, Hunter S., 332 Thompson, Neil, 657 Thompson, Randall C., 632 Thomson, Graeme, 14, 47, 602 Thornton, Gordon F., 383 Thorson, James A., 23–24, 604,

656, 668 Thucydides (Greek historian and

general), 537 Tibetan Book of the Dead, 550 Tilling, Robert I., 657 Timmer, Ashley, 660 Timmermans, Stefan, 143, 170,

619, 621, 653 Tōhoku earthquake, 494, 495, 497 Tomer, Adrian, 47 Toombs, S. Kay, 262, 632 Towers, Anna, 627 Toynbee, Arnold, 507, 510,

658, 659 Tragedy Assistance Program for

Survivors (T.A.P.S.), 380, 646 Trau, Jane Mary, 630 Travis, J., 661 Triangle Shirtwaist Company

(N.Y.), 496

Trotter, Robert T., II, 634 Trumbo, Dalton, 507, 509, 658 Trungpa, Chögyam, 550, 664 Truog, R. D., 620 Tsanakas, J. N., 620 Tsuda, Tsukada, 623 Tucci, Amy S., 293, 415 Tulsky, Fredric N., 619 Tulsky, James A., 615 Tuman, Joseph S., 660 Turner, James, 665 Turner, Ronny E., 638 Turvey, C. L., 655 Twin Towers (N.Y.), 519, 520, 521 Twycross, Alisoni, 635 Tyson, Ann Scott, 654

Ueda, Makoto, 636 Umberson, Debra, 445, 515,

649, 659 Umphrey, Laura R., 649 Uniform Anatomical Gift Act,

144, 166 Uniform Determination of Death

Act, 162 United Nations Population Fund,

658 United Network for Organ

Sharing (UNOS), 167 United States Military Academy

(West Point), 18 Unknown Serviceman of the

Vietnam Era, 308 Unnithan, N. Prabhia, 619 USS Iowa, 451 Utz, Rebecca L., 439, 651

Vacco v. Quill, 226 Vachon, Mary L. S., 669 Valadez, Jorge, 121, 616 Valentine, Christine, 127, 383, 617 Van Brunt, David, 604 Van Den Bout, Jan, 645 Van Der Geest, Sjaak, 615 Van Der Houwen, Karolijne,

607, 645 Van Dongen, Carol J., 371, 644 Van Gemert, Andre, 638 Van Wormer, Katherine, 653 VanderBos, Gary R., 652 Varah, Chad, 481 Vardaman, James M., Jr., 650 Varga, Mary Alice, 609 Varnedoe, Kirk, 603 Vastag, Brian, 661 Veatch, Robert M., 155, 157, 160,

161, 620, 623 Velie, Alan, 614 Venies, Paolo, 633 Vergara, José, 613 Verghese, Abraham, 632

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690

Verheijde, Joseph L., 621 Vernon, Glenn M., 150, 509,

619, 659 Verrengia, Joseph B., 619 Veterans Administration,

254, 512 Vicchio, Stephen J., 662,

663, 666 Vico, Giambattista, 92, 613 Victoria (queen of Great Britain,

1837–1901), 99 Vietnam Veterans Memorial, 22,

23, 513, 514 Vincent, Barry, 597 Virgin de Guadalupe (Marian

apparition and patron saint of Mexico), 120

Vizzard, Audrey, 256, 292, 631 Vovelle, Michael, 613 Vuure, D. van, 637

Wada, Jurō, 170 Wagner, Barry M., 654 Wal, Gerrit van der, 623 Walco, Gary A., 648 Wald, Elijah, 602 Wald, Florence, 192 Walker, Andrea C., 614, 648 Walker, Barbara A., 665 Walking Skeleton (Shaw), 20 Wallace, Deborah, 528, 661 Wallace, Rodrick, 528, 661 Wallace, Samuel E., 644 Wallenstein, S., 655 Walls, Jerry L., 539, 567, 663 Walmart, 318 Walsh, Froma, 642 Walter, Carolyn Ambler, 415, 643 Walter, Mariko Namba, 567 Walter, Tony, 42, 351, 601,

607, 641 Walters, Derek, 617 Walton, Douglas N., 620 Ward, Jesmyn, 499 Warren, Carol, 613 Washington v. Glucksberg, 226 Wass, Hannelore, 10, 34, 68, 353,

602, 606, 610, 642, 669 Watkins, Glenn, 602 Watson, James L., 617 Watson, Patricia J., 657 Watson, Stanley J., 634 Watterson, Barbara, 662 Watts, Jonathan S., 293, 664 Waugh, Evelyn, 307 Weaver, Hilary N., 610, 614,

615, 618 Webster, Judi, 627 Wechsler, David, 609 Wechsler, Paul, 54

Weeks, Duane O., 637 Weeks, Jane C., 634 Weinberg, Matt, 257 Weinberger-Thomas,

Catherine, 653 Weinfeld, Irwin J., 650 Weir, Robert F., 603 Weisman, Avery D., 28, 33, 181,

264, 267, 589, 604, 612, 632, 633, 653, 669

Weisner, Thomas S., 612 Weiss, Hali J., 639 Weiss, Robert S., 642, 651 Weissman, David E., 627 Welch, Alfred T., 663 Wendt, William, 523, 661 Wenger, Neil S., 628 Werth, James L., Jr., 257, 629, 635 Wertheimer, Alison, 656 Wertheimer, Michael D., 623 Wessel, Morris A., 611 Wessels, Anne B., 643 West, Candace, 183, 623 West Point (U.S. Military

Academy), 18 Weyers, Heleen, 257 Wheeler, H. Brownell, 623 White, E. B., 489, 656 White, Margot L., 218, 628 Whitehouse, Kaja, 242, 631 Whitmarsh, Andrew, 22–23, 603 Whitsett, Stan F., 647 Wickersham, Joan, 479, 484,

487, 656 Wicks, Mona Newsome, 622 Widdison, Harold A., 659 Widowed Persons Service (WPS),

439–440 Wiener, Lori S., 648 Wieseltier, Leon, 662 Wiezman, Savine Gross, 651 Wijdicks, Eelco F. M., 620 Wikan, Unni, 365, 644 Wiklund, Ingela, 633 Wilcox, Sara, 651 Wilkinson, Charles, 137, 614 Williams, Melissa Johnson, 638 Williamson, John B., 604 Wilson, Charles Reagan, 15,

602, 637 Wilson, Chris, 652 Wilson, Ward, 509, 658 Wiman, Christian, 271 Windling, Terri, 610 Winn, Peter A. S., 606, 612, 614 Winnick, Terri A., 634 Winokuer, Howard R., 376, 383,

645 Winslade, John, 602 Winston, Carole A., 625

Wirzba, Norman, 26, 604 Wittkowski, Joachim, 605 Wiztum, Eliezer, 640, 642, 646 Wolfelt, Alan, 337, 640 Wolfenstein, Martha, 610 Wong, Edward, 657 Wong, Paul T. P., 47 Wong, Steven A., 654 Wood, Trish, 529, 659 Wooden, Wayne S., 618 Woodlawn Cemetery (N.Y.), 104 Woodruff, Bob, 659 Woodruff, Lee, 513, 659 Worden, J. William, 346,

350, 377, 640, 641, 645, 646, 647, 648

World Campaign for the Protection of Victims of War, 659

World Health Organization, 187, 525, 661

World of Warcraft (online game), 528

World Trade Center (N.Y.), 519, 520, 521

Woznick, Leigh A., 415 Wrenn, Robert L., 633 Wright, Susan M., 624, 626 Wulff, David M., 667 Wunn, Ina, 612

Xu, Jiaquan, 607, 652

Yahweh (Hebrew deity), 534 Yalom, Irving D., 47 Yalom, Marilyn, 339, 639 Yamada, Yoko, 610 Yang, Shu Ching, 612 Yasien-Esmael, Hend, 663 Yim, Susan, 618 Yorba, Tomás Antonio, 246 –247 Yoshiharu, Tomatsu, 293 Yoshihito, Takada, 650 Yoshishige, Jon, 619 Young, Benjamin B. C., 618 Young, Bridget, 415, 609 Young, Ed, 611 Young, J. Z., 301, 637 Young, Jerome, 653 Young, Thomas J., 653 Youngelson-Neal, Helen, 668 Younger, Stephen M., 524, 661 Youngner, Stuart J., 173 Youngs, George A., 628

Zahan, Dominique, 113, 615 Zahn-Waxler, Carolyn, 608 ZAK A (Zihui Korbanot Ason;

Israeli disaster recovery organization), 521

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Zaleski, Carol, 541, 555, 662, 663, 665, 666

Zamarripa, Cecelia A., 616 Zamperetti, N., 620, 621 Zarri, Daniela A., 647 Zelizer, Barbie, 660 Zen Hospice Project, 198, 292

Ziegler, Jesse H., 639 Ziegler, Joanna E., 47 Zillmann, Dorf, 602 Zimmerman, Larry W., 614 Ziner, Andrew S., 46, 608 Ziony, Ruth Kramer, 418 Zizioulas, John D., 662

Zoroaster (Persian religious teacher), 322

Zoucha, Rich, 616 Zucker, Robert, 412, 431, 609, 648 Zuckerman, Phil, 664 Zumbo, Gaetano Giulio, 20 Zylicz, Zbigniew, 624

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693

Abortion, 424, 426 –428 Accidents, 204, 418, 490–491.

See also Injuries Acquired immunodefi ciency

syndrome (AIDS), 525–527, 528, 594

Active dying, 288–289 Acute care, 176 Acute grief, 356 –357 Adjuvant therapy, 274 Adolescence, 62–64

bereavement, 392, 399 life-threatening illness,

399–400, 404 suicide, 462, 472–475 treatment decisions, 405–406 violence, 388, 502

Adoption loss, 425 Adulthood, 64–66

bereavement, 417, 420–440 older, 199–201 suicide, 470

Advance directive, 116 –117, 225, 233–241

African Americans, 116 –117, 392, 421, 445

hospice and, 194–195 suicide and, 466

African cultures, 96, 112–116, 375 Aftercare (funeral), 305 Afterlife, 531–532. See also

Nonempirical ideas in African culture, 113 in Asian culture, 124, 125,

543–550 in Celtic culture, 130, 131 in Christianity, 538–542 in Greek culture, 536 –538 in Islam, 542–543 in Jewish culture, 534–536, 538 in Native American culture,

108, 111 near-death experiences,

554–562 organ donation and, 168 psychedelic experience and,

564–565 secular concepts, 552–554 in traditional cultures,

532–534 Aging, 440–445 Allowing to die, 225 Altar de muertos, 120 Altruistic suicide, 447, 454 Alzheimer’s disease, 287, 441 Ambiguous loss, 370

Ambivalence, 367 in suicide, 456 –457, 481

“American way of death,” 136 Anatomical theater, 106 Ancestors, 48, 97, 98, 109–110,

112–113, 121, 123, 124, 125, 126 –127, 130, 424, 558–559, 618n141

Animate/inanimate distinction, 55 Anniversary reaction (grief), 358 Announcement of death,

298–300. See also Notifi cation of death

Anomie (suicide), 455 Anticipatory grief, 370–371 Appropriate death, 91, 589. See

also Good death Arab culture, 132 Art therapy. See Spontaneous

drawings Artes moriendi (art of dying), 106 Artifi cial nutrition and hydration,

222, 224, 231 Ashes, 326 Asian culture, 122–129. See also

Chinese culture; Japanese culture

Assimilation, 56 Assisted death, 226 –228 Assisted living facility, 200 Assumptive world, 344, 349, 399 Attachment theory, 347, 360 Attempted suicide, 449,

462–463 Attitudes toward death, 5, 6,

43–44, 46, 103, 105–106, 108, 465

in African culture, 112–113 in Asian culture, 123–124, 125 in Celtic culture, 131 in Mexican culture, 118 in Native American culture,

110–111 in Western culture, 98–99

Autonomy, 214–215, 399 organ donation and, 168

Autopsy, 143, 144–147 psychological, 141, 451–452

Awareness contexts, 263–264

Balinese culture, 48, 97, 320, 575 Bardo (“gap”), 550 Benefi cence, 215 Bequest, 242 Bereavement, 341–343. See also

Grief; Mourning

adulthood and, 417, 420–440 children and, 391–399 college students and, 418 mortality of, 362–363 older adults and, 441 as opportunity for growth,

380–382 parental, 423–435 social support in, 301–302 spousal, 436 –440 symbols of, 300, 302

Bereavement burnout, 373 Bibliotherapy, 409 Biological understanding of

death, 53, 55, 154 Biology of suicide, 458, 459 Biopsy, 274, 276 Black Death, 105, 489 Body disposition, 34–35, 313,

321–328, 329, 330, 331–332 Bonds between living and dead.

See Continuing bonds Brain death, 154, 159–160, 161,

162, 163, 165 in Japan, 170–172

Breaking bad news, 183 Bridge programs (palliative

care), 196 Broken heart phenomenon, 363 Buddhism, 123, 125, 127, 322,

547–550 Burial, 102–104, 132, 321, 322,

324 –326. See also Grave goods

early human, 92, 93, 613n15 environmental impact of, 332 scaffold, 91, 109

Butsudan (family altar), 125, 126

Cadaveric spasm, 154 Cadavers, 146, 169

public exhibition of, 44 Calavera (skeletons or skulls), 118 Cancer, 260, 261, 273–275,

275–286, 287, 592, 594 Capital punishment, 150–151 Cardiac death, 165, 220,

272–273 Cardiopulmonary resuscitation

(CPR), 107, 204, 210, 219–220, 221, 235, 240

Caregiver-patient relationship, 174, 177, 181–185, 187, 271, 287, 402, 566

Casket, 35, 317–318, 320, 330, 332 Causality, 52

Subject Index

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Cause of death, 8, 37–38, 97, 115, 141, 581. See also Origin-of- death myths

investigation of, 143–144, 146 traditional cultures and, 95–96

Cellular death, 154 Celtic culture, 129–132 Cemeteries, 102, 104, 120, 125,

324, 326, 329, 350, 549 pet, 80

Central vs. peripheral relationship, 367

Certifi cation of death, 140–141, 142

Chain suicide, 475 Charnel house, 102–103 Chemotherapy, 274, 277 Child, death of, 370, 416,

423–435 Childbearing loss, 424–432 Children

bereavement and, 385, 391–399

communication with, 400, 406 –407, 409–415

funerals and, 34–35 in Hawaiian culture, 133 life-threatening illness and,

406 –407 social support for, 407–409 suicide and, 471–472 television programming for, 9 treatment decisions and,

405–406 understanding of death,

53–62 as victims of violence, 502 violence, 520

Chinese culture, 124–125, 127–128, 134, 329, 384, 460, 543–544, 569

Ch’ing Ming (Chinese festival), 128–129

Christianity, 98, 100, 102, 118–119, 127, 191, 322, 538–542, 553

Chronic illness, 440 Chronic pain, 283 Chronic suicide, 464 Civil War (U.S.), 660n110 Clergy, 305 Clinical death, 154 Closed awareness, 263 Closure, 379 Cluster suicides, 474. See also

Copycat suicide Codicil, 243, 247 Coffi n, 331, 335–336, 543 Cognitive transformations

(developmental), 56 –58, 59, 61–62, 63–64

College students and death, 418–420, 460, 462

Columbarium, 313 Coma, 203, 222, 223, 274 Commemoration. See

Memorialization Companion animal death. See Pet

death Compassion fatigue, 207–209 Compassionate cities, 210,

581–584 Complementary and alternative

therapies, 277–282 Complicated mourning, 359–362,

378, 388, 393 Compression of morbidity, 442 Condolence cards, 10, 140 Confucianism, 544 Congregate housing, 200 Consciousness, states of, 223. See

also Near-death experiences; Psychedelic experience of death

Continuing bonds, 337, 346, 348–350, 352

in Asian culture, 124, 125, 127 in Celtic culture, 130, 131 Internet and, 42 in traditional cultures, 97–98

Continuing care community, 200–201

Convalescent care, 176 Coping potency, 269, 271 Coping strategies, 263–271,

289–292, 302, 347–354, 401–402

Copycat suicide, 466 –467, 471, 474

Coroner, 141, 143–144, 169 Cosmopolitan society, 44–45 Creativity and grief, 381–382 Cremation, 123, 310, 313, 318, 319,

321, 322, 326 –328, 530 Critical incident stress

management, 207 Cry for help (suicide), 449,

461–463 Cryomation, 326 Cryonics, 323, 333 Crypt, 321, 325 Cultural competence, 90, 572–574 Cultural diversity, 89, 91, 112,

117, 132, 133, 134, 135, 136, 137, 182, 280, 334, 438, 453, 572–573

Cultural lag, 46 Culture, 170–172, 365, 438,

466 –467 defi nition of, 89

Curanderismo, 280 Cyberfunerals, 309, 337

Dance of death, 104–106 musical expressions of, 13 in visual arts, 18

Danger-of-death narratives, 12 Danse macabre (dance of death),

13, 18, 104–106 Day of the Dead, 88, 106, 118–122,

130, 136 Death anxiety, 27–29. See also

Terror management Death café, 46 Death certifi cate, 140–141 Death competence, 378 Death dreams, 562–564 Death education, 31–34, 570,

571, 572, 587, 596. See also Thanatology

Death investigator, 143, 450. See also Coroner; Psychological autopsy

Death knell, 34, 35, 100 Death masks, 106 –107, 136 Death notice, 6 –7, 299, 313 Death penalty, 150–151 Death rates, 35–37. See also Cause

of death; Life expectancy Death rattle, 289 Death row, 151 Death songs, 110 Death studies, history of,

32–34 Death system, 139–140, 172–173 Deathbed promises, 376 Deathbed scene, 4, 34,

100–102 Deathbed visions, 560 Deathwatch, 177, 296 Defense mechanisms, 268,

559, 561 Defi nition of death, 40, 151–163 Dementia, 287, 441 Demographics, 34 Depression, 265, 343, 362, 388,

458–459, 470, 475 Descansos (roadside memorials),

310–311 Día de los Muertos. See Day of the

Dead Diagnosis, 182–185, 216 –217, 274 Digital afterlife, 43 Dignity, 272 Directed donation, 167 Directive mourning therapy, 333 Dirge, 13, 131 Disaster, 372–373, 494–501 Discussing death with children,

409–415 Disenfranchised grief, 373–375 Disposition of the body. See Body

disposition “Do no harm,” 215

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Do not resuscitate (DNR), 219–220, 235, 240

Double effect, 227, 229 Druids, 130 Dual process model of coping,

351–352 Durable power of attorney for

health care, 237 Dyadic nature of suicide, 456 Dying persons, 185–198, 289–292.

See also Compassionate cities Islam and, 543 Tibetan Buddhism and, 550

Dysfunctional grief. See Complicated mourning

Early adulthood, 418, 450, 462, 491

Economics, health care, 178–180 Effi gy, 104 Egalitarian obits, 7 Egyptian culture, 531 Elder care, 199–201 Elderly. See Older adults Elegy, 16 –17, 131 Embalming, 315–317, 638n55 Emergency care, 201–204,

240–241 Emergency personnel, 32, 201,

202, 203, 207, 208, 241 Emerging adulthood, 64, 418 Emerging disease, 524–525,

527–529 End-of-life care, 181, 185–198 End-of-life choices, 213–214,

216, 217, 221–223, 230–231, 255–256. See also Advance directive; Estate

Entombment, 313, 321, 325, 328 Epidemic, 524 Epidemiologic transition, 38 Epitaph, 16, 310 Equivocal death, 450 Eros and Thanatos, 26 Eschatology, 553 Estate, 241–248, 250. See also

Insurance; Probate; Wills Ethical will, 245 Ethnocentrism, 90 Ethnomedicine, 280 Eulogy, 16, 330 Euphemism, 10–12, 307 Euthanasia, 225, 229–230,

630n50 Executor, 243, 248–249 Existential questions, 26,

420, 553 Extraordinary measures, 231

Fading away, 185 Fairy tales, 73–75

Familicide, 150, 505 Fatalistic suicide, 456 Fear of the dead, 92, 109, 111,

125, 321 Fêng-shui (art of divination),

124–125, 329 Fetal death. See Abortion;

Miscarriage; Stillbirth Fijian culture, 93 Filial piety, 122 Filipino culture, 122, 123, 124 Five stages (model of coping),

265–266, 393 Forensic pathology, 143 Friend death, 420 Funeral director, 304, 305,

307, 330 in African American

communities, 303 Funeral home, 304, 305, 315 Funeral meal, 296, 337–338, 373 Funerals, 295–296, 297, 311–313,

321, 330, 334–335, 549 among African Americans,

116, 117 among LoDagaa of Ghana,

114–116 attitudes toward, 303, 304, 306 children and, 69, 70–71, 77, 81 costs, 313–315, 317, 318–319 criticisms of, 306 –307 in Hawaiian culture, 135 history of, 304–305 jazz, 13, 297–298 music in, 296 –298, 331 paraphernalia, 304 psychosocial aspects of,

298–302 recent developments in,

309–309–310, 330–331, 334–335, 337

regulations, 303–304 Taoist, 134

Futile treatment, 221

Gay and lesbian suicide, 466 Gender differences, 28, 365,

367–368, 449, 470 Genocide, 516 –517 Geographic mobility, 38–40 Geriatrics, 441 Gerontology, 199 Gift exchange, 172. See also Organ

donation Globalization, 25, 42, 44, 45,

89, 581 Golden hour, 203 Good death, 587–591

Buddhist view of, 548–549 Grave goods, 92, 111, 130, 302.

See also Paper offerings

Grave liner, 318–319, 324 Grave marker, 309, 313, 325, 328 Graveside suicide, 474 Graveyard, 324 Greek culture, 536 –538, 553, 587 Green burial, 321, 331–332 Grief, 337, 343–345, 353,

356 –357. See also Bereavement; Lament; Mourning

children and, 59, 60, 61, 62, 80, 392–393

complications of, 359–362 course of, 355–358 duration of, 358–359 in Hispanic culture, 117 humor and, 24 Internet and, 42, 43 linking objects and,

333–334 models of, 347–354 narrative reconstruction in,

350–351 news reports and, 7–8 pet death and, 78, 79, 80, 81 policing of, 140 social support in, 379–380 tasks of, 345–347 in traditional societies, 98 unresolved, 108 variables, 364–376

Grief counseling, 376 –379, 594 Grief work, 347–348, 375

Hades (realm of the dead), 535, 536

Haka (family grave), 125–126, 327 Harvard criteria, 159–160, 163 Hawaiian culture, 15, 133–135,

337–338, 533–534, 558–559, 618n141

Hazards. See Risk Health care, 175–176, 178–180,

180–181, 209–210 Health care proxy, 237 Heart disease, 260, 272–273, 287,

592, 594 Heaven, 540, 542, 554. See also

Paradise Hell, 535, 541, 542, 558 Hell Notes, 127 Heroic suicide, 455. See also

Altruistic suicide Hibakusha (explosion affected),

25–26 High grief vs. low grief,

369–370 Hinduism, 123, 322, 544–546 Hispanic culture, 117–122, 137,

194, 280, 573–574 Hmong, 123

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Karma (moral law of cause and effect), 123, 544

Karoshi (“overwork death”), 493 Keening, 13, 131

La Despedida (leave-taking), 137 Lament, 13, 15, 125, 131 Language, 5, 10–12, 25, 75,

307, 375 of pain, 283 in suicidal intent, 485–487

Latino culture. See Hispanic culture

Lethality (suicide), 449, 463, 476, 478–479

Life expectancy, 35–36, 592. See also Death rates

Life insurance, 144, 253–254 Life review, 290–291, 556,

559, 560 Life-centered funeral, 310,

330–331 Life-extending technologies,

40–41 Life-span development, 53–67, 82,

402, 442 Life-threatening illness, 182–185,

260–263 children and, 387–388,

399–407 coping with, 263–271, 289–292 Internet and, 42 pain in, 282–286, 288 social support in, 289–292 treatment of, 272–286

Linear vs. systemic processes, 368–369

Linking objects, 333–334, 429 Literature, 15–18, 131

children’s, 72–75, 83–87 Little deaths, 341 Living trust, 251, 253 Living will, 225, 235. See also

Advance directive Local identity, 133, 134–135 Locked-in syndrome, 223 Loss. See Bereavement Lossography, 47 Loss-oriented coping, 351 LSD (lysergic acid diethylamide),

564, 565, 666n125 Lullabies, 75

Magical thinking, 53, 72, 262 Managed care, 180 Managed death, 46, 256 Manslaughter. See Homicide Maori culture, 476 Marijuana (medical use), 282 Martyrs, 102, 522, 543

Masks, death, 106 –107 Mass media, 6 –10, 41, 72–73, 519,

584, 585, 586 Mass murder, 503–505 Mass suicide, 455 Mature concept of death, 51–53,

66 –67, 81–82 Maturity, 445 Mausoleum, 325 Mean world syndrome, 8 Medical ethics, 170–172, 214–215.

See also Brain death Medical examiner, 141, 143–144,

169, 170 Medical technology, 40–41,

99, 153, 155, 175, 178–180, 221, 225

Medicare Hospice Benefi t, 188, 193, 194

Megadeaths, 490 Mele kanikau (Hawaiian chant), 15 Memento mori (reminder of death),

15, 101 Memorial service, 337 Memorialization, 104, 309–310,

311, 313, 325, 327, 328. See also Day of the Dead; Mourning art

Mental fi rst aid, 399 Metacrises, 418 Metastasis, 273, 275 Middle adulthood, 470, 475 Middle knowledge, 264 Middlescence, 475 Military suicides, 469–470 Minimally conscious state,

223, 224 Miscarriage, 424, 426 Mizuko (“water children”), 427 Mode of death, 141, 369–373 Moksha (“liberation”), 546 Morbidity, compression of, 442 Mortality salience, 29 Mortician. See Funeral director Mortuary, 315 Mourning, 99, 137, 345, 346 –347.

See also Bereavement; Grief Mourning art, 18–19, 20–23, 99 Mourning restraints, 115–116, 124 Movies, 9–10, 41 Murder. See Homicide Music, 12–15, 113, 296 –298.

See also Death songs Muslim beliefs. See Islam Mutual pretense, 264

Naming practices, 94–95, 125 Narcocorridos, 14 Native American culture, 94,

108–112, 280, 326, 345, 424

Holocaust, 18, 129, 373 Home care, 176, 191, 192,

196 –198, 200, 403 Home funeral, 331 Homegoing, 116 Homicide, 147–150, 372, 450.

See also Terrorism Hopelessness (suicide), 467 Horrendous deaths, 27,

523–524 Hospice, 176, 187–196

African Americans and, 116 –117

pediatric, 403 Hospitals, 176, 177 Hotline services, 481–482 Human development, 53–67,

82, 442 Humanism, 553 Humor, 23–25, 120, 482

Iceberg theory of culture, 573 Iconics, 184 Immortality, 130, 536 –538, 539,

552–554. See also Afterlife Indigent burial, 329 Infant death, 424–425 Infectious disease. See Emerging

disease Infertility, 425 Informed consent, 215–221 Injuries, 203, 432, 490–491 Inner representation, 349, 394 Institutional neurosis, 199 Insurance, 253–254 Internet, 6, 42–43, 72, 300, 309,

378, 520, 594 Internet suicide, 475 Interventional cascade, 175 Intestate succession, 243 Intuitive vs. instrumental

grieving, 368 Invisible death, 99, 107–108 Irreversibility, 51 Islam, 132, 322, 542–543, 553 Itemized pricing (funeral),

313–314

Japanese culture, 124, 125, 126, 127, 547–550, 569

Jazz funeral, 13, 297–298 Jewish culture, 129, 373,

534–536 Judaism, 322, 553 Justice (ethics), 215

Kaddish (memorial prayer), 129, 373, 536

Kaimyo (posthumous name), 125 Kanikau (Hawaiian chant), 15

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Near-death experiences, 554–562, 566

Necromancy, 98 Necropolis, 326 Neonatal death, 424, 429–430 Neonatal intensive care, 232–233 Nepenthe, 380–381 Newborns, seriously ill, 232–233 News reports. See Mass media Niche, 313, 328 Nirvana (“extinction”), 547, 548 Nonempirical ideas, 52 Nonfunctionality, 52 Nordic culture. See Celtic culture Notifi cation of death, 45, 204–207.

See also Announcement of death

Nursery rhymes, 75 Nursing facilities, 176 Nutrition and hydration, 224,

231, 288

Obituaries, 6, 7, 116, 118, 299, 309, 328

O-bon ( Japanese festival), 128–129

Oceanic culture, 132. See also Hawaiian culture

Odds of dying, 8 Ofrenda (altar), 120, 122 Older adults, 199–201, 440–445,

593 Open awareness, 264 Organ donation, 144–145,

163, 165–170. See also Transplantation

Origin-of-death myths, 92–94 Otherworld journey, 130, 554–555

Pain, 137, 282–283, 282–286, 288, 564

Palliative care, 176, 185, 187–196 children and, 403 right to die and, 230–231

Pandemic, 524 Panoramic memory, 556, 559 Paper offerings, 127–128 Paradise, 535, 540, 541 Parent death, 393–395, 420–422 Parental bereavement, 423–435 Passive euthanasia, 225 Paternalism, 171, 181, 195 Pediatric hospice, 403 Perceived similarity, 367 Peril. See Risk Perinatal loss, 424 Period effect (suicide), 470 Persistent vegetative state, 163,

223 Personal care home, 200

Pet death, 69, 78–81 Physician Orders for Life-

Sustaining Treatment (POLST), 235–237, 241

Physician-assisted death, 226 –228, 629n40

Physician-patient relationship. See Caregiver-patient relationship

Placebo, 280–281 Plastination, 44 Poetry. See Literature Policing of grief, 140 Pollution. See Fear of the dead Positivism, 553 Postmodernism, 44 Postmortem examination,

144, 146 Postmortem photography,

428, 429 Post-self, 590 Posttraumatic stress disorder

(PTSD), 388, 469, 511–512 Postvention (suicide), 484 Presumed consent (organ

donation), 168 Primary caregiver, 192, 197–198 Probate, 243, 248–251 Procession (funeral), 319 Prognosis, 193, 217, 275 Prolonged grief, 358, 362 Proxemics, 184 Proxy, 237 Psychache, 457–458 Psychedelic experience of death,

564–565 Psychic maneuvers (violence), 506 Psychic numbing (war), 509 Psychological autopsy, 141,

451–452 Psychosocial development, 55–56,

57, 58, 60–61, 62, 65, 66 Psychotherapy. See Grief

counseling Public event vs. private loss, 8, 101 Purgatory, 539–540

Quality-adjusted life years (QALYs), 210

Radiation therapy, 275–277 Rational suicide, 459 Rationing (health care),

180–181 Rebirth, 532–533, 547, 550 Recuerdo (remembrance), 137 Recurrence of grief, 359 Referred suicide, 460 Reframing, 435 Reincarnation, 544, 547, 566

Religion, 76, 344, 367, 399, 551–552, 566

death anxiety and, 28 Religiosity, 482, 551, 552 Remembrance rituals, 333–334 Remission, 260, 275 Reproductive loss. See

Childbearing loss Requiem, 13 Residential care, 176 Resilience, 392 Resocialization, 68 Resomation (alkaline hydrolysis),

326 Respite care, 198 Restoration-oriented coping, 351 Resurrection, 538, 539, 541, 566 Resuscitation. See Cardiopulmonary

resuscitation (CPR) Retirement communities,

200–201 Revictimization, 7 Right to die, 222, 227, 230–231 Rigor mortis, 154 Risk, 418, 489, 490, 491–494

suicide and, 457, 464–471 Rites of passage, 115, 137, 302 Roadside memorials, 310–311 Rule of Sevens, 405 Rural cemetery movement, 104

Samhain (Celtic festival), 130 Samsara (“passing through”),

544, 547 Scaffold burial, 91, 109 Sea burial. See Water burial Seclusion (mourning), 345 Secondary losses, 362 Secondary morbidity, 18 Secondary socialization, 68 Secularization, 99, 551,

552–554 Selective memory, 393 Self-harm. See Suicide Self-mourning, 570 Senescence, 440 Seppuku (ritual disembowelment),

454 September 11, 2001, 6, 61 Serial killer, 503 Shaman, 98, 123, 130 She’ol (underworld of the dead),

535 Shinto, 127 Shivah ( Jewish period of

mourning), 129, 373, 536 Sibling death, 395–399 Signs of dying. See Trajectory of

dying Sikh culture, 123, 137

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Six-month rule (hospice benefi t), 194

Skeleton, 118, 120 Skilled nursing facility, 201 Slasher movies, 9–10 Slippery slope argument, 230 Social context

of grief, 365 of suicide, 453–456 of war, 509–511

Social death, 289 Social history of dying, 95,

96, 97 Social learning theory, 91 Social media, 42–43 Social norms, 67, 91 Social structure, 90 Social support, 435

in bereavement, 301–302, 351, 373–375, 379–380

for children, 407–409 in life-threatening illness,

262–263, 292–293 Social thanatology, 528 Socialization, 41, 47, 49, 67–76,

81–82 Society, defi nition of, 90 Speculum mortis (mirror of death),

101 Spirit tablet, 127. See also Kaimyo Spirituality, 551–552 Spontaneous abortion, 424 Spontaneous drawings, 389, 395,

398, 401 Spontaneous shrines, 311 Spousal bereavement, 436 –440 Sterility, 425 Stillbirth, 424, 428–429 Stress, 363, 419

among caregivers, 207, 209 Structural view of society, 90 Subintentioned suicide, 464 Substituted judgment, 237 Sudden death, 100, 260–261, 287,

371. See also Notifi cation of death

Sudden infant death syndrome (SIDS), 430–431

Suicidal ideation, 449, 476 Suicide, 448–449, 456. See also

Psychological autopsy in adolescence and early

adulthood, 472–475 attempted, 462–463 biology of, 458, 459 in childhood, 471–472 chronic, 464 as cry for help, 461–463 in early adulthood, 419 as escape, 459–461, 473

grief and, 371–372 heroic, 455 in late adulthood, 476 mass, 455 methods, 476, 478–479 in middle adulthood, 475 in older adults, 440–441 prevention and intervention,

481–483, 485–487 risk factors, 464–471 statistical issues, 449–450 subintentioned, 464 theories of, 453–459

Suicide bombings, 467, 522, 523 Suicide by cop, 450 Suicide ideation, 471 Suicide notes, 478, 479–481 Suicide pacts, 474 Suicide prevention, 144 Support groups. See Social

support Surcease suicide, 459 Surgery, 275–276 Surrogate, 237 Survivor guilt, 373, 394 Suspected awareness, 263 Suspicious death, 143, 169 Suttee, 455 Symbolic healing, 282 Symbolic immortality, 537, 554 Symbolic interactionism, 91 Symbols

of bereavement, 300, 302, 345 in grave markers, 328

Sympathy cards, 10, 140

Tactical socialization, 68 Tamed death, 97, 99 Taoism, 124, 134, 543–544 Teachable moment, 31, 76, 77 Technological alienation (war),

508–509 Teen-age years. See Adolescence Television. See Mass media Terminal sedation, 229 Terminality, 268, 275 Terror management, 29–31.

See also Death anxiety Terrorism, 18, 467, 517–523 Testamentary trust, 251 Testator, 242, 244, 245, 247–248 Thanatography, 144 Thanatology, 26–27, 574, 576.

See also Death education international examples,

576 –580 research and practice, 580–581

Tibetan Buddhism, 550 Time of death. See Active dying Total care, 185, 187, 258, 402

Total war, 99 Traditional cultures, 92–98,

532–534 Trajectory of dying, 185,

286 –289 Transcendence, 560 Transmigration, 537, 544, 547,

549 Transplantation, 163, 164,

165–167, 170–172, 594. See also Organ donation

Trauma, 529 Native American history

and, 108 Trauma care, 201–204 Treatment, 272–286

children and, 405–406 withholding or withdrawing,

225–226 Trigger events, 372. See also

Recurrence of grief Tumor, 273. See also Cancer Two-track model of bereavement,

352–353

Undertaker. See Funeral director Unfi nished business, 375–376 Universality, 51 Unlived lives, 431–432 Unorthodox treatment, 281–282

Valhalla (hall of the slain), 131 Valkyries (chooser of the slain),

130–131 Vegetative state, 222, 223 Viatical settlement, 254 Vicarious reinforcement, 91 Victim-killer relationship, 147,

148, 149, 150, 506 –507 Victim-precipitated homicide, 450 Vietnam war, 8 Vietnamese culture, 124 Vigilante stories, 18 Violence, 501–507

capital punishment and, 151 children and, 388, 389, 391 college students and, 419–420 in mass media, 6, 8, 9 suicide and, 466

Virtual cemeteries, 309 Visitation, 319, 337 Visual arts, 18–23, 310, 311, 576 Visualization, 279 Vital signs, 156, 162, 165, 282

Wake, 34, 117, 131, 296, 304 War, 507–516. See also Genocide;

Terrorism children and, 386, 388, 394

War memorials, 22–23, 104

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699

World Wide Web. See Internet Wrongful death, 491

Yahrzeit (anniversary of death), 129, 536

Widowhood, 328, 438–439, 476. See also Spousal bereavement

Wills, 241–248 Wished-for child, 425

Water burial, 322–323 Werther effect (suicide), 467 Western culture, 98–108 Whole-person care, 185, 187,

258, 402

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  • Cover
  • Title
  • Copyright
  • Contents
  • Preface
  • Prologue
  • CHAPTER 1 Attitudes Toward Death: A Climate of Change
    • Expressions of Attitudes Toward Death
      • Mass Media
        • In the News
        • Entertaining Death
      • Language
      • Music
      • Literature
      • Visual Arts
      • Humor
    • Living with Awareness of Death
      • Contemplating Mortality
      • Dimensions of Thanatology
      • Death Anxiety and Fear of Death
      • Terror Management
    • Studying Death and Dying
      • The Rise of Death Education
      • Pioneers in Death Studies
    • Factors Affecting Familiarity with Death
      • Life Expectancy and Mortality Rates
      • Causes of Death
      • Geographic Mobility and Intergenerational Contact
      • Life-Extending Technologies
      • The Internet and the Digital Age
    • Examining Assumptions
      • Death in a Cosmopolitan Society
      • Exploring Your Own Losses and Attitudes
    • Further Readings
  • CHAPTER 2 Learning About Death: Socialization
    • A Child's Reasoning
    • A Mature Concept of Death
    • Understanding Death Through the Life Course
      • Infancy and Toddlerhood
      • Early Childhood
      • Middle Childhood or School-Age Period
      • Adolescence
      • Emerging Adulthood
      • Early Adulthood
      • Middle Adulthood
      • Later Adulthood
      • The Evolution of a Mature Concept of Death
    • Agents of Socialization
      • Family
      • School and Peers
      • Mass Media and Children's Literature
      • Religion
    • Teachable Moments
    • The Death of a Companion Animal
    • The Mature Concept of Death Revisited
    • Further Readings
  • CHAPTER 3 Perspectives on Death: Historical and Cultural
    • Traditional Cultures
      • Origin of Death
      • Names of the Dead
      • Causes of Death
      • Power of the Dead
    • Western Culture
      • The Deathbed Scene
      • Burial Customs
        • Charnel Houses
        • Memorializing the Dead
      • The Dance of Death
      • Death Masks
      • Invisible Death?
    • Cultural Viewpoints
      • People of Native American Heritage
      • People of African Heritage
        • The LoDagaa of Northern Ghana
        • Traditions Among African Americans
      • People of Hispanic Heritage
        • Attitudes Toward Death in Mexico
        • Día de los Muertos
      • People of Asian Heritage
        • Paper Offerings
        • Ch'ing ming and O-bon Festivals
      • People of Jewish Heritage
      • People of Celtic Heritage
      • People of Arab Heritage
      • People of Oceanian Heritage
    • Mixed Plate: Cultural Diversity in Hawaii
      • Characteristics of Hawaii's Peoples
      • Death and Local Identity
    • Death in Contemporary Multicultural Societies
    • Further Readings
  • CHAPTER 4 Death Systems: Mortality and Society
    • Certification of Death
    • The Coroner and the Medical Examiner
    • Autopsies
    • Assessing Homicide
    • Capital Punishment
    • Defining Death
      • Conventional Signs of Death and New Technology
      • Conceptual and Empirical Criteria
      • Four Approaches to the Definition and Determination of Death
        • Irreversible Loss of Flow of Vital Fluids
        • Irreversible Loss of the Soul from the Body
        • Irreversible Loss of the Capacity for Bodily Integration
        • Irreversible Loss of the Capacity for Consciousness or Social Interaction
    • The Uniform Determination of Death Act
    • Organ Transplantation and Organ Donation
    • Medical Ethics: A Cross-Cultural Example
    • The Impact of the Death System
    • Further Readings
  • CHAPTER 5 Health Care: Patients, Staff, and Institutions
    • Modern Health Care
      • Health Care Financing
      • Rationing Scarce Resources
    • The Caregiver-Patient Relationship
      • Disclosing a Life-Threatening Diagnosis
      • Achieving Clear Communication
      • Providing Total Care
    • Care of the Dying
      • Hospice and Palliative Care
        • The Origins of Hospice and Palliative Care
        • Challenges for Hospice and Palliative Care
        • The Future of Hospice and Palliative Care
      • Home Care
      • Social Support
    • Elder Care
    • Trauma and Emergency Care
    • Death Notification
    • Caregiver Stress and Compassion Fatigue
    • A Changing Health Care System
    • Further Readings
  • CHAPTER 6 End-of-Life Issues and Decisions
    • Principles of Medical Ethics
    • Informed Consent to Treatment
    • Principles of Informed Consent
    • Preferences Regarding Informed Consent
    • Choosing Death
      • Withholding or Withdrawing Treatment
      • Physician-Assisted Death
      • The Rule of Double Effect
      • Euthanasia
      • Palliative Care and the Right to Die
      • Nutrition and Hydration
      • Seriously Ill Newborns
    • Advance Directives
      • Using Advance Directives
      • Advance Directives and Emergency Care
    • Inheritance: Wills, Probate, and Living Trusts
      • Wills
        • The Formally Executed Will
        • Amending or Revoking a Will
      • Probate
        • The Duties of the Executor or Administrator
        • Laws of Intestate Succession
      • Living Trusts
    • Insurance and Death Benefits
    • Considering End-of-Life Issues and Decisions
    • Further Readings
  • CHAPTER 7 Facing Death: Living with Life-Threatening Illness
    • Personal and Social Meanings of Life-Threatening Illness
    • Coping with Life-Threatening Illness
      • Awareness of Dying
      • Adapting to "Living-Dying"
      • Patterns of Coping
      • Maintaining Coping Potency
    • Treatment Options and Issues
      • Surgery
      • Radiation Therapy
      • Chemotherapy
      • Alternative Therapies
        • The Placebo Effect
        • Unorthodox Treatment
    • Pain Management
      • The Language of Pain
      • Treating Pain
    • The Dying Trajectory
    • The Social Role of the Dying Patient
    • Being with Someone Who is Dying
    • Further Readings
  • CHAPTER 8 Last Rites: Funerals and Body Disposition
    • Psychosocial Aspects of Last Rites
      • Announcement of Death
      • Mutual Support
      • Impetus for Coping with Loss
    • Funerals in the United States
      • The Rise of Professional Funeral Services
      • Criticisms of Funeral Practices
      • New and Rediscovered Memorial Choices
    • Selecting Funeral Services
      • Funeral Service Charges
      • Comparing the Costs
        • Professional Services
        • Embalming
        • Caskets
        • Outer Burial Containers
        • Facilities and Vehicles
        • Miscellaneous Charges
        • Direct Cremations and Immediate Burials
      • Funeral and Memorial Societies
    • Body Disposition
      • Burial
      • Cremation
      • Memorialization
      • Laws Regulating Body Disposition
    • New Directions in Funerals and Body Disposition
    • Remembrance Rituals and Linking Objects
    • Making Meaningful Choices
    • Further Readings
  • CHAPTER 9 Survivors: Understanding the Experience of Loss
    • Bereavement, Grief, and Mourning
    • Tasks of Mourning
    • Models of Grief
      • Working Through Grief
      • Continuing Bonds with the Deceased
      • Telling the "Story": Narrative Reconstruction
      • The Dual Process Model of Coping
      • The Two-Track Model of Bereavement
      • Toward an Integrated Model of Grief
    • The Experience of Grief
      • Mental Versus Emotional Responses
      • The Course of Grief
      • The Duration of Grief
      • Complications of Grief
      • The Mortality of Bereavement
    • Variables Influencing Grief
      • Survivor's Model of the World
        • Personality
        • Cultural Context and Social Roles
        • Perceived Relationship with the Deceased
        • Values and Beliefs
      • Coping Patterns and Gender
      • Mode of Death
        • Anticipated Death
        • Sudden Death
        • Suicide
        • Homicide
        • Disaster
      • Multiple Losses and Bereavement Burnout
      • Social Support and Disenfranchised Grief
      • Unfinished Business
    • Grief Counseling and Grief Therapy
    • Support for the Bereaved
    • Bereavement as an Opportunity for Growth
    • Further Readings
  • CHAPTER 10 Death in the Lives of Children and Adolescents
    • Experiences with Death
    • Children as Survivors of a Close Death
      • The Bereaved Child's Experience of Grief
      • The Death of a Parent
      • The Death of a Sibling
    • Children with Life-Threatening Illnesses
      • The Child's Perception of Serious Illness
      • The Child's Coping Mechanisms
      • Providing and Organizing Care
        • Pediatric Hospice and Palliative Care
        • Decisions About Medical Treatment
        • Caring for a Seriously Ill Child
    • Support Groups for Children
    • Helping Children Cope with Change and Loss
      • Discussing Death Before a Crisis Occurs
      • Discussions When a Family Member Is Seriously Ill
      • Discussions in the Aftermath of Loss
    • Further Readings
  • CHAPTER 11 Death in the Lives of Adults
    • Death and the College Student
    • The Death of a Friend
    • The Death of a Parent
    • Parental Bereavement
      • Childbearing Losses
        • Miscarriage
        • Induced Abortion
        • Stillbirth
        • Neonatal Death
        • Sudden Infant Death Syndrome
      • Grief for "Unlived" Lives
      • The Death of an Older Child
      • The Death of an Adult Child
      • Coping with Bereavement as a Couple
      • Social Support in Parental Bereavement
    • Spousal Bereavement
      • Factors Influencing Spousal Bereavement
      • Social Support for Bereaved Spouses
    • Aging and the Aged
    • Further Readings
  • CHAPTER 12 Suicide
    • Comprehending Suicide
      • Statistical Issues
      • The Psychological Autopsy
    • Explanatory Theories of Suicide
      • The Social Context of Suicide
        • Degree of Social Integration
        • Degree of Social Regulation
      • Psychological Insights About Suicide
      • Toward an Integrated Understanding of Suicide
    • Some Types of Suicide
      • Suicide as Escape
      • Cry for Help
      • Subintentioned and Chronic Suicide
    • Risk Factors Influencing Suicide
      • Culture
      • Personality
      • The Individual Situation
    • Life-Span Perspectives on Suicide
      • Childhood
      • Adolescence and Early Adulthood
      • Middle Adulthood
      • Late Adulthood
    • Contemplating Suicide
    • Suicide Notes
    • Suicide Prevention, Intervention, and Postvention
      • Prevention
      • Intervention
      • Postvention
    • Helping a Person Who Is in Suicidal Crisis
    • Further Readings
  • CHAPTER 13 Risks, Perils, and Traumatic Death
    • Accidents and Injuries
    • Risk Taking
    • Disasters
      • Reducing the Impact of Disasters
      • Coping with the Aftermath of Disaster
    • Violence
      • Random Violence
      • Serial Killers and Mass Murderers
      • Familicide
      • Steps Toward Reducing Violence
    • War
      • Technological Alienation
      • The Conversion of the Warrior
      • Coping with the Aftermath of War
      • Making War, Making Peace
    • Genocide
    • Terrorism
      • September 11, 2001
      • Rescue, Recovery, and Mourning
      • The Mind of the Terrorist
    • Horrendous Death
    • Emerging Infectious Diseases
      • The Response to AIDS
      • Living with AIDS
      • The Threat of Emerging Diseases
    • Traumatic Death
    • Further Readings
  • CHAPTER 14 Beyond Death / After Life
    • Traditional Concepts About Life After Death
    • Jewish Beliefs About Death and Resurrection
    • Classical Greek Concepts of Immortality
    • Christian Beliefs About the Afterlife
    • The Afterlife in Islamic Tradition
    • Death and Immortality in Asian Religions
      • Hindu Teachings About Death and Rebirth
      • The Buddhist Understanding of Death
      • After-Death States in Tibetan Buddhism
    • The Consolations of Religion
    • Secular Concepts of Immortality
    • Near-Death Experiences: At the Threshold of Death
      • NDEs: A Composite Picture
      • Dimensions of Near-Death Experiences
      • Interpreting Near-Death Experiences
    • Death Themes in Dreams and Psychedelic Experiences
    • Beliefs About Death: A Wall or a Door?
    • Further Readings
  • CHAPTER 15 The Path Ahead: Personal and Social Choices
    • Exploring Death and Dying
    • Cultural Competence
    • New Directions in Thanatology
      • Gaining a Global Perspective
      • Bridging Research and Practice
    • Creating Compassionate Cities
    • Living with Death and Dying
      • Humanizing Death and Dying
      • Defining the Good Death
    • Death in the Future
    • Postscript and Farewell
    • Further Readings
  • Epilogue
  • Notes
  • Credits and Sources
  • Name Index
    • A
    • B
    • C
    • D
    • E
    • F
    • G
    • H
    • I
    • J
    • K
    • L
    • M
    • N
    • O
    • P
    • Q
    • R
    • S
    • T
    • U
    • V
    • W
    • X
    • Y
    • Z
  • Subject Index
    • A
    • B
    • C
    • D
    • E
    • F
    • G
    • H
    • I
    • J
    • K
    • L
    • M
    • N
    • O
    • P
    • Q
    • R
    • S
    • T
    • U
    • V
    • W
    • Y