CONTEXTUALIZING DEATH

Sonya Merrill, MD, PhD

Presbyterian Hospital of Dallas

September 7, 2005

OUTLINE

Death in the Context of:

Two ancient cultures Four major world religions Modern medicine Society The individual

Ancient CulturesEgypt

Mesopotamia

Ancient Egypt

ANCIENT EGYPT General Principles

Preoccupation with life and desire to “continue living” after death

Afterlife resembles an improved earthly life Continuing bodily existence:

mummification attempts to recover bodies fear of being eaten by animals

“Ideal” life span: 100 years

ANCIENT EGYPTThe Soul Ba: the soul which animates the body, represented

as a bird flying away at the time of death Akh: the spirit which survives death and which can

be good or evil, equipped with “spells” that are useful after death

Ka: represented by a person’s image or statue and thought to be a “protecting genius” after death

Suyt: a person’s shadow

ANCIENT EGYPTThe Body and its Preservation Mummification: removal of decay-prone viscera

enabling preservation of majority of body parts; process lasting 30-200 days

Step 1: Removal of entrails through left-sided thoracic incision and storage in canopic jars bearing images of the sons of the god, Horus Liver (human son, Imesty) Lungs (ape son, Hapy) Stomach (jackal son, Duamutef) Intestines (hawk son, Qebekhsenuef)

ANCIENT EGYPTCanopic Jars

ANCIENT EGYPTThe Body and Its Preservation Step 2: Removal of other organs

Heart: “seat of intelligence” so after removal, wrapped in linen and replaced/sewn into chest cavity

Brain: not always removed as not deemed very important; when removed, long hooked rods inserted into nostrils to snag tissue

Step 3: Application of natron (natural desiccant) Step 4: Complete drainage of all bodily fluids Step 5: Wrapping of body in yards of linen

ANCIENT EGYPTThe Body and Its Burial The Opening of the Mouth ceremony: eyes, ears, nostrils

and mouth touched to symbolize opening and person’s revival

Tombs: contained biographical information to preserve occupant’s name and reputation; varied according to importance of deceased

VIP burial arrangements: Old Kingdom—wooden coffin inside stone sarcophagus Middle Kingdom—human-shaped wooden coffin with mask over

mummy’s head inside stone sarcophagus New Kingdom—elaborately painted anthropoid nested coffins, e.g.,

Tutankhamun’s 3 nested coffins

ANCIENT EGYPTThe Body and Its Burial

ANCIENT EGYPTAfterlife: The Rough Guide How to get there: by boat, sailing on a day-night

journey with the Sun God navigate using basic spells from funerary texts left near the

body

ANCIENT EGYPTAfterlife: The Rough Guide Where to go when you arrive:

Field of Offerings: a land on the western horizon where the deceased work in fields and orchards to harvest offerings for Osiris

Paradise: where the deceased reaps the fruits of his own labor and enjoys a blissful existence

ANCIENT EGYPT Afterlife: The Rough Guide

What to pack: Deceased require basic provisions to survive in

the afterlife Initially, basic provisions (bread, beer, meat, wine,

linens) were placed in tombs Later, models of provisions were deposited to

guarantee that supplies would last forever

ANCIENT EGYPTAfterlife: The Rough Guide

Traveling companions: Models of servants

included for purpose of eternally producing necessary supplies

Ancient Mesopotamia

ANCIENT MESOPOTAMIAGeneral Principles Death is inevitable: “when the gods created

men, they set aside death for mankind and kept eternal life in their own hands”

The ideal death: surrounded by family and friends while lying on a special funerary bed with a chair on the left serving as a seat for the soul after its release from the body

ANCIENT MESOPOTAMIAGeneral Principles Euphemism: speaking of “death” summons it, so

instead: “to cross the Khubur,” “to go up to heaven,” “to go to one’s

fate,” “to be invited by one’s gods,” “to come to land on one’s mountain,” “to go on the road of one’s forefathers”

Gradual process: rather than instantaneous end to earthly existence Individual ancestor is dependent on his descendents’

offerings After several generations, ancestral spirits are collectivized Finally, individual is annihilated and recycled into a new

soul

ANCIENT MESOPOTAMIAThe Soul Etemmu: ghost associated with physical remains Napistu: life force or “breath of life” Zaqiqu: birdlike spirit able to fly and slip through

small spaces, associated with dreaming as it can leave the body during sleep

Etemmu and zaqiqu descend with the body to the netherworld at death; if the body is destroyed, etemmu is also destroyed, leaving behind only zaqiqu

ANCIENT MESOPOTAMIAThe Body and Its Burial Preparation: ceremonial washing, tying mouth shut,

perfuming, dressing in clean clothes

Public viewing: before the funeral

Burial: in the ground in a coffin, sarcophagus or tomb Elites were buried in vaults below their houses or palaces while

others were buried in public cemeteries

Last rites: burnt offering When a king died, his throne, table, weapon and scepter were

burned

ANCIENT MESOPOTAMIAFuneral Customs Mourning rituals lasting up to 7 days Family and close friends expected to participate; in the

case of royalty, the entire population must mourn Professional mourners sometimes employed Funeral laments express mourners’ grief and eulogize

the deceased Physical displays of grief: wearing plain clothes,

tearing clothes, wearing sackcloth, not bathing or grooming, fasting

ANCIENT MESOPOTAMIAAfterlife: The Rough Guide Where: underground Climate: dark, damp and dreary How to get there: cross demon-infested lands, cross Khubur

River with the aid of its guardian god, gain entry through 7 gates to the city of the netherworld with its gatekeeper’s permission

ANCIENT MESOPOTAMIAAfterlife: The Rough Guide

Your hosts: meet the royal couple, Nergal and Ereshkigal, and their courtiers who: welcome the dead instruct them in the local rules show them to their lodgings in the netherworld (size

and grandeur do not correlate with the deceased’s earthly behavior)

ANCIENT MESOPOTAMIA Afterlife: The Rough Guide How to pack: take as many personal items as you can afford

Travel provisions for the journey: food and sandals (or a chariot, if you were wealthy)

Things you might need when you arrive: food, weapons, toiletries, jewelry

Hostess gifts: to placate the netherworld gods such as Marduk

ANCIENT MESOPOTAMIA Objects from the Royal Tombs of Ur

ANCIENT MESOPOTAMIA Afterlife: The Rough Guide How to have a good time: your happiness after

death depends on the quality and quantity of offerings made by your survivors offerings must be made continually to ensure success

in the afterlife How to have an awful time: if your survivors

don’t make offerings, or if your death is violent or premature, your restless ghost wanders the earth attacking people

Four Major World Religions

JudaismChristianity

IslamHinduism

Judaism

JUDAISMOrigin of Death “God saw all that he had made, and it was very good”

Gen 1.31

The first humans, Adam and Eve, disobey God Gen 3

Death is introduced to the world as a consequence of human disobedience: “for dust you are and to dust you will return” Gen 3.19

Being bene Adam (sons of Adam) makes all future people subject to the penalty of death

Thus death is an inevitable and feared event

JUDAISMWhat happens when we die? Death occurs when rwh, divine life-giving force that

distinguishes living from dead, leaves body Body returns to dust and rwh returns to air or to God In ancient Judaism, no guarantee of life after death

for individual Jew

JUDAISMWhat happens after we die?

Sheol as metaphor for death: ghostly, subterranean land of dead inferior copy of life on earth not necessarily hell (i.e., a place of torment), but

certainly place to avoid for as long as possible as it entails permanent separation from God – even for righteous person

JUDAISMSheol “The days of my life are few enough: turn your eyes

away, leave me a little joy, before I go to the place of no return, the land of murk and deep shadow, where dimness and disorder hold sway, and light itself is like the dead of night.” Job 10.18-22

JUDAISMWhat happens after we die? The possibility of an afterlife

Hope for individual’s life after death was widespread by Rabbinic period as seen in Dead Sea Scrolls

In medieval times, Maimonides stated that one who doesn’t believe in resurrection of dead isn’t a true Jew

“O my God, the soul which you gave me is pure: you created it, you formed it, you breathed it into me, you preserve it within me; and you will take it from me. But you will restore it to me in the hereafter.” Authorized Daily Prayer Book p. 5

JUDAISMCare of the Dying

Presence at time of death/departure of soul Recitation of at least last part of Shema (Deut

6.4-5) at moment of death Shut eyes and mouth of deceased Place sheet over his/her face Position his/her feet facing doorway Do not leave deceased alone before burial

JUDAISMPreparing the Body Immediate preparation for burial to preserve human

sanctity Close family members should not be present during

preparations All deceased persons, rich or poor, wrapped in same

simple, white shroud reflecting belief that all people considered equal

Shrouded body wrapped in prayer shawl with one fringe cut off to symbolize mourning and loss

Cremation and embalming are forbidden

JUDAISMFuneral Rites Funeral lamentations in presence of deceased “Rending the garments”: mark of separation with tear

made over heart region to symbolize broken heart Recitation of Psalm 23 and other Psalms pertaining

to person’s life Eulogy praises deceased and expresses grief on

behalf of mourners and rest of community

JUDAISMBurial Rites Burial on day of death: “His body

shall not remain all night … you shall bury him on that day.” Deut 21:23

Simple wooden casket since wood decomposes at roughly same rate as body In Israel no caskets are used– body is

interred only in prayer shawl In ancient times, after body’s

decomposition, bones were preserved in ossuary

JUDAISMBurial Rites

JUDAISMBurial Rites Kaddish (Aramaic word meaning "holy" or

"sacred”): special prayer for deceased recited as dirt shoveled onto grave

Funeral guests must wash their hands after contact with dead (need for purification)

JUDAISMMourning Rituals

Shivah (“seven”): week-long period of mourning, placing aside everyday routine to focus attention on grief Sitting low as a symbol of "being brought low" in grief No "luxurious" bathing or cutting hair (no vanity) Wearing cloth slippers or sandals instead of shoes Covering mirrors (again, no vanity) No business transactions Holding memorial services in home both morning and evening

JUDAISMMourning Rituals

Sheloshim (“thirty”): second, less intense, period of mourning which includes Shivah plus 23 days; mourners return to "normal" routine and activities

Kaddish: repeated at Yahrzeit (first anniversary of death) and at other memorial services (Yizkor) four times yearly

Christianity

CHRISTIANITYOrigin of Death

Shared with Judaism (and later, Islam): “Original sin” of first

humans brought penalty of death not only to Adam and Eve but to all people

CHRISTIANITYThe most important death… Crucifixion of Jesus

common means of execution of criminals in Roman Empire

“…the soldiers took charge of Jesus. Carrying his own cross, he went out to the place of the Skull (which in Aramaic is called Golgotha). Here they crucified him….” John 19.16-18

CHRISTIANITY…because it ends all Death Resurrection of Jesus:

“…our Savior Jesus Christ ...destroyed death and has brought life and immortality…” 2 Tim 1.10

“Death is swallowed up in victory: O Death, where is thy sting? O grave, where is thy victory?” Hosea 13.14/1 Cor 15.54-55

CHRISTIANITYDoctrine of Resurrection

Formulated based on eye-witness accounts of Jesus’ death and resurrection as well as on his teachings

“For as by man came death, by a man has come also the resurrection of the dead. For as in Adam all die, so also in Christ shall all be made alive.” I Cor 15.21-22

CHRISTIANITYWhat happens after we die? Destination determined by individual’s acceptance or

rejection of salvific death and resurrection of Jesus Heaven

Eternal life for believer in “perfected” body Life in continual presence of God Absence of death, pain, grief, war, conflict Metaphors of “streets of gold”, etc.

Hell Separation from God Limited period (annihilationism) or eternal punishment Metaphors of “lakes of fire and brimstone”

CHRISTIANITYHow is death observed? During life: through Sacraments

Baptism: “we were buried with him [Christ] through baptism into death in order that, just as Christ was raised from the dead through the glory of the Father, we too may live a new life [on earth and in the afterlife].” Rom 6.4

Eucharist: “whenever you eat this bread and drink this cup, you proclaim the Lord’s death until he comes.” 1 Cor 11.26

CHRISTIANITYMoment of Death

Last rites: “into thy hands, Merciful Savior, we commend the soul of thy servant, now departed from the body … receive him into the arms of thy mercy…”The Book of Common Prayer

CHRISTIANITYPreparing the Body

Deceased’s body treated with great respect Care taken to prepare body for burial reflects

Christian belief in eternal life and bodily resurrection

CHRISTIANITYFuneral Rites In Roman Catholic Church (and others), friends and

family gather evening before main funeral liturgy to pray and keep watch with deceased’s family Prayers offered for deceased as well as those who have been

bereaved

Funeral mass: time to commend deceased to God's mercy and to take strength from Eucharist which celebrates the death and resurrection of Christ

CHRISTIANITYFuneral Rites

CHRISTIANITYBurial Rites

Traditionally, burial of body in grave or tomb (as Jesus was buried in tomb)

Cremation not forbidden in most branches of Christianity

Islam

ISLAMOrigin and Purpose of Death Origin of death: as in Judaism and Christianity

original sin of Adam and Eve, and its punishment: “In the earth you will live, and in it you will die …” Quran 7.24

Will of God: “It is not possible for a soul to die except with the permission of

God at a term set down on record.” Quran 3.139

Time of trial: Life is time of probation and decision: while alive, individuals

are free to direct their lives along straight path back to God (sirat ulMustaqim) or to reject God Quran 1.5

ISLAMWhat happens when we die?

Body and spirit: separated, then reunited Bashar: “flesh” or body Ruh: God’s “breath” or soul which animates bashar;

persists after death but exists apart from body until reunion on Day of Resurrection

Nafs: “spiritual vitality” linking body and soul; escapes at time of death (and also leaves body at night in sleep and returns in morning) Quran 6.60f

ISLAMWhat happens after we die? Angel of death gathers those due to die Quran 32.10/9-11

Body is buried and decays Soul escapes and may either be raised into interim

body or remain in suspended state Body and soul reunited on Day of Resurrection (yaum

ulQiyama): “…we will raise him up on the day of resurrection…”Quran 20.125

Appearance before God on Day of Judgment (yaum udDin)

ISLAMJudgment and Afterlife Day of Judgment: “on the Day of Resurrection we will

bring out a written record: each man will see it spread open” Quran 17.14

No one can “redeem” or “atone” for another’s misdeeds

Garden of Reward: for those who turn to God during life (eternal pleasure)

Fire of Jahannam: for those who reject God during life (eternal burning with fire)

ISLAMComforting the Dying When Muslim nears death, those around him remind

him of God's mercy and forgiveness by: Reciting verses from Quran Giving physical comfort Encouraging him to pray, particularly declaration of faith:

"I bear witness that there is no god but Allah"

Those with deceased encouraged to remain calm, pray for departed, and begin preparations for burial

ISLAMPreparing the Body Close deceased’s eyes Wash body with clean and scented water, in manner similar to

ablutions for prayer Wrap body in sheets of clean, white cloth (kafan)

ISLAMPreparing the Body

Burial within 8 hours if possible No embalming or other disturbance of body Autopsy may be performed, if necessary, but

done with utmost respect for dead

ISLAMFuneral Rites

Funeral prayers commonly held outdoors, in courtyard or public square, not inside mosque

ISLAMFuneral Rites Community gathers and

imam stands in front of deceased, facing away from worshippers

Prayers over dead (four takbirs: proclamations of God’s greatness)

Recitation of whole Quran if possible

ISLAMFuneral Rites

Mourning should not be excessive: this disturbs dead and shows lack of acceptance of God’s will/purpose regarding death: When Muhammad's own son died, he said: "The

eyes shed tears and the heart is grieved, but we will not say anything except which pleases our Lord."

ISLAMFuneral Rites Only men of community accompany body to grave

site Cemetery set aside for Muslims is preferred

ISLAMBurial Rites Body is laid in grave (without coffin if permitted by

local law) on right side, facing Mecca Tombstones, elaborate markers, flowers and other

mementos are discouraged

ISLAMMourning Period Family and friends observe 3-day mourning period

Increased devotion, receiving visitors and condolences, and avoiding decorative clothing and jewelry

Widows observe extended mourning period (iddah) of 4 months and 10 days Qur'an 2:234

Widows must not remarry, move from their homes, or wear decorative clothing or jewelry

Hinduism

HINDUISMTraversing a Continuum

“Hinduism is the map of how to live appropriately … in order to move towards (and perhaps attain) the goal”

J Bowker, The Meanings of Death. Cambridge: CUP, p. 131

HINDUISMEternal Soul

Soul does not die with body: “Those who are truly wise do not mourn for the dead

any more than they do for the living. … Just as embodied selves pass through childhood, youth and old age in their bodies, so too there is a passing [at death] to another body.” Bhagavad Gita 2.12

HINDUISMGoal: Free the Self Brahman/Nirvana: freed self has attained state of

wisdom regarding soul’s eternality Freedom achieved by renouncing all desires:

absence of preoccupation with bodily selfGita 2.71f

State of power experienced both in life and after death

State of happiness and peace from being eternally with Krishna

HINDUISMCycle of Death and Rebirth Self is unchanged yet reborn repeatedly until it finds it

way to liberation with guidance from Gita and other scriptures Samsara: cycle of rebirth which continues until

brahman/nirvana is reached Karma: actions and consequences; bad karma can only be

overcome by achieving moksha (release that comes when one realizes that one cannot influence karma)

Kashi: dying in right city provides shortcut to moksha…

HINDUISMInsignificance of Death During samsara, death occurs many times and

is thus of little importance One death is merely a stage, a milestone, in a

long process Continuing self has already passed on when

“person” dies (or is cremated) if one is good, soul leaves through brahmarandhra

(small opening in crown of head) but if one is evil, it leaves through anus

HINDUISMAfterlife Preta: intermediate condition of soul

immediately after death Judgment and afterlife:

Early literature: domain of Yama, ruler of ancestors (place where families reunited and pain and sorrow of

this life removed) Later and post-Vedic literature: vivid descriptions of

hell-like places of torture and punishment (narakas), where the punishment fits the crime

HINDUISMMoment of Death

Meditation on God at time of death: soul can influence its next form aided by namakirtana, or chanting god’s name

until one ceases to be aware of anything else Preferable to die at home Candle is lit by deceased’s head

HINDUISMPreparing the Body Body is placed at house

entrance with head facing south

Body is bathed, anointed with sandalwood and wrapped in cloth

Elaborate funeral processions

HINDUISMFuneral Rites Cremation is ideal method for dealing with dead

(although holy men, Untouchables and infants are buried): Releases soul of: “the eye to the sun, the breath (atman) to

the wind, the body to the plants” Rig Veda 10.16.3

Controls pollution created by death Allows family to be brought back into society because

death causes separation Preferably takes place on day of death

HINDUISMFuneral Rites

HINDUISMFuneral Rites Closest relative of

deceased (usually eldest son) lights funeral pyre by accepting flaming kusha twigs from Doms (Untouchable Hindu caste responsible for tending funeral pyres)

HINDUISMFuneral Rites Body is an offering to

Agni, god of fire After cremation, ashes and

bone fragments are collected and immersed in holy river, e.g., Ganges

After funeral, mourners undergo purifying bath

HINDUISMMourning Rituals Immediate family remains

in state of intense pollution for set number of days

Then close family members meet for ceremonial meal and often give gifts to the poor or to charities

Rice balls (pinda) offered to dead person’s spirit during memorial services

HINDUISMMourning Rituals Contribute to deceased’s merit and pacify his soul so

it will not linger ghost-like in world but pass through realm of Yama, god of death: Ekoddista: ritual to render benign a deceased individual’s

preta Sraddha: 16-stage ritual taking up to a year and including

not only one deceased individual but also up to 4 generations of ancestors

Modern MedicineHow Doctors took the Place of Priests

at the Deathbed

The Medicalization of Death In ancient times, doctor’s presence at deathbed was

rare: this was priest’s role When involved at all, doctor’s role was merely to

predict time of death –so priest could do his job

C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 76-78

The Medicalization of Death After the Enlightenment, dying under medical care became a

“status symbol” as medicine was finally empowered to “do battle” with death Dissection enabled improved understanding of pathophysiology Diseases were described and categorized New vision of “natural death” was available: death at end of long life

due to clinically identifiable illness Death could even be prevented (or at least delayed) by understanding

disease

C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 76-78.

Religion, Medicine and Death

“… modern rationality, of which medicine is an example, is itself a religious orientation, providing an imagined community, rites of inclusion and membership, and guidance for a meaningful death.”

Seale. Constructing Death. Cambridge: CUP, 1998, pp. 75-76.

Cradle to Grave

Death as Biological Imperative Cells are preprogrammed to apoptose after

certain number of divisions DNA errors accumulate over time with

continued environmental exposures Cumulative effects of cell death impair organ

functions needed to sustain life Teleologically, death may be adaptive at

population level: people don’t compete with their offspring for scarce resources

Searle. Constructing Death. Cambridge: CUP, 1998, pp. 35-36

DEFINITIONS OF DEATHCardiopulmonary Death Previously easily diagnosed by irreversible cessation of

respiration and circulation which necessarily led to death of all organs

After advent of ventilators, death no longer equated with absence of circulation and respiration since machines could sustain these functions

Use of this definition would jeopardize organ harvesting for transplants due to organ deterioration during period immediately after cessation of respiration and circulation

Currently accepted in USA as one of two valid definitions

A Scholthauer and B Liang, “Definitions and implications of death.” Hematology/oncology Clinics of North America 16:6 (2002)

DEFINITIONS OF DEATHWhole-Brain Death

1968: Harvard Medical School committee defines death as irreversible coma: “a state of unreceptivity and unresponsivity, with no movement, breathing, or reflexes, accompanied by a flat EEG”

1970: Kansas legally recognizes “the absence of spontaneous brain function” as equivalent to cardiopulmonary death

1980: Uniform Determination of Death Act declares that “an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead”

DEFINITIONS OF DEATHWhole-Brain Death

By this definition, healthy organs can be harvested as artificial circulation and respiration are maintained

USA, Germany, Japan, and France all accept this definition of death

DEFINITIONS OF DEATHHigher-Brain Death

Applicable to PVS patients: those without cortical function responsible for emotion, cognition and awareness but who maintain at least partial brain stem function

Courts have been reluctant to adopt this definition because absence of higher, cortical brain activity is harder to prove with certainty, at least in short term

However, some courts have allowed “life”-sustaining treatment of PVS patients to be discontinued (e.g., Quinlan, Cruzan, Schiavo)

Modern Medical Death Rites Life insurance: manages consequences of one’s death Wills: disposition of one’s possessions after death Death certificates: enshrine in law “cause of death” Autopsies: identify cause of death if not obvious Inquests: identify cause of death if suspected to be

“unnatural” Burial (+/- embalming) OR cremation and interment of

ashes: confines deceased to known “resting place” also serving as memorial

Death in Society: Doctors and Patients

Nationality

Ethnicity

Class

DOCTORSDifferences in End-of-Life Care

Death in ICU preceded by decision to limit care: Belgium: 65% Canada: 70% USA: 75% Israel: 91%

J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine 29:2 (2001)

DOCTORSDifferences in End-of-Life Care Decisions to withhold versus withdraw care—survey

of western European physicians 93% sometimes withheld treatment 77% sometimes withdrew treatment Physicians with strong religious beliefs (and those

from countries with deeper religious roots such as Greece, Italy and Portugal) less likely to withdraw life support

J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine 29:2 (2001)

DOCTORSDifferences in End-of-Life Care Withdrawal of nutrition considered acceptable in

PVS patients in: USA: 89% Britain: 65% Belgium: 56% Japan: 17%

J-L Vincent, “Cultural differences in end-of-life care.” Critical Care Medicine 29:2 (2001)

PATIENTSDifferences in End-of-Life Decisions Ethnicity:

Patients in cultures that are more individualistic, secular, pragmatic, scientific tend to prefer full open awareness—as opposed to cultures which are familial, sacred, traditional, emotional

In favor of closed awareness: Mexican, Japanese In favor of full open awareness: Anglos

Most interested in carrying out wishes of dying: Japanese Most wills and life insurance: AnglosC Seale. Constructing Death. Cambridge: CUP, 1998, pp. 179-181

PATIENTSDifferences in End-of-Life Decisions

Ethnicity: In USA, whites significantly more likely than blacks—

to discuss treatment preferences before death to complete living wills to designate Durable Medical Power of Attorney to limit care in certain situations and withhold

treatment before death

S Hopp and S Duffy, “Racial variations in end-of-life care.” Journal of the American Geriatrics Society 48:6 (2000)

PATIENTSDifferences in End-of-Life Decisions Class:

Persons of higher socioeconomic class are 2.7 times more likely to desire full open awareness of terminal diagnosis

C Seale. Constructing Death. Cambridge: CUP, 1998, p. 179

The Individual“My Death”

Images of Death

“I Will Die” What is required to

grasp this notion: “I will die”

How can I use what I know about life to construct an understanding of its negation, death?

Self-awareness Logical thought Conceptions of:

Probability Necessity Causation Time Finality Separation

R Kastenbaum. The Psychology of Death. New York: Springer, 2000, pp. 30-35

Death and Psychological Development

Developmental Stage 1: Up to age 5 – Death is not final– Death is diminution of aliveness– Death involves separation

Nagy, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, 51-53

Death and Psychological Development

Developmental Stage 2: Ages 5-9– Death is final– Death is not inevitable – if one is clever and

lucky– Death personification – death as separate

person

Nagy, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, 51-53

Death and Psychological Development

Developmental Stage 3: Over age 10 – Death is final– Death is inevitable– Death is universal

Nagy, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, 51-53

Stages of Dying

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

E Kubler-Ross, in R Kastenbaum. The Psychology of Death. New York: Springer, 2000, 216-217

Getting the Timing Right “The material end of the

body is only roughly congruent with the end of the social self. In extreme old age, or in disease, when mind and personality disintegrate, social death may precede biological death. Ghosts, memories and ancestor worship are examples of the opposite: a social presence outlasting the body.”

Euthanasia: social death is pre-empted by actively hastening biological death

Hospice: social death is pushed back as far as possible until biological death occurs

C Seale. Constructing Death. Cambridge: CUP, 1998, pp. 34, 184

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