Sociology Of Death And Dying Research Paper

1. The Broken Connection

Traditional societies are characterized by widely shared and explicit norms of social behavior, in general, and of mortuary ritual, in particular. People knew how to behave when faced with death and dying. In many modern societies, individuals no longer have such clear social rules to guide their behavior. They often feel confused or uneasy in these circumstances. Although the roots of this change are complex, it appears related to a fundamental change in the traditional nature of society as composed of both the living and the dead. ‘If the structure of African cultures is that of a dialogue (between the living and the dead), then the structure of Western society is that of a monologue—but the monologue of the dead’ (Bastide 1968, p. 104). Lifton (1978) proposed the term ‘the broken connection’ to describe how the link between the living and the dead has been severed in contemporary society. Conceptually, the issue can be put in terms of a question: Where are the dead? ‘In the West, post-death conceptions typically involve the integrity and continuity of one’s personal self. In the East, the ultimate goal is often an undifferentiated and impersonal oneness with the universe’ (Kearl 1989, p. 27). The literal and symbolic responses to this question, therefore, continue to provide key insights into the deep structure of society.

2. Impact Of Recent Social Trends

Since the mid-twentieth century, there have been a series of dramatic changes in how death and terminal illness are perceived in the West. These changes reflect recent social trends such as secularization, medicalization, and more recently, death awareness.

2.1 Secularization

From a religious perspective, dying was the ‘defining moment’ in a person’s life (Seale 1998). Typically, a religious authority would assist at this feared rite of passage to the ‘next world.’ With the decline of religious belief, in general, and fear of damnation, in particular, death lost much of its sacred or theological importance. Instead death became a time of separation from loved ones at the ending of a human life (Kearl 1989) while dying increasingly became a private act. The shift from religious to secular is illustrated by changes in the image of a ‘good death.’ Modern secularists wished for an ‘unconscious death,’ a pain-less sudden demise during sleep, which in the Age of Belief was considered an ‘accursed death’ since it left no opportunity for the deceased to prepare to meet his or her Maker (Aries 1974). Gorer (1965), in a widely cited monograph, argued that death had replaced sex as the modern form of pornography, an embarrassing taboo topic. Becker (1974) claimed that although fear of death was universal, modern society was characterized by the pathological ‘denial of death.’

Secularism also contributed to the rise of lay professionals as part of a funeral industry, especially in the USA, which exploited the denial of death. The resulting commercialism contributed to enormous and seemingly unnecessary costs which was brought to international attention by the popular critique, The American Way of Death (Mitford 1963).

2.2 Medicalization

As the majority of people began to die in hospitals, death and dying gradually came under medical control. The resulting impersonal bureaucratic care led to their physical and emotional isolation, characterized by ‘the loneliness of the dying’ (Elias 1985). The dramatic rise of life support technology, moreover, created situations in which a person was neither fully alive nor completely dead. As a result, medicalized death lost its status as a defining moment, but became instead an arbitrary time when the machines were finally turned off. ‘Death in the hospital is no longer the occasion of a ritual ceremony, over which the dying person presides amidst his assembled relatives and friends. Death is a technical phenomenon obtained by the cessation of care’ (Aries 1974, p. 88). This situation also created a need for new definitions of death, the most widely accepted being that of brain death or, more controversially, the demise of the cerebral cortex, associated with the irreversible loss of personhood. Brain death, which opened up the possibility for the transplantation of organs, was widely accepted in the West but remained highly controversial in Japan (Seale 1998).

2.3 Death Awareness

The denial of death ultimately led to ‘the revival of death’ ( Walter 1994) in the form of a movement for death awareness. As an ideology, it argued forcefully for openness and a life-affirming attitude in the face of death. As a social movement, it led to creation of new institutions for caring for the dying and their families. It is significant that the two best known and charismatic figures of the movement were women: Elizabeth Kubler-Ross, an Austrian-born psychiatrist who worked in a large county hospital in Chicago, and Cicely Saunders, a social worker, nurse, and com-mitted Christian who retrained as a physician in order to be ‘taken seriously’ (Cline 1996). Although both were physicians, they sought to demedicalize dying by reasserting the ‘feminine values’ of mutuality, equality, and the ‘affirmation of love through intimate talk’ (Seale 1998, p. 176). ‘Coming to terms with my own death or with bereavement is increasingly seen as an inner psychological process in which others are marginal, except to provide ‘‘support’’ for me as I go through a ‘‘natural’’ process’ ( Walter 1994, p. 189). This psychologization of death and dying often means that those who accompany the dying and bereaved are caring professionals and members of self-help groups who have undergone similar losses and function in place of the traditional community.

3. Sociology Of The Dying

A landmark in the sociological study of dying patients was the work of Glaser and Strauss (1965, 1968) who developed two frameworks for analyzing the inter-action between the dying person and the medical staff: contexts of awareness and dying trajectories. ‘Contexts of awareness’ referred to the degree of shared knowledge between patient and doctor concerning the fatal prognosis which ranged from ‘closed,’ if only the doctor knew, through intermediate stages (‘suspicious,’ ‘mutual pretense’) to ‘open’ when both parties could freely discuss the terminal illness. At the time of the original study, closed awareness was the norm, and it remains common in certain countries like Japan or Italy ( Walter 1994, Seale 1998).

3.1 Dying Trajectories

Dying trajectories are ‘perceived courses of dying rather than the actual courses’ (Glaser and Strauss

1968, p. 6). The trajectories were based on the ‘time for dying’ (Glaser and Strauss 1968) as expressed in a pair of dichotomies: expected unexpected, sudden linger-ing. There were four basic dying trajectories: sudden unexpected, most commonly seen in the Emergency Room; sudden expected, common in intensive care units; lingering unexpected as in the uncertain course of an AIDS patient; lingering expected, as in the final stages of cancer. Each hospital ward was thus geared to a specific dying trajectory and used specific strategies to maintain its routine or ‘sentimental order.’ Medical personnel and family members experienced most distress when an actual trajectory deviated from its predicted course. Glaser and Strauss’s work contributed to changes in the training of doctors and nurses. The social history of death and dying (Aries 1974) provided an important comparative critical perspective of contemporary ‘invisible death’ and one more voice calling for a return to ‘death with dignity.’

4. Hospices

Death in traditional society was often characterized by sudden unexpected dying trajectories, as is still common in the Third World. In modern societies, the lingering death of the elderly from chronic diseases became the norm. Their death was less disruptive since they had undergone a ‘social death’ in which they were disengaged from their previous social roles and obligations. At the same time, hospitals with their ‘fiction of probable recovery’ (Glaser and Strauss 1965, 1968) were increasingly criticized as inappropriate places for the care of the dying (Kubler-Ross 1969, Walter 1994).

The first hospice, an institution for the special needs of the dying and their families, was founded by Cicely Saunders in 1967 (Cline 1996). Its name deliberately recalled ‘a much older medieval tradition when hospices were wayside places of rest and refuge for pilgrims’ (Seale 1998, p. 113). The dying were thus implicitly considered individuals on a spiritual quest. The hospice ideology was holistic, providing physical, emotional, social, and spiritual care; egalitarian, with expertise based on knowledge and skills rather than status or formal qualifications; and conceived of the entire family, not merely the patient, as the ‘unit of care.’ It had a strong sense of mission and charismatic leadership. This ideology differed radically from the specialized, hierarchical, disease orientation of the ‘medical model,’ in which death was often experienced by the physician as a personal or technological failure. Instead the dying were encouraged to undergo a psychological and spiritual journey toward final re-conciliation (Kubler-Ross 1969) and personal authenticity (Becker 1973). The ‘home care’ option allowed some individuals to die at home. ‘A major reward for those dying an aware death was that of emotional accompaniment involving the affirmation of a secure social bond … If I hadn’t known, how could I have helped him …’ (Seale 1998, pp. 175–6).

The hospice as an institution has undergone phenomenal growth in its first 30 years to number over 5,000 worldwide at the end of the twentieth century (Seale 1998, p. 114). With growth has come a predictable trend away from charismatic leadership toward greater routinization, professionalization, and ‘managed death’ (Seale 1998). Hospice and palliative care will remain important for future investigation.

5. Stages Of Dying

Based on interviews with cancer patients, Elizabeth Kubler-Ross devised an influential schema of five stages to describe the emotional response of terminal patients: denial (‘Not me!’), anger (‘Why me!’), bargaining (trading a pious deed for more time), depression (mourning the lost opportunities) and final reconciliation (a peaceful, if not happy, ‘OK, it is me’). Kubler-Ross did state that not everyone goes through all five stages nor necessarily in this order, but rather the process of dying is highly individualistic. Nevertheless, these stages did represent a breakthrough at the time for conceptualizing the ideal emotional journey of the dying. Parkes (1986) devised a similar set of stages for the grief process: numbness, pining, disorganization, despair, and finally, reorganization and recovery. From a sociological perspective, the communal aspects of dying are notably absent from these stage theories. Rather, they reflect the social shift to individualism. Each dying person is encouraged to embody the ‘Sinatra syndrome’ ( Walter 1994) and be able to say, in words of his well-known song, ‘I did it my way.’ The emphasis on ‘the discourse of therapy’ in place of shared ritual makes the dying person in a sense ‘the chief mourner’ (Seale 1998). Despite methodological and other criticisms, these stage theories remain highly influential.

6. Euthanasia

Euthanasia derives from the Greek, meaning literally ‘good death’ but in practice refers to right of a dying person to commit suicide alone or with the help of a physician. Hospice ideology supports ‘passive euthanasia,’ the withholding of treatment which may result in death but firmly rejects ‘active euthanasia,’ any-active measures designed to end life, which is legal only in The Netherlands. Proponents of active euthanasia place great emphasis on autonomy and the senselessness of pain and suffering. In a broader sense, they desire to ‘preserve an intact narrative of self- identity up to the point of death’ (Seale 1998, p. 8). Opponents of euthanasia usually believe that the sanctity of life places limits on individual choice and fear coercive use by family members or unethical authorities as occurred in Nazi Germany. The right to die will remain an important topic for future research and public debate.

7. Sociology Of The Dead: Funerals—Ritual Uniformity

In contrast to the widespread interest in the dying, much less attention has been given to the sociology of the dead. Despite the social changes noted above, funeral rituals themselves have remained largely un-changed ( Walter 1994). This certainly appears true in the USA where, despite the tremendous hetrogeneity in terms of religion, ethnicity, and social class, the basic structure of funerals remain remarkably uniform: rapid removal of the corpse to the funeral parlor, embalming (which many individuals believe, incorrectly, is required by law), institutionalized viewing of the cosmetically restored corpse, and disposal by burial, with a reliance upon professional or religious experts (Kearl 1989). Likewise in the UK, where a majority of the dead are cremated, atheists, Christians, and Hindus undergo similar treatment in crematoria (although Hindus are likely to stay to watch the burning body). Except for the practice of dispersing ashes in places of personal significance, only a tiny minority perform alternative ‘do it yourself’ ceremonies ( Walter 1994).

8. AIDS And The Imagined Community Of Mourners

The AIDS epidemic has refocused interest on ‘the way we die’ (Nuland 1994) and the social meaning of such deaths (Ariss 1997). The shared fate of HIV infection has consolidated a local sense of community and at times a larger global one. One of the most poignant exemplars of such a community of living and the dead is the ‘AIDS Memorial Quilt,’ begun in 1987 by gays and their friends to commemorate the lives of individuals who died of AIDS. By 1992, the Quilt had more than 20,000 memorial panels. ‘The quilt … shows how death of the most fearful kind can draw people together’ ( Walter 1994, pp. 194–5). Likewise the dramatic sudden death of high profile individuals (e.g., President Kennedy, Princess Diana) may temporarily recreate the solidarity of an ‘imagined community’ of mourners who vicariously participate in traditional ceremonies via television and the Internet. This analysis recalls the seminal work of the great French sociologist, Emile Durkheim (1995) who showed how mourning ritual reinforced the cohesiveness and core values of the social group. While the Internet is becoming an important focus of investigation, many traditional sociological topics (gender, ethnicity, social class) remain relatively neglected (Cline 1996).

A central task for the sociologist is to explore the dialectic of how death can threaten the basis of society or, alternatively, enhance its solidarity.

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