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The future of death: Death in the hands of science
The Future of Death: Death in the Hands of Science Leslie M. Thompson,
PhD
HISTORICAL VIEWS
Medical technology plays a major role in definitions of and attitudes about death, but medical science alone cannot solve the mysteries of or the dilemmas accompanying dying and death.
To the primitive mind death resulted from external powers, from demons or evil spirits within, or from some other force that had face or form and even some vestige of personality, if not humanity, about it. The body became a battleground in which powerful forces contended, usually with the fate of the soul or spirit at stake. One might, it was thought, appease or exorcise the evil process over which we had little conspirit or even use spiritual or other edical science has dramatically increased the life ex· trol-today compels us to confront a powers to overwhelm the unruly prespectancy and significantly enhanced growing range of ethical, political, med- ences leading to death. the quality of life for most people. Sci- ical' and other dilemmas. Thanks to Although death inevitably trience has helped minimize the average improved hygiene, better diets, mira- umphed, a certain personal element person's personal encounters with cle drugs, sophisticated intervention nevertheless pervaded the whole pro' death. Still, fears of death grip human- techniques, and a welter of additional cess. Benign spirits frequently aided ity. In fact, the institutionalization of advances, we now live longer, have medical practice, the increasing legis- better health in general, and can lative mandates, the underlying para- even -to paraphrase WordsworthThe once simple act digms and metaphors of modern sci- have intimations of immortality. Yet, ence, and the fragmentation and spe- for all this, we still stand in ignorance of dying today cialization of industrial society have in and awe before the unknown finality compels us to many ways depersonalized the process of death. confront growing If many people now view death as a of dying, while engendering growing new fears of death. This article briefly matter of biologic necessity, as opposed range of ethical, reviews historical attitudes toward to divine retribution, most people still political, medical, .death and then emphasizes significant consider death a problem. This proband other trends that influence nurses and other lem has many facets, not the least of dilemmas. medical professionals who interact which is that death intrudes as an unwelcome visitor into our self-perceived with dying patients. Our attitudes toward death have un- inalienable rights to long life, the purdergone dramatic change in this cen- suit of happiness, and the gratification tury, but despite miraculous medical of each and every hedonistic or narcis- weak humanity, the evil spirits often advances and increasing prognostica- sistic whim or desire that flits through succumbed to blandishments, threats, tions of death's demise, we have no as- our minds. This problem, moreover, rituals, or exorcisms. In the Western surance that death will ever cease to be has not been solved by the advances of tradition even the Devil demonstrated our constant companion through life. medical technology. We no sooner a geniune - albeit invidious- personal The once simple matter of dying-a eliminate or minimize a disease-po- interest in the soul or spirit of each lio, for instance-when an apparently person. Thus, each life had, even if in new one like AIDS arises to shatter negative and fearful terms, a value and NURS OUTLOOK 1994;42:175-80. the sense of security engendered by a sense of importance associated with Copyright" 1994 by Mosby-Year Book, Inc. 0029-6554/94/$3.00 + 0 35/1/51319 science. it. These reasons alone impelled the
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masses of people to reject early materialistic views of death. Without the tools of modern technology, few people had the audacity, much less the desire, to employ human creativity and ingenuity to "fix" the problem of death. We have discovered, however, that the battle with death suited the spiritual better than the material world. CONTEMPORARY VIEWS The body, not the soul, is the focal pointof the current battle againstdeath. Our society places little stock in demons, evil spirits, or other previously recognized agents of death. In addition, few people give more than lip service to the rituals, myths, symbols, and images that in earlier societies propped up the spirit, explained the mysterious workings of nature (including life and death), and spoke to the human spirit about life's unfathomable mysteries. Naked spirits cowering before a vast and growing cosmos and an impersonal
For all our
edvences, we still stand in ignorance and awe before the unknown finality of death.
and indifferent world are ill equipped to deal with a hedonistic, secular world that diminishes spiritual values and reveres the human body incarnate. If the body incarnates the temple of human existence, it becomes important to gratify every physical desire or urge. Of course, this view of the body intensifies the problem about death. Now,however, we confront death with an arsenal of new weapons of humanity's own devising, and we place our confidence in trained, certified technicians, rather than shamans or witch doctors, to lead in the battle against death. As has been the case historically, we 176
Thompson
still contend with equally lethal enemies, but they have different names, and the battle takes place in a dramatically different setting. There is nothing personal about this confrontation. In lieu of a small, personal cosmos teeming with living spirits and appropriately stocked with consoling symbols and human-centered rituals and ceremonies, we now wage the battle in a huge, seemingly indifferent cosmos. Instead of the family and even the community as a whole uniting to fight invisible harbingers of death, we now equip highly trained microbe hunters, virus annihilators, organ transplant technicians, and other specialists with weapons of human ingenuity, and we commission, even command, these leaders to wage battle against death. Each new weapon resulting from medical technology brings new hope, but death is resilient. Just as victory over death seems imminent, or at least possible in the foreseeable future, death makes its counterattack. With victories over most communicable diseases and with significant progressunderway in the battles against cancer, heart disease, and other major killers, we find ourselves physiologically and psychologically shocked by AIDS. AIDS has not only attacked the human body and engendered a national and international epidemic of fear, but it has shaken the collective psyche as well. AIDS is both a physiologic and symbolic disease that has exposed serious weaknesses in the battle to solve the problem of death. A careful look at the dynamics of AIDS provides some insights into the future of death. AIDS AS A PARADIGM FOR FIGHTING DISEASES The rapid development of resources to study AIDS, the quick unraveling of its causes, and the promising new leads toward a possible vaccine all demonstrate modern science's achievements and promise. This processlikewise underscores the extent to which the current battle with death focuses on the body and on technical solutions to the
problems of death. More important, the attack on AIDS calls attention to the dearth of life-supporting, integrative symbols to support the healing, nurturing, or dying process. This scientific battle against AIDS also demonstrates the loss of community in contemporary society and the lack of support systems to ease most of life's
Few people today give more than lip service to the rituals, myths, symbols, and images that once spoke to the human spirit about life's unfathomable mysteries.
traumas from birth, adolescence, and marriage to divorce, dying, and death. Attention to the body as a thing unto itself to be repaired, sustained, junked, destroyed, or, perhaps, eventually to be resuscitated leaves little room to nurture the spirit or even to explore the intricate relationships between body and mind. In this respect, we must note the symbolic aspects of AIDS, a disease that attacks the body's own defense mechanisms. AIDSappears to be a cruel trick of nature to demonstrate that the body's long evolutionary defense mechanisms stand impotent, like the Maginot Line. Even more invidiously, the AIDS virus utilizes the body's defense mechanisms for its own perpetuation. Our attempts to deal with AIDS underscore Lifton and Olson's assertion that traditional systems of symbols through which humanity comprehended the world no longer provide spiritual solace or channels for life.' In today's reductionistic milieu, viruses, retroviruses, germs, bacteria, militant cells, and other intricate workings of nature lack the per-
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sonality and symbolic power of evil spirits. Since most of our new symbols in the fight against death stem from a scientific base, the whole endeavor becomes a mechanical enterprise to sustain the body. Failure becomes a personal affront to the specialists involved; human emotions and fears become intrusive elements to be eliminated, and science becomes the safeguard against the unknown. The symbolism, therefore, is impersonal, secular, and fraught with apprehension. AIDS engenders special fears because it adumbrates the possibility that perhaps other, as yet unknown, maybe inconceivable, forms of death loom ahead. Is it possible, people ask, that nature may confound science by perpetuating ad infinitum a series of deadly battles within the human body?
itself. In fact, she observes that in contemporary society! disease equals death.s These insights obviously apply equally to AIDS. What this analysis does not indicate, however, is the efficacy of the new symbolism in addressing the needs of the human spirit. The symbolism, rituals, and metaphors about AIDS, like those associated
people would seriously consider going back to the "good old days,{( People now suffer less physically while dying, they lead lives of higher quality; they live longer; they have more meaningful options; and they can reasonably expect all of these trends to continue. Unfortunately, the difficulties associated with death will also proliferate and intensify, The boundaries between life and death will continue to shift, with all Viruses, the accompanying moral, ethical, and retroviruses, germs, political ramifications. Increased use of manufactured and cultivated bodily bacteria, and parts, genetic engineering, possible militant cells lack brain transplants, in vitro conception, the personality and incubation and birth, and yetsymbolic power of un thought-of advancesin medical technology will continue to shatter tradievil spirits. tional concepts of personhood, fatherhood and motherhood, birth, life, and death. The allocation of health care rewith other contemporary human ac- sources will influence the process of NEED FOR RITUAL, SYMBOL, tivities.Iack compelling links with the living and dying for massive numbers MYTH A symbolic look at AIDS and the bat- spiritual domain. Rather than helping of people. Ethical and legal decisions tle against death also demonstrates that usher the human spirit through life's concerning abortion, euthanasia, and we still need ritual, symbol, and myth traumas and linking the individual life suicide will continue to plague the colto confront life's traumas. For example, with the community, and even the lective psyche, becausethere is little to we discuss AIDS through the use of living cosmos, the new symbolism be- indicate that contemporary or future highly metaphoric, frequently milita- speaks of society's fragmentation, re- practice of medicine will fix the probristic language. We enact rituals of at- ductionistic tendencies, and secular- lem of death. Death is a personal process. Even tack on the disease itself with scientists ism. This symbolism emphasizes disand technicians as both tacticians and connection, rather than connection, when afforded the maximum level of the prophets of hope, we place great and destruction, rather than creation. support, the dying person slowly or psychological and symbolic stock in Symbols, of course, evolve from and rapidly faces diminished possibilities, sophisticated apparatus, and in concert represent massive social forces and hu- systematic loss of connection with with the staffs of hospitals and other man fears and anxieties, as well as as- friends, loved ones, and the daily rituinstitutions, we join in routines of effi- pirations and hopes. AIDS and the gen- als of life; and ultimately a face-to-face ciency to exorcise and destroy aberrant eral reaction to it have demonstrated confrontation with the unknown, On a cells, to repair or replace defective that in our battle with death, we asa physiological level, science can ease parts, to alter genetic ally various bodily society have come to hold a limited this process; but so far at least, effiprocesses, and in general to keep the view of human life and human poten- ciency, sterile professionalism, scienbody functioning. These activities do tial. Despite our reliance on science, we tific paraphernalia, and technical apnot constitute a moral drama with have not yet been able to use comput- proaches have not sufficed to replace souls hanging in the balance, but a ers and other scientific equipment to old-fashioned virtues such as touch, desperate attempt to salvage bodies and create new symbols for us, and we love, concern, compassion,and human promote general human happiness. In have mounting evidence that we can- companionship. These attributes, it short, both the symbolic and realistic not continue to place unlimited faith seems, do not rest easily in the modern aspects of AIDS merely underscore and in technical solutions to human medical milieu, and it seems unlikely that this situation will soon change. reinforce Sontag's observations about problems. Dying is a lonely, singular activity, the metaphoric nature of most diseases. inextricably interwoven with the qualSontag, for example, refers to cancer as THE FUTURE OF DEATH a demonic pregnancy, a disease like TB This assertion brings us back to the ity of living. People living improverwhich became identified with death problem of death and its future. Few ished spiritual, social,intellectual lives NURSING OUTLOOK
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lack the resources for a meaningful experience with dying. In addition, the circumstances and location of dying exacerbate well-entrenched and intensifying societal tendencies inimical to spiritual growth and creativity. The very professionals in attendance during the dying process are conditioned by reductionistic training, which militates against empathy, personal interaction, and extensive personal involvement with patients or clients. In short, the dying processintensifies those personal and societal tendencies that have accompanied people throughout their lives,
for touching, compassion, or communication. In addition, both literal battles and battles against death have become increasingly impersonal. One option might be to alter the nature of the battle against death. While striving strenuously to perpetuate bodily existence, we might also recognize the need to approach this affair in a holistic manner bringing to bear psychological, physiological, and spiritual considerations upon the patient, the family, and friends. In addition, we might investigate approaches to dying that would encourage the reintegration of death into the life cycle. Even with genetic engineering and The Quality of the Dying psychic conditioning of various kinds, Process If we do not conquer death by elimi- it seems unlikely that, in the near funating it, is there a value to living for ture at least, we will ever see death as hundreds of years or forever? Who less than the enemy to be destroyed. would want to live forever, and why? This imagery derives from deep inner As we find ourselves impelled into this resources in our psyche thadear death's brave new world of death, we confront potential to interfere with our right to again the wisdom of Ecclesiastes, that happiness; that reflect our desire for there is a time to be born and a time to scientific quick fixes; that demonstrate die. If this is the case, can we afford to our impatience with hard-fought, painleave death in the hands of science, or ful moral or spiritual achievements, should we use the benefits of science to and that demonstrate our diminished provide the dying with a nurturing, view of the human spirit's ability to spiritual environment that feeds the encounter, entertain, and even accept the possibility of death. Nevertheless, the attitude of victory at all costs will not suffice in a battle that death is destined to win. The new symbolism Battlefields seem unlikely places for bespeaks of tenderness, affection, and genuine husociety's man concern . At an earlier point in fragmentation, human history, warfare consisted of hand-to-hand combat with the enemy. One came to respect, hate, or fear a tendencies, and dreaded enemy confronted in personal secularism. combat. The short bow began the process of distancing one from one's enemy. Gunpowder enhanced this process. Now guided missiles and other spirit while sustaining the body? In the modern weapons make possible the face of overpowering social forces, how wholesale destruction of a nameless, can we effect such changes? faceless enemy, whom one neither sees To address these questions, let us nor engages in any personal way. Intake one final look at our metaphors of stead, these living spirits (or potendeath as a battle and death in the hands tially ourselves, for that matter) crop of science. These two images create an- up as numbers on some statistical table tithetical concepts in our mind, for indicating the success or failure of scenes of battle seem unlikely places some military endeavor.
reductionistic
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The battle with death has followed much the same path. Once a matter of family and community concern that involved both symbolic and literal touching, the battle against death now becomes an increasingly lonely, impersonal vigil. Skilled technicians employ their arsenal of equipment and personal knowledge to fight the various harbingers of death, while the patient's
We have mounting evidence that we cannot place unlimited faith in technical solutions to human problems.
mind and spirit cower in frightful isolation, awaiting the outcome of the battle for the human body. Imbued by a lifetime of conditioning and years of professional training, the nurses and other professionals in this battle frequently have little time or inclination to evoke metaphors of touch or, for that matter, literally to touch a patient in a way not linked to the performance of some task. For many of the same reasons, and because of their own fears of death, family and friends, despite their good intentions, frequently do little to humanize the struggle against death. On the contrary, the commonly used metaphor the "hands of science" conjures up a warmer, more comforting vision of life than the view of death as a battle-that is, until we realize that the cold, impersonal hands of modern science contribute to the sterile, impersonal view of sick and dying people as consumers, as machines to be fixed . or repaired, as objects for research, and as bodies whose unruly spirits inhibit and interfere with the treatment of disease. Of course, I am speaking metaphorically about science, but our future attitudes about and treatment of death will be determined in large measure by our ability to rethink and
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reshape reductionistic, secular, mechanistic, metaphoric, and symbolic Concepts of human life. Within this context, the symbolic connotations of the hand provide an apt starting point for considering death in the future. As a matter of fact, the hands of science have not only demonstrated the resourcefulness and vigor of human intelligence, but these hands have initiated a scientific revolution that promises almost unlimited possibilities for the enhancement of human life. We cannot afford to forfeit this future by neglecting the spirit and focusing attention solely on the body. The hands of science need also to be the hands of compassion, love, communication, and connection.
New Approaches to Dealing with Death An alternative to this situation would be to strive for the fullest development of each human life, to expand opportunities for human creativity, to recognize death's integral role in all of life, and to reexamine all areas of life from birth to death to ferret out attitudes, approaches, and systems of thought which circumscribe and limit human potential for living and dying. Millions of persons do not easily change pervasive social forces, but even now there are increasing manifestations of a revolt against a strictly secular, reductionistic practice of medicine and a rising wave of determination not to abandon the spirit in some blind pursuit of bodily immortality. Numerous positive signals suggest our increasing desire to develop holistic concepts of nursing practice. Courses in death and dying and related topics routinely occupy prominent places in nursing curricula. Nursing professionals more frequently discuss humanistic approaches to care-giving in the professional literature and at professional meetings. Bookssuch as May's The Patient's Ordeal, Cassell's The Nature of Suffering, and the Siegels' Love, Medicine, and Miracles suggest significant new approaches for professional practice in dealing with dying patients. We NURSING OUTLOOK
are also witnessing a massive patients' rights movement, a major new emphasis on patient and family education, and emerging new directives and policies on such matters as resuscitation. In addition, the hospice movement and a proliferating number of self-help groups advocate and practice a holistic approach to the care and treatment of dying patients. Churches and other institutions have also begun to address these issues. All of these initiatives bespeak of a widespread concern about the dehumanizing potential of modern technology and a desire to enhance the quality of life and, thereby, the quality of death. Despite these hopeful signs, we must not underestimate the seductively invidious power of the forces that condition our thinking. We must not confuse knowledge about an issue with actuall y practicing what we know. We must heighten our awareness of the extent to which the scientific apparatus, the institutional settings, and the other circumstances of contemporary nursing practice serve to mediate between us and the fundamental condi-
Is it possible that nature may confound science by perpetuating ad infinitum a series of deadly battles within the human body?
tions of our existence , denying us much of the immediacy and richness of human life. The underlying scientific paradigms of the nursing profession, widely accepted metaphors concerning the mechanistic nature of the human body, the increasing reliance on specialists, federal regulations and other policies, the growing absence of family and other traditional caregivers, and
JULY/AUGUST 1994
the demand for efficiency and profitability in hospitals and other institutions - all conspire to depersonalize the dying process. These circumstances demand more than fragmented, factual knowledge on the part of nurses. Rather, nursing professionals must initiate an educational process predicated on symbolsand metaphors of integration and incorporation. We must, in
Death is a personal process.
short, develop new philosophical concepts and new educational strategies. These tasks will be difficult in a society whose emphasis on individualism has stunted our knowledge of the connections, interactions, and relations among people," The future of death seems secure, but we must wait to see if the continued advances of medical knowledge will solve, intensify, or help eliminate the problem of death. It hardly seems likely that we will soon cease to view death as anything but the enemy or that we will desist from describing the dying processas a battle. It is, however, in humanity's best interest to reassess and reassert the humanistic and spiritual dimensions of dying. It would be a strange irony if human creativity and intelligence should combine to shape an increasingly circumscribed, reductionistic view of human life and human potential. The creative mind, which has afforded us the amazing medical achievements of this century, will also make possible more caring, nurturing possibilities for dying. The realization of these possibilities will not come easily, becauseeach new success contributes to a rising wave of expectation that engenders the need for even more spectacular gains, but these advancesalone will not eliminate death or diminish its traumatic effect. We can benefit from future scientific advances; but, more than anything else, Thompson
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people need more satisfying, fulfilling, purposeful lives-an eternity or even an extra 10 years of meaningless existence would speak poorly for modern science and for humanity itself. _ REFERENCES 1. Lifton R), Olson E. Living and dying. New York, Praeger, 1974. 2. Sontag S. Illness as metaphor. New York, Vintage, 1977. 3. Cassell E). The nature of suffering and the goals of medicine. New York Oxford University Press, 1991.
SELECTED BIBLIOGRAPHY Achterberg ). The shaman. the SSCin a research perspective. In, Achterberg), ed. Imagery in healing, shamanism and modern medicine. Boston, Shambhala Publications, New Science Library, 1985,27. Aries P. Death inside out. In, Steinfels P, Veatch RM, eds. Death inside out. New York. Harper &. Row, 1974,9-2.4. Aries P. The hour of our death. New York. Alfred A. Knopf, 1981. Brabant S, Forsyth C), Melancon C. The meaning of death in the real world. Illness, Crises &. Loss, Multidisciplinary Linkages 1992;2.(1).7. Callahan D. Pursuing a peaceful death, Hasting Cent Rep 1993;2.3(4),33-8. Campbell r. Myths to live by. New York. Viking Press I 1972.
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Cassell EJ. Dying in a technological society. In, Steinfels P, Veatch RM, eds. Death inside out. New York, Harper &. Row, 1974:43-8. DcSelincourt E, Barbishire H. Ode, intimitations of immortality from recollections of early childhood. In, DcSelincourt E, Barbishire H, eds. The poetical works of William Wordsworth. Vol. 4. Oxford, England, Oxford at the Clarendon Press, 1947. DeSpeidcr LA, Strickland A1. The last dance, encountering death and dying. 3rd ed. Mountain View, California. Mayfield, 1992. Harrington A. The immortalist. New York. Avon Books, 1969. Hedrick HL, Isenberg DH, Martini CJM. Selfhelp groups, empowerment through policy and partnerships. In, Katz AH, Hedrick HL, Isenberg DH, et al. Self-help, concepts and applications. Philadelphia. Charles Press, 1992,355. Hinton I. Dying. Baltimore. Penguin Books, 1967. lung CG. The undiscovered self. New York, New American Library, 1957. Kass LR. Toward a more natural science. biology and human affairs. New York. Free Press, 1985. Katz ). The silent world of doctor and patient. New York, Free Press, 1984. Kubler-Ross E. On death and dying. New York, Macmillan, 1969. Lachs J. Intermediate man. Indianapolis, Hackett, 1981. Lakoff G, Johnson M. Metaphors we live by. Chicago, University of Chicago Press, 1980.
Lepp I. The psychology of loving. New York. New American Library, 1963. M:1Y WF. The patient's ordeal. Bloomington, Indiana, Indiana University Press, 1991. Pellegrino ED. Humanism and the physician. Knoxville, Tennessee. University of Tennessee Press, 1979. ScottR. The body as property. New York. Viking Press, 1981. Shneidman ES. Death. current perspectives. 3rd ed. Palo Alto, California, Mayfield, 1984. Siegel BS.Love, medicine &. miracles. New York, Harper &. Row, 1986. The Hastings Center. On the uses of the humanities. vision and application. New York, Hastings Center, 1984. Thomas 1. The youngest science. notes of a medicine-watcher. New York. Viking Press, 1983. Thompson LM, Bruhn )G, Kutscher AH, et al., eels. Perspectives on life-threatening illness for allied health professionals. New York, Haworth Press, 1993. Wass H, Berardo FM, Neimeyer RA. Dying, facing the facts. 2nd eel. Washington, Hemisphere, 1988. Wecnolsen P. Transcendence of loss over the life span. Washington, Hemisphere, 1988.
LESLIE M. THOMPSON is associate vice president for research and dean of the graduate school at Texas Woman's University, in Denton, Texas.
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NURSING OUTLOOK
PhD
HISTORICAL VIEWS
Medical technology plays a major role in definitions of and attitudes about death, but medical science alone cannot solve the mysteries of or the dilemmas accompanying dying and death.
To the primitive mind death resulted from external powers, from demons or evil spirits within, or from some other force that had face or form and even some vestige of personality, if not humanity, about it. The body became a battleground in which powerful forces contended, usually with the fate of the soul or spirit at stake. One might, it was thought, appease or exorcise the evil process over which we had little conspirit or even use spiritual or other edical science has dramatically increased the life ex· trol-today compels us to confront a powers to overwhelm the unruly prespectancy and significantly enhanced growing range of ethical, political, med- ences leading to death. the quality of life for most people. Sci- ical' and other dilemmas. Thanks to Although death inevitably trience has helped minimize the average improved hygiene, better diets, mira- umphed, a certain personal element person's personal encounters with cle drugs, sophisticated intervention nevertheless pervaded the whole pro' death. Still, fears of death grip human- techniques, and a welter of additional cess. Benign spirits frequently aided ity. In fact, the institutionalization of advances, we now live longer, have medical practice, the increasing legis- better health in general, and can lative mandates, the underlying para- even -to paraphrase WordsworthThe once simple act digms and metaphors of modern sci- have intimations of immortality. Yet, ence, and the fragmentation and spe- for all this, we still stand in ignorance of dying today cialization of industrial society have in and awe before the unknown finality compels us to many ways depersonalized the process of death. confront growing If many people now view death as a of dying, while engendering growing new fears of death. This article briefly matter of biologic necessity, as opposed range of ethical, reviews historical attitudes toward to divine retribution, most people still political, medical, .death and then emphasizes significant consider death a problem. This proband other trends that influence nurses and other lem has many facets, not the least of dilemmas. medical professionals who interact which is that death intrudes as an unwelcome visitor into our self-perceived with dying patients. Our attitudes toward death have un- inalienable rights to long life, the purdergone dramatic change in this cen- suit of happiness, and the gratification tury, but despite miraculous medical of each and every hedonistic or narcis- weak humanity, the evil spirits often advances and increasing prognostica- sistic whim or desire that flits through succumbed to blandishments, threats, tions of death's demise, we have no as- our minds. This problem, moreover, rituals, or exorcisms. In the Western surance that death will ever cease to be has not been solved by the advances of tradition even the Devil demonstrated our constant companion through life. medical technology. We no sooner a geniune - albeit invidious- personal The once simple matter of dying-a eliminate or minimize a disease-po- interest in the soul or spirit of each lio, for instance-when an apparently person. Thus, each life had, even if in new one like AIDS arises to shatter negative and fearful terms, a value and NURS OUTLOOK 1994;42:175-80. the sense of security engendered by a sense of importance associated with Copyright" 1994 by Mosby-Year Book, Inc. 0029-6554/94/$3.00 + 0 35/1/51319 science. it. These reasons alone impelled the
M
a
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JULY/AUGUST 1994
Thompson
175
masses of people to reject early materialistic views of death. Without the tools of modern technology, few people had the audacity, much less the desire, to employ human creativity and ingenuity to "fix" the problem of death. We have discovered, however, that the battle with death suited the spiritual better than the material world. CONTEMPORARY VIEWS The body, not the soul, is the focal pointof the current battle againstdeath. Our society places little stock in demons, evil spirits, or other previously recognized agents of death. In addition, few people give more than lip service to the rituals, myths, symbols, and images that in earlier societies propped up the spirit, explained the mysterious workings of nature (including life and death), and spoke to the human spirit about life's unfathomable mysteries. Naked spirits cowering before a vast and growing cosmos and an impersonal
For all our
edvences, we still stand in ignorance and awe before the unknown finality of death.
and indifferent world are ill equipped to deal with a hedonistic, secular world that diminishes spiritual values and reveres the human body incarnate. If the body incarnates the temple of human existence, it becomes important to gratify every physical desire or urge. Of course, this view of the body intensifies the problem about death. Now,however, we confront death with an arsenal of new weapons of humanity's own devising, and we place our confidence in trained, certified technicians, rather than shamans or witch doctors, to lead in the battle against death. As has been the case historically, we 176
Thompson
still contend with equally lethal enemies, but they have different names, and the battle takes place in a dramatically different setting. There is nothing personal about this confrontation. In lieu of a small, personal cosmos teeming with living spirits and appropriately stocked with consoling symbols and human-centered rituals and ceremonies, we now wage the battle in a huge, seemingly indifferent cosmos. Instead of the family and even the community as a whole uniting to fight invisible harbingers of death, we now equip highly trained microbe hunters, virus annihilators, organ transplant technicians, and other specialists with weapons of human ingenuity, and we commission, even command, these leaders to wage battle against death. Each new weapon resulting from medical technology brings new hope, but death is resilient. Just as victory over death seems imminent, or at least possible in the foreseeable future, death makes its counterattack. With victories over most communicable diseases and with significant progressunderway in the battles against cancer, heart disease, and other major killers, we find ourselves physiologically and psychologically shocked by AIDS. AIDS has not only attacked the human body and engendered a national and international epidemic of fear, but it has shaken the collective psyche as well. AIDS is both a physiologic and symbolic disease that has exposed serious weaknesses in the battle to solve the problem of death. A careful look at the dynamics of AIDS provides some insights into the future of death. AIDS AS A PARADIGM FOR FIGHTING DISEASES The rapid development of resources to study AIDS, the quick unraveling of its causes, and the promising new leads toward a possible vaccine all demonstrate modern science's achievements and promise. This processlikewise underscores the extent to which the current battle with death focuses on the body and on technical solutions to the
problems of death. More important, the attack on AIDS calls attention to the dearth of life-supporting, integrative symbols to support the healing, nurturing, or dying process. This scientific battle against AIDS also demonstrates the loss of community in contemporary society and the lack of support systems to ease most of life's
Few people today give more than lip service to the rituals, myths, symbols, and images that once spoke to the human spirit about life's unfathomable mysteries.
traumas from birth, adolescence, and marriage to divorce, dying, and death. Attention to the body as a thing unto itself to be repaired, sustained, junked, destroyed, or, perhaps, eventually to be resuscitated leaves little room to nurture the spirit or even to explore the intricate relationships between body and mind. In this respect, we must note the symbolic aspects of AIDS, a disease that attacks the body's own defense mechanisms. AIDSappears to be a cruel trick of nature to demonstrate that the body's long evolutionary defense mechanisms stand impotent, like the Maginot Line. Even more invidiously, the AIDS virus utilizes the body's defense mechanisms for its own perpetuation. Our attempts to deal with AIDS underscore Lifton and Olson's assertion that traditional systems of symbols through which humanity comprehended the world no longer provide spiritual solace or channels for life.' In today's reductionistic milieu, viruses, retroviruses, germs, bacteria, militant cells, and other intricate workings of nature lack the per-
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sonality and symbolic power of evil spirits. Since most of our new symbols in the fight against death stem from a scientific base, the whole endeavor becomes a mechanical enterprise to sustain the body. Failure becomes a personal affront to the specialists involved; human emotions and fears become intrusive elements to be eliminated, and science becomes the safeguard against the unknown. The symbolism, therefore, is impersonal, secular, and fraught with apprehension. AIDS engenders special fears because it adumbrates the possibility that perhaps other, as yet unknown, maybe inconceivable, forms of death loom ahead. Is it possible, people ask, that nature may confound science by perpetuating ad infinitum a series of deadly battles within the human body?
itself. In fact, she observes that in contemporary society! disease equals death.s These insights obviously apply equally to AIDS. What this analysis does not indicate, however, is the efficacy of the new symbolism in addressing the needs of the human spirit. The symbolism, rituals, and metaphors about AIDS, like those associated
people would seriously consider going back to the "good old days,{( People now suffer less physically while dying, they lead lives of higher quality; they live longer; they have more meaningful options; and they can reasonably expect all of these trends to continue. Unfortunately, the difficulties associated with death will also proliferate and intensify, The boundaries between life and death will continue to shift, with all Viruses, the accompanying moral, ethical, and retroviruses, germs, political ramifications. Increased use of manufactured and cultivated bodily bacteria, and parts, genetic engineering, possible militant cells lack brain transplants, in vitro conception, the personality and incubation and birth, and yetsymbolic power of un thought-of advancesin medical technology will continue to shatter tradievil spirits. tional concepts of personhood, fatherhood and motherhood, birth, life, and death. The allocation of health care rewith other contemporary human ac- sources will influence the process of NEED FOR RITUAL, SYMBOL, tivities.Iack compelling links with the living and dying for massive numbers MYTH A symbolic look at AIDS and the bat- spiritual domain. Rather than helping of people. Ethical and legal decisions tle against death also demonstrates that usher the human spirit through life's concerning abortion, euthanasia, and we still need ritual, symbol, and myth traumas and linking the individual life suicide will continue to plague the colto confront life's traumas. For example, with the community, and even the lective psyche, becausethere is little to we discuss AIDS through the use of living cosmos, the new symbolism be- indicate that contemporary or future highly metaphoric, frequently milita- speaks of society's fragmentation, re- practice of medicine will fix the probristic language. We enact rituals of at- ductionistic tendencies, and secular- lem of death. Death is a personal process. Even tack on the disease itself with scientists ism. This symbolism emphasizes disand technicians as both tacticians and connection, rather than connection, when afforded the maximum level of the prophets of hope, we place great and destruction, rather than creation. support, the dying person slowly or psychological and symbolic stock in Symbols, of course, evolve from and rapidly faces diminished possibilities, sophisticated apparatus, and in concert represent massive social forces and hu- systematic loss of connection with with the staffs of hospitals and other man fears and anxieties, as well as as- friends, loved ones, and the daily rituinstitutions, we join in routines of effi- pirations and hopes. AIDS and the gen- als of life; and ultimately a face-to-face ciency to exorcise and destroy aberrant eral reaction to it have demonstrated confrontation with the unknown, On a cells, to repair or replace defective that in our battle with death, we asa physiological level, science can ease parts, to alter genetic ally various bodily society have come to hold a limited this process; but so far at least, effiprocesses, and in general to keep the view of human life and human poten- ciency, sterile professionalism, scienbody functioning. These activities do tial. Despite our reliance on science, we tific paraphernalia, and technical apnot constitute a moral drama with have not yet been able to use comput- proaches have not sufficed to replace souls hanging in the balance, but a ers and other scientific equipment to old-fashioned virtues such as touch, desperate attempt to salvage bodies and create new symbols for us, and we love, concern, compassion,and human promote general human happiness. In have mounting evidence that we can- companionship. These attributes, it short, both the symbolic and realistic not continue to place unlimited faith seems, do not rest easily in the modern aspects of AIDS merely underscore and in technical solutions to human medical milieu, and it seems unlikely that this situation will soon change. reinforce Sontag's observations about problems. Dying is a lonely, singular activity, the metaphoric nature of most diseases. inextricably interwoven with the qualSontag, for example, refers to cancer as THE FUTURE OF DEATH a demonic pregnancy, a disease like TB This assertion brings us back to the ity of living. People living improverwhich became identified with death problem of death and its future. Few ished spiritual, social,intellectual lives NURSING OUTLOOK
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lack the resources for a meaningful experience with dying. In addition, the circumstances and location of dying exacerbate well-entrenched and intensifying societal tendencies inimical to spiritual growth and creativity. The very professionals in attendance during the dying process are conditioned by reductionistic training, which militates against empathy, personal interaction, and extensive personal involvement with patients or clients. In short, the dying processintensifies those personal and societal tendencies that have accompanied people throughout their lives,
for touching, compassion, or communication. In addition, both literal battles and battles against death have become increasingly impersonal. One option might be to alter the nature of the battle against death. While striving strenuously to perpetuate bodily existence, we might also recognize the need to approach this affair in a holistic manner bringing to bear psychological, physiological, and spiritual considerations upon the patient, the family, and friends. In addition, we might investigate approaches to dying that would encourage the reintegration of death into the life cycle. Even with genetic engineering and The Quality of the Dying psychic conditioning of various kinds, Process If we do not conquer death by elimi- it seems unlikely that, in the near funating it, is there a value to living for ture at least, we will ever see death as hundreds of years or forever? Who less than the enemy to be destroyed. would want to live forever, and why? This imagery derives from deep inner As we find ourselves impelled into this resources in our psyche thadear death's brave new world of death, we confront potential to interfere with our right to again the wisdom of Ecclesiastes, that happiness; that reflect our desire for there is a time to be born and a time to scientific quick fixes; that demonstrate die. If this is the case, can we afford to our impatience with hard-fought, painleave death in the hands of science, or ful moral or spiritual achievements, should we use the benefits of science to and that demonstrate our diminished provide the dying with a nurturing, view of the human spirit's ability to spiritual environment that feeds the encounter, entertain, and even accept the possibility of death. Nevertheless, the attitude of victory at all costs will not suffice in a battle that death is destined to win. The new symbolism Battlefields seem unlikely places for bespeaks of tenderness, affection, and genuine husociety's man concern . At an earlier point in fragmentation, human history, warfare consisted of hand-to-hand combat with the enemy. One came to respect, hate, or fear a tendencies, and dreaded enemy confronted in personal secularism. combat. The short bow began the process of distancing one from one's enemy. Gunpowder enhanced this process. Now guided missiles and other spirit while sustaining the body? In the modern weapons make possible the face of overpowering social forces, how wholesale destruction of a nameless, can we effect such changes? faceless enemy, whom one neither sees To address these questions, let us nor engages in any personal way. Intake one final look at our metaphors of stead, these living spirits (or potendeath as a battle and death in the hands tially ourselves, for that matter) crop of science. These two images create an- up as numbers on some statistical table tithetical concepts in our mind, for indicating the success or failure of scenes of battle seem unlikely places some military endeavor.
reductionistic
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The battle with death has followed much the same path. Once a matter of family and community concern that involved both symbolic and literal touching, the battle against death now becomes an increasingly lonely, impersonal vigil. Skilled technicians employ their arsenal of equipment and personal knowledge to fight the various harbingers of death, while the patient's
We have mounting evidence that we cannot place unlimited faith in technical solutions to human problems.
mind and spirit cower in frightful isolation, awaiting the outcome of the battle for the human body. Imbued by a lifetime of conditioning and years of professional training, the nurses and other professionals in this battle frequently have little time or inclination to evoke metaphors of touch or, for that matter, literally to touch a patient in a way not linked to the performance of some task. For many of the same reasons, and because of their own fears of death, family and friends, despite their good intentions, frequently do little to humanize the struggle against death. On the contrary, the commonly used metaphor the "hands of science" conjures up a warmer, more comforting vision of life than the view of death as a battle-that is, until we realize that the cold, impersonal hands of modern science contribute to the sterile, impersonal view of sick and dying people as consumers, as machines to be fixed . or repaired, as objects for research, and as bodies whose unruly spirits inhibit and interfere with the treatment of disease. Of course, I am speaking metaphorically about science, but our future attitudes about and treatment of death will be determined in large measure by our ability to rethink and
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reshape reductionistic, secular, mechanistic, metaphoric, and symbolic Concepts of human life. Within this context, the symbolic connotations of the hand provide an apt starting point for considering death in the future. As a matter of fact, the hands of science have not only demonstrated the resourcefulness and vigor of human intelligence, but these hands have initiated a scientific revolution that promises almost unlimited possibilities for the enhancement of human life. We cannot afford to forfeit this future by neglecting the spirit and focusing attention solely on the body. The hands of science need also to be the hands of compassion, love, communication, and connection.
New Approaches to Dealing with Death An alternative to this situation would be to strive for the fullest development of each human life, to expand opportunities for human creativity, to recognize death's integral role in all of life, and to reexamine all areas of life from birth to death to ferret out attitudes, approaches, and systems of thought which circumscribe and limit human potential for living and dying. Millions of persons do not easily change pervasive social forces, but even now there are increasing manifestations of a revolt against a strictly secular, reductionistic practice of medicine and a rising wave of determination not to abandon the spirit in some blind pursuit of bodily immortality. Numerous positive signals suggest our increasing desire to develop holistic concepts of nursing practice. Courses in death and dying and related topics routinely occupy prominent places in nursing curricula. Nursing professionals more frequently discuss humanistic approaches to care-giving in the professional literature and at professional meetings. Bookssuch as May's The Patient's Ordeal, Cassell's The Nature of Suffering, and the Siegels' Love, Medicine, and Miracles suggest significant new approaches for professional practice in dealing with dying patients. We NURSING OUTLOOK
are also witnessing a massive patients' rights movement, a major new emphasis on patient and family education, and emerging new directives and policies on such matters as resuscitation. In addition, the hospice movement and a proliferating number of self-help groups advocate and practice a holistic approach to the care and treatment of dying patients. Churches and other institutions have also begun to address these issues. All of these initiatives bespeak of a widespread concern about the dehumanizing potential of modern technology and a desire to enhance the quality of life and, thereby, the quality of death. Despite these hopeful signs, we must not underestimate the seductively invidious power of the forces that condition our thinking. We must not confuse knowledge about an issue with actuall y practicing what we know. We must heighten our awareness of the extent to which the scientific apparatus, the institutional settings, and the other circumstances of contemporary nursing practice serve to mediate between us and the fundamental condi-
Is it possible that nature may confound science by perpetuating ad infinitum a series of deadly battles within the human body?
tions of our existence , denying us much of the immediacy and richness of human life. The underlying scientific paradigms of the nursing profession, widely accepted metaphors concerning the mechanistic nature of the human body, the increasing reliance on specialists, federal regulations and other policies, the growing absence of family and other traditional caregivers, and
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the demand for efficiency and profitability in hospitals and other institutions - all conspire to depersonalize the dying process. These circumstances demand more than fragmented, factual knowledge on the part of nurses. Rather, nursing professionals must initiate an educational process predicated on symbolsand metaphors of integration and incorporation. We must, in
Death is a personal process.
short, develop new philosophical concepts and new educational strategies. These tasks will be difficult in a society whose emphasis on individualism has stunted our knowledge of the connections, interactions, and relations among people," The future of death seems secure, but we must wait to see if the continued advances of medical knowledge will solve, intensify, or help eliminate the problem of death. It hardly seems likely that we will soon cease to view death as anything but the enemy or that we will desist from describing the dying processas a battle. It is, however, in humanity's best interest to reassess and reassert the humanistic and spiritual dimensions of dying. It would be a strange irony if human creativity and intelligence should combine to shape an increasingly circumscribed, reductionistic view of human life and human potential. The creative mind, which has afforded us the amazing medical achievements of this century, will also make possible more caring, nurturing possibilities for dying. The realization of these possibilities will not come easily, becauseeach new success contributes to a rising wave of expectation that engenders the need for even more spectacular gains, but these advancesalone will not eliminate death or diminish its traumatic effect. We can benefit from future scientific advances; but, more than anything else, Thompson
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people need more satisfying, fulfilling, purposeful lives-an eternity or even an extra 10 years of meaningless existence would speak poorly for modern science and for humanity itself. _ REFERENCES 1. Lifton R), Olson E. Living and dying. New York, Praeger, 1974. 2. Sontag S. Illness as metaphor. New York, Vintage, 1977. 3. Cassell E). The nature of suffering and the goals of medicine. New York Oxford University Press, 1991.
SELECTED BIBLIOGRAPHY Achterberg ). The shaman. the SSCin a research perspective. In, Achterberg), ed. Imagery in healing, shamanism and modern medicine. Boston, Shambhala Publications, New Science Library, 1985,27. Aries P. Death inside out. In, Steinfels P, Veatch RM, eds. Death inside out. New York. Harper &. Row, 1974,9-2.4. Aries P. The hour of our death. New York. Alfred A. Knopf, 1981. Brabant S, Forsyth C), Melancon C. The meaning of death in the real world. Illness, Crises &. Loss, Multidisciplinary Linkages 1992;2.(1).7. Callahan D. Pursuing a peaceful death, Hasting Cent Rep 1993;2.3(4),33-8. Campbell r. Myths to live by. New York. Viking Press I 1972.
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Cassell EJ. Dying in a technological society. In, Steinfels P, Veatch RM, eds. Death inside out. New York, Harper &. Row, 1974:43-8. DcSelincourt E, Barbishire H. Ode, intimitations of immortality from recollections of early childhood. In, DcSelincourt E, Barbishire H, eds. The poetical works of William Wordsworth. Vol. 4. Oxford, England, Oxford at the Clarendon Press, 1947. DeSpeidcr LA, Strickland A1. The last dance, encountering death and dying. 3rd ed. Mountain View, California. Mayfield, 1992. Harrington A. The immortalist. New York. Avon Books, 1969. Hedrick HL, Isenberg DH, Martini CJM. Selfhelp groups, empowerment through policy and partnerships. In, Katz AH, Hedrick HL, Isenberg DH, et al. Self-help, concepts and applications. Philadelphia. Charles Press, 1992,355. Hinton I. Dying. Baltimore. Penguin Books, 1967. lung CG. The undiscovered self. New York, New American Library, 1957. Kass LR. Toward a more natural science. biology and human affairs. New York. Free Press, 1985. Katz ). The silent world of doctor and patient. New York, Free Press, 1984. Kubler-Ross E. On death and dying. New York, Macmillan, 1969. Lachs J. Intermediate man. Indianapolis, Hackett, 1981. Lakoff G, Johnson M. Metaphors we live by. Chicago, University of Chicago Press, 1980.
Lepp I. The psychology of loving. New York. New American Library, 1963. M:1Y WF. The patient's ordeal. Bloomington, Indiana, Indiana University Press, 1991. Pellegrino ED. Humanism and the physician. Knoxville, Tennessee. University of Tennessee Press, 1979. ScottR. The body as property. New York. Viking Press, 1981. Shneidman ES. Death. current perspectives. 3rd ed. Palo Alto, California, Mayfield, 1984. Siegel BS.Love, medicine &. miracles. New York, Harper &. Row, 1986. The Hastings Center. On the uses of the humanities. vision and application. New York, Hastings Center, 1984. Thomas 1. The youngest science. notes of a medicine-watcher. New York. Viking Press, 1983. Thompson LM, Bruhn )G, Kutscher AH, et al., eels. Perspectives on life-threatening illness for allied health professionals. New York, Haworth Press, 1993. Wass H, Berardo FM, Neimeyer RA. Dying, facing the facts. 2nd eel. Washington, Hemisphere, 1988. Wecnolsen P. Transcendence of loss over the life span. Washington, Hemisphere, 1988.
LESLIE M. THOMPSON is associate vice president for research and dean of the graduate school at Texas Woman's University, in Denton, Texas.
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