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The ‘Pornography’ of death

"Doctor: We are here with a peculiar request. Chaplain and I are working with a group of people from the hospital who are trying to learn more about very sick and dying patients. I wonder if you feel up to answering some of our questions?
Patient: Why don’t you ask and I’ll see if I can answer them.
Doctor: How sick are you?
Patient: I am full of metastasis…’’
From On Death and Dying, Kubler-Ross (1969)

Kubler-Ross short quote from her book is part of an interview with one of the many patients she interviewed. Heady, blunt and daring words for the nineteen-sixties, and perhaps even now in many hospitals all over the world even among the more progressive Western world nations. Kubler-Ross insists upon an honest dialogue between the dying person, his family and his caregivers and to allow people to voice their feelings and fears. The researcher suggests of making the time of one’s dying one of clarity and significance, aided by family and health care providers. There is a great Zen story about a monk who ventures too close to the ledge and falls over, grasping a vine. There are two tigers pacing below, and he notices a rat gnawing at the vine. He also notices a strawberry growing out of the nearby bush. The monk reaches over and picks the strawberry. How sweet it tastes. Life acquires flavour, zest and savour. It also becomes as precious and sweet as that strawberry because priorities get rearranged. Pain is reduced and it could become part of the totality of an experience that will not be again, but which paradoxically always was before.

In this essay I will attempt to explore the denial of death by society and medical practitioners and describe a more honest perspective of allowing terminally ill patients to deal with the reality of their disease and its prognosis. Let as move with the earliest theories of denial of death and then consider the religious decline and social construction eras that led to the elevation of science and technology and transition to the physicians to handle the war against death.

Historical view death denial

Feifel (1990) noted that the place of death in psychology was practically tera ingognitia and off-limits enterprise until the mid-20th century. The author provides a historical account of the major changes that shifted and expanded the awareness and research in the area of dying, and death began to emerge as an authentic and fertile undertaking. Some of these reasons were the shift from spiritual mastery over self to physical conquest of nature. A second major change was the events of the World War II, with its defence of democratic values, such as the Holocaust which challenge racism, following a number of serious urgent social problems. All these events forced psychology to look beyond its traditional positivism. The growing importance of existential psychology in Europe with its emphasis of death as a philosophical theme facilitated the view that psychology must be rooted in human beings and not in a mathematical physical model. Furthermore, the discovery of an atomic bomb and the progress of physical science have created a new posterity threat for social immortality and the possibility to destroy not only society but history as well.

The existential issues of meaning, purpose, death, anxiety, and temporality dominate that era, and research in the area of dying and death began to emerge as an authentic and fertile undertaking (Feifel, 1969). Feifel (1990) describes the US hospitals’ attitudes towards the dying patient in early 1960’s. The writer explains through her research topic (attitudes toward death), funded by the National Institute of Mental Health, that at no time professional personnel could ever inform patients that they had serious illness from which they could die. The issue of death was never discussed with the patient. A seemingly unconscious goal was the elimination of death. People died in institutions, not at home. . . . Unrealistic optimism lead to a ‘conspiracy of silence’ where the patient and medical staff knew the truth but withheld it from the patient.

In England an important contributor to the denial of death thesis was Gorer (1965), who wrote an article “The Pornography of Death” stating that the social prudery which prevents natural death from being spoken about in an open and dignified fashion leads to pornographic means of coming to terms with the inevitability of death in the form of violent literature and media programming.

French historian Aries (1974) in his analysis of western attitudes toward death from the time of the Middle Ages to the present, refers to ‘the lie’ in modern western society of hiding from the patient the gravity of the situation. According to Aries, this lie originated in the USA in the mid-nineteenth century and then spread throughout industrialized Europe . While the original motive was to shield the patient from the unpleasant reality of terminal illness it became no longer for the sake of the dying person, but for society’s sake. For Aries, death in modern society is ‘shameful and forbidden’, so that the pleasant rhythm of social life is not interrupted.

Freud and Heidegger view of death

Freud during the Great War communicates a strong sense of epistemic changes in his paper ‘Our Attitudes to Death’ (1915)[1]. He observed: `should we not confess that in our civilized attitude towards death we are once again living psychologically beyond our means, and should we not rather turn back and recognize the truth. Would it not be better to give death the place in reality and in our thought which its due’ (pp.88-9).

Heidegger’s analysis was similarly a reaction to the Great War. In Being and Time (1927) death is shown to be determinant of Dasein. Its looming presence ‘stand before us- something impending…Death is the possibility of the absolute impossibility of Dasein [It] reveals itself as that possibility which is one’s ownmost, which is non-relational, and which is not to be outstripped’ ( Heidegger, 1962, p.294). Human death is pre-eminently a singular event, a particularity in a life which, as Heidegger noted death defines that life and constitutes Dasein. Its ‘truth’ lies at the heart of Dasein. In bringing the life of a person to a close, death both totalizes and individualizes that Dasein. Since death is forever awaiting, death has the capacity to fundamentally intensify the person’s subjective apprehension of their life. This is an ineluctable dimension of human personhood and Heidegger’s analysis inspired Sartre in Being and Nothingness (1943) and made his basis for a critique of modernity based on the ‘denial’ or ‘sequestration’ of death.

Social construction, self –esteem and transition to the physicians

Bendle (2001) argues that the present episteme of death is deeply embedded in modern culture and both facilitates and restricts the production and analysis of scientific, philosophical, cultural, and economic questions and solutions relating to the administration of death. Death, the author asserts, is not simply an event but rather a collection of processes apprehended in human experience, and that culture is characterised by any discourses on death (mythic, religious, philosophic, ethical, biological, medical, economic, psychological). All these processes and discourses are articulated to both facilitate and delimit our experience and thinking about death.

In Lack and transcendence, David Loy illuminates that a great deal of psychological suffering is due to a sense of lack caused by our unconscious desires to reify our egos and to make something objective and permanent of our mortal existence. In Loy’s poetic phase “Time is the canvas we erect before us to hide the sneering skull, the bottomless void “(Loy 1996 p.39). Loy critiques the philosophers of Nietzche and Heidegger for their failures to fully cognize non-self and impermanence, and attracts all fame-projects which purports to give authors some fleeting permanence in a universe of constant change. The purpose of this essay is to bring the denial of death into the clinical arena in order to instigate critical thinking about current care of the terminally ill. 

Ernest Becker's book, The Denial of Death, (1973) deals with the denial of one's mortality. The author suggests that the full realization of one's own mortality is mostly unbearable, absolutely terrifying and horrific. Becker offers an existential psychoanalytic apology for religion as the least destructive form of the universal and necessary denial of death and asks how conscious are we of what we are doing to earn our feeling of heroism? Becker further asserts that were we to become conscious of our denial of death and of the false cultural structures that we have erected in order to give ourselves a patina of heroism, it would unleash a mighty blast of truth that would fundamentally change the world.

Cultural worldviews evolved to protect the humans’ abject terror by the ongoing awareness of their vulnerability and mortality. Solomon, Greenberg, Pyszczynski (1998) noted how cultural worldviews facilitate effective terror management by providing individuals with a vision of reality that supplies answers to universal cosmological questions such as Who am I ? Where did I come from? What should I do? What will happen to me when I die? .These questions are answered almost by all societies and provide their members with the satisfaction of meaning, permanence, stability in their universe and affords opportunities for individuals to live forever.  Solomon, Greenberg, Pyszczynski (1998) argue that eligibility for immortality is however limited to those who do the right thing with the social roles that exist in a given culture. The resulting perception that one is a valuable member of a meaningful universe constitutes self-esteem and this is the primary psychological mechanism by which cultures serves its death-denying function.

Solomon, Greenberg, Pyszczynski (1998) provide an excellent description of the early journey of the neonates attachments to provide a sense of profound safety and security and how the infant is transformed into a symbol-sharing immortality-seeking member of a culturally constructed universe. The early processes is further enhanced when children join their social milieu by learning the language, beliefs, and customs of their culture with their parental affection becoming so contingent on the child’s code of behaviour. Children come to associate being good with being safe (good=safe=alive) and being bad with being helpless and vulnerable (bad=insecure=dead). According to Solomon, Greenberg, Pyszczynski (1998) this is how self-esteem originally becomes an anxiety buffer.

This analysis by Solomon, Greenberg, Pyszczynski (1998) has several important implications. First self-esteem is an individual psychological attribute that is culturally constructed and it gives purpose and direction to individual lives (Goldschmidt 1990). Second self- esteem vary across time and space and so too an infinite variety of cultural worldviews, which all are fundamentally religious in nature. Thirdly the anxiety-buffering capacity of an individual’s worldview serve to ameliorate the anxiety associated with the awareness of death and this might explain partly why human beings have such a difficult time peacefully coexisting with different others.

Self -esteem is the primary psychological mechanism by which culture serves its death-denying function. Cultural worldviews consists of shared illusions that serve to ameliorate anxiety associated with the awareness of death through the provision that one is a valuable member of a meaningful universe. This notion is giving birth to acquire and maintain self-esteem and provoke extreme and extremely disparate responses (Solomon, Greenberg, Pyszczynski 1998). The implication is that a culture is partly responsible for the death denying illusion.

Physicians denial and avoidance of death is reported by many researchers including Elisabeth Kobler-Ross and Herman Feifel. Kobler-Ross found that doctors were resistant to and angry about her efforts to get access to their dying patients, sometimes flatly denying that they had any terminally ill patients on their caseload (Kobler-ross 1969). Doctors’ own fear of death and their powerful role in curing or saving patients from death may relax their own more conscious fears of dying, and such deeply-felt anxieties can have a powerful impetus to enter and succeed in the profession. Kaspar (1959 noted ‘’We all work to live, but the doctor has a bonus incentive; he works directly against Man’s adversary, Death” ( p.260).

Laqueur (1999) discusses medicine and how is now perceived as promising power over death and as offering mastery over the miseries of life. The author suggests that withdrawal of death from realm of the socio-cultural and everyday life is no longer considered capable of dealing with death, and the new phenomena of human being becoming submissive to science and medicine is emerging more eminently in our societies.

With the modern decline of religion and elevation of science and technology, the fight against death is a war, with the charge led by the physician. Instead of an encounter with the singular truth of death, a new emphasis on mere performance reigns, ‘institutional death viewed in the medical profession as a case of failure and the aim becomes the prolongation of life at all costs (Porter, 1997, p.699).

Indeed, ‘in the course of the twentieth century an absolute new type of dying has made an appearance in some of the most industrialized, urbanized, and technologically advanced areas of the Western world- and this is probably only the first stage’ (Ariès, 1981, p.560). Death became incorporated into a highly elaborate, industrialized process administered by highly trained professionals and technicians deploying a vast array of new technologies. Consequently, ‘the hospital became the place, not where the patient came to die but where the apparently terminal patient might almost miraculously be rescued from death. Doctors thereby assumed control over the rituals of death: what was left of the “good death” of the religious ("The Art of Dying") yielded to the priests in white coats’ (Porter, 1997, p.692). Death has moved from the moral order to the technological order (Cassell, 1978, p.121).

Death has been drained of its previous ritual, symbolic, mythological and cosmological significance and has been institutionalized within a highly technologized healthcare system. This death system is characterized by a profound contradiction between ‘the impossible hypothesis of success’, and the unacknowledged certainty of ultimate failure (Porter 1997, p 692). For Arie, death in modern society is ‘shameful and forbidden, so that a pleasant rhythm of scial life is not interrupted. The old savagery is creeping back under the mask of medical technology. The death of the patient in the hospital, covered with tubes, is becoming a popular image, ‘’more terrifying than the transi [‘’perished one’’] or skeleton of macabre rhetoric’ (Ariès, 1981, p.614). What an ignominious destiny if the future of medicine turns into bestowing meagre increments of unenjoyed life (Porter, 1997, pp. 717). Laqueur (1999) agrees that ‘nowhere has biomedicine proved to be more clueless than in the face of what is still the final denouement’ (p.9) Such failure may constitute a reprise of Nietzsche’s observation that ‘God is dead- albeit a new god (Bendle 2001).

The Heideggerian analysis allows us to see how the contemporary episteme of death is intrinsically unable to comprehend the singular nature of human death because it does not observe the ‘ontological difference’, that is, it knows nothing of, or does it recognise, the distinction between the ontological and the ontic. Heidegger distinguishes between an ontological inquiry as dealing primarily with Being; and an ontical inquiry is concerned primarily with entities and the facts about them, the ontic as naturalistic bodies, that which is at hand (Heidegger, 1962, p3). 

Viewing human life ontically, there is nothing, including death and we cannot administered, manage or sudmitt to calculation. However considering the ontolodical dimension of human being an alternative world emerges which Heidegger refers to Dasein as an entity which does not just occur among entities but its very Being and that Being is an issue for it. Dasein is ontically distinctive in that it is ontological (Heidegger, 1962, p.32). Because the way of Being of Dasein is towards its death, it does not merely perish but rather dies, or enters a ‘state of dying’, characterized above all else by its awareness and reflexivity of what if faces and undergoes (p.291). This condition it is fundamental and constitutive of it, it is its ontological structure the condition of being human as such.

The ontological dimension of a human being death for Dasein cannot be grasped by those sciences, technologies or discources that remain only at the ontic level and that the current episteme of death needs a new perspective to capture the essence and significance of death for Dasein.  Heidegger, held that we are cast into the world and cannot escape the dread of our solitariness. We face others as impersonal beings, a faceless crowd, and everything in our lives is contingent and meaningless and to exist authentically is to face death, which stabilizes our lives.

Kubler-Ross explains how the therapeutic relationship with the terminally ill permits a replication of the earliest mother-infant bonds and a return to the good parent. Hagglund (1972) suggest during his therapeutic work with patients a process of depression and clinging, to denial, to paranoia and anger, and finally to acceptance of fate and gratitude and a great affection to the therapist. Feifel's (1977) perspective is that as dying patients' emotional needs are met, untapped potentials for responsible behaviors are uncovered. This allows these patients to become less depressed, to feel that they are more in control and less inadequate. Spiegel, Bloom, and Yalom (1981) provided empirical evidence supportive of Feifel's (1977) prognostications regarding the benefits of meeting the emotional needs of the terminally ill. Their study of the effects of group support for terminally ill cancer patients demonstrated benefits in patients' self-esteem, mood and affect, overall efficacy of coping capacities and enhancement of the patients' quality of life.

Conclusion

In this essay we have examined the existence of an attitude toward dying in western society and that was mainly the denial of death, the medicalization of death and the segregation of the dying. The need for a change of attitude toward death from denial to acceptance of the ‘naturalness’ of dying is important for better treatment of the terminally ill. We must be mindful not to increase suffering but also remember that the tasks of prolonging life and increasing quality of life need not be mutually exclusive, even for the dying patient. Kubler-Ross (1969) noted that we cannot help the terminally ill patient in a meaningful way if we do not include the significant others in his life. The hospital with its impersonal atmosphere where the dying person is placed in the care of strangers is not a proper setting. Pantilat (2002) pointed out that too often patients die alone and in pain, with their concerns and fears unattended by physicians.

Death is an existential fact, and it is more than likely the model for all human feelings of abandonment and separation. It is then so difficult to understand why one should not feel anxious when confronted with departing the life he finds so rewarding and enriching. There is sometimes an element of denial of death in both patient and therapist and the reality-principle that death is or should be as much a part of our discussion as Life need to be acknowledged by both sides. Existential Psychological Theory places great importance on the undeniable truism that man is inexorably alone. Existential isolation and aloneness refers to an unbridgeable gulf between oneself and any other being. A confrontation with one's death and finiteness will inevitably lead to existential isolation as it promotes awareness that no one can die with one or for one. Heidegger (1962) stated that no one could take the other's death away from him.  Existential Psychotherapy offers a beacon that illuminates their path to surmounting the challenges of existential meaninglessness, existential isolation and existential death anxiety.

The existentialists consider death as essential to the discovery of meaning and purpose in life and suggest that death and life are interdependent. The price for denying death is undefined anxiety, and self alienation. To completely understand himself, man must confront death, and become aware of personal death (May 1961). Rollo May existential approach suggests that we can help the client to confront normal anxiety which is an unavoidable part of human condition. Thomas (1990) noted that an existential therapist  view of personality structure empasizes the depth of experiences at any given moment, and that the therapist does not spend a great deal of time in helping the client to recover a personal past. Frankl (1963) supported this view and added that it is not how long one lives but how one lives that determine the quality and meaningfulness of life. Therefore the way one perceives life and death affects one’s level of anxiety.

References

Aries, P., (1974) Wstern Attitudes Toward Death. Baltimore: Johns Hopkins University Press

Loy. D., (1996) Lack and Transcendence: The Problem of Death and Life in Psychotherapy, Existentialism, and Buddhism

Feifel, H. (1959). Attitudes toward death in some normal and mentally ill populations. In H. Feifel, (Ed.). The meaning of death. New York: McGraw Hill.

Feifel, H. (1977). New meanings of death. New York: McGraw Hill.

Kubler-Ross, E. (1969). On death and dying. New York: MacMillan

[1] Freud, S. (1915) Our Attitudes Towards Death. In S Freud 1985 Civilizations, Society and Religion. Ringwoood; Penguin.

 

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