Is Death Denied in Contemporary Australian Society - Essay Example

?Is death denied in contemporary Australian society? As health professionals and patients in contemporary Australia increasingly become involved in care situations that are likely to lead to death, there is has been an increase in the literature devoted to such issues as palliative care and end of life decision making. Most people would agree that the objective of all concerned in these situations is to ease the transition from life to death, especially in terms of medical factors like pain management. There is a balance to be struck between offering medical interventions, and offering relief from suffering, and in recent times there is thankfully an increased amount of attention and resource devoted to the needs of the dying. The emergence of hospices and palliative care teams has done much to improve this difficult area of healthcare. Nursing and hospice care professionals, rather than doctors and surgeons, are more routinely faced with dilemmas which related to the dignity of the person, and the way that psychological and social factors can impact positively or negatively on the experiences of patients, relatives and medical staff. This is an area which is less well researched, and the present paper considers the widely held assumption that Australian society generally denies death, and seeks to protect its citizens from facing up to the emotional consequences of death for themselves and their close relatives. At the present time there are heated debates about the ethical and moral issues surrounding death, ranging from support for medically assisted deaths, to vehement opposition of any intervention that could potentially hasten death. These are important issues which Australian society must tease out and openly examine if it is to provide the kind of end of life care that patients expect. The alleged tendency of Australian society to deny death could be seen as endangering attempts to improve end of life care. If people prefer to distance themselves from death, and to avoid talking or thinking about it then it is very difficult to work out what kind of treatment or care would be their ideal preference. For this reason it is important to consider attitudes and cultural values on a wide scale when considering medical and social processes. A medical service which is out of tune with the prevailing culture is unlikely to provide a sensitive and appropriate level of care. A closer look at this intriguing area of healthcare studies reveals that the whole “death denying” label may not be quite as accurate an assessment as it appears on first sight. Historians such as Jalland (2002) and Davis and George (1990) trace the evolution of Australian beliefs and customs from the aboriginal concepts of “The Eternal Dreaming” to the experiences of Australian soldiers in the First World War who were taught to repress the horrors of mass warfare with the so-called “stiff upper lip,” (Jalland, 2002, 306) and to a much more mixed modern situation where multiple ideologies and customs struggle for prominence. Despite a very evident diversity in modern Australia, this notion that the country is a “death denying” nation persists into the present day. Evidence for this “denial of death thesis” is found in the ideas of social scientists in the period from 1955 to 1985. (Zimmermann and Rodin, 2004, 121). Certain traditions such as elaborate funerals and mourning rituals for bereaved families were noted as being important markers of the transition from life to death, in earlier historical periods. In traditional Catholic societies, for example, it was usual to hold a wake to mark the departure of a beloved family member, followed by commemorative mass celebrations. In Jewish societies there are similar commemorative events, and these rituals are deliberately communal and inclusive, providing a supportive framework for bereaved families to lean on while experiencing the first painful stages of loss. (O’Gorman, 1998, 1131-1132) The community as a whole took part in these rituals, and death in such a context is very much part of everyone’s normal life experiences and social engagements. In Australian aboriginal culture the dead are eternally connected with features of the landscape, and this means that death is always present when individuals move around familiar territories. Elements of all of these cultures persist in modern Australia and continue to perform a useful function for many people. On an individual level this assumption that we tend to avoid death sounds entirely understandable, especially for younger people, but as the population ages. It is true that death is more medicalized than it used to be in Western societies but this may not have the distancing function that people suppose it to have. Research in the 1980s has investigated western cultural views on death and came up with some surprising results. Kellehear, for example, questions the appropriateness of the psychological term “denial” in the context of dying, and argues that this is a generalization about society that is not true and not helpful. Kellehear points out that this concept of “denial of death” may well have been true in the 1950s when patients tended not to be informed of terminal diagnosis, for example, and palliative care was disguised as treatment. It is certainly not typical in contemporary Australia for such a diagnosis to be withheld from a patient. This means that patients are brought into a situation of facing up to impending death, and its implications for patient and family. Kellehear argues that if there is a death denying attitude at large in contemporary society, then it is much more evident in the medical profession, who are focussed on curing patients, than in patients themselves: “In psychiatric terms, the long-standing view of the dying as denying may in fact be a projection of denial by medical people.” (Kellehear, 1984, 716). There are indeed some problems with the use of the word “denial” in the context of societal attitudes to death. Kastenbaum argues that this word is a specialist psychiatric term: “authentic denial usually is found either with people suffering from psychoses or, in a transient form, people who are suddenly overwhelmed by catastrophic events” (Kastenbaum, 2000, 90) For the vast majority of people denial is a fleeting experience which soon passes, and not a permanent feature. The use of the term to describe a feature of the whole of Australian society appears, then, to be rather excessive and potentially misleading. It is generally accepted that as medical science began to offer more successful treatments, so Western Cultures focussed more on prolongation of life, and less on the formalities of death. The rise of the hospice movement can be seen as a reaction to the realization that medical care cannot prolong life indefinitely, and a desire to push the segregation of the dying patient into the final stages where curative interventions are no longer possible. Many people die in a hospital setting, and medical treatment at the end of life is very common. It is argued that this medicalization of a natural process emphasizes people’s desire to keep death in compartmentalized “other” space far from everyday experiences. Modern funeral practices area tend also to remove the deceased person from his or her family as soon as possible, and the last caring preparation of the body is left to strangers and professionals. It does seem that people in modern society are reluctant to engage with the very real and physical presence of a recently deceased person. Denial of death may well be a tactical perspective from the funeral director or medical carer’s point of view, to enable efficient processing of individual cases, but it may not in fact represent all views, and it certainly does not typify modern hospice aspirations. For some people death at home is the ultimate isolation from the world at large, and the hospice can be a more positive integration for the patient and his or her family between the person who is dying and the outside world: “The emphasis of palliative care should not be on undoing the ‘denial’ of death that the segregation of the dying is said to represent but on creating a supportive environment for the dying and their families, both in the hospital and at home.” (Zimmermann and Rodin, 2004, 126) Seen in this light, the hospice is a demonstration of a hybrid space which is both medical and homely, taking care of emotional and spiritual needs as well as medical ones. The willingness of families to engage with hospice and home care arrangements demonstrates that there is a willingness to invest the process of dying with extra special meaning and seriousness. Further evidence of the increasing engagement of Western societies with the process of dying is found in the increasing numbers of other professionals who offer additional support in the end phases of life. Social workers have a vital role to play “as the advocate for the material needs of the dying and the bereaved.” (Small, 2001, 963) Interestingly also, Small sees the role of the social worker in contemporary western societies as being also one of gradually educating the public in ways of dealing with dying. Much like the hospice movement, which has acted as a beacon to show improved techniques and a more humane way of dealing with the finality of death, social workers are potentially useful in moving people away from distraction and avoidance tactics such as activity and optimism, and towards “the sense of worth and dignity that can come through mourning.” (Small, 2001, 965) This increased involvement of a range of professional disciplines including social work, counselling and pastoral care workers is evidence of a shift in the latter half of the twentieth century from a medical/scientific view of death towards something more holistic. (O’Gorman, 1998, 1130) Far from being a traumatic event that is to be feared and denied, “with unconditional love and a more enlightened attitude, dying can be a peaceful even transformative experience.” (O’Gorman, 1998, 1130). Although the rejection and denial of death conscious thought has been common in the past, there are signs that contemporary psychologists are beginning to engage more with different approaches which are more accepting of death as part of an on-going process. As people live longer, and often spend many months or even years suffering chronic or acute conditions in full anticipation of impending death, it is becoming more and more necessary to deal with the negative impact of a failure to integrate death more comfortably within standard world views. Kastenbaum argues for various awareness raising techniques and ways of “working and playing with the thought of death from youth through old age.” (Kastenbaum, 2000, 72) In this way the signal of fear and denial can be changed into something other than an “antianxiety shield” (Kastenbaum, 2000, 74) In seeking further evidence of a society’s views on death it is necessary to step outside the narrow world of hospitals and social work and look at the wider culture as expressed in films, newspapers, literature and music. Walter (1991) argues that the counter culture philosophies of the 1960s went a long way towards breaking down old taboos and repressive practices and opened up a path towards much greater openness on all kinds of topics, including death and dying, and that feminists, too, have chipped away at the edifice of technological supremacy: “Women seem more able to accept the failure for rationality that terminal illness represents, and to work with feelings even though technology can no longer cure.” (Walter, 1991, 298) Scholars who investigate the feelings and thoughts of dying patients offer a number of insights into the way that death is viewed by those most affected by it. McNamara’s extensive work on Australian terminally ill patients and their families with respect to the imminence of death recounts many examples which show that most people are in fact deeply concerned about everything to do with the dying process. Far from being afraid, or denying what is happening, most patients are very articulate about the things that worry them. Patients report struggling with the physical indignities and often it is a dislike of the embarrassment that troubles them more than the actual dying process. Many patients are also troubled more by the social aspects than the physical ones, especially when they are no longer able to control bodily functions: “In this context, the social death happens at some time before the biological death, when the person ceases to interact with others in a socially meaningful way.” (McNamara, 2001, 57). The context of Australia broadly follows the pattern of western societies outlined above, especially with regard to the great improvements that have been made in the late twentieth and early twenty first societies. From a traditionally masculine and hierarchical view of the medical world, with its tacit suppression of unpleasant or difficult messages Australian society has moved towards a more feminine and holistic inclusion of medical, social and psychological factors. It is dangerous, however, to make too many far-reaching generalisations about the whole of Australian society. The geography and history of the continent give it close affiliation with many Western and non-Western cultures which have very different cultural and religious influences. Waddell and McNamara (1997), for example, cite the different expectations of patients and families with a Chinese ethnic background. It is likely that Eastern traditions and philosophies which advocate patience and acceptance will influence patients to be comfortable with a more passive approach, unwilling to fight against the dying process, and more willing to take what comes in a calm and accepting way. In such context a lack of interest in diagnosis or treatment options may be very far from denial of death, but rather a courageous acceptance of its inevitability and a desire to integrate the dying process into a continuum of life with all the family. In a study based in Perth, there were clear differences between Anglo Australians and Western Australians as a group, in terms of their attitude to issues like euthanasia, but the authors warn against drawing too many tight conclusions from this: “inferences must be avoided as they can lead to the development of stereotypes.” (Waddell and McNamara, 2010, 155). Similarly, there was a statistically valid difference in the willingness of Anglo Australians and Chinese Australians to be informed of a terminal diagnosis, but each ethnic group displayed a range of views. The authors conclude that “the most positive lesson they (=medical professionals_ can learn from the results of the present study is to disclose with sensitivity and consideration.” (Waddell and McNamara, 2010, 156) This example illustrates the danger of interpreting too much into what people seem to be doing or saying. The truth is that Australian society is extremely diverse, with rural and urban communities, different social classes and political persuasions, as well as many different ethnic and social groups. The implications of this diversity are immense. Australian hospitals and hospices tend to offer “one-size-fits-all” approach which imposes a direct confrontation with all the details of diagnosis and treatment, and the imposition of standard pathway. Concepts such as “a good enough death” are used by professionals as a rough and ready response to a situation which threatens to become too complex. Part of the difficulty is not that people want to deny that death is happening, or turn away from the consequences, but that many people lack a framework and most importantly a vocabulary with which to discuss these issues. What a “good enough death” actually means in practice tends to be defined by a combination of local custom and practice with some patient consultation. In conclusion then, it seems that generalizations about Australian society and its attitudes to death are mostly misleading. It is true that some individuals are fearful of death, but when this is broken down and analysed it transpires that often it is the process of dying or the meaning attached to death that causes the negative emotions. Psychologists and other support workers already work hard to offer reassurance and different ways of framing death, and it is clear that these strategies are very effective in many cases. Medical staff are open with patients, and care plans are negotiated with patient involvement, all of which demonstrates an acceptance of death and a willingness to engage with its meaning and its consequences. Kellehear’s view that “To say that our contemporary societies are “death-denying” has no theoretical or practical explanatory value,” (Kellehear, 1984, 713) is therefore largely substantiated in the literature outlined above. Australian society may well have tended towards a denial of death in the early twentieth century when medical advances were beginning to offer more radical treatment options, but at the present time, Australians and their medical carers succeed in dealing with death on an increasingly open and accepting way. References Davis, A. and George, J. (1990) States of Health: Health and Illness in Australia. 2nd Edn. Sydney: Harper Education. Jalland, P. (2002) Australian Ways of Death: A Social and Cultural History, 1840-1918. New York: Oxford University Press. Kastenbaum, R. (2000) The Psychology of Death. 3rd Edn. New York: Sage. Kellehear, A. (1984) Are we a ‘Death-Denying’ Society? A Sociological Review. Social Science and Medicine 18 (9), 713-723. McNamara, B. (2001) Fragile Lives: Death, Dying and Care. Crows Nest, N.S.W.: Allen and Unwin. McNamara, B. (2004) Good enough death: autonomy and choice in Australian palliative care. Social Science and Medicine 58, 929-938. O’Gorman, S. (1998) Death and dying in contemporary society: an evaluation of current attitudes and the rituals associated with death and dying and their relevance to recent understandings of health and healing. Journal of Advanced Nursing 27, 1127-1135. Small, N. (2001) Social Work and Palliative Care. British Journal of Social Work 31, 961-971. Waddell, C and McNamara, B. (1997) The stereotypical fallacy: A comparison of Anglo and Chinese Australians’ thoughts about facing death. Mortality 2 (2), 149-161. Walter, T. (1991) Modern Death: Taboo or Not Taboo? Sociology 25 (2), 293-310. Zimmermann, C. and Rodin, G. (2004) The denial of death thesis: sociological critique and the implications for palliative care. Palliative Medicine 18, 121-128. Read More